abstract presentation 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 simple squat assessment: post-intervention changes to pain and function austin w. strabala, ms, lat, atc*; kyle sela, pt, dpt, ocs, scs, cscs†; forrest q. pecha, ms, lat, atc* *st. luke’s sports medicine, boise, id; †movement guides inc., meridian, id full citation strabala aw, sela k, pecha fq. simple squat assessment: post-intervention changes to pain and function. clin pract athl train. 2020;3(1):11-12. https://doi.org/10.31622/2020/0003.5. presented at the 3rd annual athletic trainers in the physician practice society meeting and conference, columbia south carolina. february 28-29, 2020 abstract background: squatting to toilet seat height is a movement pattern most people do daily. simple verbal and tactile feedback while squatting can improve an individual’s ability to squat safely and efficiently. the simple squat assessment (ssa) is a screening and intervention tool used to assess an individual’s ability to squat to toilet seat height. purpose: to determine if intervention through the ssa will improve function and decrease pain when squatting to toilet seat height. methods: 690 participants were enrolled in the ssa. participants were asked to squat to toilet seat height (43cm) and were scored from 0-3 for function. performance improvement was indicated if a participant received a score of 0 or 1. a score of 3 indicated the ability to squat under control, without assistance of hands, without pain, and with proper form. a score of 2 indicates the ability to squat under control, without pain, without assistance, but with improper form. a score of 1 indicates the individual must use hands for assistance to perform this test under control. a score of 0 indicates the individual is unable to perform or has increased pain rated from 0-10 on the pain scale. pain scores were assessed using a 0-10 visual analog scale (vas). intervention consisted of verbal and tactile feedback to improve form. the participant was then re-tested, re-scored, and asked to re-evaluate their pain post-intervention. results: 690 participants (137 males, 553 females). (males44.7±18.5yrs, females 47.9±17.0yrs). 565 individuals scored a 2 or 3 on the ssa. 125 individuals scored a 0 or 1 (110 participants-0, 15 participants-1) and were treated with intervention. 54.4% (68/125) of participants who scored a 0 or 1 were able to improve their score to a 2 or 3 post intervention. 77% (95/125) reported a decrease in pain through intervention. conclusion: application of the ssa identifies those individuals who would benefit from simple intervention to reduce pain and improve form of a functional movement that all able individuals must perform daily. squat mechanics can be improved in a short amount of time that can improve everyday movement. correspondence austin strabala. 2618 n alamo rd, boise, id. email: strabala@slhs.org references 1. bushman tt, grier tl, canham-chervak mc, anderson mk, north jw, jones bh. (2015). pain on functional movement screen tests and injury risk. j strength cond res. 2015;29(s11):s65-70. https://doi.org/10.1519/jsc.000000000 0001040. 2. hawker ga, gignac ma, badley e, davis am, french mr, li, y., et al. a longitudinal study to explain the pain-depression link in older adults with osteoarthritis. arthritis care res (hoboken). 2010;63(10):1382– https://doi.org/10.31622/2020/0003.5 mailto:strabala@slhs.org https://doi.org/10.1519/jsc.0000000000001040 https://doi.org/10.1519/jsc.0000000000001040 simple squat assessment: post-intervention changes to pain and function 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 1390. https://doi.org/10.1002/acr.20298. 3. lezin n, watkinscastillo s. the impact of musculoskeletal disorders on americans: opportunities for action. 3rd ed. rosemont, il: bone and joint initiative usa, 2016:112. 4. schoene d, wu sm, mikolaizak as, menant jc, smith st, delbaere k, lord sr. discriminative ability and predictive validity of the timed up and go test in identifying older people who fall: systematic review and meta-analysis. j am geriatr soc. 2013;61(2):202–208. https://doi.org/10.1111/jgs.12106. 5. wilkie r, blagojevic-bucknall m, belcher j, chew-graham c, lacey rj, mcbeth j. widespread pain and depression are key modifiable risk factors associated with reduced social participation in older adults. medicine. 2016;95(31). https://doi.org/10.1097/md.0000000000 004111. https://doi.org/10.1002/acr.20298 https://doi.org/10.1111/jgs.12106 https://doi.org/10.1097/md.0000000000004111 https://doi.org/10.1097/md.0000000000004111 manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 welcome to clinical practice in athletic training: letter from the editorin-chief cameron j. powden, phd, lat, atc indiana state university, terre haute, in key phrases practice-based research, athletic training, sports medicine, evidence-based practice correspondence dr. cameron powden, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: cameron.powden@indstate.edu twitter: @campowden full citation powden cj. welcome to clinical practice in athletic training: letter from the editor-in-chief. clin pract athl train. 2018;1(1):1-2. https://doi.org/10.31622/2018/0001.1 submitted: may 19, 2018 accepted: may 23, 2018 editorial evidence-based practice is an essential component of health care in which emphasis is placed on gathering the best available evidence in order to make informed clinical decisions. as such, this places a heavy demand on the literature to be timely and clinically applicable. producers of healthcare research are primarily associated with academic research centers conducting research with non-patients in controlled settings.1 much of this literature cannot be readily translated into clinical practice to inform decisionmaking and thus creates a chasm for healthcare providers between the best-available evidence and clinically feasible applications.2 the profession of athletic training is not shielded from these burdens. currently, there is a need within the field of athletic training to produce and disseminate research findings that are “real-world” in their designs, applications, and conclusions. this type of research is often referred to as transitional, practice-based, or action research. research of this variety takes place at the point-of-care in real patient populations to answer relevant clinical questions. it is completed by clinicians working together to answer communitybased healthcare questions and translating research findings into clinical practice.2 such practicebased research is patient and clinician focused in its needs, outcomes, and dissemination. overall, there is a need within the athletic training community to develop high quality outlets for practice-based research. our goal at clinical practice in athletic training: a journal of practice-based, outcomes, and action research (clin at) is to provide a clinician-friendly journal that excels in the dissemination of peer reviewed, clinically relevant research through an online, open-access platform for the dissemination of practice-based research in the field of athletic training. the journal will allow for clinical outcomes and process research that evaluates the products of athletic training practice from a patient and clinician perspective. to accomplish these goals, clin at will provide an outlet for individuals involved in the enhancement of the many forms of athletic training clinical practice, including those that do not hold the athletic training credential. clin at’s senior and section editors include individuals from diverse athletic training background ranging from nationally recognized athletic training researchers to practicing athletic trainers in a varied selection of clinical settings. due to the diversity of the editors and the unique goals of the journal, our manuscript types are equally unique. we offer eight manuscript types that include: • disablement model case studies and reports • validation case reports • point-of-care research • clinical outcomes research https://doi.org/10.31622/2018/0001.1 welcome to clinical practice in athletic training: letter from the editor-in-chief 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 • quality improvement (pdsa cycle) reports • preceptor case studies • clinical expertise commentary • patient-centered care commentary these manuscript types have been crafted to enhance the clinical applicability and application of findings within the clinical decision making process. additionally, clin at has an international standard serial number (issn) from the library of congress and will be issuing a digital object identifier (doi) for each published article. we feel that the diversity of our editorial board in combination with our unique manuscript types will allow for the cultivation of clinically applicable research. we are formally inviting all athletic trainers and those involved in the athletic training profession (medical directors, physicians, physical therapists, mental health counselors, etc.) to engage with the journal as both a contributor, reader, and reviewer. we hope to provide the practicing athletic trainer the opportunity to highlight their clinical expertise in an accessible format. finally, clin at invites comments about how we can meet the needs of our readers and the field of athletic training via e-mail. references 1. sauers el, mcleod tc, bay rc. practicebased research networks, part i: clinical laboratories to generate and translate research findings into effective patient care. j ath train. 2012; 47(5): 549-556. https://doi.org/10.4085/1062-605047.5.11 2. bowen sj, graham id. from knowledge translation to engaged scholarship: promoting research relevance and utilization. arch phys med rehabil. 2013;94(1):s3-8. https://doi.org/10.1016/j.apmr.2012.04. 037 https://doi.org/10.4085/1062-6050-47.5.11 https://doi.org/10.4085/1062-6050-47.5.11 https://doi.org/10.1016/j.apmr.2012.04.037 https://doi.org/10.1016/j.apmr.2012.04.037 editorial manuscript type preceptor case study 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 secondary school athletic training facility scavenger hunt orientation joseph vogler, ms, lat, atc unionville high school, kennett square, pa abstract the purpose of this case study is to explain an educational game that was utilized as part of an orientation component with commission on accreditation of athletic training education (caate) accredited professional phase athletic training students. the students were guided through a scavenger hunt in 3 phases to help locate items within the athletic training facility and then analyze the item’s function and non-traditional usages. in phase 1 the students were asked to search throughout the athletic training facility and fostered engage in dialogue regarding unknown items. the preceptor asked the students to retrieve random items during phase 2. during phase 3 the preceptor found random items and asked the students to think of traditional and nontraditional uses for the chosen item. this activity utilized the educational theory of bloom’s taxonomy to introduce knowledge of athletic training supplies and equipment, and help students implement that knowledge into future clinical practice. additionally, medical education literature has shown that games engage learners by increasing interest, retention, and stimulates students into higher levels of thinking. key phrases orientation, observation experiences correspondence mr. joseph vogler, unionville high school, 750 unionville road, kennett square, pa 19348. e-mail: jvogleratc@gmail.com twitter: @gouathltraining full citation vogler j. secondary school athletic training facility scavenger hunt orientation. clin pract athl train. 2018;1(1):30-32. https://doi.org/10.31622/2018/0001.6 submitted: april 30, 2018 accepted: may 30, 2018 introduction professional athletic training students (atss) in commission on accreditation of athletic training education (caate) accredited athletic training programs (atps) are required to engage in clinical education experiences at various sites throughout the curriculum. many atss begin clinical rotations at secondary schools and are unaware that often times secondary school athletic trainers are forced to be more resourceful than their collegiate counterparts due to decreased budgets and staffing ratios.1 since many secondary school athletic training facilities are smaller than their collegiate counterparts, organization skills and knowing where items are located is essential for students.2 due to these differences, atss assigned to the secondary school must hone in on their organization and resourcefulness skills from day one. as a result, the training activity described in this paper was done on one of the first days atss began a rotation at the secondary school level during the professional phase. athletic training student characteristics the activity was performed with 1-2 caate accredited professional phase atss in their first secondary school clinical rotation. preceptor characteristics the preceptor practiced at a local secondary school in a large suburban school district. the preceptor has been an athletic trainer for 4 years and has been a preceptor for 2 ½ of those 4 years. the preceptor has been through a formal graduate level class on educating athletic trainers and attended numerous preceptor workshops over the previous 3 years. there are 2 other https://doi.org/10.31622/2018/0001.6 secondary school athletic training facility scavenger hunt orientation 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 athletic trainers, 1 part time, 1 full time, who interacted with the atss on a semi-regular basis. experience as an orientation to the secondary school setting, the atss took part in a scavenger hunt that has been designed in three phases. in phase 1 the atss were asked to explore and rummage through closets, cabinets, drawers, and kits to discover the location of all items in the clinic. if they did not know the item or its function, they were supposed to ask a preceptor for explanation. once the students completed phase 1 by searching through the entire athletic training room, phase 2 was introduced gradually when the preceptors start asking students to find random items from around the clinic. phase 3 usually occurred once atss were familiar with all items. in this phase the preceptors pulled various items and asked the atss if they could think of 3-5 nontraditional functions for that item as it related to athletic training clinical practice. the objective of phase 1 was to familiarize the atss with all supplies and items located in the athletic training facility and to spark conversations about the function of the items. the obvious benefit to this is that in an urgent situation (i.e. needing an epinephrine injector in the gymnasium for a patient experiencing anaphylactic shock) the ats is familiar with the location of the item. an additional benefit is that the athletic trainer had an opportunity to plan for future educational discussions based on what items the ats was familiar and unfamiliar with. for example, if the ats asked questions about modalities, the preceptor could spend some time discussing modalities in greater detail. questions that sparked further dialog were often about unique non-traditional items such as, “why is there a can of dusting spray in the rehab area?” (correct answer: to help decrease the friction of the slideboard), or “why are there two tongue depressors taped together in the football equipment removal kit?” (correct answer: to remove cheek pads from a football helmet in a cervical spine emergency). however, there have also been questions posed about therapeutic modality and rehabilitation equipment that was not seen at previous observations such as, “how do you use the vibracussor?” or, “what type of rehabilitation is a baps board used for?” the objective of phase 2 was to get students familiar with important items or items that may have been missed. often times this was used as an informal assessment to make sure students were familiar with the location of emergency and acute care items. for example, making sure that a student knew where nasal sponges were, so that during a situation where a patient presented with an epistaxis, they are able to treat the bleeding before there was significant blood loss. the objective of phase 3 was to encourage the atss to think outside of the box and help them understand that in the athletic training setting, especially at the secondary school level, athletic trainers must be resourceful and items can serve many purposes. phase 3 sparked other conversations that led to a chain reaction of tangential learning. the preceptor prompted the ats by finding a random item, such as baby powder, and asked them to list 3-5 athletic training uses of that item. for example, baby powder can be utilized for reducing friction in a multitude of ways. often times the atss mentioned the most common usages such as treating chaffing or sweat reduction in a shoe or cleat. however, often the students did not think of the additional usages, such as using baby powder to help slide on a neoprene sleeve, or helping a patient put on a wet sock back on over a fresh ankle taping. additionally, baby powder can be used with deep oscillation therapy (i.e., the hivamat 200 evident unit),3 and this particular usage created an educational opportunity to learn about deep oscillation therapy on numerous occasions. results and discussion the overall results of the activity have been positive. the atss started out thinking that the task was busy work, yet soon realize that it ignited educational discussions. the execution of this activity worked best when the ats starts at the clinical site and a period of the day with a low patient-load, to allow an opportunity for open dialog. after the scavenger hunt, there was a short debriefing session among the atss to ask for their impressions and ways to make the activity better in the future. there was some competitive nature to the activity as the atss competed to be the first to find items, and to come up with more unique answers during the phase 3 questions. secondary school athletic training facility scavenger hunt orientation 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 clinical bottom line when looking at educational research, the scavenger hunt activity aligned with bloom’s taxonomy, an educational theory explained by benjamin bloom in 1956, with each phase of learning building upon the previous phase of learning.4 in bloom’s taxonomy, there are 6 levels (1. knowledge, 2. comprehension, 3. application, 4. analysis, 5. synthesis, 6. evaluation) that students experience during instruction.4 when analyzing the scavenger hunt in phases 1 and 2, the ats are asked to retrieve knowledge by looking for items and then asked to comprehend that knowledge by posing questions for clarification and explanation from the preceptor.4 in phase 3 the atss were asked to apply, analyze, and synthesize their knowledge as they critically thought about the usage of items in clinical practice.4 the ultimate goal is that the atss will then take what they have learned in the scavenger hunt and put it together with other components of their athletic training education to apply this knowledge to their future clinical practice.4 additionally, by turning this experience into a scavenger hunt the atss saw it as a game and were competitive. in medical education games have been indicated to promote interest, increase retention, and stimulate students into higher levels of thinking within bloom’s taxonomy.5,6 student perspective athletic training students have stated, “i really enjoyed the scavenger hunt activity that we did at the beginning of the semester. it helped me to feel more comfortable in the [athletic training facility] and was helpful for when i needed to find something quickly. it was a really fun way to get oriented and feel more confident there.” moreover, “the scavenger hunt game in the athletic training [facility] is very beneficial and an engaging game. it helped me learn where everything is in the room in a short amount of time. knowing where all the equipment and supplies are is very important, so there is no delay or questioning when needed to acquire equipment/supplies.” references 1. mazerolle sm, raso sr, pagnotta kd, stearns rl, casa dj. athletic directors’ barriers to hiring athletic trainers in high schools. j athl training. 2015;50(10):1059-1068. https://doi.org/10.4085/1062-605050.10.01 2. cooper l. ready to renovate. training & conditioning. http://trainingconditioning.com/4ats/ready-renovate. october 11, 2017. accessed may 21, 2018. 3. compass richmar corporation. operating instructions: hivamat 200 evident. 2017. http://richmarweb.com/websites/richmar/i mages/pdf/operation-manuals/hivamat200-evident-manual.pdf. accessed march 21, 2018. 4. bloom bs, engelhart md, furst ej. taxonomy of educational objectives: the classification of educational goals handbook i: cognitive domain. new york, ny: david mckay company; 1956. 5. meterissian s, liberman m, mcleod p. games as teaching tools in a surgical residency. med teach. 2007;29:e258-e260. https://doi.org/10.1080/0142159070166 3295 6. akl ea, mustafa r, slomka t, alawneh a, vedavalli a, schunemann hj. an educational game for teaching clinical practice guidelines to internal medicine residents: development, feasibility and acceptability. bmc med educ. 2008;8(50). https://doi.org/10.1186/1472-6920-8-50 https://doi.org/10.4085/1062-6050-50.10.01 https://doi.org/10.4085/1062-6050-50.10.01 https://doi.org/10.1080/01421590701663295 https://doi.org/10.1080/01421590701663295 https://doi.org/10.1186/1472-6920-8-50 abstract introduction manuscript type clinical outcomes research 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 functional balance assessment of firefighters during mass-screening examinations rachel m. eiler, dat, lat, atc*; zachary k. winkelmann, phd, scat, atc†; and kenneth e. games phd, lat, atc‡ *novacare rehabilitation, minneapolis, mn; †university of south carolina, columbia sc; ‡indiana state university, terre haute, in abstract firefighters are tactical athletes who are required to complete rigorous tasks as part of their job functions. the focus of this clinical outcomes assessment was to assess functional balance assessment through the use of the anterior reach test with and without personal protective equipment (ppe) during a mass-screening examination. the screening was completed with 61 active firefighters in a local fire department with access to athletic training services. the results of the anterior reach assessment identified a significant difference of a firefighter’s anterior reach when donning and doffing ppe. anterior reach distances were significantly reduced (p < 0.001) on the right leg with (mean = 55.78 cm ± 7.53 cm) and without ppe (mean = 58.92 cm ± 6.47 cm). similarly, significant decrements (p = 0.003) in left leg anterior reach distance in firefighters donning (mean = 57.67 cm ± 8.25 cm) and doffing (mean = 59.82 cm ± 6.31 cm) ppe. clinical application of these findings suggests that healthcare providers working with tactical athletes, specifically firefighters, should consider the risks associated with donning ppe such as functional balance deficits. key phrases pre-participation exams and screenings, emerging settings correspondence dr. zachary k winkelmann, university of south carolina, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation eiler rm, winkelmann zk, games ke. functional balance assessment of firefighters during mass-screening examinations. clin pract athl train. 2020;3(2):45-49. https://doi.org/1031622/2020/0002.6. submitted: december 19, 2019 accepted: may 15, 2020 patients sixty-one firefighters from a midwestern fire department were included in this mass-screening examination. all of the firefighters were considered career, full-time employees of the city municipality. sixty firefighters identified as male and 1 firefighter identified as female. the firefighters ranged in age from 25 to 64 years of age (mean = 41.07 ± 9.23 years) and had between two and 34 years of experience (mean = 15.31 ± 9.41 years) in the fire service. the body composition of the firefighters was of average height (28.03 ± 1.08 cm) and aboveaverage mass (105.58 ± 20.87 kg). during the intake process, the firefighters completed a past medical history form. from this process, 12 firefighters (19.7%) reported having chronic pain, 16 firefighters (26.2%) reported a previous head/neurological injury, 42 firefighters (68.9%) reported having a previous surgery, and 24 firefighters (39.3%) indicated an ongoing orthopedic injury at the time of the mass-screening examination. it is important to indicate here that while 39.3% of the firefighters reported an ongoing injury, none of these individuals were on restricted or light duty. thus, they were required to execute and perform all job-related tasks. intervention the intervention was a three-day, mass-screening event at the fire department’s training center. the firefighters arrived at the firefighter training center during their shift in crews of three to seven people. each firefighter completed a past medical history form and patient-reported outcome measures via an online survey (qualtrics, inc, provo, ut). once the patients completed the online survey, they proceeded to complete a series of functional screenings throughout the training center. figure 1 outlines the flow chart of massscreening intervention process. mailto:winkelz@mailbox.sc.edu https://doi.org/1031622/2020/0002.6 functional balance assessment of firefighters during mass-screening examinations 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 the first stage of the functional screening included patient intake (height, weight, leg length, tibial tuberosity height, and hand length), the weight bearing lunge test, and the closed kinetic chain upper extremity stability test. once all patients completed these stations, they proceeded to the second stage of the function screenings that consisted of the anterior reach portion of the y-balance test, the landing error scoring system (less), and the functional movement screen (fms). the firefighters completed each of these tests while donning their station attire that included a t-shirt, athletic shorts/pants, and tennis shoes, or while donning their personal protective equipment (ppe) which included their jacket, pants, boots, helmet, mask, and condensed air tank. during the anterior reach, the firefighter’s mask was not connected to the condensed air tank during the completion of the anterior reach. the mask is the piece of equipment that covers the firefighter’s face into which the condensed air tank attaches to provide the firefighter with oxygen. once the patient completed the tests while donning and doffing their ppe, their mass-screening examination was completed. outcome measures the focus of this clinical outcomes’ assessment was dynamic balance assessed using the anterior reach portion of the y-balance test. the ybalance test measures dynamic balance using single limb stance excursion.1 prior to the ybalance test, the star excursion balance test (sebt) was used to identify chronic ankle instability, at-risk athletes for lower extremity injury, and assess overall physical performance.1 the y-balance test was developed to improve the repeatability of the sebt.1 the anterior reach assessment was utilized because previous research suggests that asymmetries in the anterior direction indicated balance deficits that increased the risk for injury.2,3 specifically, the anterior reach has high intrarater reliability at 0.91.1,2 to be mindful of time guided by the literature, we only assessed the anterior reach out of the three directions for the y-balance test. prior to the firefighter completing the assessment, the athletic trainer provided verbal and modeling instruction on how to complete the anterior reach assessment of the y-balance test. during the anterior reach assessment, each firefighter successfully completed the test three times while donning ppe (figure 2) and three times doffing ppe (figure 3) for a total of six trials of the anterior reach completed using an established protocol.1 the order was not controlled for the patients to start with or without their ppe. the anterior reach test was completed using the ybalance test kit, which includes three pipes in the anterior, posteromedial, and posterolateral direction.1 for the mass-screening examination, only the anterior pipe was measured. the pipe was marked in 0.5 centimeters increments for measurements, where the firefighter pushes the reach indicator box along the pipe, marking the determination of the reach distance, and returning patient online survey patient intake functional screening figure 1. flow chart of mass-screening intervention process figure 2. anterior reach assessment with personal protective equipment functional balance assessment of firefighters during mass-screening examinations 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 to the starting point while maintaining their balance on their stance leg.1 once all patients completed the anterior reach assessment, the data were entered into a custom spreadsheet application and analyzed in a commercially available statistics package. first, the absolute reach distance was calculated by summing the three reach distances and dividing by three for the average on the right and left leg with and without ppe. next, the data were normalized by dividing the maximum reach distance in each leg for each condition by the limb length of the patient. this number was multiplied by 100 to calculate the relative anterior reach distance.1 normalizing the data occurred to be able to compare the data among the individuals with different leg lengths. results the majority (54/61, 88.5%) of the firefighters were self-reported right leg dominant. table 1 provides the descriptive statistics for the anterior reach assessment. a paired sample t-test was utilized to analyze the data. results of the data analysis identified a significant difference (p < 0.000) for the right leg anterior reach distance when the firefighters were doffing their ppe (mean = 58.92 cm ± 6.47 cm) as compared to when they were donning their ppe (mean = 55.78 cm ± 7.53 cm). similar results were identified on the left leg with a significant difference (p = 0.003) for anterior reach distance donning and doffing ppe. table 1. anterior reach results condition mean (cm) standard deviation (cm) standard error (cm) right leg ppe 55.78 7.53 0.96 right leg no ppe 58.92 6.47 0.83 left leg pee 57.67 8.25 1.06 left leg no ppe 59.81 6.30 0.81 ppe = personal protective equipment after normalizing the measurements per patient, we identified a significant difference in relative anterior reach distance for the right (p < 0.01) and left (p = 0.026) leg when donning and doffing their ppe. table 2 provides relative normalized reach distance descriptive measures per assessment condition. table 2. anterior reach normalized results condition mean (cm) standard deviation (cm) standard error (cm) right leg ppe 69.23 21.26 2.72 right leg no ppe 72.72 22.19 2.84 left leg pee 71.31 22.79 2.92 left leg no ppe 73.49 22.76 2.91 ppe = personal protective equipment discussion in 2018, 58,835 firefighters were injured on the fireground.4 strain or overexertion were the leading cause of fireground injuries.4 with the high rate and risk of injury during the job, firefighters are required to don ppe that limits smoke inhalation, chemical exposure, and fire contact resulting in burns.5 as a part of their ppe, figure 3. anterior reach assessment without personal protective equipment functional balance assessment of firefighters during mass-screening examinations 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 firefighters must also wear a compressed air tank which was identified in previous literature to have a negative effect on postural control and functional balance.6 there are various ppe designs that are worn by firefighters, but regardless of the design, ppe significantly impairs functional balance.7 when donning ppe, firefighters had a decrease in movement speed by a 13% increase in performance time and made more errors on a balance exam.7 by knowing that the ppe could impair functional balance, it is vital to understand how decreases functional balance may predispose a firefighter to a musculoskeletal injury on the fireground. results of this study found that there is a significant difference between the relative anterior reach distance for the right leg as compared to the left leg when patients are donning and doffing their ppe. anterior reach decreased when donning ppe, due to the impairments of the functional balance. the anterior reach assessment was completed while donning and doffing firefighter ppe. previous research has identified that the thermal layer (pants and jacket) alters a firefighter’s gait speed during balance testing. ppe negatively effects gait by decreasing step length thus slowing one’s speed.8 although we were not assessing gait, we did identify that wearing the ppe significantly altered the firefighter’s functional balance. based on the literature, functional balance and gait are affected by donning ppe. this is of concern to the safety and wellness of the firefighters. the longer someone is in a live fire, the more functional balance is affected. if someone is moving slower and paired with balance decrements at the onset, there is a grave concern that exposure to heat while donning ppe may result in the trips and falls that contribute to the high statistics of sprains and strains in the united states fire service. one mechanism that may improve functional balance while donning ppe is by increasing resistance and aerobic training, as the literature supports that a more physically active firefighter has less physical impairment. 9 in regard to the limited anterior reach that was found in this study, one proposed mechanism for the decrements is limited dorsiflexion at the ankle. ankle dorsiflexion for firefighters is impacted by their boots.10-12 the literature supports that boot type (rubber versus leather) influences a firefighter’s balance with rubber boots, increasing their risk for falls.10-12 common tasks of firefighters include climbing ladders, emergency lifts to rescue victims in burning buildings, and assembling equipment to put out fires. as such, ankle dorsiflexion and functional balance are both required. future research on ppe gear analysis would assist the industry in identifying how to create protective turnout gear that limits chemical exposure and exposure to fires that also allows for movement and range of motion. clinical application the data collected can assist in determining limitations that the patient’s experiences with their ppe. this allows clinicians to be able to understand the potential causes of the mechanism of injury and design rehabilitation plans to prevent the injury from reoccurring. by determining the limitations during the mass screening, the clinician can work with the patient on goal setting and injury prevention. due to the equipment having a negative effect on the patient’s performance in the anterior reach, it may be beneficial to have the patient complete exercise, physical activity, and therapeutic rehabilitation with their ppe to train the body to replicate the conditions in which they are required to work. this change may result in more job-specific rehabilitation, with future investigations necessary to explore firefighters’ ability to complete movements. clinicians are also able to develop resistance and aerobic training exercise plans to increase the firefighter’s overall physical fitness to reduce their physical impairments, which can result in improving their physical ability while donning ppe. references 1. plisky pj, gorman pp, butler rj, kiesel kb, underwood fb, elkins b. the reliability of an instrumented device for measuring functional balance assessment of firefighters during mass-screening examinations 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 components of the star excursion balance test. n am j sports phys ther. 2009;4(2):92. 2. haffer sw, teyhen ds, lorenson cl, et al. ybalance test: a reliability study involving multiple raters. mil med. 2013;178(11):1264-1270. https://doi.org/10.7205/milmed-d-1300222. 3. de la motte sj, gribbin tc, lisman p, beutler ai, deuster p. the interrelationship of common clinical movement screens: establishing population-specific norms in a large cohort of military applicants. j athl train. 2016;51(11):897-904. https://doi.org/10.4085/1062-605051.9.11. 4. campbell r, evarts b, molis jl. united states firefighter injury report 2018.national fire protection association. 2019. accessed at: https://www.nfpa.org/-/media/files/newsand-research/fire-statistics-andreports/emergencyresponders/osffinjuries.pdf. 5. guidotti tl, clough vm. occupational health concerns of firefighting. annu rev public health. 1992;13(1):151-171. https://doi.org/10.1146/annurev.pu.13.05 0192.001055. 6. punakallio a, lusa s, luukkonen r. protective equipment affects balance abilities differently in younger and older firefighters. aviat apace environ med. 2003;74(11):1151-1156. 7. hur p, hsiao-wecksler e, rosengren k, horn g, smith d. effect of protective clothing and fatigue on functional balance of firefighters. j ergonomics. 2013;2(004). https://doi.org/10.4172/2165-7556.s2004. 8. park k, rosengren ks, horn gp, smith dl, hsiao-wecksler et. assessing gait changes in firefighters due to fatigue and protective clothing. safety science. 2011;49(5):719726. https://doi.org/10.1016/j.ssci.2011.01.012 . 9. kong pw, suyama j, cham r, hostler d. the relationship between physical activity and thermal protective clothing on functional balance in firefighters. res q exerc sport. 2012;83(4):546-552. https://doi.org/10.1080/02701367.2012. 10599144. 10. chiou ss, turner n, zwiener j, weaver dl, haskell we. effect of boot weight and sole flexibility on gait and physiological responses of firefighters in stepping over obstacles. hum factors. 2012;54(3):373386. https://doi.org/10.1177/0018720811433 464. 11. garner jc, wade c, garten r, chander h, acevedo e. the influence of firefighter boot type on balance. int j ind ergon. 2013;43(1):77-81. http://dx.doi.org/10.1016%2fj.ergon.2012 .11.002. 12. chander h, garner jc, wade c. slip outcomes in firefighters: a comparison of rubber and leather boots. occup ergon. 2016;13(2):67-77. https://doi.org/10.3233/oer-160241. https://doi.org/10.7205/milmed-d-13-00222 https://doi.org/10.7205/milmed-d-13-00222 https://doi.org/10.4085/1062-6050-51.9.11 https://doi.org/10.4085/1062-6050-51.9.11 https://www.nfpa.org/-/media/files/news-and-research/fire-statistics-and-reports/emergency-responders/osffinjuries.pdf https://www.nfpa.org/-/media/files/news-and-research/fire-statistics-and-reports/emergency-responders/osffinjuries.pdf https://www.nfpa.org/-/media/files/news-and-research/fire-statistics-and-reports/emergency-responders/osffinjuries.pdf https://www.nfpa.org/-/media/files/news-and-research/fire-statistics-and-reports/emergency-responders/osffinjuries.pdf https://doi.org/10.1146/annurev.pu.13.050192.001055 https://doi.org/10.1146/annurev.pu.13.050192.001055 https://doi.org/10.4172/2165-7556.s2-004 https://doi.org/10.4172/2165-7556.s2-004 https://doi.org/10.1016/j.ssci.2011.01.012 https://doi.org/10.1016/j.ssci.2011.01.012 https://doi.org/10.1080/02701367.2012.10599144 https://doi.org/10.1080/02701367.2012.10599144 https://doi.org/10.1177/0018720811433464 https://doi.org/10.1177/0018720811433464 http://dx.doi.org/10.1016%2fj.ergon.2012.11.002 http://dx.doi.org/10.1016%2fj.ergon.2012.11.002 https://doi.org/10.3233/oer-160241 manuscript type disablement model case study 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study s. andrew cage, med, lat, atc*†; brandon j. warner, med, lat†‡; and diana m. gallegos, ms, lat, atc* *university of texas at tyler, tyler, tx; †university of north carolina greensboro, greensboro, nc; ‡grand canyon university, phoenix, az abstract the purpose of this disablement model case study was to describe the case of a collegiate baseball pitcher suffering from a labral lesion and supraspinatus strain that may have been the result of posterior glenoid dysplasia. despite gross instability and glenohumeral external rotation weakness, the patient was initially able to continue to pitch. while posterior glenoid dysplasia has been described in literature, there have not been studies that have evaluated soft tissue changes that may be associated with this bony morphology abnormality. in this case, the patient reported to the athletic training staff complaining of pain, tightness, and a “clunking” sensation in and around his glenohumeral joint. the patient reported right shoulder pain being worse following pitching, but not experiencing symptoms during the act of pitching. the patient was initially treated with cupping and therapeutic exercise and was able to continue pitching. as the season progressed, the patient reported needing increasingly longer time to recover from pitching outings. the patient continued to present with a positive o’brien’s (active compression) test, weakness with internal and external rotation, and visible scapular protraction at rest. upon referral to the team physician, radiographs were ordered to evaluate for bony pathology. the patient was diagnosed with posterior glenoid dysplasia and referred for magnetic resonance arthrogram. this imaging revealed a labrum tear and subscapularis strain. the patient was referred for surgery, at which time a labrum and subscapularis debridement, and subacromial bursectomy were performed. the patient was then instructed to follow up with the athletic training staff to initiate therapeutic exercise as prescribed by the attending surgeon. when evaluating glenohumeral weakness and instability, the clinician must consider bony abnormality as a potential factor. if initial treatment attempts do not result in improvements, the clinician must exhaust all diagnostic options to determine the exact nature of the offending pathology. key phrases glenoid fossa, labrum pathology, rotator cuff correspondence s. andrew cage, university of texas at tyler, 11325 preakness dr. flint, tx 75762. e-mail: sacage@uncg.edu full citation cage sa, warner bj, gallegos dm. posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study. clin pract athl train. 2020;3(2):50-54. https://doi.org/1031622/2020/0002.7. submitted: may 10, 2019 accepted: june 2, 2020 introduction posterior glenoid dysplasia is a relatively uncommon condition affecting the glenoid fossa of the scapula.1 generally, this condition has been described in osteoporotic patients, but has also been found to have a high incidence in young baseball players.1,2 glenoid dysplasia is believed to be the result of a failure of the glenoid precartilage to ossify during gestation and early childhood.1 additionally, it has been suggested that there may be a hereditary component, with individuals potentially passing the morphology to future generations of their genetic line.3 it has been suggested that the stresses applied to the anterior and posterior glenoid during overhead throwing my result in changes to the structure of the glenoid over time.4 while there have been some data collected regarding the incidence and description of this condition, the authors were unable to find a study that reported the effects of this abnormal morphology on soft tissue structures such as the glenohumeral labrum.1 in a study examining the role of glenoid abnormalities in shoulder pain, kirimura and his colleagues found that 89 of 91 young baseball players reporting with shoulder pain exhibited posterior glenoid dysplasia.2 currently the primary focus of existing literature is on bony mailto:sacage@uncg.edu https://doi.org/1031622/2020/0002.7 posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 pathologies associated with this abnormal morphology.5 thus, it is the purpose of this case study to describe a labrum tear and subscapularis strain of the right shoulder in a collegiate baseball player who also exhibited posterior glenoid dysplasia. this case will describe the presentation of injury, diagnosis, treatment, patient reported disablements, and outcomes. patient information the patient described in this case is a 19-year-old collegiate baseball pitcher. the patient reported a history of long term, high intensity, high frequency bouts of pitching, but had previous only been troubled by muscular tightness and delayed onset muscle soreness in his right shoulder. while he did not associate the symptom with pitching or pain, the patient also stated that his shoulder would “clunk” or “pop” when taken through certain motions. the patient noted that he did not experience symptoms while pitching, but would begin to feel pain and tightness within the first 24hours post pitching. initial evaluation revealed a positive o’brien’s (active compression) test, negative anterior apprehension test, negative jobe’s relocation test and weakness with glenohumeral internal and external rotation. the patient was placed on a preventative therapeutic exercise program that incorporated cupping therapy to address his reported muscular tightness and reported instability. differential diagnosis and evaluation after initially reporting symptoms, the patient was evaluated following each pitching outing. the patient stated that the pain he was experiencing made it difficult to use his right arm during driving, and that he was unable to hold his cellular telephone in his right arm while talking for an extended period of time. the patient reported that his pain felt as though it was “too deep to touch,” and that while treatment and exercise provided temporary relief, he would still experience the same level of pain after pitching. given that the patient stated he was experiencing increasing levels of dysfunction, and presented with positive labrum symptoms, the treating athletic trainer made the decision to have the patient evaluated by the team physician. at this time, the differential diagnosis included: labrum pathology, scapular dyskinesis, rotator cuff and scapula stabilizer weakness. two weeks after the patient initially reported his symptoms, during the team physician’s evaluation, it was noted that the patient has multidirectional glenohumeral instability. however, instability tests did not elicit the pain that the patient stated was his primary concern. following initial evaluation, the team physician determined it was necessary to pursue diagnostic imaging. radiographs revealed posterior glenoid dysphasia. consultation with the team orthopedic surgeon led to the patient being schedule for a magnetic resonance (mr) arthrogram to further evaluate the soft tissue structures of the shoulder. the mr arthrogram revealed significant inflammatory signal, leading the orthopedic surgeon to conclude that the patient had suffered an injury to his labrum and rotator cuff (figure 1). figure 1. mr arthrogram of patient's right shoulder posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 at this time, the surgeon explained to the patient that without performing arthroscopic surgery it would be difficult to fully appreciate the severity of the damage to labrum and rotator cuff. the patient stated that the intensity and duration of the pain he felt following pitching was affecting his activities of daily living, and he wished to undergo surgery to address any damage that had been sustained. body structure and function given the injury and patient population, the primary diagnostic tools utilized to determine the need for an mri arthrogram were orthopedic special tests, strength and range of motion tests, and patient reported history. at the initial time of injury, the patient presented with full range of motion, inability to pitch for long durations, and a 4/5 strength deficit with glenohumeral internal and external rotation. activity and participation in order to help the patient determine if he would be able to continue to participate in further competitions, the patient was allowed to pitch in one more competition following diagnostic imaging. the patient stated that while he was pitching, he did not notice significant pain. however, the patient experienced fatigue faster than he normally would have, and was unable to pitch longer than two innings. the following day the patient reported an increase in pain and stiffness compared to his previous pitching appearances. environmental and personal factors outside of baseball related activities, the patient stated that the pain he was experiencing in his shoulder was affecting his activities of daily living. specifically, the patient stated that the intensity of pain inhibited his ability to obtain adequate quality sleep. additionally, the patient reported difficulty turning the steering wheel of his car without patient. after his last pitching appearance, the patient stated that he was unable to brush his hair and teeth without pain. given this increase in pain and the knowledge that there was some form of structural damage within his shoulder, the patient stated his desire to have his injuries surgically addressed as soon as possible. when consulting with the team orthopedic surgeon, the patient made the decision to delay surgery until after he had taken his final examinations out of concern for being unable to focus properly on his studies. intervention immediately after initially reporting symptoms, the patient began participating in a rehabilitation plan consisting of elastic tubing and dumbbell exercises designed to address the present rotator cuff and scapula stabilizer weakness. these exercises were completed five to six times a week. in addition to these exercises, the patient continued to participate in his normal elastic tubing and range of motion exercises as part of his normal warmup prior to throwing. during this time the patient was allowed to continue throwing as tolerated. once the patient began to experience worsening symptoms and it was determined that continuing to pitch was not a viable option, the patient was instructed to discontinue all throwing and upper body weightlifting activities. the patient was then consented and scheduled for surgery following his final examination. upon performing arthroscopic surgery, the surgeon found subacromial bursitis, a 20% subscapularis tear and fraying of the labrum at the attachment site of the long head of the biceps brachii. based off of these findings, the surgeon performed a subacromial bursectomy, subscapularis debridement, and biceps brachii debridement. during his evaluation, the surgeon determined that the present posterior glenoid dysphasia was not severe enough to warrant surgical correction. posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 outcomes body structure and function after one week of rest following surgery, the patient began participating in light range of motion and strengthening exercises. as the patient regained range of motion and strength, exercises progressed in terms of intensity and volume. throughout the progression in exercise the patient experienced intermittent bouts of expected soreness, but stated that his shoulder was beginning to feel increasingly stronger and pain free. within four weeks, the patient had regained sufficient strength and range of motion to begin a throwing program. over the course of the summer, the patient was able to progress in terms of distance and repetitions until he was cleared to begin training to pitch during the following fall baseball practices. activity and participation through the surgical intervention and the initiation of the therapeutic exercise and throwing program, the patient was able to increase his amount and distance of throwing in order to be prepared to pitch when non-traditional practices began the following fall. after throwing, the patient noted that his soreness was not as intense or severe as it had been prior to surgery and rehabilitation. when asked, the patient noted that he felt as if he was able to recover more quickly than he had been prior to surgery. aside from baseball and pitching, sleep and activities of daily living that required extensive upper body usage began to grow easier as strength and range of motion improved. had the patient not elected to undergo surgery, his symptoms would have likely continued to worsen to the point where they were affecting his activities of daily living even worse. fortunately, the patient lived locally with his family who were able to assist him as needed, and he was able to complete his final examinations without incident. environmental and personal factors given the patient’s expressed desire to be able to complete his final examinations in as little pain as possible, he remained adherent to his limitation regarding throwing and upper body weightlifting. following surgery, the patient adhered to all scheduled rehabilitation times and was only absent from the athletic training clinic for a short period in order to vacation with his family. because the ultimate decision was to discontinue activity until the patient’s structural damage could be appropriately addressed there were no adverse effects from the chosen course of treatment. discussion this case describes the diagnosis and management of a patient suffering from subacromial bursitis, labral tear, and subscapularis partial tear with a secondary finding of posterior glenoid dysphasia. while posterior glenoid dysphasia is an uncommon finding, it has been described in a number of young baseball players complaining of shoulder pain.2 furthermore, in this case the posterior glenoid dysphasia did not appear to be the source of pain in the patient’s shoulder. the team orthopedic physician did state that the glenoid dysphasia could have contributed to the humeral head resting against the glenoid fossa differently, but could not definitively attribute the soft tissue damage to the structural abnormality. overall, the choice to discontinue throwing even though the patient was still able to pitch effectively at the time was made based off the patient’s concerns regarding educational goals. had the patient chosen to continue to participate, it is possible that they would have been able to continue pitching. however, this continued participation may have led to worsening symptoms or further structural damage. ultimately, the patient was able to return to throwing following surgery and therapeutic activity, and no adverse outcomes were reported. posterior glenoid dysplasia as a secondary finding to labrum tear and subscapularis strain: a case study 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 clinical bottom line within the scope of clinical practice, it is entirely possible for clinicians to encounter diagnostic findings that are not well described in literature. in some instances, the available literature may indicate that these findings are part of the cause of the symptoms with which a patient presents. in all cases, clinicians must use their clinical qualifications to evaluate and re-evaluate a treatment and rehabilitation plan. should conservative treatment fail and surgical intervention be warranted, the clinician may learn that previous findings were not the ultimate cause of a patient’s symptoms. in these cases, a clinician must be prepared to adjust their treatment and rehabilitation plans accordingly. at all times, a clinician must prioritize their patient’s safety and personal values. based off of these values, clinicians may change their course of action within reason. references 1. seagger rm, loveridge j, crowther maa. beware of glenoid dysplasia mimicking bone trauma in the injured shoulder. int j shoulder surg. 2009;3(2):37-40. https://dx.doi.org/10.4103%2f09736042.57934. 2. kirimura k, nagao m, sugiyama m. high incidence of posterior glenoid dysplasia of the shoulder in young baseball players. j shoulder elbow surg. 2019;28:82-87. https://doi.org/10.1016/j.jse.2018.06.021. 3. andrews sn, smithson sf, bunker td. dominant inheritance of primary glenoid dysplasia. report of a father and son. shoulder & elbow. 2009;1:93-94. https://doi.org/10.1111/j.17585740.2009.00024.x. 4. mochizuki y, natsu k, kashiwaga k, yasunaga y, ochi m. changes of the mineralization pattern in the subchondral bone plate of the glenoid cavity in the shoulder joints of throwing athletes. j shoulder elbow surg. 2005;14:616-619. https://doi.org/10.1016/j.jse.2005.02.016. 5. walch g, badet r, boulahia a, khoury a. morphologic study of the glenoid in primary glenohumeral osteoarthritis. j arthroplasty. 1999;14:756-760. https://doi.org/10.1016/s08835403(99)90232-2. https://dx.doi.org/10.4103%2f0973-6042.57934 https://dx.doi.org/10.4103%2f0973-6042.57934 https://doi.org/10.1016/j.jse.2018.06.021 https://doi.org/10.1111/j.1758-5740.2009.00024.x https://doi.org/10.1111/j.1758-5740.2009.00024.x https://doi.org/10.1016/j.jse.2005.02.016 https://doi.org/10.1016/s0883-5403(99)90232-2 https://doi.org/10.1016/s0883-5403(99)90232-2 manuscript type evidence to practice review 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 best practices in patellar tendinopathy management: an evidence to practice review christopher j burcal, phd, atc*; adam b rosen phd, atc*; tony taylor, ms, atc; and mike nicola, ms, atc university of nebraska at omaha, omaha, ne *these authors contributed equally to this work abstract patellar tendinopathy (pt) is a degenerative condition that is common in sporting populations due to the loads placed on the tendon during dynamic activity. pt often occurs in overtraining situations; however, it may also occur in conjunction with and/or worsen through poor biomechanics, persistent inflammation, and altered movement patterns. although sports medicine practitioners have evidence to support the prevalence of this injury, we do not have a strong base of evidence surrounding the contributing factors and pathophysiology that lead the pain and disability reported in patients with pt. the purpose of this evidence to practice review was to summarize a systematic review on interventions to treat pt. the authors aimed to include any randomized controlled trial that treated patients with pt and used the victorian institute of sport assessment patellar tendon questionnaire (visa-p) as an outcome measure. seven different pt interventions were described and summarized by the authors in this review. on the conservative end of the treatment spectrum, eccentric loading programs and extracorporeal shockwave therapy were found to be effective at reducing pain. more invasive approaches often utilized after failed conservative treatment, such as platelet-rich plasma injections and arthroscopic tenotomy, were also deemed effective. therapeutic ultrasound and sclerotherapy were found to be ineffective treatments, and corticosteroid injections are contraindicated in patients with pt. the review highlights that both conservative and invasive treatment approaches can reduce pain in patients with pt. however, there is still no consensus on the optimal treatment protocols for patients with pt due to the variability in in protocols. thus, we recommend utilizing an individualized approach and appropriate clinical judgement to guide treatments derived from a thorough patient history and physical/biomechanical examination to identify interventions with the highest likelihood of resolving symptoms. key phrases therapeutic devices, therapeutic exercise, rehabilitation correspondence dr. christopher burcal, 6001 dodge street, hk 207v, omaha ne 68182. e-mail: cburcal@unomaha.edu twitter: @c_burcal full citation burcal cj*, rosen ab*, taylor t, nicola m. best practices in patellar tendinopathy management: an evidence to practice review. clin pract athl train. 2019;2(1):4-10. https://doi.org/10.31622/2019/0001.2. click here for supplemental videos submitted: february 14, 2019 accepted: february 25, 2019 original reference and summary everhart js, cole d, sojka jh, higgins jd, magnussen ra, schmitt lc, flanigan dc. treatment options for patellar tendinopathy: a systematic review. arthroscopy. 2017;33(4):861872. summary clinical problem and question patellar tendinopathy (pt) is a common, degenerative condition that affects up to 45% of collegiate and elite jumping athletes.1 many athletes with pt suffer from long-term knee pain and movement impairments which frequently causes athletes to limit or discontinue sport participation.2,3 several risk factors have been identified including an increased training load, decreased hamstring flexibility, an inferiorlyplaced patella, and reduced quadriceps strength.4,5 the majority of these risk factors are modifiable, suggesting there is a strong likelihood that patients can respond positively to therapeutic intervention.4,5 despite the frequency of pt, the pathological sequence and contributing factors to the reports of pain and disability are not universally agreed https://doi.org/10.31622/2019/0001.2 https://vimeo.com/320590928/e0231f5cc7 best practices in patellar tendinopathy management: an evidence to practice review 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 upon. histopathological findings of patients suggest symptoms are not due to the inflammatory response and are rather due to degeneration of the tissue.6 collagen fiber pattern disruption is often noticeable during sonographic examination in those with pt.7 although not an inflammatory response, the involved patellar tendon may show thickening and have a greater cross-sectional area upon inspection.8,9 this poor understanding of the pathological sequence leads to a decreased ability to develop and identify treatments that can effectively treat pt. due to the lack of consensus of the causes and perpetuation of pt, intervention protocols vary widely. therefore, the purpose of the reviewed study was to assess the effectiveness of interventions used to manage pt. summary of literature the guiding systematic review’s authors conducted a systematic search of pubmed, google scholar, cinahl, uptodate, cochrane reviews, and sportdiscus to identify published clinical trials for the treatment of pt. studies that were included in the systematic review had to meet the following inclusion criteria: (1) patients must have been diagnosed with chronic or acute pt, (2) used the victorian institute of sports assessment patellar tendinopathy questionnaire (visa-p) as an outcome, (3) have a clinical trial/therapeutic outcome design, (4) be reported in english, and (5) be an original research study published in a peer-reviewed journal. the search identified 691 potential articles that were screened for inclusion criteria, resulting in a total of 15 studies included in the systematic review and meta-analysis. five studies investigated eccentric exercise training, 4 studies evaluated surgical intervention, 4 studies evaluated extracorporeal shockwave therapy, 2 investigated platelet-rich plasma (prp) injections, 2 evaluated steroid injection therapy, 1 evaluated therapeutic ultrasound, and 1 study investigated sclerotherapy. summary of interventions seven different treatment strategies were reported ranging from a more conservative approach of using eccentric therapeutic exercises to surgical intervention. eccentric exercise protocols ranged from twice weekly to 7 days a week and from 5-weeks long to 12-weeks long. exercises included eccentric strength training of the quadriceps and hamstrings, and single-limb squats on a 25° decline board. these were performed at a slow speed, approximate 30 seconds count, at 15 repetitions for three sets. surgery involved both open and arthroscopic patellar tenotomy, with a range of postoperative rehabilitation protocols incorporating eccentric exercises. extracorporeal shockwave therapy ranged from a single treatment session to 3 sessions in 3-day to 1-week intervals, with up to 1500 impulses of 0.18mj/mm2. prp injections were given in the most painful location, up to 2 treatments over a 2-week period. up to two corticosteroid injections were investigated, and one protocol began eccentric rehabilitation exercises 3-4 days after receiving the steroid injection. low-intensity pulsed ultrasound was applied for 20-minutes a day, 7-days a week for 12 weeks (2-ms burst of 1 mhz @ 100hz). sclerotherapy is a treatment that destroys microvessels that form during the pathophysiological sequela of pt; the investigation included in this sr used a single dose of a sclerosing agent guided by ultrasonography. summary of outcomes the authors of the guiding systematic review utilized the visa-p to determine the efficacy of each pt intervention. the visa-p is a patientreported outcome that assesses the symptoms, ability to complete functional tasks, and ability to best practices in patellar tendinopathy management: an evidence to practice review 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 complete sports.10 it can be scored within each domain, but composite scores range from 0 to 100, with 0 representing maximal levels of perceived disability, and 100 representing no symptoms (i.e. healthy).10 a minimal clinically important difference of 13 from preto posttesting has been established for the visa-p.11 with the ease of administration and grading, the visa-p is a useful tool in determining treatment responses in patients with pt. findings and clinical implications this systematic review assessed the evidence and elucidated intervention strategies that appear to be the most effective in patients with pt (table 1). in addition, athletes and recreationally active individuals often push through activities despite their condition, playing, and practicing through low to moderate pain and symptoms. these behaviors make it difficult for clinicians as they may have to choose between symptom management rather than promote tissue healing.12 evidence also suggests that promoting tissue healing and managing symptoms are not mutually exclusive, as complete removal from sport may be contraindicated as loading is necessary to maintain healthy tendons.13 the key for clinicians is to manage and reduce training loads, which can be done by utilizing a painmonitoring model with visual analogue scales.14 in addition, poor patient compliance with eccentric protocols are often implicated in the lack of overall success due to their painful nature.15 heavy slow resistance training has become popular as an alternative method to traditional eccentric exercises to improve patient outcomes, as the treatment techniques is considered less painful while demonstrating improvements of histological factors associated with tendon healing.16 based on the findings of the systematic review, our own review of the evidence, and clinical expertise, we propose a framework for treating patients with pt (figure 1). a thorough patient history and physical examination should be used to identify painful movements and any postural alignment issues/biomechanical insufficiencies which may need to be addressed during therapeutic rehabilitation. in both acute and chronic pt, the primary management strategy should consist of a two-pronged approach incorporating a loading program and therapeutic modalities. the loading program can aid in long-term pain relief, and should consist of eccentric and heavy slow resistance exercises (see supplemental videos).17 heavy slow table 1. summary of treatment efficacy for patients with patellar tendinopathy intervention # of studies effect size of improvement in visa-p scores (95% ci) eccentric exercises 5 61% (53% to 69%) prp injections 2 55% (5% to 105%) extracorporeal shockwave therapy 4 54% (22% to 87%) steroid injections 2 20% (-20% to 60%) surgery 4 57% (52% to 62%) low-dose therapeutic ultrasound 2 50% (42% to 58%) moderate-dose therapeutic ultrasound 1 86% (82% to 90%) high-dose therapeutic ultrasound 1 27% (21% to 34%) effect sizes reported reflect the magnitude of improvement on the visa-p from pre-intervention scores. thus, a pre-intervention score of 50 and a post-intervention score of 75 would represent a 50% improvement in the visa-p. based on this data, patellar tendinopathy patients treated with either eccentric exercises or surgery consistently display a positive response to their treatment. https://vimeo.com/320590928/e0231f5cc7 best practices in patellar tendinopathy management: an evidence to practice review 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 resistance exercises consist of a concentric action over a longer period of time (about 30 seconds),17 thus emphasizes both concentric and eccentric strength of agonist and antagonist muscle groups. the current systematic review also supports the use of extracorporeal shockwave therapy and prp injections for pain reduction in patients with pt. extracorporeal shockwave therapy has also shown efficacy in patients with medial tibial stress syndrome.18,19 however, it is an expensive treatment and not practical for all athletic trainers. therefore, we recommend one considers both the time and financial investments implicated with using extracorporeal shockwave therapy when treating patients with pt. if pain and function fail to improve in your patient over a 6-month period, we suggest athletic trainers refer their athlete to a surgeon to discuss a patellar tenotomy. surgery has been shown to be effective in the long-term at reducing pain in patients with pt. however, this is not the ideal approach for all athletes or patients with pt, thus we also suggest several adjunct therapies. consistent evidence supports the use of isometric exercises for reducing pain in patients with pt.17 prp injections may also be used, either prior to beginning a loading program, or afterwards to accelerate recovery. strapping may also be considered when managing patients with pt, as infrapatellar strapping has been shown to reduce pain and alter lower limb biomechanics.20,21 ineffective approaches include both lowand high-dose therapeutic ultrasound, as well as sclerotherapy. corticosterioid injections may sound like a logical treatment, however they are contraindicated for patients with pt and should not be used. while this systematic review reports varied levels of efficacy of different treatments for reducing pain in patients with pt, they all used the visa-p as an outcome. we strongly recommend clinicians continue to utilize such validated patientreported outcomes as a mean to track treatment success and aid in the clinical decision-making process. we also recommend incorporating quality improvement practices that utilizes patient-reported outcomes to address patients on an individual basis, in an effort to optimize your clinical management of patients with pt. clinical bottom line several treatment protocols are available with varying success to manage patients with pt. exercise protocols including isometric, eccentric, and heavy slow resistance exercises often report the best patient outcomes. extracorporeal shockwave therapy and prp injections are also effective adjuvant interventions, and can be incorporated when a patient is not responding to an initial conservative treatment approach. failed conservative treatments often lead to surgical interventions such as debridement to remove degenerative tissues to promote healing. due to the wide variety of options, there is no consensus on the optimal treatments to improve outcomes in patients with pt. however, the literature shows that nearly all patients with pt can be treated effectively. considerable evidence supports the use of conservative eccentric loading exercises, however, in lieu of a positive response to such conservative approaches, surgical intervention is effective at improving patient outcomes. references 1. lian ob, engebretsen l, bahr r. prevalence of jumper's knee among elite athletes from different sports: a cross-sectional study. am j sports med. 2005;33(4):561-567. https://doi.org/10.1177/0363546504270 454. 2. khan km, maffulli n, coleman bd, cook jl, taunton je. patellar tendinopathy: some aspects of basic science and clinical management. br j sports med. 1998:346355. https://doi.org/10.1136/bjsm.32.4.346 https://doi.org/10.1177/0363546504270454 https://doi.org/10.1177/0363546504270454 https://doi.org/10.1136/bjsm.32.4.346 best practices in patellar tendinopathy management: an evidence to practice review 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 3. cook jl, khan km, harcourt pr, grant m, young da, bonar sf. a cross sectional study of 100 athletes with jumper's knee managed conservatively and surgically. the victorian institute of sport tendon study group. br j sports med. 1997;31(4):332-336. http://dx.doi.org/10.1136/bjsm.31.4.332. 4. morgan s, van vuuren ecj, coetzee ff. causative factors and rehabilitation of patellar tendinopathy: a systematic review. s afr j physiother. 2016;72(1). https://dx.doi.org/10.4102%2fsajp.v72i1. 338. 5. morton s, williams s, valle x, diaz-cueli d, malliaras p, morrissey d. patellar tendinopathy and potential risk factors: an international database of cases and controls. clin j sport med. 2017;27(5):468-474. https://doi.org/10.1097/jsm.0000000000 000397. 6. khan km, cook jl, kannus p, maffulli n, bonar sf. time to abandon the "tendinitis" myth. bmj (clin res ed). 2002;324(7338):626-627. https://doi.org/10.1136/bmj.324.7338.62 6. 7. peace kal, lee jc, healy j. imaging the infrapatellar tendon in the elite athlete. clin radiol. 2006;61(7):570-578. https://doi.org/10.1016/j.crad.2006.02.00 5. 8. helland c, bojsen-moller j, raastad t, et al. mechanical properties of the patellar tendon in elite volleyball players with and without patellar tendinopathy. br j sports med. 2013;47(13):862-868. https://doi.org/10.1136/bjsports-2013092275. 9. pfirrmann cw, jost b, pirkl c, aitzetmuller g, lajtai g. quadriceps tendinosis and patellar tendinosis in professional beach volleyball players: sonographic findings in correlation with clinical symptoms. eur radiol. 2008;18(8):1703-1709. https://doi.org/10.1007/s00330-0080926-9. 10. visentini pj, khan km, cook jl, kiss zs, harcourt pr, wark jd. the visa score: an index of severity of symptoms in patients with jumper's knee (patellar tendinosis). victorian institute of sport tendon study group. j sci med sport. 1998;1(1):22-28. https://doi.org/10.1016/s14402440(98)80005-4. 11. hernandez-sanchez s, hidalgo md, gomez a. responsiveness of the visa-p scale for patellar tendinopathy in athletes. br j sports med. 2014;48(6):453-457. https://doi.org/10.1136/bjsports-2012091163. 12. rudavsky a, cook j. physiotherapy management of patellar tendinopathy (jumper's knee). j physiother. 2014;60(3):122-129. https://doi.org/10.1016/j.jphys.2014.06.0 22. 13. saithna a, gogna r, baraza n, modi c, spencer s. suppl 3: eccentric exercise protocols for patella tendinopathy: should we really be withdrawing athletes from sport? a systematic review. open orthop j. 2012;6:553. https://dx.doi.org/10.2174%2f18743250 01206010553. 14. silbernagel kg, thomeé r, eriksson bi, karlsson j. continued sports activity, using a pain-monitoring model, during rehabilitation in patients with achilles tendinopathy: a randomized controlled study. am j sports med. 2007;35(6):897-906. https://doi.org/10.1177/0363546506298 279. 15. lorenzen j, krämer r, vogt p, knobloch k. systematic review about eccentric training in chronic patella tendinopathy. sportverletz sportschaden. 2010;24(4):198-203. https://doi.org/10.1055/s-0029-1245818. 16. malliaras p, barton cj, reeves nd, langberg h. achilles and patellar http://dx.doi.org/10.1136/bjsm.31.4.332 https://dx.doi.org/10.4102%2fsajp.v72i1.338 https://dx.doi.org/10.4102%2fsajp.v72i1.338 https://doi.org/10.1097/jsm.0000000000000397 https://doi.org/10.1097/jsm.0000000000000397 https://doi.org/10.1136/bmj.324.7338.626 https://doi.org/10.1136/bmj.324.7338.626 https://doi.org/10.1016/j.crad.2006.02.005 https://doi.org/10.1016/j.crad.2006.02.005 https://doi.org/10.1136/bjsports-2013-092275 https://doi.org/10.1136/bjsports-2013-092275 https://doi.org/10.1007/s00330-008-0926-9 https://doi.org/10.1007/s00330-008-0926-9 https://doi.org/10.1016/s1440-2440(98)80005-4 https://doi.org/10.1016/s1440-2440(98)80005-4 https://doi.org/10.1136/bjsports-2012-091163 https://doi.org/10.1136/bjsports-2012-091163 https://doi.org/10.1016/j.jphys.2014.06.022 https://doi.org/10.1016/j.jphys.2014.06.022 https://dx.doi.org/10.2174%2f1874325001206010553 https://dx.doi.org/10.2174%2f1874325001206010553 https://doi.org/10.1177/0363546506298279 https://doi.org/10.1177/0363546506298279 https://doi.org/10.1055/s-0029-1245818 best practices in patellar tendinopathy management: an evidence to practice review 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 tendinopathy loading programmes. sports med. 2013;43(4):267-286. https://doi.org/10.1007/s40279-0130019-z. 17. lim hy, wong sh. effects of isometric, eccentric, or heavy slow resistance exercises on pain and function in individuals with patellar tendinopathy: a systematic review. physiother res int. 2018;23(4):e1721. https://doi.org/10.1002/pri.1721. 18. moen m, rayer s, schipper m, et al. shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. br j sports med. 2012;46(4):253-257. https://doi.org/10.1136/bjsm.2010.08199 2. 19. newman p, waddington g, adams r. shockwave treatment for medial tibial stress syndrome: a randomized double blind shamcontrolled pilot trial. j sci med sport. 2017;20(3):220-224. https://doi.org/10.1016/j.jsams.2016.07.0 06. 20. de vries a, zwerver j, diercks r, et al. effect of patellar strap and sports tape on pain in patellar tendinopathy: a randomized controlled trial. scand j med sci. 2016;26(10):1217-1224. https://doi.org/10.1111/sms.12556. 21. rosen ab, ko j, brown cn. single-limb landing biomechanics are altered and patellar tendinopathy related pain is reduced with acute infrapatellar strap application. knee. 2017;24(4):761-767. https://doi.org/10.1016/j.knee.2017.03.00 3. https://doi.org/10.1007/s40279-013-0019-z https://doi.org/10.1007/s40279-013-0019-z https://doi.org/10.1002/pri.1721 https://doi.org/10.1136/bjsm.2010.081992 https://doi.org/10.1136/bjsm.2010.081992 https://doi.org/10.1016/j.jsams.2016.07.006 https://doi.org/10.1016/j.jsams.2016.07.006 https://doi.org/10.1111/sms.12556 https://doi.org/10.1016/j.knee.2017.03.003 https://doi.org/10.1016/j.knee.2017.03.003 best practices in patellar tendinopathy management: an evidence to practice review 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 figure 1. overview of effective therapies and recommended course of treatment. loading programs isometric exercises eccentric exercises heavy slow resistance exercises therapeutic modalities extracorporeal shockwave therapy platelet rich plasma injections initial conservative management secondary management after 6 months of conservative treatment failure surgical intervention open tenotomy arthroscopic tenotomy adjunct/adjuvant therapies shockwave therapy platelet rich plasma patellar tendon strapping contraindicated therapies corticosteroid injections ineffective therapies low and high dose therapeutic ultrasound sclerotherapy clinical outcomes research 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 clinician-administered versus self-administered suboccipital release on superficial backline function colin wilhite, ms, atc1, kristin a. paloncy, edd, atc2, karen rawkowski, pt, atc1, todd daniel phd, atc3 1 mercy sports medicine, springfield, mo; 2 north central college, naperville, il; 3 rstats institute, springfield mo abstract the effectiveness of trigger point release in the suboccipital region to improve hamstring mobility has been established in the literature, but the research has not clarified whether selfadministered soft tissue techniques produce the same improvements to mobility as when the clinician delivers the manual trigger point release. the purpose of the study was to assess whether the same increase in hamstring mobility within the superficial backline function that is achieved with a clinician-administered suboccipital trigger point release can also be obtained through a patient/self-administered method. the study employed a randomized, descriptive laboratory design in which 60 participants reported for a single data collection session and were randomly assigned to either a clinician-administered or self-administered treatment group. there was a statistically significant main effect for the intervention (f(1,58) = 18.24, p < .001, eta = .239) indicating that both the clinician-administered and the selfadministered groups improved in their hamstring mobility from pretest to posttest; but there was not a statistically significant interaction of time and group (f(1,58) = 18.24, p = .360, eta = .014) indicating that the effectiveness of suboccipital trigger point release on hamstring mobility did not differ between groups. the significant finding in this study is that toe touch distance – indicating improved hamstring mobility – increased for all participants following a suboccipital trigger point release. the significant clinical implication from the study is that improvement in hamstring mobility was similar whether the suboccipital trigger point release was clinician-administered or self-administered. if a clinician properly instructs a patient on how to perform a trigger point release in the suboccipital region, the selfadministered intervention can be just as effective at improving hamstring mobility as when the clinician performs the release. this finding allows clinicians to extend the scope of their treatment by empowering patients to effectively treat their own myofascial trigger points. key phrases clinician-rated outcome, manual techniques, myofascial release correspondence dr. kristin paloncy, 30 north brainard, stadium room 308, naperville, il 60540 630-637-5515 e-mail: kapaloncy@noctrl.edu full citation wilhite c, paloncy ka, rakowski k, daniel t. clinicianadministered versus self-administered suboccipital release on superficial backline function clin pract athl train. 2019;2(2):12-19. https://doi.org/10.31622/2019/0002.3. submitted: february 8, 2019 accepted: april 23, 2019 introduction trigger points are hyperirritable, localized areas of tightness within a band of skeletal muscle that can cause referred pain.1 referred pain is experienced in 1 area of the body, although the cause of the pain originates in a different area of the body. trigger points arise from the degradation of proper body alignment which is typically the result of poor posture.2-4 in these cases, the body necessarily recruits other muscles to compensate for body misalignment in order to maintain static positions.2-4 these misaligned static positions leave muscles contracted and the compensatory muscular contraction frequently leads to hypersensitivity in the form of trigger points. 2-4 individuals who spend hours a day seated at a desk, hunched over a computer, or curled around a mobile device routinely engage a forward head posture. a forward head posture requires that posterior neck muscles be engaged to maintain static tension in order to keep the head upright.2-3 this compensatory action within the nervous system can manifest as active trigger points. trigger points are thought to be formed when sarcomeres, which are considered the https://doi.org/10.31622/2019/0002.3 clinician-administered versus self-administered suboccipital release on superficial backline function 13 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 building blocks of muscles, become overactive.2-5 when this overactivity occurs and these myofilaments stop sliding over one another naturally, the sarcomere continues to stay in a switched-on position. this state of contraction leads to muscle pain, hypertonia, and stiffness, which is called a trigger point.3-5 evidence is clear that the restriction to tissue caused by trigger points negatively affects the mobility of other parts of the body by causing extra tension along the connecting fascial tissue.1-4 fascia comprises sheets of web-like tissue surrounding muscles and joints, connecting different sections of the body to one another, allowing the body to function as 1 unit.5-10 as illustrated in figure 1, the superficial back line is a fascial tract consisting of 4 pieces connecting large sections of the body to one another. two pieces attach at the supraorbital ridge, go over the top of the head, down both sides of the spine, and attach again on the lower leg. the second 2 pieces travel from the distal section of the femur, down the posterior aspect of the lower leg, and attach at the metatarsal heads of each foot.8 these structures consist of the epicranial fascia, cords of the erector spinae, the sacrotuberous ligament, the hamstrings, the triceps surae, and the plantar fascia. the primary function of the superficial backline is to create the extension and hyperextension needed for an individual to maintain an upright posture. clinical theory describing myofascial chains such as the suboccipital back line originates from the assumption that the muscles of the human body do not function as independent units.10 instead, muscles are interconnected in identified chains and linked through fascial structures creating a system of structural continuity.10 following this philosophy, trigger points that disrupt this function by causing pain or negatively affecting the mobility of 1 area of the superficial back line – such as the suboccipital muscles – will affect mobility along this facial tissue of the superficial backline, affecting even the distal region of the hamstrings.8 figure 1: illustration of superficial backline fascia because sections of the body are connected by different fascial tracts, activation of a trigger point within a given muscle can affect the motion of other joints within the same fascial tract.2-4 for example, a trigger point in the serratus anterior can cause referred pain in a patient’s medial elbow on the ipsilateral side.11 in the case of clinician-administered versus self-administered suboccipital release on superficial backline function 14 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 improperly stabilized forward head posture, tension can develop along the entire superficial backline as additional muscles are recruited to maintain an upright posture. however, trigger point release in the suboccipital region can reduce neural tension and act as a reset button for the nervous system, allowing patients to properly stabilize their head and neck.4,8 this decrease in neural tension allows greater flexibility of movement and better function of the superficial backline. manual trigger point release is one of the many myofascial release methods used by clinicians to reduce pain and increase tissue extensibility in muscles with identified trigger points.11-16 the particular manual trigger point release technique of interest to this study was in the suboccipital region.4 trigger point release in the suboccipital region restores head and neck motion by applying light pressure to any trigger point in the occipital muscles while the patient lies supine on a treatment table. in most cases, clinicians apply pressure manually using their fingertips to any area of tissue in the suboccipital region that feels tight or elicits pain.11-14 devices such as lacrosse balls or dowel rods can also be used to release trigger points, in place of the clinician’s fingertips.11-14 studies have shown that, following a trigger point release treatment, overall function of the superficial back line (measured by hamstring flexibility) immediately increases.2,4 although the trigger point release technique in the suboccipital region is typically administered by a clinician, the technique can be readily employed by patients themselves. however, research into the effectiveness of trigger point release in the suboccipital region has not clarified whether self-administered soft tissue techniques produce the same improvements to mobility as the clinician delivering the trigger point release. the purpose of the study was to assess whether the same increase in hamstring mobility within the superficial backline function that is achieved with a clinician-administered suboccipital-region trigger point release can also be obtained through a patient-administered method. patients the study employed a randomized descriptive laboratory design in which participants reported for a single data collection session. following institutional irb approval, participants were recruited from a division i university in the midwest through verbal announcements. participants included a convenience sample (n = 60) of 18-24 year-olds who were randomly assigned to either a control group (n = 30) or an experimental group (n = 30). the sample comprised 31 males (51.7%) and 29 females (48.3%). all participants gave written consent and were subject to inclusion criteria of having no current pain or injuries to the neck or back; however, all participants were assessed for the presence of trigger points in their suboccipital muscles and all of them had trigger points, although none were painful enough to preclude their participation in this study. all of the original 60 participants (100%) were included in the study. intervention on the day of the study, all participants reported to a classroom laboratory at the university and signed in on an attendance sheet. those who signed in on an odd-numbered line were assigned to the clinician-administered (control) group, and those who signed in on an even-numbered line on the attendance sheet were assigned to the selfadministered (experimental) group. each participant (both control and experimental group) completed 3 baseline measurements using the slide ruler box and the researcher recorded the mean score as the pre-test score. a meta-analysis of the criterion-related validity of the slide ruler clinician-administered versus self-administered suboccipital release on superficial backline function 15 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 box sit-and-reach test presents evidence that this is an effective method for measuring hamstring extensibility (mobility), and that the clinician should use the average of 3 tests in their reported score.15 following baseline measurements, the researcher worked individually with each participant. participants in the clinician-administered group were asked to lie supine on a treatment table while the researcher performed a trigger point release technique in the suboccipital region on the participant for 2 minutes. the researcher was an athletic trainer with 2 years of practice, who had completed all coursework in a post-professional masters athletic training program that emphasized manual therapies and included training in myofascial release including trigger point release therapy. to perform the trigger point release technique in the suboccipital region, the researcher held their forearms in a supine position at the same level as the participant. using the fingers of both hands, the researcher started in the thoracic spine area and gently massaged the soft tissue while moving fingers superiorly through the cervical spine stopping when the base of the occiput was reached. once the occiput was reached, the researchers moved their fingers inferiorly about ½ 1 inch (over the c1/c2 area) then while cradling the posterior cervical area, palpated with the fingers for areas of tightness which identified trigger points. the researcher confirmed these were trigger points by asking the participant if this pressure caused pain. while on the trigger point(s), the researcher then applied gentle pressure anteriorly for approximately 30 seconds to 1 minute per trigger point until they felt the tissue start to release and soften.4,8,14 the participants in the self-administered group were asked to lie supine on a treatment table. the researcher performed a trigger point release technique in the suboccipital region for 5 seconds using the same method of application as the control group. this was done so that the participant could identify the feeling they should replicate during the trigger point release. during this time, the participant was asked to take note in feeling what pressure over the trigger point felt like and how much pressure the clinician was applying. each participant was then given a 1 inch diameter plastic dowel rod that they placed in the suboccipital region of their head. they were instructed to reproduce the same sensation as they had felt by the clinician for 2 minutes. therefore, the actual trigger point release was performed utilizing the plastic dowel rod as a selfadministered technique, and the initial hands-on portion done by the researcher was just maintained long enough to teach the participant how to replicate this sensation on their own. immediately following completion of the clinicianadministered or self-administered trigger point release intervention in the suboccipital region, all participants were again measured on standing forward flexion. participants were measured 3 times on their standing forward flexion distance score using the slide ruler box. the mean score was recorded as the post-test superficial backline function score. all participants were then thanked for their participation and dismissed. outcomes measures the researchers in this study utilized toe touch distance as the single measurement of hamstring mobility. standing forward flexion distance was measured using a slide ruler box and served as the baseline (pre-test) measurement of the participants’ superficial backline function. to obtain this measurement participants were instructed to stand with their feet together and knees locked on top of a platform next to the slide ruler box. they were then instructed to bend forward from the hips, while keeping the distal extremity locked, and attempt to touch their toes and hold for a single breath cycle (eliminating clinician-administered versus self-administered suboccipital release on superficial backline function 16 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 bouncing movements) before returning to the start position. the participants’ extended fingers moved the slide on the scale to a final position and the measurement was recorded in centimeters. the participants repeated this task 3 times; both pretest and post-test following the intervention and the mean score was recorded as the final measurement of hamstring mobility. all measurements and subsequent intervention were conducted by a single trained evaluator to control for variability and bias. kippers18 found toe touch to be a valid and reliable test to measure active trunk and hamstring range of motion across all body types. further, another study concluded that toe touch distance could be used as the sole measurement of hamstring mobility to accurately assess for an increase of mobility following clinician-administered trigger point release in the suboccipital region.4 results before conducting hypothesis testing these data were examined for potential violations of the assumptions of the repeated-measures anova. data were assessed for outliers using boxplots; no outliers were found. a shapiro-wilk test showed that both the pretest (p = .46) and the posttest data (p = .10) were normally distributed. while conducting the mixed repeated measures anova (pretest to posttest, control vs. experimental), box’s test of equality of covariance matrices was non-significant (m = 5.72, p = .138), indicating that the covariance matrices were equivalent, so all anova interpretations were done using multivariate tests. there was a statistically significant main effect for the intervention (f(1,58) = 18.24, p < .001, eta = .239) indicating that both the clinicianadministered and the self-administered groups improved from pretest (m = 4.74, sd = 7.96) to posttest (m = 6.79, sd = 7.58). but there was not a statistically significant interaction of time and group (f(1,58) = 18.24, p = .360, eta = .014) indicating that neither group outperformed the other. these findings show that the intervention was successful at increasing mobility an average of 2 centimeters regardless of whether the intervention was conducted by a clinician or by the patient. the magnitude of the mobility increase is displayed in figure 2. discussion this study supports existing research findings that hamstring mobility, as measured by toe touch distance, significantly increases following trigger point release in the suboccipital region.2,4 in a randomized clinical trial, aparicio2 found the suboccipital trigger point release technique significantly improved hamstring function as measured by toe touch distance, straight leg raise, and popliteal angle. further, studies showed that when a release was performed on a trigger point which was causing an area of restriction that was within a fascial tissue structure, such as the superficial back line, it had figure 2: increases in superficial backline function distances by group (in) clinician-administered versus self-administered suboccipital release on superficial backline function 17 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 a positive effect on other areas that connected to this line.16-18 this study demonstrates that a properly taught, self-administered suboccipital trigger point release is equally effective as a clinicianadministered treatment. the finding that both clinician-administered and self-administered suboccipital trigger point release delivers immediate improvements in mobility has implications for treating back pain. in a similar study examining the effectiveness of reducing trigger point sensitivity in the neck and upper back, the investigators measured pain intensity following a prescribed home-based program of ischemic pressure and stretching.19 the authors concluded that when monitored periodically by a clinician, home-based programs using selfadministered therapy techniques are an effective method for reducing trigger point pain.19 while this study has shown that this manual technique can improve the overall function of the superficial back line, it should be noted that the reason why is still unclear. one possible reason for this outcome could be that the released tension relaxes the tissue in a way that allows more movement throughout the entire fascial line. the chain itself has too much tension, and this tension should be relieved to gain more motion. the single-iteration methodology employed in this study demonstrates that immediate release is possible. however, this study does not show how long that relief will last, nor does it address the effects of multiple self-applications of the technique. additional research should examine how long relief continues after a single application of the technique and should introduce a longitudinal component to study whether patients who trained to perform suboccipital trigger point release on themselves can use repeated applications of the technique to reduce back pain or other symptomology. furthermore, this research opens the possibility of exploring other trigger point release techniques known to be effective when delivered by clinicians and exploring their amenability to self-administration by patients. clinical application this study demonstrates that a properly taught self-administered suboccipital trigger point release was equally effective as a clinicianadministered treatment. the current study adds to the existing findings in three ways. first, this study demonstrates that when trigger points in the suboccipital area are released, an increase in mobility observed immediately. second, this study demonstrates that immediate increases in mobility can be attained when the trigger point release technique in the suboccipital region is employed by a properly trained patient in the absence of a clinician. third, the amount of training needed to teach a patient to effectively perform the trigger point release technique in the suboccipital region requires less than a minute. in a clinical environment dominated by managed care clinicians in a therapy setting are limited in treatment times and number of clinic visits with their patients; therefore, it is of great benefit when a clinician can identify manual therapy techniques, such as the suboccipital trigger point release, that can be taught to their patients and successfully administered outside of the clinical setting. this allows the clinician time within the scheduled therapy session to focus their intervention on other clinical goals. the significant finding in this study is that, following a suboccipital trigger point release, toe touch distance increased for all participants. these findings indicate that if a clinician properly instructs a patient on how to perform a suboccipital trigger point release, the intervention is just as effective as when the clinician performs the suboccipital trigger point release. future research should explore the long-term effects of clinician-administered versus self-administered suboccipital release on superficial backline function 18 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 suboccipital release on toe touch over time, as well as the reason behind these effects, as the current study only measured the immediate effects and not the direct cause of them. references 1. fernandez-de-las-penas c. dommerholt j. myofascial trigger points: peripheral or central phenomenon? curr rheumatol rep. 2014;16(395), 394–400. https://doi.org/10.1007/s11926-0130395-2. 2. aparicio e. blanco c. sendin f. immediate effects of the suboccipital muscle inhibition technique in subjects with short hamstring syndrome. j manipulative and physiol ther. 2009;32(4), 262–269. https://doi.org/10.1016/j.jmpt.2009.03.00 6. 3. fernandez-de-las-penas c. carratalatejada m. luna-olivia l. & miangolarrapage j. the immediate effect of hamstring muscle stretching in subjects’ trigger points in the masseter muscle. j of musculoskelet pain. 2006;14(3), 27–35. https://doi.org/10.1300/j094v14n03_05. 4. trokey t. effect of suboccipital release soft tissue technique on toe touch measurement. [master’s thesis]. springfield, mo: missouri state university; 2014. 5. kaprail m, jetly s, sarin a, kaur p. to study the effect of myofascial trigger point release in upper trapezius muscle causing neck disability in patients with chronic periarthritis shoulder. sport exerc med open j. 2019;5(1): 1-4. http://dx.doi.org/10.17140/semoj-4-167. 6. benjamin m. the fascia of the limbs and back: a review. j of anat. 2009;214(1),1– 18. https://doi.org/10.1111/j.14697580.2008.01011.x. 7. kline c. fascial manipulation. j of the am chiropr assoc. 2011;48(2), 2–5. 8. myers t. anatomy trains. 3rd ed. new york, ny: churchill livingstone elsevier; 2014. 9. schleip r., klingler w., lehmann-horn f. fascia is able to contract in a smooth musclelike manner and thereby influence musculoskeletal mechanics. in: proceedings of the 5th world congress of biomechanics: munich, germany, july 29 august 4, 2006. bologna: medimod; 2006: 51-54. 10. wilke j, krause f, vogt l. what is evidencebased about myofascial chains? a systematic review. arch phys med rehabil. 2016;97(3), 454-461. https://doi.org/10.1016/j.apmr.2015.07.0 23. 11. barnes m. the basic science of myofascial release: morphologic change in connective tissue. j bodyw mov ther. 1997;1(4), 231– 236. https://doi.org/10.1016/s13608592(97)80051-4. 12. celik d, & mutlu e. clinical implication of latent myofascial trigger point. curr pain headache rep. 2013;17(8),353. https://doi.org/10.1007/s11916-0130353-8. 13. fernandez-de-las-penas c. interaction between trigger points and joint hypermobility: a clinical perspective. j man manip ther. 2005;17(2),74–76. https://dx.doi.org/10.1179%2f10669810 9790824721. 14. fryer g. the effect of manual pressure release on myofascial trigger points in the upper trapezius muscle. j bodyw mov ther. 2005;9(4),248–255. https://doi.org/10.1016/j.jbmt.2005.02.00 2. 15. mayorga-vega d, merino-marban r, viciana j. criterion-related validity of sitand-reach tests for estimating hamstring and lumbar extensibility: a meta-analysis. j sports sci med. 2014;13(1),1-14. https://doi.org/10.1007/s11926-013-0395-2 https://doi.org/10.1007/s11926-013-0395-2 https://doi.org/10.1016/j.jmpt.2009.03.006 https://doi.org/10.1016/j.jmpt.2009.03.006 https://doi.org/10.1300/j094v14n03_05 https://doi.org/10.1111/j.1469-7580.2008.01011.x https://doi.org/10.1111/j.1469-7580.2008.01011.x https://doi.org/10.1016/j.apmr.2015.07.023 https://doi.org/10.1016/j.apmr.2015.07.023 https://doi.org/10.1016/s1360-8592(97)80051-4 https://doi.org/10.1016/s1360-8592(97)80051-4 https://doi.org/10.1007/s11916-013-0353-8 https://doi.org/10.1007/s11916-013-0353-8 https://dx.doi.org/10.1179%2f106698109790824721 https://dx.doi.org/10.1179%2f106698109790824721 https://doi.org/10.1016/j.jbmt.2005.02.002 https://doi.org/10.1016/j.jbmt.2005.02.002 clinician-administered versus self-administered suboccipital release on superficial backline function 19 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 16. jonsson c. the role of myofascial trigger points in shoulder pain: a literature review. j of australian traditional-med society. 2012;18(3),139–143. 17. lucas k, polus b, rich p. latent myofascial trigger points: their effects on muscle activation and movement efficiency. j bodyw mov ther. 2014;8(3),160–166. https://dx.doi.org/10.1016/j.jbmt.2003.12. 002. 18. kippers v, parker a. toe-touch test: a measure of its validity. phys ther. 1987;1(4),1680–1684. https://doi.org/10.1093/ptj/67.11.1680. 19. hanten w, olson s, butts n, nowicki a. effectiveness of a home program of ischemic pressure followed by sustained stretch for treatments of myofascial trigger points. phys ther. 2000;80(10),997–1003. http://dx.doi.org/10.1093/ptj/80.10.997. https://dx.doi.org/10.1016/j.jbmt.2003.12.002 https://dx.doi.org/10.1016/j.jbmt.2003.12.002 https://doi.org/10.1093/ptj/67.11.1680 http://dx.doi.org/10.1093/ptj/80.10.997 manuscript type point-of-care assessment at a free, out-of-hours orthopedic clinic 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 point-of-care assessment at a free, out-of-hours orthopedic clinic whitney m. graves, dat, lat, atc1; zachary k. winkelmann, phd, scat, atc2; kenneth e. games, phd, lat, atc1 1cumberland university, lebanon, tn; 2university of south carolina, columbia, sc; 3indiana state university, terre haute, in abstract access to healthcare is a challenge for many americans living in rural communities. hospital systems have created programs and developed models to improve access to care. however, documentation of the role of these clinics serving different populations and various types of communities is quite scarce. the purpose of this article is to describe the patient satisfaction and procedures assessed at the point-of-care during a 14-week, out-of-hours free orthopedic clinic in the southeastern united states. one hundred and twenty-nine patients attended the orthopedic clinic and completed a patient satisfaction survey following their patient encounter. at the end of the 14-week, 89% (n=115/129) of the patients were highly satisfied with the staff and physician politeness and 100% (n=129/129) of patient encounters were highly satisfied with staff and physician professional manner. during this study, 72% (n=93/129) of patients reported that their injury and treatment plan was explained in an understandable manner, and 75% (n=97/129) of patient encounters reported that staff and physicians answered all of their questions in an understandable way. of those surveyed, 95% (n=123/129) of patients reported that they were highly satisfied with the free clinic and the service that was provided. overall, 96% (n=124/129) of patients reported that they would come back to the free, out-of-hours orthopedic clinic outside of just the fall football season. the point-of-care assessment described the number of x-rays taken, mri’s ordered, follow-up appointments scheduled, and potential revenue generated through surgeries scheduled during the 14-week time period. moreover, the access to specialized sports medicine care has expanded to reach underserved populations such as pediatrics and those unable to miss work to seek healthcare. the results of this assessment have provided the orthopedic clinic staff and patients with data to support changes to improving patient-centered and low-cost healthcare visits. key phrases clinic and hospital patient population, healthcare economics (value and worth), organizational and personal outcomes correspondence dr. whitney graves, indiana state university, 3200 belotes ferry road, lebanon, tn 37087. e-mail: wgraves@cumberland.edu twitter: @whit_graves full citation graves wm, winkelmann zk, games ke. point-of-care assessment at a free, out-of-hours orthopedic clinic. clin pract athl train. 2019;2(3):16-21. https://doi.org/10.31622/2019/0003.2 submitted: march 3, 2019 accepted: august 7, 2019 introduction in the united states, a lack of insurance and underinsurance composes a significant national public health problem.1 as of 2014, in the united states, 50.7 million individuals, 16.7% of the population, were uninsured and many more experienced barriers to obtaining health care.1 some of these barriers include: means/cost of transportation, lack of understanding with medical terminology, and wait time in the waiting room. despite large gains in health coverage, some people continued to lack coverage, and the affordable care act (aca) remained the subject of political debate.7 attempts to repeal and replace the aca stalled in summer 2017, but there have been several changes to implementation of the aca under the trump administration that affect coverage.7 in 2017, the number of uninsured rose for the first time since implementation of the aca to 27.4 million.7 certain population subgroups have a low amount of health insurance coverage, including ethnic minorities, residents of southern and urban locations, and low-income households.1 specifically in the southern state of alabama, 33% of its population is uninsured and the highest uninsured rate for the state is in southern alabama near birmingham.2 there is a substantial need to provide health care for uninsured individuals in the united states and southern states such as alabama in particular. previous research has shown that one method to improve access to care is through free medical clinics, which has been cited to have high patient satisfaction feedback https://doi.org/10.31622/2019/0003.2 point-of-care assessment at a free, out-of-hours orthopedic clinic 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 due to access to care.3 at east alabama orthopaedics & sports medicine in opelika, alabama, the staff provided athletic training services to local secondary schools in the lee county which includes auburn, alabama. lee county, alabama has a vast array of current socioeconomic status among residents with the 2016 median household income being $45,056 and predominantly white residents (67.9%).4 in the east alabama orthopaedics & sports medicine clinic, the patient panel is predominately lower and middle-class income status, and a high number of self-pay patients. according to the u.s. census bureau, the majority of patients seen in the east alabama orthopaedics & sports medicine clinic would be considered underserved. opelika, alabama is considered a rural area with about 15% of the population speak a language other than english. there is a 3.5% hispanic population and 11.5% korean population. about 15% of the population under the age of 65 has a disability, and about 15-20% of people under the age of 65 have no form of health insurance.4 the poverty rate is at 30%. twenty-three percent of the population for whom poverty status is determined in lee county, al (34,085 out of 148,121 people) live below the poverty line.4 this number is higher than the national average of 14%. the largest demographic living in poverty is male between the ages of 18-24, followed by female between the ages of 18-24, and finally female between the ages of 25-35.4 additionally, the clinic serves an estimated 2,000 veterans from lee county, alabama. the cost of healthcare is sometimes a burden on the patients, and especially the studentathletes that the staff provides healthcare to. the student-athletes that we provide medical care make up a large percentage of the underserved community and often times these patients will not come in to see the physician to receive medical treatment due to the office visit or insurance copay costs. at east alabama orthopaedics & sports medicine, a patient’s continuity of care is a concern as some patients abandon care due to outstanding balances or them not having the funds to come in and see the doctor. east alabama orthopaedics & sports medicine clinic currently has a free orthopedic clinic outside of business hours. the facility serves patients on saturday mornings outside of the normal clinic hours for 2-4 hours during the fall school semester as it aligns with football season. a typical patient load during one saturday session is 20 to 25 student-athletes. the free orthopedic clinic runs for 14-weeks beginning the first saturday following the start of football season and ending the saturday after the alabama state championship football game. the services provided at the orthopedic clinic include diagnostic imaging (xrays), bracing, scheduling of mris at east alabama orthopaedics & sports medicine, full orthopedic evaluations, and concussion assessment. these services are provided and performed at no cost to the student-athlete or their family regardless of insurance status. the staff for the free orthopedic clinic included two orthopedic surgeons, one sports medicine physician with training in neurology, seven athletic trainers, an outreach coordinator, and administrative personnel. the staff was paid as part of their contracts for their services meaning that there were no upfront or recurring costs for stipends or salaries. currently, the out-of-hours free orthopedic clinic lacks any form of patient survey or satisfaction assessment regarding the services provided from the staff. as such, the purpose of this point-of-care assessment was to explore the patient satisfaction, access to sports medicine services, and potential cost-benefit for the community. methods prior to the start of the 2018 football season, the lead athletic trainer for the free, out-of-hours orthopedic clinic implemented a patient satisfaction survey for patients to complete following their visit. the patient satisfaction survey consisted of five questions measured using 5-point likert scale with one additional yes/no item. this six-question instrument aimed to determine each patient’s perception of the following constructs: (1) politeness and professionalism of personnel, (2) explanation and understanding of injury and point-of-care assessment at a free, out-of-hours orthopedic clinic 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 treatment, (3) satisfaction of the free orthopedic clinic, and (4) if the patient would seek healthcare again from the facility. table 1 provides the items from the patient satisfaction survey. throughout the 14-weeks that the free orthopedic clinic was open, the lead athletic trainer administered a paper survey to each patient as they checked out. the patient satisfaction assessment was collected anonymously. once the patient completed the survey, the patient placed their survey into a locked drop box near the exit of the east alabama orthopaedics & sports medicine clinic. this survey was given and completed by 129 patients. following the 14 week data collection period, the lead athletic trainer compiled patient responses from the survey using microsoft excel. concurrently, the lead athletic trainer also tracked all patient data and procedures during the office visit that the patient received. the patient data and procedures included the (1) reason for office visit, (2) body region being evaluated, (3) type of evaluation, (3) evaluation complexity, (4) radiographs taken, (5) mri ordered, (6) surgery scheduled, (7) follow-up appointment scheduled, and (8) if the patient was a football player or non-football player. upon completion of collecting patient data and procedures, along with the satisfaction surveys, the leader athletic trainer analyzed the data and compiled the findings for a presentation to physicians and east alabama orthopaedics & sports medicine stakeholders. results the study consisted of male and female middle to high school aged patients who participated in football, cheer, volleyball, tennis, and baseball. the major body regions evaluated during the data collection period were knee and shoulder. there were 121 musculoskeletal-based encounters and seven reported concussions. overall, the majority of evaluation complexity that each physician documented was considered moderate level. medicare defines an evaluation complexity of moderate level as face to face time spent with a patient requiring 20-25 minutes of care.6 ninety-six radiographs were taken in the clinic and thirty-three patient encounters required an mri to be ordered. ninety-four encounters deemed a follow up appointment was necessary and 38 re-check evaluations were documented. seven surgical procedures were generated during this time frame. overall, the results from this study presented a positive effect and an increase in the number of radiographs taken, mri’s ordered, follow-up appointments made, and surgeries each physician obtained during that time period compared to not having a saturday nonbusiness hours clinic. the results also showed that overall patients were highly satisfied from the healthcare they were table 1. patient satisfaction survey question were our personnel polite and courteous?* did our personnel take care of you in a professional manner?* did we explain your injury and treatment plan in an understandable manner?* did we answer all of your questions in an understandable way?* overall, how satisfied were you with the free service you received from us?* would you come to a saturday morning clinic outside of football season? # * = measured using likert scale of 5=highly satisfied, 4=satisfied, 3=adequate, 2=unsatisfied, 1=very unsatisfied, # = yes/no item point-of-care assessment at a free, out-of-hours orthopedic clinic 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 receiving. the patient satisfaction survey results identified that 89% (n=115/129) of patient encounters were highly satisfied with staff and physician politeness, and 100% (n=129/129) of patients were highly satisfied with the at and physician professional manner. 95% (n=123/129) of patients reported that they were highly satisfied with the free injury clinic and services that were provided. overall, 96% (n=124/129) of patients reported that they would come back to a saturday morning clinic outside of the fall football season. moreover, the clinic potentially saved patients anywhere from $9,400 to $14,200, or $75 to $113 per patient (n=125).this was based on clinic procedure fees. in addition, the out-of-hours clinic could serve as a revenue stream for east alabama orthopaedics & sports medicine through referrals. in order to analyze if the free services performed to potential revenue from follow-up appointments, we calculated the potential revenue using the east alabama orthopaedics & sports medicine clinic costs for an mri, surgical procedure, or a follow-up appointment in the clinic. in total, east alabama orthopaedics & sports medicine generated $32,900 to $39,900 from the 94 patients, or $350 to $424 per patient. to present this data to stakeholders, a cost-benefit ratio is recommended. for the specific out-of-hours clinic, a total benefit per patient on the low end of procedure fee estimate would be $350 and the cost was $75 which gives a positive benefit-to-cost ratio of 4.667. we calculated this cost-benefit ratio by dividing the total benefit per patient (low end$350) by the cost ($75). table 2 and table 3 provide details related to the procedures performed during the period, and the follow-up services scheduled with the potential revenue generated for east alabama orthopaedics & sports medicine, respectively. clinical application providing patient-centered care is one of the most important things we can do in health care. the patient has options and can choose where to seek services to meet their healthcare needs. measurement and understanding of the patient, caregiver, and family experience of healthcare provides the opportunity for reflection and improvement of healthcare and patient outcomes. often times we, as healthcare providers, seem to forget what is really important for patient satisfaction. it is vital to review and reflect on picker’s eight principles of patient-centered care in relation to our own practice.5 it is important to involve patients in decision making, recognizing they are individuals with their own unique values and preferences.5 proper coordination of care can alleviate patients feeling vulnerable and powerless in the face of an illness or injury5 in healthcare, patients expressed their worries that they were not being completely informed about their condition or prognosis. 5 physical comfort will come after healthcare providers enhance patient education and information.5 the level of physical comfort that patients report has a significant table 2. procedures performed during the free clinic procedure count cost total costs saved initial evaluation low moderate high 0 72 17 $50 $75 $100 $ 0 $5,400 $1,700 re-evaluation low moderate high 0 36 2 $50 $75 $100 $ 0 $2,700 $200 radiographs taken 96 $50 $100 $4,800 $9,600 point-of-care assessment at a free, out-of-hours orthopedic clinic 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 impact on their experience with us as providers. providing accommodation for family and friends and involving them in the decision-making process can enhance patient care and ease the overall patient experience for everyone. providing patients with understandable information regarding medications, ongoing treatment, physical limitations and access to physical or financial support will supply patients a better continuity and transition to care. finally, patients need to know they can access care when it is needed.5 the ease and availability of scheduling appointments, accessibility to specialists and providing clear instructions on how and when to get referrals are all great examples of how we can enhance patients access to care. gaining a better understanding of patient satisfaction, while measuring actual care provided our clinic with greater insight on what areas of patient care need to be strengthened and what areas of patient care we are excelling in. after reflecting on picker’s eight principles of patient centered care and our patient satisfaction survey results that was completed in this study, we were pleased to see that our clinic was on the right tract for providing optimal patient centered care. this project has opened opportunities to reach the underserved population, student athletes, and working men and women who cannot get away from their job during the monday thru friday work week; and also allow for quality healthcare visits. the result of the cost-benefit ratio demonstrates that the potential revenue generated from 75% (n=94/125) patients (age 18-24) that referred to the east alabama orthopaedics & sports medicine clinic for follow-up services will be greater than any “lost” costs incurred by offering the out-of-hours free clinic. as such, the clinic has not only brought a reduced healthcare option to the student-athletes in the county, it also provides a valuable revenue stream to the clinic. in addition, the gains from this project has demonstrated that east alabama orthopaedics & sports medicine provides an experience that is highly satisfied by the patients. after compiling all of the data, the report was presented to east alabama orthopaedics & sports medicine stakeholders and physicians. during the presentation, the possibility of extending the free saturday morning clinics beyond the football season was proposed. during the collaborative discussion, the stakeholders and lead athletic trainer discussed the pros and cons of an extension of providing the out-of-hours clinic during the spring and summer months. after reviewing the results and patient satisfaction responses, the group came to an agreement that the community would greatly benefit from extending the out-of-hour clinic services, while providing east alabama orthopaedics & sports medicine an opportunity for community outreach. the increased volume of patients from opening a clinic on saturday also increases the surgical load and patient visits for physicians, which in turns increases potential revenue to the clinic. we do acknowledge that there are still barriers to care for patients with no insurance regarding follow-up care. future research should look at different models to continue follow-up patient care for those with no insurance in order to better educate clinics on how to provide the best patient centered care for this population. we suggest that clinics table 3. potential revenue for follow-up appointments procedure count cost potential revenue mri 33 $500 $16,500 surgical procedure 7 $1,000 $2,000 $7,000 $14,000 in clinic appointment with physician 94 $100 $9,400 point-of-care assessment at a free, out-of-hours orthopedic clinic 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 providing outreach and per diem athletic training services consider creating an out-of-hours clinic using a similar model to improve the access to care for the population, which improves the chance that patients come back for further care in turn generating in increased revenue stream. references 1. rebholz cm, macomber mw, althoff md, et al. integrated models of education and service involving community-based health care for underserved populations: tulane student-run free clinics. southern med j. 2013;106(3):217-223. https://doi.org/10.1097/smj.0b013e3182 87fe9a. 2. fronstin p. sources of health insurance and characteristics of the uninsured: analysis of the march 2011 current population survey. ebri issue brief. 2011;362. 3. ellett jd, campbell ja, gonsalves wc. patient satisfaction in a student-run free medical clinic. fam med j. 2010;42(1):6-18. 4. data usa. data usa: lee county, al. https://datausa.io/profile/geo/lee-countyal/. accessed february 25, 2019. 5. oneview. the eight principles of patientcentered care. https://www.oneviewhealthcare.com/theeight-principles-of-patient-centered-care/. 6. accessed february 26, 2019. 7. medicare learning network: documentation guidelines for evaluation and management (e/m) services. https://www.cms.gov/outreach-andeducation/medicarelearningnetworkmln/mlnedwebguide/e mdoc.html. accessed april 30, 2019. 8. the uninsured and the aca: a primer key facts about health insurance and the uninsured amidst changes to the affordable care act. https://www.kff.org/uninsured/report/theuninsured-and-the-aca-a-primer-key-factsabout-health-insurance-and-the-uninsuredamidst-changes-to-the-affordable-care-act/. accessed april 30, 2019. https://doi.org/10.1097/smj.0b013e318287fe9a. https://doi.org/10.1097/smj.0b013e318287fe9a. https://datausa.io/profile/geo/lee-county-al/ https://datausa.io/profile/geo/lee-county-al/ https://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/ https://www.oneviewhealthcare.com/the-eight-principles-of-patient-centered-care/ https://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnedwebguide/emdoc.html https://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnedwebguide/emdoc.html https://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnedwebguide/emdoc.html https://www.cms.gov/outreach-and-education/medicare-learningnetworkmln/mlnedwebguide/emdoc.html https://www.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/ https://www.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/ https://www.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/ https://www.kff.org/uninsured/report/the-uninsured-and-the-aca-a-primer-key-facts-about-health-insurance-and-the-uninsured-amidst-changes-to-the-affordable-care-act/ abstract presentation 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 mesenchymal stem cells: sources, clinical applications and outcomes for common musculoskeletal conditions steven boyton, ms, atc, otc; lindsey clemensen, med, atc, otc flagstaff bone and joint, flagstaff, az full citation boyton s, clemenson l. mesenchymal stem cells: sources, clinical applications and outcomes for common musculoskeletal conditions. clin pract athl train. 2020;3(1):4-5. https://doi.org/10.31622/2020/0003.2. presented at the 3rd annual athletic trainers in the physician practice society meeting and conference, columbia south carolina. february 28-29, 2020 abstract background: the clinical use of mesenchymal stems cells (msc) in musculoskeletal medicine has become increasingly recognized in the medical field as a promising treatment modality. mscs have been defined as spindle shaped cells that are capable of rapid proliferation and selfrenewal contained within several tissues including bone marrow, synovial and adipose tissue, blood and periosteum. mscs are currently being used in clinical trials for musculoskeletal purposes including the enhancement of tissue regeneration, bone and cartilage defects and tissue repair. currently a variety of stem cell products, methods and applications are being used which can provide many misconceptions for the most appropriate use of this modality in orthopedics. the decision for the functionally relevant cell type is important to understand for providers to have the most effective outcomes. methods: common methods of evaluating the effect of mscs in orthopedics include patient rated outcomes, advanced imaging comparisons, arthroscopic evaluation after treatment and gene expression analysis. a comprehensive literature review was conducted to evaluate the most highlevel evidence available for msc’s being utilized in orthopedics. this is important to understand for clinicians to make informed decisions for the most appropriate clinical applications of mscs. conclusion: despite the many positive outcomes being demonstrated with msc therapies, in the literature for various orthopedic conditions, the magnitude of these positive effects have been diverse due to the lack of standardization of the msc cell product. further research is required to provide an insight into long term outcomes relative to other treatment modalities. additionally, research must also determine if the use of msc therapies can become a viable treatment option for musculoskeletal pathologies in orthopedic practices to use with standardized products and processing methods. clinical bottom line: the literature for msc therapy outcomes that have been observed in clinical trials have been lacking standardization with regards to how stem cells are being obtained, processed and utilized for musculoskeletal conditions. further research is required to provide an insight into long term outcomes relative to other treatment modalities. additionally, research must also determine if the use of msc therapies can become a viable treatment option for musculoskeletal pathologies in orthopedic practices to use with standardized products and processing methods. correspondence steven boyton, 2292 hano trail, flagstaff, az 86005. e-mail: sboyton@flagstaffboneandjoint.com references 1. kim jd, lee gw, jung gh, kim ck, kim t, park jh, cha ss, you yb. clinical outcome of autologous bone marrow aspirates concentrate (bmac) injection in degenerative arthritis of the knee. eur j https://doi.org/10.31622/2020/0003.2 mailto:sboyton@flagstaffboneandjoint.com mesenchymal stem cells: sources, clinical applications and outcomes for common musculoskeletal conditions 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2-20 orthop surg traumatol. 2014;24(8):1505-1511. https://doi.org/10.1007/s00590-0131393-9. 2. koh yg, jo sb, kwon or, suh ds, lee sw, park sw, choi yj. mesenchymal stem cell injections improve symptoms of knee osteoarthritis. arthroscopy. 2013;29(4):748-755. https://doi.org/10.1016/j.arthro.2012. 11.017. 3. awad me, hussein ka, helwa i, abdelsamid me, aguilar-pere a, moshen i, hunter m, et al. meta-analysis and evidence base for the efficacy of autologous bone marrow mesenchymal stem cells in knee cartilage repair: methodological guidelines and quality assessment. stem cells int. 2019: 3826054. https://doi.org/10.1155/2019/38260 54. 4. lopa s, colombini a, moretti m, de girolamo l. injective mesenchymal stem cell-based treatments for knee osteoarthritis: from mechanisms of action to current clinical evidences. knee surg sports traumatol arthrosc. 2019;27(6), 2003-2020. https://doi.org/10.1007/s00167-0185118-9. 5. chahla j, piuzzi ns, mitchell jj, dean cs, pascual-garrido c, laprade rf, muschler gf. intra-articular cellular therapy for osteoarthritis and focal cartilage defects of the knee: a systematic review of the literature and study quality analysis. j bone joint surg am. 2016;98(18):1511-1521. https://doi.org/10.2106/jbjs.15.0149 5. 6. harrell cr, markovic bs, fellabaum c, arsenijevic a, volarevic v. mesenchymal stem cell-based therapy of osteoarthritis: current knowledge and future perspectives. biomed pharmacother. 2019;109:2318-2326. https://doi.org/10.1016/j.biopha.2018 .11.099. 7. jones ia, chen x, evseenko d, vangsness jr ct. nomenclature inconsistency and selective outcome reporting hinder understanding of stem cell therapy for the knee. j bone joint surg am. 2019;101(2):186-195. https://doi.org/10.2106/jbjs.17.0147 4 https://doi.org/10.1007/s00590-013-1393-9 https://doi.org/10.1007/s00590-013-1393-9 https://doi.org/10.1016/j.arthro.2012.11.017 https://doi.org/10.1016/j.arthro.2012.11.017 https://doi.org/10.1155/2019/3826054 https://doi.org/10.1155/2019/3826054 https://doi.org/10.1007/s00167-018-5118-9 https://doi.org/10.1007/s00167-018-5118-9 https://doi.org/10.2106/jbjs.15.01495 https://doi.org/10.2106/jbjs.15.01495 https://doi.org/10.1016/j.biopha.2018.11.099 https://doi.org/10.1016/j.biopha.2018.11.099 manuscript type clinician expertise commentary 4 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 clinical experts statement: the definition, prescription, and application of cupping therapy s. andrew cage, med, lat, atc1,2; diana m. gallegos, ms, lat, atc1; brian coulombe, dat, lat, atc4; brandon j warner, med, lat, atc2,3 1the university of texas at tyler, 2university of north carolina greensboro, kinesiology, 3grand canyon university, 4texas lutheran university key phrases college and university patient population, therapeutic devices, manual techniques, cupping therapy author characteristics the first author, andrew s. cage, has obtained his international cupping therapy therapist certification and is a member of the international cupping therapy association. mr. cage also has several peer-reviewed publications as well as international, national, regional, and local presentations on the use of cupping therapy in sports medicine and rehabilitation. mr. cage has presented numerous times on evidence based approaches on the use of cupping therapy and uses cupping therapy extensively in his clinical practice. further, brandon warner and diana gallegos, have also received certifications in cupping therapy and myofascial decompression and use cupping therapy in their clinical practice regularly. both mr. warner and ms. gallegos have several peer-reviewed publications and presentations at the national, regional, and local levels. correspondence s. andrew cage, the university of texas tyler, 11325 preakness dr., flint, tx 75762. e-mail: sacage@uncg.edu full citation cage sa, gallegos dm, coulombe b, & warner bj. clinical experts statement: the definition, prescription, and application of dry cupping therapy. clin pract athl train. 2019;2(2): 4-11 https://doi.org/10.31622/2019/0002.2. submitted: may 29, 2019 accepted: june 6, 2019 introduction cupping therapy is an ancient modality the use of which has been documented as early as 3300 bc.1 in the past two decades, dry cupping therapy has grown in popularity in the united states and other countries where western medicine is the primary source of healthcare.1 a large amount of this popularity can be attributed to increased media interest resulting from elite level athletes receiving cupping therapy.2,3 even though cupping therapy has gained popularity as a treatment device in the united states, there is still no consensus on the ideal parameters for applying a cupping therapy treatment to patients competing in amateur or professional athletics.1 the lack of consensus related to this medical issue can be attributed at least in part to a lack of high quality studies, lack of randomized controlled trials involving subjects participating in organized athletics, and a lack of standardized methodology.1,4,5 within the medical and healthcare field, various methods of creating consensus statements on best practices are commonly used and accepted.6-9 these techniques have been used to publish consensus statements in areas including respiratory, urologic, and geriatric medicine.6-9 in instances in which there are deficiencies or contradictions within the current literature, the delphi technique is one method of determining consensus that can be employed.6 therefore, the purpose of this clinical expertise commentary was to use the delphi technique to develop a clinical expertise statement on the definition and description of cupping therapy, as well as the prescription and application of dry cupping therapy when providing athletic training services. this statement was to be created with the intent of serving as a guide for clinicians until gaps in literature could be addressed. methods a review of the available literature was conducted using pubmed and googlescholar to locate published materials that could contribute to an initial list of statements to utilize in the delphi process. the review focused on: description and definition of cupping therapy, prescription of https://doi.org/10.31622/2019/0002.2 clinical experts statement: the definition, prescription, and application of dry cupping therapy 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 cupping therapy, and application of cupping therapy. the literature search looked for english language studies that had been published after 2013. ultimately, 31 sources were utilized in the creation of the literature review.1-5,10-35 upon completion of the review of literature, a panel of 10 athletic trainers who held a postprofessional credential in cupping therapy were invited to participate in a series of online surveys and forums. demographic information for the panel of experts can be found in table 1. table 1. panel demographic information sex male (n=5), female (n=5) age (years) 31.3 ± 5.01 certified athletic training experience (years) 7.0 ± 3.71 patients treated weekly with cupping therapy 9.1 ± 4.01 age, experience, and patients treated presented as means with sd. after collecting demographic information from the panelists, the delphi technique was utilized in a similar manner to that which was performed by maher et al.6 panelists with a history of regularly performing formally trained cupping therapy as part of their daily athletic training practice were identified by the primary investigator and independently recruited to participate. panelists received an electronic copy of the literature review, and were asked to review it for one week. panelists were then surveyed on a series of statements regarding the definition and description, prescription, and application of cupping therapy on their patient population. panelists were asked to rate each statement based off of whether or not they felt it warranted inclusion in the overarching clinical expertise statement (1 = definitely do not include to 9 = definitely include). using the protocol outlined in table 2, all statements were analyzed by the primary investigator to determine if they warranted inclusion, exclusion or modification. following the first round, panelists received a web-based spreadsheet that outlined the results of the first survey. the spreadsheet also included areas for panelists to comment on what they felt should be modified in the statements that had not qualified for inclusion in order for them to be included in the final clinical expertise statement. after modifications were made to the remaining statements, the second survey was sent to the panelists asking them to re-rate the revised statements. upon completing the second round of surveying, consensus was reached on all included statements based off each included statement having a median rating of 8 or higher. results following the review of literature, 67 statements were developed. these statements addressed the definition and description of cupping therapy, prescription of cupping therapy (specifically, indications and contraindications), and the application of cupping therapy. all 10 panelists participated in the demographics survey, as well as the first and second round of rating statements. seven out of 10 panelists provided comments and suggested revisions for the statements that did not warrant inclusion or exclusion after the first round of rating. additionally, five panelists were contacted in a one-on-one fashion to request clarification on comments or to provide clarifications on the investigator’s remarks. table 2. statement inclusion key statement result threshold applied definitely include 1. ≥ 80% of panel rated statement = 9 2. median rating of ≥ 8 maybe include 1. ≥ 70% of panel rated statement = 9 2. medial rating of ≥ 7 definitely exclude 1. ≤ 80% of panel rated statement = 1 2. median rating of ≤ 2 review 1. major revisions suggested by panelist. 2. < 70% of panel rated statement = 9 clinical experts statement: the definition, prescription, and application of dry cupping therapy 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 after the rating of the original 67 statements was completed, 31 statements remained unmodified, four were excluded, and 32 were presented to the panel for revisions. a total of six of the statements regarding the description and definition of cupping therapy were combined into a single statement. additionally, a single statement was created regarding mediums from five statements following agreement on oils were the preferable mediums to lotions. statements regarding the number of pumps to use with plastic cups on experienced and inexperienced patients were combined into two respective statements. additionally, the statement regarding the use of cupping therapy on the appendages of a pregnant patient was modified to include physician consent as a necessity. of the remaining 30 statements from the first round of rating, eight modified statements were reviewed and rated in the second round. during this round of rating, all eight were unmodified and included in the final overarching statement. as all remaining statements had reached a consensus, it was concluded that there was no need to undergo a second round of revisions and ratings. thus, the final 39 statements are presented in table 3, table 4, and table 5 as the panel’s clinical expert statement on the description, prescription, and application of cupping therapy in athletic training. discussion the purpose of this study was to develop a clinical statement on the description and definition, prescription, and application of cupping therapy in athletic training. the literature review results in 67 initial statements. following 2 rounds of rating, 39 statements were included in the final clinical expert statements. ultimately, the goal of this consensus clinical expert statement was to attempt to reach a level of agreement based off of expert opinion in the absence of high-quality evidence. this method was chosen based off the success of using it in other healthcare professions to create consensus statements for conditions and interventions that did not have clearly set guidelines.6 the delphi technique has been used by other authors to reach consensus statements on a variety of medical conditions.6-9 maher6 noted this technique had exceptional utility when used for establishing guidelines for conditions that were not well documented in research-based literature. upon completion of the first round of review, revisions were made to the statements that qualified for modification based off of input from the panelists. revisions were made to condense and clarify the description and definition of cupping therapy, the use of cupping therapy on the appendages of pregnant patients, the amount of suction used on patients with and without experience with cupping therapy, and the types of mediums used for applying cupping therapy. these statements are intended to serve as a tool for athletic trainers looking to incorporate cupping therapy into their clinical practice. through review of these statements, athletic trainers may be able to practice cupping therapy with the knowledge that these aspects of the practice have been reviewed by a clinician-driven panel. the authors encourage all athletic trainers and allied healthcare practitioners looking to practice cupping therapy to carefully review and consider each of these statements. the information contained within these statements is not inclusive of all individual scenarios and circumstances. extenuating variables such as patient health, state and federal regulations, cultural beliefs, and patient values may affect the ability of a clinician to implement these statements into their practice. the authors strongly encourage individuals to seek out formal education and training in cupping therapy prior to administering treatments to patients. the statements contained within this document should be viewed as a resource and not a rigid set of guidelines for practicing cupping therapy. clinical experts statement: the definition, prescription, and application of dry cupping therapy 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 table 3. agreed upon definition of cupping therapy1,4,5,12,17,21 cupping therapy description/definition 1. cupping therapy utilizes suction from one of a variety of methods. 2. cups used for cupping therapy can be made of materials including plastic, glass, rubber, silicone, and wood. 3. some methods of creating suction on the tissue being treated include: pumping air from a plastic cup, creating an oxygen deficit in a glass cup with an open flame, and manually manipulating a silicone cup. 4. cupping therapy utilizes negative pressure to have a mechanical effect on treated tissues. 5. traditional cupping therapy was a commonly used technique prior to the 20th century. during the turn of this century, trends indicate that there was a decline in use, possibly due to the advancement of medical research or the ambiguity of bloodletting procedures. however, this ancient practice has begun to re-emerge as a viable option for orthopedic injuries. this increase may be contributed to the 2016 olympics or continued research in optimizing outcomes for athletes. 6. there is some evidence to suggest that cupping therapy can decrease musculoskeletal pain. 7. there is some evidence to suggest that cupping therapy can increase regional and local blood flow. table 4. agreed upon prescription of cupping therapy1,2,5,13,15,22,29 indications 1. musculoskeletal pain is an indication for the use of cupping therapy. 2. neurological pain is an indication for the use of cupping therapy provided direction is given by the patient’s neurovascular specialist. 3. muscle tightness is an indication for the use of cupping therapy. 4. myofascial adhesions within a muscle are an indication for the use of cupping therapy. 5. subacute and chronic muscular injuries are an indication for the use of cupping therapy. contraindications 1. open wounds are a contraindication for the use of cupping therapy. 2. pregnancy is a contraindication for cupping therapy over the lower back or torso. 3. cupping therapy treatments on the appendages of pregnant patients should be done with caution, and when possible with physician consent. 4. neurovascular compromise is a contraindication for the use of cupping therapy in the absence of referral by a neurovascular specialist. 5. cupping therapy should not be performed on a muscle that has suffered an injury within the past 2472 hours. cupping therapy for athletic related injuries 1. there is a need for a larger number of high-quality studies on the use of cupping therapy in athletic training. 2. several case studies have been published that suggest cupping therapy may be a viable treatment option for athletics related injuries. 3. in the absence of high-quality studies specific to athletics related injuries, clinicians and educators must rely on studies conducted on participants from the general population. 4. there is no time required for patients to refrain from participation in sport-related activities following use of cupping therapy, provided they complete an adequate dynamic warm up and are not experiencing soreness above patient tolerance. clinical experts statement: the definition, prescription, and application of dry cupping therapy 8 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 although the panel was able to reach consensus on the included statements, this study did have limitations. the literature review was designed to provide panelists with an overview of the most current literature. however, there was not a number of high-quality studies assessing the effects of cupping therapy. additionally, the majority of these studies did not follow a standardized methodology that may have given the panel the opportunity to provide learner guidelines regarding the application of cupping therapy. due to this limitation, the literature review was reviewed by a clinician with extensive experience with cupping therapy in order to ensure the literature review was completed in the most comprehensive and insightful way possible. furthermore, the use of athletic trainers with their primary job setting as college/university may limit the generalizability to other job settings. athletic trainers practicing in settings where the majority of their patients are minors may have additional considerations they need to make. future research should incorporate panelists from other athletic training settings to increase the generalizability of table 5. agreed upon considerations of cupping therapy1,4,5,12,15,29 application 1. when treating a minor, it is necessary to educate the patient’s parent or guardian and obtain consent from said guardian prior to performing cupping therapy. 2. cupping therapy should be performed by or under the supervision of a properly educated healthcare professional. 3. depending on the location, goal, and patient allergies, clinicians should use mediums such as coconut oil, grapeseed oil, and seedless massage oil to minimize patient discomfort during cupping therapy treatments. 4. an area with more body hair may require the use of more oil, but may still be more difficult to achieve suction on. 5. therapeutic effects can be seen after as little as 10-minutes of treatment when using static cupping therapy depending on therapeutic goals. 6. static cupping therapy can be performed safely for up to 30-minutes depending on patient comfort and therapeutic goals. 7. when using plastic pump cups with patients who have not been cupped before, starting with 1 pump based on patient comfort is recommended. 8. clinicians should use an amount of suction that does not elicit a painful response when treating patients who have not received cupping therapy treatments before. 9. depending on therapeutic goals and patient tolerance, clinicians can generally use more suction when treating patients who have receive cupping therapy treatments before. 10. clinicians can affect the amount of suction achieved during fire cupping by decreasing the amount of time from when the flame is removed from the cup and when the cup is placed on the intended treatment area. 11. provided a patient's soreness has not increased and patients can tolerate the amount of suction, clinicians can utilize cupping therapy in the presence of muscular soreness. reasons to discontinue/adverse effects 1. if a patient expresses discomfort during cupping therapy, the clinician should discontinue treatment. 2. if blisters begin to form during cupping therapy, the clinician should discontinue treatment. 3. if blisters do form during cupping therapy, standard wound care treatment is appropriate provided there are no signs of infection. 4. if a patient begins to become lightheaded during cupping therapy, the clinician should discontinue treatment. 5. presence of ecchymosis related to a previous cupping therapy treatment does not disqualify a patient from being treated with cupping therapy again provided the patient is not experiencing soreness. following treatment 1. patients should be instructed to hydrate properly following cupping therapy. 2. patients can reasonably expect to feel soreness similar to what would be expected after a deep tissue massage following cupping therapy. clinical experts statement: the definition, prescription, and application of dry cupping therapy 9 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 these statements. a final limitation that is that the delphi technique has been suggested to not meet the same standards as other scientific methods.6 that being said, the controlled feedback and clinician input that is characteristic of this technique is ideally suited for creation of a consensus statement on a treatment technique that currently has gaps and contradictions within the available literature. conclusions the remaining 39 statements provide an expert statement on the definition and description, prescription, and application of cupping therapy for athletic training clinical practice. this cliniciandriven expert statement using the delphi technique provides a framework for safe and effective cupping therapy practices based off of best available evidence and clinician expertise. this statement is presented with the intent of providing direction for decision making regarding the prescription and application of cupping therapy. the cupping therapy panel of experts the authors would like to thank: travis armstrong, ms, lat, atc (arizona christian university, glendale, az), alifonzo garcia, ms, lat, atc (arizona christian university, glendale, az), kerri kalina, ms, lat, atc (university of texas at dallas, richardson, tx), tracy lott, ms, lat, atc 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https://doi.org/10.25035/jsmahs.03.02.02 16. chen b, guo y, li my, chen zl, guo y. standardization of cupping therapy may reduce adverse effects. qjm-int j med. 2016;4(1)287. https://doi.org/10.1093/qjmed/hcv220 17. chi lm, lin lm, chen cl, wang sf, lai hl, peng tc. the effectiveness of cupping therapy on relieving chronic neck and shoulder pain: a randomized controlled trial. evid based complement and alternat med. 2016. https://doi.org/10.1155/2016/7358918 18. denegar cr, saliba e, saliba s. therapeutic modalities for musculoskeletal injuries. champaign, il: human kinetics. 2017. 19. emerich m, braeunig m, clement hw, ludtke r, huber r. mode of action of cupping – local metabolism and pain thresholds in neck pain patients and healthy subjects. complement ther med. 2014;22(1):148-158. https://doi.org/10.1016/j.ctim.2013.12.01 3 20. ernst e. testing traditional cupping therapy. j pain. 2009;10(6):555. https://doi.org/10.1016/j.jpain.2009.02.0 01 21. escaloni j, young i, loss, j. cupping with neural glides for the management of peripheral neuropathic pain: a case study. j man manip ther. 2019;27(1):54-61. https://doi.org/10.1080/10669817.2018. 1514355 22. fiesler t, warner bj, berry va, mesman dl, cage sa. low back pain as a complication of slipped capital femoral epiphysis in a collegiate volleyball player. j athl train. 53(6s), s-322. https://doi.org/10.4085/1062-605053.6s.s1 23. gozubuyu ob, devran s, akikol m. the effects of dry cupping therapy on muscle thickness and elasticity of upper back muscles. j body move ther. 2018;22(4):851. http://dx.doi.org/10.1016/j.jbmt.2018.09. 018 24. kouskoukis ce, leider m. cupping: the art and the value. am j dermatopathol. 1993;5(3):235-239. 25. lee sy, sin ji, yoo hk, kim ts, sung ky. cutaneous myobacterium massiliense infection associated with cupping therapy. clin exp dermtol. 2014;39:904-907. https://doi.org/10.1111/ced.12431 26. lin cw, wang jt, choy cs, tung hh. iatrogenic bullae following cupping therapy. j altern complemt med. 2009;15(11):1243-1245. https://doi.org/10.1089/acm.2009.0282 https://doi.org/10.1002/nau.21253 https://doi.org/10.1111/j.1532-5415.2011.03497.x https://doi.org/10.1111/j.1532-5415.2011.03497.x https://doi.org/10.1016/j.jams.2018.02.001 https://doi.org/10.1016/j.jams.2018.02.001 https://doi.org/10.1016/j.ejphar.2010.06.048 https://doi.org/10.1016/j.ejphar.2010.06.048 https://doi.org/10.15640/ijhs.v5n3a2 https://doi.org/10.4085/1062-6050-52.6.s1 https://doi.org/10.4085/1062-6050-52.6.s1 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.25035/jsmahs.03.02.02 https://doi.org/10.1093/qjmed/hcv220 https://doi.org/10.1155/2016/7358918 https://doi.org/10.1016/j.ctim.2013.12.013 https://doi.org/10.1016/j.ctim.2013.12.013 https://doi.org/10.1016/j.jpain.2009.02.001 https://doi.org/10.1016/j.jpain.2009.02.001 https://doi.org/10.1080/10669817.2018.1514355 https://doi.org/10.1080/10669817.2018.1514355 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.4085/1062-6050-53.6s.s1 http://dx.doi.org/10.1016/j.jbmt.2018.09.018 http://dx.doi.org/10.1016/j.jbmt.2018.09.018 https://doi.org/10.1111/ced.12431 https://doi.org/10.1089/acm.2009.0282 clinical experts statement: the definition, prescription, and application of dry cupping therapy 11 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 27. liu z, chen c, li x, zhao c, li z, liang w, lin y. is cupping blister harmful? – a proteomical analysis of blister fluid induced by cupping therapy and scald. complement ther med. 2018;36:25-29. https://doi.org/10.1016/j.ctim.2017.11.00 2 28. liu w, piao s, meng x, wei lh. effects of cupping on blood flow under the skin of back in healthy human. world j acupint moxibustion. 2013;23(3):50-52. https://doi.org/10.1016/s10035257(13)60061-6 29. lowe dt. cupping therapy: an analysis of the effects of suction on skin and the possible influence on human health. complemet ther clin pract. 2017;29:162168. https://doi.org/10.1016/j.ctcp.2017.09.0 08 30. lu mc, yang cj, tsai sh, hung cc, chen sj. intraperitoneal hemorrhage after cupping therapy. j emerg med. 2018;1-3. https://doi.org/10.1177/102490791878 4076 31. mcnulty e, thompson t, mckeon jm. dry cupping with motion is effective for achieving small gains in hamstring flexibility in healthy adults. j athl train. 2018;53(6s):s-152. https://doi.org/10.4085/1062-605053.6s.s1 32. mohammadi s, roostayi mm, naimi ss, baghban aa. the effects of cupping therapy as a new approach in the physiotherapeutic management of carpal tunnel syndrome. phsyiother res in. 201;e1170. https://doi.org/10.1002/pri.1770 33. parapia la. history of bloodletting by phlebotomy. b j haematol. 2008;143(4):490-495. https://doi.org/10.1111/j.13652141.2008.07361.x 34. potter nb, wilson, jc. internal medicine: a work for the practicing physician on diagnosis and treatment with a complete desk index. philadelphia, pa: j.b. lippincott company. 1919. 35. valmyre a. cupping. bjm. 1924;1(3295):351-352. https://doi.org/10.1016/j.ctim.2017.11.002 https://doi.org/10.1016/j.ctim.2017.11.002 https://doi.org/10.1016/s1003-5257(13)60061-6 https://doi.org/10.1016/s1003-5257(13)60061-6 https://doi.org/10.1016/j.ctcp.2017.09.008 https://doi.org/10.1016/j.ctcp.2017.09.008 https://doi.org/10.1177/1024907918784076 https://doi.org/10.1177/1024907918784076 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.1002/pri.1770 https://doi.org/10.1111/j.1365-2141.2008.07361.x https://doi.org/10.1111/j.1365-2141.2008.07361.x manuscript type quality improvement reports 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 quality improvement in athletic training education on female athlete triad kristen a. paloncy-patel, edd, atc*; melissa r. penkalski, dnp, aprn, cpnp-pc, ae-c†; shannon m. hauschildt, ma, pa-c†, natalie b. allen, med, rdn† *north central college, naperville, il; †missouri state university, spring field, mo abstract there are significant health risks associated with the female athlete triad (triad), therefore early detection and prevention is key. athletic trainers often serve as the frontline defense and can have a crucial role in identifying the triad. yet knowledge, confidence, and practice standards in the recognition, referral and treatment is lacking. the purpose of the following quality improvement document is to provide athletic trainers with a framework for improving triadspecific knowledge, confidence, and practice standards. the 2014 female athletic triad coalition consensus statement provides an evidence-based risk stratification system for detection and referral of the triad. the coalition suggests including triad-specific preparticipation examination (ppe) screening questions and utilization of the female athlete triad cumulative risk assessment on all clearance and return to play decisions for female athletes. though there are efforts to educate athletic trainers about disordered eating in athletes, these efforts do not specifically include the triad. many female athletes are currently being cleared at their ppe without being adequately assessed for this syndrome or without appropriate referral for management and treatment. therefore, it is important for ats to improve their knowledge, confidence, and practice standards specific to the triad. key phrases injury risk reduction, preparticipation exams and screening, college and university patient population, female athlete triad correspondence dr. kristen paloncy-patel, north central college, 30 north brainard, stadium room 308. naperville, il 60540. e-mail: kapaloncy@noctrl.edu full citation paloncy-patel k, penkalski m, hauschildt s, allen n. quality improvement in athletic training education on female athlete triad. clin pract athl train. 2020;3(2):6-14. https://doi.org/10.31622/2020/0002.3. submitted: november 6, 2019 accepted: june 8, 2020 current model the syndrome of female athlete triad (triad) was defined in 1997 in an american college of sports medicine position statement.1 modified from its original definition, the three components of the triad now include low energy availability with or without disordered eating, menstrual dysfunction, and low bone mineral density.1,2 previously, the prevalence of the triad was thought to be 1-4% and impacting mostly endurance athletes.1,2 however the current definition is much more encompassing and emphasizes the fact that the components do not need to present simultaneously. therefore, the prevalence of the triad expected to be much higher and among a much larger population.1,2 since the triad was identified, recognition and prevention strategies have emphasized a collaborative effort among healthcare providers.2-4 due to the nature of many traditional athletic training settings and the high level of interaction with athletes, certified athletic trainers (ats) often act as the frontline defense and an integral part of the multidisciplinary team in identifying athletes at risk for eating disorders.4 the current processes in place to educate entrylevel athletic trainers on the assessment, identification, and management of the triad fall under competency php-43, php-46, and php-47 in the 5th edition of the competencies published by the commission on accreditation of athletic training education (caate).5 the competencies are5: • php-43: describe the principles and methods of body composition assessment to assess a mailto:kapaloncy@noctrl.edu https://doi.org/10.31622/2020/0002.3 quality improvement in athletic training education on female athlete triad 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 patient’s health status and to monitor changes related to weight management, strength training, injury, disordered eating, menstrual status and/or bone density status. • php-46: identify and describe the signs, symptoms, physiological and psychological responses of patients with disordered eating or eating disorders. • php-47: describe the methods of appropriate management and referrals for patients with disordered eating or eating disorders in a manner consistent with current practice guidelines. (nata, 2011, p.15). a new edition of the competencies will be published in 2020 by the caate, however the new standards continue to not specifically mention the triad.6 in 2008, the national athletic trainers’ association (nata) published a position statement on preventing, detecting, and managing disordered eating in athletes.4 this statement emphasizes that a crucial action for the at is to establish a screening approach for disordered eating that “recognizes signs and symptoms of the full spectrum of maladaptive eating and weight loss behaviors, as well as predisposing risk factors associated with their development” (p.81).4 this can be achieved through medical history questions on the ppe as well as standardized, self-reported screening questionanaires.4 these questionnaires are not without their flaws for the athletic population. athletes can feel shame, guilt, and denial associated with eating disorders or could be worried that their athletic careers could be jeopardized if their coach found out about their eating disorder. therefore, the accuracy of responses in a self-reported screening questionnaire may be poor.4,7-9 numerous screening instruments have been designed specifically for the athletic population. however, the concern about these screening instruments is the lack of extensive testing for internal and criterion validity, response bias, and generalizability.4,10 therefore, the combination of screening methods to include the ppe, standardized self-reported questionnaires, individual interviews, and direct observation of athletes is described to be best practices for identifying and preventing disordered eating.4 the dissemination of knowledge regarding the screening and treatment of the triad is lacking.11, 12 in a recent investigation of collegiate athletic trainers’ knowledge of the triad, it was found that while about half of ats have heard of the triad, most could not accurately define the disorder.12 further, most ats are not engaging in appropriately targeted screening or treatment recommendations.12 it is possible that since caate competencies and the nata position statement addresses disordered eating as a more general category and do not specifically address the triad, the knowledge, identification, appropriate screening, and treatment of the triad remain low12 and do not lend to early detection of this syndrome specifically.12 specifically, only 38% of ats are able to correctly identify the three components of the triad. while about half of athletic trainers screen collegiate athletes for unspecific eating disorders, only 26% of ats screen specifically for the triad.11, 12 furthermore, only 18% of ats felt comfortable treating the triad.11 in 2014, a consensus statement was published which included the “female athlete triad cumulative risk assessment score” focusing on the clinical management of athletes affected by the triad.13 the publication also includes a screening tool to identify and assess at-risk athletes. these guidelines, which are uniquely specific to the triad rather than other screening instruments identifying unspecific disordered eating, were not found in most athletic training literature or implemented into practice within the athletic training profession. quality improvement in athletic training education on female athlete triad 8 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 in a review of the practice processes for athletic trainers at the target collegiate setting, we found no formal screening tool were used to evaluate for the triad. for two years prior to the start of the current study, 18 stress fractures in female athletes were recorded out of 234 total female athletes’ measures (rate of .077 per 100 athleteexposures (aes)). for national comparison, data from a 10-year ncaa injury surveillance program reported a total of 671 stress fractures over 1,1778,145 aes for an overall injury rate of 5.70 per 100,000 aes.14 within our practice review, athletes who suffered these injuries lost a total of 848 days of sport participation, averaging 56 days of lost time. of the 18 female athletes with recorded stress fractures, 14 saw the team registered dietitian (rd). two athletes quit their athletic participation and no longer received services so were excluded from the study and two other females were referred but never met with the rd. of the 14 athletes seen by the team rd, 85% were identified as having low energy availability with or without disordered eating and other triad components. at this time, we questioned if there may be an improved process to help ats increase knowledge specific to the triad and confidence in early recognition which would result in improved practice. the purpose of this quality improvement study was to determine if there were significant gains in knowledge, recognition/referral confidence, and practice standards in the triad through an educational in-service and introduction to ppe triad-specific screening questions and the female athlete triad cumulative risk assessment in a four-year, division i institution with 17 collegiate ats. pdsa cycle plan we first began by researching the specific recommendations for screening female athletes for the triad and the female athlete triad cumulative risk assessment. recommendations are to screen female athletes focusing on full menstrual history, energy availability, disordered eating history, and reasons for hormonal therapy use.15 in this research phase, we found the triad coalition reported that early detection of athletes at risk for the triad is crucial to prevention. while there are concerns of efficacy for many screening tools, the recommendation is that all female athletes undergo annual screening with the triadspecific self-report questionnaire.13 a list of recommended screening questions may be viewed in table 1. the triad coalition further recommends that if the athlete has any risk for one triad component as identified through the screening process, a more in-depth interview and evaluation should occur. in addition, evidence on risk factors for the triad demonstrate that low bone mineral density and bone stress injuries is greater with cumulative risk factors for the triad and therefore should be considered before making clearance or return to participation decisions.13,16,17 the female athlete triad cumulative risk assessment developed by the triad coalition provides an objective method of determining the athlete’s risk for the triad by using evidence-based factors and assigning a point value based on the magnitude of risk (low, medium, high) for assessment criteria and scores.13 this risk assessment tool was used with permission and may be viewed in table 2. the triad coalition recommends utilization of the female athlete triad cumulative risk assessment for all participation and return to participation decisions for female athletes.13 next, we had conversations with our team physician, team rd, and the head at. we first spoke with the team physician to see if he would support the implementation of the female athlete triad cumulative risk assessment and screening quality improvement in athletic training education on female athlete triad 9 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 table 1: triad consensus panel screening questions* have you ever had a menstrual period? how old were you when you had your first menstrual period? when was your most recent menstrual period? how many periods have you had in the past 12 months? are you presently taking any female hormones (oestrogen, progesterone, birth control pills)? ▸ do you worry about your weight? are you trying to or has anyone recommended that you gain or lose weight? are you on a special diet or do you avoid certain types of foods or food groups? have you ever had an eating disorder? have you ever had a stress fracture? have you ever been told you have low bone density (osteopenia or osteoporosis)? *the triad consensus panel recommends asking these screening questions at the time of the sport pre-participation evaluation. reprinted with permission questions into the preparticipation physical examinations for all female athletes. we explained that he would have a role in ordering the bone dual-energy x-ray absorptiometry (dexa) scans on all athletes (part of the female athlete triad cumulative risk assessment) as well as reviewing all scores and screening question responses before giving final clearance in the preparticipation physical examinations. we discussed the risks and benefits of preforming bone dexa scans on all athletes and ultimately decided, given the very low radiation used, it was important to include these scans so that we could follow the female athlete triad cumulative risk assessment protocol in its entirety. we also explained that we would involve the ats by first educating them on the triad through an in-service and then having them take a role in administering/reviewing screening questions and conducting aspects of the female athlete triad cumulative risk assessment. he reviewed the evidence and agreed to support this. we spoke to the team rd (who was also part of the interdisciplinary research team) about her role in implementing the female athlete triad cumulative risk assessment and screening questions in the preparticipation physical exam. her role would be to educate athletes that scored a moderate or high risk in the assessment on the triad and develop nutrition goals with the athlete through individual meetings. she agreed to take on this role. it is important to note that the rd for our institution is based on-campus and has a high amount of direct interaction weekly within the athletic training room. there is potential for pushback on requiring large commitments from interdisciplinary team members such as the rd at institutions if their services are structured differently. finally, we spoke with the head at about 1) implementing the female athlete triad cumulative risk assessment and screening questions into all pre-participation physical examinations for all female athletes at the college, and 2) meeting with and educating all collegiate ats on the tools and process. we predicted that by meeting with and educating all collegiate ats on the tools and processes, their knowledge of the triad, confidence in recognition and when to refer, as well as practice standards involving the triad would increase. we determined as a group that was best to plan for the implementation of these two goals prior to both pre-participation physicals and before fall practices began. the last step we took in planning was to develop a knowledge, confidence, and practice standards assessment tool that we could deliver to the athletic trainers. the research team created a 22– question survey assessment that measured all variables. the knowledge, confidence, and practice standards survey assessment were examined for face validity by a panel of experts (n=5) who had experience in survey design. no changes were made to the survey instrument quality improvement in athletic training education on female athlete triad 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 based on their feedback. reliability of the survey instrument was determined by running a cronbach alpha on a sample of athletic trainers (n=17) to determine the internal consistency or average correlation of the items in the survey instrument. the overarching alpha for the whole instrument was calculated as a value of 0.92 which suggests the instrument has acceptable reliability. do a pretest posttest design with the survey instrument was utilized to assess if knowledge, confidence, and practice standards in the triad improved through the educational session and implementation of the ppe screening questions and female athlete triad cumulative risk assessment. on the day of the athletic training educational session, the survey instrument was administered to all 17 ats (10 full time, 7 intern/graduate assistants) at the college. responses served as the pretest assessment of triad knowledge, confidence, and practice standards. following the pretest, in an educational session that lasted approximately one hour, the team rd presented information utilizing a self-developed powerpoint presentation on the triad including components, effects of the syndrome, risks, signs and symptoms to watch for, and when to refer. in addition, information specifically on the universities’ history with missed time for female athletes with previous triad diagnoses and goals of the quality improvement study including the athletic trainers’ role in the study was included. finally, a review of the triad-specific ppe screening questions and the components of the female athlete triad cumulative risk assessment tool was provided. it was explained to the ats that they would have a role in assisting in the review of the ppe screening questions to identify areas of concern. it was also explained to the ats that they also may have a role in assisting in administering the female athlete triad cumulative risk assessment. the research team decided it was best for the team rd to lead this educational session because they were most familiar with the triad and the female athlete triad cumulative risk assessment tool. immediately after participating in the educational in-service, the survey instrument was again given to the athletic trainers which served as the posttest assessment of triad knowledge, confidence, and practice standards. table 1. female athlete triad: cumulative risk assessment quality improvement in athletic training education on female athlete triad 11 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 the educational in-service with the ats was the quality improvement strategy that we focused on for this study as a way to improve ats’ triadspecific knowledge, confidence, and practice standards as measured by the results of the pretest posttest survey. however, we would like to disclose that following this educational inservice, action did occur to further implement what was discussed. like other years, ats assisted in the preparticipation physical examinations of new and returning athletes on their assigned athletic teams which coincided with the start of specific athletic seasons. it was the ats’ role to review all screening questions (now including those specific to the triad) in the medical history section of the ppe with the athletes on their team(s). following this, several graduate assistant ats completed the female athlete triad cumulative risk assessment on all female athletes in the universities’ biomedical laboratory. when considering implementation of this process, please note dexa scans must be completed by a trained administrator and it is not required that this person be an at. dexa scans were performed on all female athletes by the ats under the order of the team physician. lastly, after the review of all ppe screening questions and the generation of a score for the female athlete triad cumulative risk assessment, those who scored a moderate or high risk for the triad were identified and referred to the team rd for follow up. we followed this detailed process annually over the next 3 full academic years and tracked new triad referrals and diagnoses over this time period. study prior to computing analyses, the responses on the knowledge assessment was screened for accuracy, missing data, outliers and assumptions (normality). the knowledge assessment had 9 items on the pretest and posttest; however, a summary score for both tests were derived and these values were screened and included in the statistical analysis. data appeared to be accurate without missing values. also, there were no outliers assessed by boxplots in jasp. lastly, the data did not appear to be normal as the distribution of the data showed a slight negative skew and had a significant value, using the p<.05 criterion, for the shapiro-wilk test of normality (p= .022). however, given that a paired samples t-test is considered a robust analysis, especially with a large sample size, this was the test performed with a total sample size of 17. a paired samples t-test was performed to examine differences in knowledge between the pretest and posttest. results revealed a significant difference between these two measures, t(16) = -8.90, p< .001, d= -2.16. in other words, knowledge in the triad significantly increased after participating in the education seminar (pretest; m= 6.53, s = 0.80, posttest; m= 8.47, s= 0.62). see figure 1 for a visual display of the means and +2 standard deviations. prior to computing analyses, the responses on the confidence and practice standards assessment was screened for accuracy, missing data, outliers and assumptions (normality). the confidence assessment had 6 items on the pretest and posttest while the practice standards assessment had 7 items; however, a summary score for both assessments for each test (i.e. pretest and posttest) were derived and these values were screened and included in the statistical analysis. data appeared to be accurate without missing values or outliers assessed by boxplots in jasp. lastly, the data appeared to be normally distributed as assessed by the distribution and the shapiro-wilk test of normality (confidence, p= .859; practice standards, p= .193). there was a total sample size of 17 participants. quality improvement in athletic training education on female athlete triad 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 a paired samples t-test was performed to examine differences in confidence between the pretest and posttest. results revealed a significant difference between these two measures, t(16) = -3.46, p= .003, d= -0.84. in other words, confidence significantly increased after participating in the seminar (pretest; m= 35.24. s = 10.20, posttest; m= 40.82, s= 9.22). a paired samples t-test was performed to examine differences in practice standards between the pretest and posttest. results revealed a significant difference between these two measures, t(16) = -4.24, p< .001, d= -1.03. in other words, practice standards significantly increased after participating in the education seminar (pretest; m= 4.06. s = 1.78, posttest; m= 5.12, s= 1.32). the most significant barrier we found to implementing this educational session was finding a common time where the 17 ats would all be together and fitting this into their already busy schedules. we determined it was best to provide the educational session separate from the annual in-service day. due to this barrier it was determined that it should be explored if future educational sessions could be offered as an electronic training module to be completed independently. act based on what we learned from this quality improvement investigation study, short-term knowledge, confidence, and practice standards in ats’ recognition and referral of the triad can be significantly improved with a specific educational in-service including an introduction to utilizing triad-specific screening question on the ppe and the female athlete triad cumulative risk assessment as a guideline for athletic clearance determinations. despite widespread awareness and efforts of the triad, many female athletes are currently being cleared at their ppe without being adequately assessed for this syndrome or without appropriate referral for management and treatment.13,18 even with structured education in athletic training education programs and the nata consensus statement as a practice guide, there is a lack of standard of care guidelines for the evaluation and management of the triad.13,18 female athletes with the triad have significant health risks therefore early detection and prevention is key. the 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad expert panel provides an evidencebased approach to a developed risk stratification system that helps to increase the knowledge, confidence, and practice standards in detection and referral for the triad. this quality improvement study provides evidence that when athletic trainers receive specific education on the triad and utilize the ppe screening questions and female athlete triad cumulative risk assessment, their knowledge, confidence, and practice standards for the triad significantly improves. acknowledgements thank you to jessica willis, rstats coordinator at rstats institute in springfield, missouri for assistance with statistical calculations. references 1. otis c, drinkwater b, johnson m, loucks a, wilmore j. acsm position statement: figure 1. athletic trainers' knowledge on the female athlete triad assessment quality improvement in athletic training education on female athlete triad 13 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 the female athlete triad. med sci sports exerc. 1997;29(5):i-ix. https://doi.org/10.1097/00005768199705000-00037. 2. nattiv a, loucks ab, manore mn, et al. acsm position statement: the female athlete triad. med sci sports exerc. 2007;39:1867-1882. https://doi.org/10.1249/mss.0b013e3 18149f111. 3. temme ke, hoch az. recognition and rehabilitation of the female athlete triad/tetrad: a multidisciplinary approach. curr sports med rep. 2013 may 1;12(3):190-9. https://doi.org/10.1249/jsr.0b013e3 1829610b. 4. bonci cm, bonci lj, granger lr, johnson cl, malina rm, milne lw, ryan rr, vanderbunt em. national athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes. j athl train. 2008 jan;43(1):80-108. https://doi.org/10.4085/1062-605043.1.80. 5. caate 2011 5th edition competencies. commission on accreditation of athletic training education website. https://caate.net/wpcontent/uploads/2014/06/5th-editioncompetencies.pdf. accessed october 2019. 6. caate 2020 standards for accreditation of professional athletic training programs. commission on accreditation of athletic training education website. https://caate.net/new-standardsrelease-for-professional-masters-levelathletic-training-programs/. accessed october 2019. 7. wilmore jg. eating disorders in athletes: a review of the literature. j sci sport med. 2001;4(2):145-159. https://doi.org/10.1016/s/14402440(01)80025-6. 8. brownell kd, rodin j. eating, body, weight, and performance in athletes: disorders of modern society. philadelphia, pa: lea & febiger; 1992: 128-143. https://doi.org/10.1016/s14402440.01.80025-6. 9. johnson c, powers ps, dick r. athletes and eating disorders: the national collegiate athletic association study. int j eat disord. 1999;26(2):179-188. https://doi.org/10.1002/(sici)1098108x. 10. fairburn cg, cooper z. the eating disorder examination. british journal of sports medicine. 2002;36(1):45-50. https://doi.org/10.1192/bjp.154.6.807 . 11. troy k, hoch az, stavrakos je. awareness and comfort in treating the female athlete triad: are we failing our athletes? wmj. 2006;105(7):21. 12. kroshus e, defreeze jd, kerr jy. collegiate athletic trainers’ knowledge of the female athlete triad and relative energy deficiency in sport. j athl train. 2018;53(1): 51-59. https://doi.org/10.4085/10626052.11.29. 13. de souza mj, nattiv a, joy e, misra m, williams ni, mallinson rj, gibbs jc, olmsted m, goolsby m, matheson g, panel e. 2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad. br j sports med. 2014;48(4):289. https://doi.org/10.1249/jsr.0000000 000000077. 14. rizzone kh ackerman ke, roos kg, dompier tp, kerr zy. the epidemiology of stress fractures in collegiate studentathletes, 2004-2005 through 20132014 academic years. j athl train. 2017;52(10): 966-975. https://doi.org/10.4085/1062-605052.8.01. 15. tenforde as, barrack mt, nattiv a, fredericson m. parallels with the female athlete triad in male athletes. sports medicine. 2016;46(2):171-82. https://doi.org/10/1007/s40279-0150411-y. https://doi.org/10.1097/00005768-199705000-00037 https://doi.org/10.1097/00005768-199705000-00037 https://doi.org/10.1249/mss.0b013e318149f111 https://doi.org/10.1249/mss.0b013e318149f111 https://doi.org/10.1249/jsr.0b013e31829610b https://doi.org/10.1249/jsr.0b013e31829610b https://doi.org/10.4085/1062-6050-43.1.80 https://doi.org/10.4085/1062-6050-43.1.80 https://caate.net/wp-content/uploads/2014/06/5th-edition-competencies.pdf https://caate.net/wp-content/uploads/2014/06/5th-edition-competencies.pdf https://caate.net/wp-content/uploads/2014/06/5th-edition-competencies.pdf https://caate.net/new-standards-release-for-professional-masters-level-athletic-training-programs/ https://caate.net/new-standards-release-for-professional-masters-level-athletic-training-programs/ https://caate.net/new-standards-release-for-professional-masters-level-athletic-training-programs/ https://doi.org/10.1016/s/1440-2440(01)80025-6 https://doi.org/10.1016/s/1440-2440(01)80025-6 https://doi.org/10.1016/s1440-2440.01.80025-6 https://doi.org/10.1016/s1440-2440.01.80025-6 https://doi.org/10.1002/(sici)1098-108x https://doi.org/10.1002/(sici)1098-108x https://doi.org/10.1192/bjp.154.6.807 https://doi.org/10.1192/bjp.154.6.807 https://doi.org/10.4085/1062-6052.11.29 https://doi.org/10.4085/1062-6052.11.29 https://doi.org/10.1249/jsr.0000000000000077 https://doi.org/10.1249/jsr.0000000000000077 https://doi.org/10.4085/1062-6050-52.8.01 https://doi.org/10.4085/1062-6050-52.8.01 https://doi.org/10/1007/s40279-015-0411-y https://doi.org/10/1007/s40279-015-0411-y quality improvement in athletic training education on female athlete triad 14 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 june 2020 16. tenforde as, sayres lc, mccurdy ml, et al. identifying sex-specific risk factors for stress fractures in adolescent runners. med sci sports exerc. 2013;45:1843– 51. https://doi.org/10.1177/0365354651 5572142. 17. barrack mt, gibbs jc, de souza mj, et al. higher incidence of bone stress injury with increasing female athlete triad risk factors: a prospective multisite study of exercising girls and women. am j sports med. 2014;42(2):949-958. https://doi.org/10.1177/0363546513 520295. 18. nattiv a, loucks ab, manore mm, et al. american college of sports medicine position stand. the female athlete triad. med sci sports exerc. 2007;39:1867– 82. https://doi.org/10.1249/mss.0b013e3 18149f111. https://doi.org/10.1177/03653546515572142 https://doi.org/10.1177/03653546515572142 https://doi.org/10.1177/0363546513520295 https://doi.org/10.1177/0363546513520295 https://doi.org/10.1249/mss.0b013e318149f111 https://doi.org/10.1249/mss.0b013e318149f111 manuscript type quality improvement (pdsa cycle) report 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 implementing a behavior health policy in the secondary school jamie nikander, dat, lat, atc1; lindsey e. eberman, phd, lat, atc2 1west olympia sports medicine, olympia, wa; 2indiana state university, terre haute, in abstract site-specific policies and procedures outlining the available services and emergency action plan (eap) is vital to any athletic training clinic. the purpose of the following document is to provide athletic trainers with a framework for the development and successful implementation of evidencebased policies and procedures to improve athletic training services at secondary schools. using a behavioral health policy as an example, the challenges and barriers to the development and implementation of new policies at a secondary school will be discussed. policy development was largely influenced by each of the individual stakeholders involved in the approval process including school administration, school nurses and counselors, as well as community organizations. as in any setting, challenges to implementation of the behavioral health policy in these schools did occur. each secondary school or school district will have a different model for medical services that will inherently change the policy at each location. athletic trainers must know the resources available to them on and offcampus, and develop policies and procedures dependent on these resources. for clinicians in any athletic training setting, it is important to review your current policy and procedure manual to determine where improvements can be made. these documents help ensure patients are being provided the best possible care and help protect athletic trainers legally. key phrases policy and procedure development, professional standards, secondary schools patient population correspondence dr. jamie nikander, west olympia sports medicine, 1620 cooper point rd sw, olympia, wa 98502. e-mail: jamie.nikander@providence.org twitter: @jnikanderatc full citation nikander j, eberman le. implementing a behavior health policy in the secondary school. clin pract athl train. 2018;1(1):21-29. https://doi.org/10.31622/2018/0001.5 submitted: may 8, 2018 accepted: may 29, 2018 current model in 2011, the commission on accreditation of athletic training education (caate) published the 5th edition of the competencies required to be taught and evaluated in entry-level athletic training education.1 “psychosocial strategies and referrals”1 remains to be a stand-alone competency vital to the minimum education for athletic trainers.1 identification, referral, and support for patients with behavioral health conditions will also be included in the updated competencies that will apply in 2020 as minimum athletic training education advances to a master’s degree.2 athletic trainers must have the ability to recognize when a patient is experiencing a social, emotional, or psychological concern.1,3 in addition to simple recognition, the role delineation study,4 which guides practicing athletic trainers4, states that athletic trainers must understand the steps for intervention which includes emergency management, emergency action planning, and appropriate referrals. although athletic trainers may currently be familiar with the impact of injury on mental health as it relates to athletic identity and participation, it may be even more important to understand underlying behavioral health conditions and when life events that are related, or unrelated, to athletic participation may trigger a more serious psychological concern.3 in the college and university setting, athletic trainers have resources from both the national athletic trainers association (nata), the national collegiate athletics association (ncaa), and each individual institution regarding psychological concerns in this population. however, for athletic trainers in the secondary school setting, there may be limited resources. as most colleges and universities have student health centers and psychological services available for referral on campus, secondary school athletic trainers may be in a unique setting to require community resources and outside relationships to assist in management and referral of these patient cases. athletic trainers in the secondary school setting need to have an understanding of the common conditions https://doi.org/10.31622/2018/0001.5 implementing a behavior health policy in the secondary school 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 experienced by their patient population, and have site-specific policies and procedures reflective of best practices. site-specific policies and procedures outlining the available services and emergency action plans (eap) is vital to any athletic training clinic to minimize organization and personal risk.4 the first step for athletic trainers is to establish the need for site-specific policies and prioritize the development of these policies based on patient needs. in review of the current policies and procedures manual at the target high school, there was a clear need for several new or updated policies. within the needs assessment, we noted that a behavioral health policy was not currently included in the policy and procedure manual. as athletic trainers are bound by the practices set forth in position and consensus statements provided by the nata, it was clear that our clinic could be legally vulnerable in a legal setting without procedures guiding the management of psychological concerns. of the identified needs, the behavioral health policy then became our first priority. the purpose of the following document is to provide athletic trainers with a framework for the development and successful implementation of evidence-based policies and procedures to improve athletic training services at secondary schools. using the process of developing a behavioral health policy for three high schools within a rural school system in indiana as an example, the challenges and barriers to the implementation of new policies at a secondary school will be discussed. pdsa cycle plan researching the topic for your chosen policy and procedure is important for the drafting of the document, as well as the advocacy and education that may be required for staff and stakeholders to buy-in to implementation. for the behavioral health policy, research was focused on epidemiology of mental health concerns in adolescents5,6, recommendations for best practices3,7, athletic trainers practice analysis4, and what athletic trainers already know about identifying psychosocial concerns.8 in the research phase, we also chose to reach out to school counselors as a key resource in the development of the policy. the school counselors provided us with specific contact information for community behavioral health resources, contact information for appropriate school administration as well as current policies for management of behavioral health concerns during school hours. during school hours, teachers and other school personnel had direct access to guidance counselors as well as an established emergency response team. although these individuals were not on campus during most athletic practices and events, it served as a framework for the hierarchy of communication within the school administration that we needed to implement when an incident did occur. after discussion with guidance counselors, we were also able to establish the best mechanism for follow-up of non-emergent concerns that could be addressed during the following school day, which was an important portion of our final document. table 1. timeline for implementation of behavior health policy. draft document january 12 review draft with supervisor january 20 schedule meeting with outreach coordinator january 31 develop educational materials february 15 schedule meeting with school counselors february 20 schedule meeting with school nurse february 25 schedule meeting with school administration february 28 edit document with stakeholder feedback march 1 submit for final approval march 15 disperse to each secondary school march 20 discuss policy with staff and students march 25 it is also important to consider each of the individual players that might be involved in the approval process of a new policy. stakeholder buy-in is a common challenge encountered when attempting to implement change in any setting. the timeline for implementation included individual meetings with each stakeholder that would be impacted or included in the policy. developing education materials such as handouts and microsoft powerpoint® presentation may be implementing a behavior health policy in the secondary school 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 an effective way to communicate the importance of the change you are intending to implement at each of these stakeholder meeting. the individual meetings and discussions that were included in the process of implementing a behavioral health policy were integral to the successful approval by the school board (table 1). do the behavioral health policy was developed for a hospital-based athletic training outreach program that provided services to three area secondary schools. the purpose of the policy was to outline the referral and management processes for psychological concerns. the policies were highly reflective of the suggestions from the nata interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement.3 table 2 outlines the sections that were present in our policy and procedure document that were developed based on best-practice guidelines. table 2. sections of behavioral health policy & procedure document. policy brief statement of guiding principles recognition depression, anxiety disorders, substance and alcohol abuse, adhd, eating disorders/disordered eating, bullying, and hazing procedures emergency referral, nonemergent referral, bullying, suspected child abuse, documentation contacts school administration, school counselors and nurses, community emergency rooms, community behavioral health centers when developing the document, keep the audience, most likely highly influential stakeholders, in mind. the final policy and procedure (appendix a), whereby the introduction included information to establish the need for the patient population as well as the policy. especially for a topic such a psychosocial concerns, it was important to educate stakeholders on what the impact of these conditions are in secondary school settings, as well as the educational background and role that athletic trainers are prepared to play when such situations arise.4 when drafting a document, it is also important to remember that a policy is very different from procedures, and they should be easily identified as separate components of a document. a policy should be a short 2-3 sentence summary of the overall expectations or principles for the policy. a procedure on the other hand, are typically long, very descriptive, step-by-step instructions on how to achieve the policy.9 the following is an example of the behavioral health policy developed for these schools: the athletic trainer is responsible for the recognition and referral of psychological concerns in studentathletes. the athletic training staff will differentiate between emergent and non-emergent concerns and refer to the school administration and appropriate medical professionals in all cases. the athletic training staff will report any concerns to the high school administration and parents/guardian for further case management. study as in any setting, challenges to implementation of a new policy in the secondary school setting did occur. for this particular model of outreach athletic training services, a policy/procedure had to be developed that was broad enough to cover 3 different athletic training facilities. this document did not include any site-specific contact information or emergency action plan details. this model would then allow for the approval of an overarching behavioral health policy that would then require each individual clinic to develop an amendment to this document that included site-specific contact information and locations. the biggest challenge was the lack of accountability for individual clinics to develop site-specific policies and procedures. the response to a behavioral health incident may not be as effective without the requirement of this amendment from each individual clinic. another unexpected barrier was the inconsistency of hours that school nurses spent onimplementing a behavior health policy in the secondary school 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 campus. the school district has a pool of school nurses that provide services during limited hours at several different locations depending on weekly needs. during initial drafting of this document, school nurses played important roles as potential healthcare providers to assist in response and follow-up care for emergency cases such as self-harm or physical violence towards others. however, after meeting with several stakeholders, we decided to edit the document to reflect minimal requirements of school nurses to respond or be involved in these patient cases. although the model for secondary school services will be different at each site, it is important for athletic trainers to know the resources available to them on-campus and within the community, and develop policies and procedures dependent on these resources. an additional barrier during implementation was the sharing of medical information related to a patient. the health insurance portability and accountability act (hipaa) and the family education rights and privacy act (ferpa) place strict and important guidelines for the protection of personal health information of minors.10 in the development of the behavioral health procedures, school counselors were a required call after an emergent situation, as well as a resource for athletic trainers in non-emergent cases. upon review of the confidentiality waiver located in athlete’s pre-participation evaluation, it appeared that school counselors were not specifically listed as individuals in which health information may be shared. to avoid any potential legal complications for sharing medical or personal information between athletic trainers and school counselors, the form was modified to specifically list school guidance counselors. this will hopefully ensure that each patient and parent will be agreeing to the collaboration of these individuals in patient care. act for clinicians in any athletic training setting, it is important to review your current policy and procedure manual to determine where improvements can be made. policy and procedure manuals are meant to guide clinical practice at your site, and include details about any services you may provide. these documents help ensure your patients are being provided the best possible care, but they also help protect you legally. although the current project remains in the “study” phase, the information gathered will need to be used to enhance and continually evolve this policy. school administrators and athletic trainers should conduct an end-of-year review to discuss modifications and improvements to the policy. the efficiency of emergency response, timeliness of communications and referrals, as well as patient outcomes may be areas worth evaluating. clinical bottom line the first step to in improving your policies is to establish the need. this step may include researching nata position and consensus statements to evaluate how your current practices compare to best practice guidelines. during development of policies and procedures, it is important to meet and discuss procedures with each stakeholder who may be involved and impacted after implementation. after approval from the needed stakeholders, it is also important to remember that the process is not yet complete. staff education and evaluation of policy and procedure implementation success is a continuous process. although barriers will undoubtedly arise during the development and implementation process, improving policies and procedure manuals for athletic training services in the secondary school setting is possible with a clear plan and the inclusion of stakeholders throughout the process to improve buy-in. references 1. national athletic trainers association. the athletic trainer educational competencies. 5th edition. the comission on accredidation of athletic training education, austin tx. 2011. accessed january 2017. 2. caate 2020 standards for accreditation of professional athletic training programs. comission on accreditation of athletic training education website. https://caate.net/new-standards-releasefor-professional-masters-level-athletictraining-programs/. accessed may 2018. 3. neal tl, diamond ab, goldman s, et al. interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. j athl train. 2015;50(3):231-249. implementing a behavior health policy in the secondary school 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 https://doi.org/10.4085/1062-605050.3.03 4. henderson, j. the 2015 athletic trainer practice analysis study. omaha, ne: board of certification; 2015. accessed january 2017. 5. mental health information. national institute of mental health website. www.nimh.nih.gov/health/topics/index.shtml. accessed january 2017. 6. substance abuse and mental health services administration, results from the 2013 national survey on drug use and health: mental health findings. nsduh series h-49, hhspublication no. (sma) 14-4887. 7. rockville, md: substance abuse and mental health services administration, 2014. 8. bonci cm, bonci lj, granger lr, et al. national athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes. j athl train. 2008;43(1):80-108. https://doi.org/10.4085/1062-605043.1.80 9. cormier ml, zizzi sj. athletic trainers' skills in identifying and managing athletes experiencing psychological distress. j athl train. 2015;50(12):1267-1276. https://doi.org/10.4085/1062-605050.12.02 10. ray r, konin jg. management strategies in athletic training. 4th edition. champaign, il: human kinetics; 2011. 11. department of education. joint guidance on the application of the family educational rights and privacy act (ferpa) and the health insurance portability act of 1996 (hipaa) to student health records. 2008. https://www2.ed.gov/policy/gen/guid/fpc o/doc/ferpa-hipaa-guidance.pdf. accessed january 2017. https://doi.org/10.4085/1062-6050-50.3.03 https://doi.org/10.4085/1062-6050-50.3.03 https://doi.org/10.4085/1062-6050-43.1.80 https://doi.org/10.4085/1062-6050-43.1.80 https://doi.org/10.4085/1062-6050-50.12.02 https://doi.org/10.4085/1062-6050-50.12.02 implementing a behavior health policy in the secondary school 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 appendix a psychological concern: recognition and referral policy introduction the rate of mental disorders in youth is high, with approximately 1 in every 4-5 meeting the criteria.1 athletic trainers in the secondary school setting may play a vital role in identifying and referring patients with psychological concerns. adolescent athletes are exposed to the same stressors that place them at-risk for new or worsening mental disorders as other adolescents; however, performance expectations, time-loss, career ending injuries, team conflict, and other sports-related pressure may cause additional strain.1 although approaching patients regarding mental health may be uncomfortable or new for athletic trainers, we may have unique relationships with our patients that allow them to confide, seek help, or speak openly in our presence. the secondary school athletic trainer must be prepared to recognize, respond, refer and advocate for a patient’s mental health appropriately. this policy was developed for a hospital-based athletic training outreach program with the purpose of outlining the referral and management process of psychological concerns. the policies outlined below were highly reflective of the suggestions from the national athletic trainers’ association (nata) interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement, 1 and athletic trainers should familiarize themselves with this resource. this consensus statement, as well as an nata position statement regarding mental health, can be found on the nata website. policy the athletic trainer is responsible for the recognition and referral of psychological concerns in studentathletes. the athletic training staff will differentiate between emergent and non-emergent concerns and refer to the school administration and appropriate medical professionals in all cases. the athletic training staff will report any concerns to the high school administration and parents/guardian for further case management. recognition distinguishing an emergent versus a non-emergent case is crucial in the management of psychological concerns in athletes and is outlined in the consensus statement as well as later in this policy. as athletic trainers we interact with our patients often daily, and build close relationships. triggering events in life or sport can cause the worsening or development of a psychological concern. it is important for athletic trainers to be empathetic and recognize when these triggering events may have occurred to better monitor the patient’s status. triggering events specific to athletes may be overtraining, termination of sport participation, inability to manage sport, academic, and personal expectations, injury, as well as any changes in home or social environments. athletic trainers may see these events begin to affect motivation, pain levels, injury occurrence, attention, mood, or behavior. although there does not always need to be a specific triggering event prior to development or worsening of a mental disorder, athletic trainers need to recognize these changes as they are some of the primary signs of mental disorders. the primary mental disorders discussed in the nata consensus statement include: • depression • anxiety disorders • substance and alcohol abuse • adhd • eating disorders implementing a behavior health policy in the secondary school 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 • bullying and hazing. athletic trainers should read this consensus statement and understand the signs and symptoms of each. detailing each disorder is beyond the scope of this policy, but athletic trainers should attest to having read and understood this document, as well as the consensus statement, prior to patient contact. suicide any student-athlete who has expressed intent, indicated a plan, or has attempted or discussed attempted suicide, should be treated as an emergency referral. athletic trainers should not engage in an attempt to determine the seriousness of the expressed thoughts. stay with the patient, listen, and make an immediate referral. • if an attempt is in progress: call ems. • if an attempt has not already begun: call the school counselor and/or school administrator. parent/guardian will also be notified immediately. if these individuals are not available to respond, call the “insert community resource name.” procedures as stated in nata interassociation recommendations for developing a plan to recognize and refer studentathletes with psychological concerns at the secondary school level: a consensus statement, a “yes” to any of the following questions should constitute an emergency: o am i concerned the student-athlete may harm himself/herself? o am i concerned the student-athlete may harm others? o am i concerned the student-athlete is being harmed by someone else? o did the student-athlete make verbal or physical threats? o is the student-athlete exhibiting unusual ideation or thought disturbance that may or may not be due to substance use? o does the student-athlete have access to a weapon? o is there potential for danger or harm in the future? any threat or perceived suicide attempt, changes in mental status or destructive behaviors constitutes an emergency under any circumstances and ems should be activated. in the case of a “yes,” school administration (principal/athletic director and school counselor) should be immediately notified. if administration is currently not on-site, they should still be notified about the incident as soon as reasonably possible. if possible, one athletic trainer will continue to monitor and manage the patient, while another athletic trainers call administration, parents, and/or referral. if a second athletic trainer is not available, a school administrator can be used to contact parents. the responding school administrator will also be responsible for activating ems if needed. if possible, the athletic trainer should always defer the incident to a school counselor, administrator, or the school nurse or health assistant. as a school nurse is not always on campus, athletic trainers should report to the guidance counselor first. once a non-emergent situation is deferred to a school administrator, the athletic trainer can be relieved of immediate responsibility and return to other duties. bullying: the school corporation has a no-tolerance policy for bullying of any kind. bullying can include physical, sexual, or emotional abuse. if the athletic trainer witnesses or suspects bullying, this includes hearing student-athletes discussing previous events, they are to report to the school administration or school guidance counselors immediately. the athletic trainer will intervene in the case of active bullying. child abuse: suspicion alone mandates and justifies action by a healthcare provider. athletic trainers will make a direct report to department of children’s services or a law enforcement agency. however, athletic implementing a behavior health policy in the secondary school 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 trainers will report that a call was made to appropriate school administrators and the sports medicine director. • child protective services: 1-800-800-5556 emergent referral process listed below are the options for referral or resources in the case of an emergency. 1. list local behavioral health organizations & contact information 2. list local emergency rooms & contact information 3. national suicide prevention lifeline: 1-800-273-talk (8255) 4. child abuse/neglect hotline: 1-800-800-5556 non-emergent referral process student-athletes must be referred to the school counselor prior to non-emergent referral to the local behavioral health clinic. our school corporation has a working relationship with this clinic and the proper forms required for referral are available from a school guidance counselor and attached to this document. notify parents, school administration, and counselors. documentation after any of the above incidents, multiple levels of documentation are required within 48 hours of the incident. 1. “incident report” formthis form is available from the athletic office. upon completion, follow instructions on the form to distribute to the athletic director or appropriate administrator. a. this form can be saved on the computer, but needs to be password protected. 2. sportsware (medical records system)-document this incident in the “notes” tab under the “athletes” tab. no specific injury needs to be created unless relevant. this documentation needs to at least include: a. date b. time c. observations d. summary of patient encounter e. who was contacted and when f. referral g. plan of care/follow-up. 3. following a mental health referral, a note from the treating healthcare provider should be obtained prior to return to activity. legal considerations in the case of self-harm, or harm to others, patients and parents should be aware that patient and personal information will be shared among appropriate personnel. this is addressed in the medical release form of the pre-participation physical packet. contact information each individual school should compile a contact list and working relationships with the following personnel to effectively execute these policies and procedures: • principal implementing a behavior health policy in the secondary school 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 • assistant principal • athletic directors • assistant athletic directors • school nurse/nurses and health assistants • school counselors • local behavioral health centers and hospitals. sources of additional information • emergency action plan guidelines: mental health emergency secondary school athletes https://www.nata.org/sites/default/files/mental_health_eap_guidelines.pdf • interassociation recommendations for developing a plan to recognize and refer student athletes with psychological concerns at the secondary school level: a consensus statement • indiana state suicide prevention plan: http://www.in.gov/issp/files/plan.pdf • indiana state statutes: https://www.childwelfare.gov/topics/systemwide/lawspolicies/state/?cwigfunctionsaction=statestatutes:main.getresults • suicide prevention organizations in indiana (contacts) http://www.in.gov/isdh/25392.htm reference 1. neal tl, diamond ab, goldman s, et al. interassociation recommendations for developing a plan to recognize and refer student-athletes with psychological concerns at the secondary school level: a consensus statement. j athl train. 2015;50(3):231-249. https://www.nata.org/sites/default/files/mental_health_eap_guidelines.pdf http://www.in.gov/issp/files/plan.pdf https://www.childwelfare.gov/topics/systemwide/laws-policies/state/?cwigfunctionsaction=statestatutes:main.getresults https://www.childwelfare.gov/topics/systemwide/laws-policies/state/?cwigfunctionsaction=statestatutes:main.getresults http://www.in.gov/isdh/25392.htm manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 developing the athletic training clinical scholar lindsey e eberman indiana state university, terre haute, in key phrases practice-based research, practice-led research, quality improvement correspondence dr. lindsey eberman, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: lindsey.eberman@indstate.edu twitter: @isuathltraining full citation eberman le. developing the athletic training clinical scholar. clin pract athl train. 2019;2(1): 1-3. https://doi.org/10.31622/2019/0001.1. submitted: february 3, 2019 accepted: february 19, 2019 editorial the 2020 standards for accreditation of professional athletic training programs1 requires that athletic training programs prepare their graduates to integrate the core competencies into their clinical practice. the core competencies derived from the former institute of medicine,2 and now national academy of medicine healthcare competencies, include patientcentered care, interprofessional and collaborative practice, evidence-based practice, quality improvement, health care informatics, and professionalism. throughout these core competencies graduates are expected to use evidence to inform practice (standard 62), use systems of quality improvement (standard 63), and use data to drive informed decisions (standard 64).1 in the development of a patient care plan, graduates will need to be able to assess the patient’s status on an ongoing basis by collecting and analyzing patient-reported and clinician-rated outcomes (standard 69).1 all of these tactics contribute to scholarly clinical practice by informing decisions locally, but could also inform the practice of others, thus having a global affect through dissemination as practicebased research. as programs strategize how to teach these tactics to students, administrators are also likely deliberating how to support core faculty and planning for ongoing training of preceptors to demonstrate contemporary expertise. programs should consider this an opportunity to meet all of the standard expectations using the aforementioned scholarly clinical practice tactics and practice-based research. however, to effectively engage students, preceptors, and core faculty, program administrators must cultivate buy-in and expose everyone to different types of practice-based research. specifically, a shift from faculty-led student scholarship to preceptorfacilitated clinical scholarship will need to occur. but this shift can’t perpetuate conflicts between “the classroom” and “the athletic training facility” where these often assumptions between stakeholders in both environments that scholarly practices is not occurring. as these expectations shift, programs need to provide resources and help preceptors recognize that implementing these tactics will not only improve their clinical practice, but will also have the added benefits of enhancing clinical teaching and creating opportunities for collaboration with faculty to disseminate practice-based research. practice-based research involves clinicians answering relevant healthcare questions that matter to them and their patients, and translating research findings into practice. this can be achieved through a variety of scholarly activities. examples of scholarship that require critical appraisal of the literature include evidence to practice reviews and validation case reports. in an evidence to practice review, a clinical scholar develops a question, hopefully about a problem they are trying to solve in their own practice, reviews the available literature, identifies a systematic review or meta-analysis, and helps to interpret and summarize this level 1 evidence for others. to apply this evidence to practice, the clinical scholar can take the systematic review or meta-analysis and apply the research recommendations with one patient, or a series of https://doi.org/10.31622/2019/0001.1 developing the athletic training clinical scholar 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 1 – february 2019 patients, to determine if the best-evidence recommendations actually work in clinical practice. these are validation case reports and help us understand whether controlled studies with homogenous participant populations can translate in the real world. athletic training students and preceptors can partner in development of evidence to practice reviews and validation case studies, especially as a scholarly activity early in an academic program where critical appraisal of the literature is the primary learning outcome. quality improvement is a systematic approach to analyzing clinical practice and improving performance. one of the first mechanisms of quality improvement is self-reflection, such as accurately viewing our own practice, and is achievable through tasks such as chart reviews. reflection should be a regular habit in clinical practice, and can move from self-reflection to seeking feedback from others such as colleagues or a directing physician. the act of chart reviewing can also serve as a mechanism to explore shared characteristics of patient histories, how we use selective tissue testing in developing a differential diagnosis, rates of diagnoses, or time to recovery after using specific interventions. document and chart reviews serve as an appraisal of one’s own practice and help clinical scholars appreciate the landscape of the healthcare clinic or facility. they help us define what is currently happening and are the first step in the plan-do-study-act cycle of quality improvement. these are also a form of point-of-care research, particularly those that synthesize several patient cases to determine trends in practice. from a preceptor perspective, this might serve as a preliminary mechanism to teach athletic training students about the expectations of medical documentation while also helping to inform clinical practice decisions in the future. once a clinical scholar has a good understanding of the current practice landscape, they can begin to explore what changes need to be made to enhance efficiency by comparing current processes with those detailed as best-practices in the evidence. then the clinical scholar can apply and study the change; analyze the data, and determine if the change resulted in the expected outcome. finally, based on the data, clinical scholars will adapt, adopt, or abandon the change. this process, the plan-do-study-act cycle, is a form of quality improvement and can be documented and disseminated. the key to any quality improvement project is to understand that it is a continuous process, not just a one-time activity. so engaging students in this process regularly and continuously will socialize them to the tactics and make them habitual in clinical practice. to effectively assess a patient’s progress, athletic trainers need to be collecting and analyzing patient-reported and clinician-rated outcomes. clinical outcomes research is a mechanism for communicating how measurement tools have been used in practice. because these papers can be written from a variety of perspectives, clinical scholars could evaluate a specific outcome measure, or compare multiple measures in several patients from the same population or experiencing the same injury or illness. the application of outcome measures with one single patient is a great first step toward clinical integration. this data gathering technique can help with individual patient progress and ensure patient safety. as clinical scholars evolve, they should consider applying outcome measures to larger populations to determine clinician effectiveness, specifically regarding the interventions we apply. clinical practice effectiveness of physical medicine and rehabilitation procedures is largely unknown, especially regarding interventions applied to patients that are not college-aged, white, or male. unfortunately, most best-practice recommendations have been developed from high quality evidence, but in very homogeneous and often uninjured populations, which limits some of the recommendations. clinical outcomes research can help develop evidence to support our decision-making, and because it is a tactic that we should be doing with each and every patient in their personalized care plans, it should be part of daily duties. as athletic training students move from interdependence to independent clinical developing the athletic training clinical scholar 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 1 – february 2019 care, one mechanism for practice performance evaluation in clinical education is a clinical outcomes research report, where the student demonstrates clinical competence through patient outcomes to preceptors and program personnel. clinicians hoping to integrate evidence into their practice are looking for clinically relevant research, which is evidence that comes from within practice and informs decisions at a global level. the traditional thesis is no longer relevant to meet these needs, especially for developing a clinical scholar. professional masters programs should strongly consider these practice-based research initiatives as they meet multiple standards1 and outcomes of the program. these activities should transcend the program through sequentially planned experiences over the course of the curriculum. a constructivist approach that has students making meaning from experience to experience, reinforces the previous learning and minimizes the stigma of research in clinical practice. this is how we change the culture of athletic training and embrace evidence in clinical practice! references 1. commission on accreditation of athletic training education. 2020 standards for accreditation of professional athletic training programs. available at: https://caate.net/wpcontent/uploads/2018/09/2020standards-for-professional-programscopyedited-clean.pdf. accessed on january 26, 2019. 2. institute of medicine. crossing the quality chasm: a new health care system for the 21st century, washington, dc; 2001. https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf manuscript type disablement model case study 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 acute management of an abductor digiti minimi strain in a collegiate baseball player: a patient-centered case study s. andrew cage, med, lat, atc1,2, diana m. gallegos, ms, lat, atc1, brandon j. warner, med, lat, atc2,3 1the university of texas at tyler, tyler, tx; 2the university of north carolina greensboro, greensboro, nc , 3grand canyon university, phoenix, az abstract the purpose of this disablement model case study was to describe the case of a collegiate baseball player suffering from an isolated abductor digiti minimi strain. despite an initial decrease in function, the treating sports medicine staff was able to provide the necessary care to allow the patient to participate in the final games of his career. while the anatomy and function of abductor digiti minimi are well described in the literature, there is no documentation of isolated abductor digiti minimi injuries. in this case, the patient injured the medial aspect of his hand when hitting a baseball. the patient experienced immediate pain along with the sensation of “tightening” throughout the hypothenar eminence. the following day the patient reported difficulty with sleeping and daily activities due to pain. although fracture tests were negative, the patient exhibited significant weakness and pain with fifth finger abduction and flexion leading to physician referral. the team physician noted pain with active ulnar deviation in addition to previous symptoms. at this time, the patient was diagnosed with an abductor digiti minimi strain. the patient stated that he was in his final season of competition and wished to continue participating with his team. the patient consented to a treatment plan involving local injection of lidocaine and bupivacaine along with compression via kinesiology tape®. using these methods, the patient was able to participate in the final two games of his career. following the cessation of baseball activities, the patient noted that he had no recurrent symptoms or complications from his injury. when prescribing treatment for patients in a competitive setting, it is paramount that clinicians take into account patient centered values. if there is no risk of significant, long term injury, clinicians should attempt to provide patients with the means to participate in activities if they should desire. key phrases abductor digiti minimi, college and university patient population, functional testing correspondence s. andrew cage, the university of texas tyler, 11325 preakness dr., flint, tx 75762. e-mail: sacage@uncg.edu full citation cage sa, gallegos dm, warner bj. acute management of an abductor digiti minimi strain in a collegiate baseball player: a case study. clin pract athl train. 2018;1(2):9-13. https://doi.org/10.31622/2018/0002.3. submitted: august 16, 2018 accepted: october 1, 2018 introduction the abductor digiti minimi is a small muscle that makes up a portion of the hypothenar eminence. originating from the pisiform, pisohamate ligament, and flexor retinaculum, the abductor inserts on the proximal phalanx of the fifth digit as well as the sesamoid bone when present. primarily, this muscle is responsible for the abduction of the fifth digit.1 the muscle receives its neurological innervation from the deep branch of the ulnar nerve and vascular supply from the ulnar artery.2 apart from its role in fifth digit abduction, no other functions have been described for the abductor digiti minimi. the abductor digiti minimi has been implicated in approximately a quarter of the cases of dupuytren’s contracture of the hand.3 in some cases, this compression of the ulnar nerve can be caused by the presence of an accessory abductor digiti minimi muscle.4 in spite of the abductor digiti minimi’s involvement in ulnar nerve pathologies, there is no peer reviewed literature describing an isolated injury to the abductor digiti minimi.3,4 furthermore, without a body of literature, it is difficult to create an evidence based approach to treating these injuries and the subsequent dysfunctions that occur. thus, it is the purpose of this case study to describe an isolated abductor digiti minimi in a collegiate baseball player. this case will describe the mechanism of injury, https://doi.org/10.31622/2018/0002.3 acute management of an abductor digiti minimi strain in a collegiate baseball player: a patient-centered case study 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 diagnosis, treatment, patient reported disablements, and outcomes. patient information the patient described in this case is a right 22year-old collegiate baseball player who fielded the shortstop position. when playing, the patient would throw right-handed and bat left-handed. the patient had a previous history of surgical excision of the hook of the hamate in his right hand from the previous year, but was otherwise healthy and fully functional. after hitting a baseball during competition, the patient reported immediate pain along the medial aspect of his right hand. initial evaluation revealed moderate pain, but full strength and range of motion with all wrist and digit motions. for the remainder of the game, the patient was able to participate at full capacity, but was instructed to report to the athletic training staff the following day. differential diagnosis and evaluation the following day, the patient reported to the athletic training clinic complaining of increased pain. the patient stated that the pain had disrupted his sleep, made it difficult to turn the steering wheel of his car while driving to the clinic, and was significantly worse than the previous day. the patient’s hand was diffusely tender to palpation along the medial aspect of the hypothenar eminence. while all fracture tests were negative, the patient presented with enough pain and weakness with fifth digit abduction and grip strength that physician referral was warranted. at this time, the differential diagnosis included: tfcc injury, wrist sprain, wrist strain, subluxing extensor carpi ulnaris. two days after the initial injury during the team physician’s evaluation, it was also noted that the patient was experiencing pain with ulnar deviation. however, the most explicit pain and weakness was elicited with resisted fifth digit abduction. following a comprehensive exam, the patient was diagnosed with an abductor digiti minimi strain. it was at this time that the patient expressed his concern regarding his ability to participate in the upcoming tournament. his concern were compounded by the fact that he was in his last year of eligibility, and the upcoming tournament represented his last opportunity to participate in collegiate baseball. with the patient’s desires and values in mind, treatment options were discussed, and the patient was educated on the potential outcomes of all of them. given that other conservative treatment options would have resulted in a significant delay in returning to competition, the decision was ultimately made to perform local injections of lidocaine and bupivacaine at the insertion of the abductor digiti minimi prior to the upcoming competitions in addition to being taped to provide as much compression as possible without inhibiting function (figure 1). kinesiology tape® was chosen to allow the patient the most range of motion possible at the wrist while also providing compression. a first strip of tape was cut and then applied over the medial aspect of the hypothenar eminence with 50 % tension. a second strip of tape was split half way, with the anchor covering the ulnar styloid. once the anchor was affixed, the split ends of the tape were then wrapped around the wrist medial to lateral in an effort to provide as much compression as possible without occluding neurovascular structures. body structure and function given that the injury was muscular in nature, the primary diagnostic tools utilized were strength and range of motion tests. at the initial time of injury, the patient presented with full range of motion and adequate wrist and digit strength with only mild pain. however, by the following day, the patient’s strength with fifth digit abduction had decreased to a 4/5. the patient was still able to perform ulnar deviation with full acute management of an abductor digiti minimi strain in a collegiate baseball player: a patient-centered case study 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 figure 1: compression tape for digiti mini strain. strength, but noted increased pain from the previous day. additionally, the patient could no longer perform the motion without experiencing significant pain. activity and participation in order to determine if the patient would be able to participate in the upcoming games, functional testing was performed consisting of hitting and throwing drills prior to the initiation of interventions. with the decrease in strength and increase in pain, the patient began to experience difficulty gripping his bat and throwing with both accuracy and velocity. if the patient decreased his velocity he could throw more accurately, but he expressed concern that this may affect his ability to remain competitive at his position. the patient stated that he believed that he would be able to improve both the accuracy and velocity of his throws if his pain levels were decreased. environmental and personal factors outside of baseball related activities, the patient stated that the pain he was experiencing in his hand was affecting his daily activities. specifically, the patient stated that the intensity of pain inhibited his ability to obtain quality sleep and drive his motor vehicle. other activities that the patient’s hand pain affected included being able to type on his computer. the patient reported having to change his typing form in order to mitigate the intensity of pain he was experiencing. this change in form resulted in the patient’s homework assignment taking significantly longer than it would have otherwise. given the inconveniences created for the patient’s in his collegiate activities and in his daily life, he wished for his injury to be healed as quickly as possible interventions three days post injury, the patient was seen in the athletic training room prior to his first postseason competition. the patient’s skin was prepped using an alcohol prep pad, and a mixture of lidocaine and bupivacaine was injected near the proximal aspect of the hypothenar eminence. two strips of kinesiology tape® were then used to provide as much compression as possible without impeding wrist or hand motion. while this technique had not necessarily been described in the current literature, the clinician used knowledge of the structures being taped and the principles behind compression tape to approximate the best tape job possible for the goals in mind. follow up evaluation revealed that the patient did not experience any further pain at rest, or with motion, and demonstrated full strength with fifth digit abduction and grip strength. the patient was then taken to the field to ensure that he would be able to grip and swing a bat, and grip and throw a baseball. after demonstrating the ability to swing a bat without pain, the patient then hit off of a tee to provide resistance to his swing. once the patient had passed this sportspecific testing, the patient was cleared to participate in the day’s competition. outcomes body structure and function the patient was able to regain fifth finger abduction, wrist ulnar deviation, and grip acute management of an abductor digiti minimi strain in a collegiate baseball player: a patient-centered case study 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 strength after the application of lidocaine and bupivacaine injections in combination with compression taping at the proximal aspect of the hypothenar eminence. along with the recovered strength, the patient noted that there was little to no pain for roughly three hours post injection. however, after the three hour time frame had elapsed, his pain gradually increased again. when asked, the patient said this period of relatively pain-free activity was enough to allow him to comfortably and effectively participate in his competitions at full function. activity and participation through the use of the proposed treatment plan, the patient was able to participate in the final two contests of his career. while participating, the patient was able to perform at a high level and maintain the standard of performance he had throughout the season. the patient noted that if any of the competitions had gone longer than their regulation length, he may have had increased difficulty in completing in them, but had no severe issues completing a standard game. aside from baseball, both sleeping and activities of daily living that required gripping or fifth digit abduction continued to bother him. if the injury had taken place during the regular season, the patient may have required considerations from his instructors regarding completion of course work that required a large amount of typing or writing. fortunately, the academic year had concluded by this point in the season, and the patient was not required to perform extensive writing or typing that might have exacerbated the symptoms of his injury. within a week of completing his final season, the patient reported significant decreases in pain following relative rest combined with regular icing and nsaid usage, and was pain free by the twoweek mark. environmental and personal factors given the patient’s expressed desire to participate in the final competitions of his playing career, he remained stringently adherent to all appointments and measures taken to allow him to participate. while the patient reported a slight increase in pain from baseline following each of the two competitions, he stated that is was well within tolerable limits if it meant he was allowed to continue to play. furthermore, the patient was not allergic to lidocaine, bupivacaine, or the adhesive from the kinesiology tape®. as such, the patient suffered from no adverse effects from the chosen treatment course. discussion this case describes the diagnosis and management of a patient suffering from an isolated abductor digiti minimi strain. while the abductor digiti minimi’s involvement in other pathologies has been described, there is no documentation detailing strains to the muscle and the treatment thereof.3,4 fortunately, this case resulted in a positive outcome for the patient which allowed him to achieve his goals. however, the short timeframe did not allow for a measurement of progression of the injury while continuing participation in baseball. had this injury occurred at a different phase of the season, the clinician would have been able to attempt other conservative treatments and chart the progression of the patient’s outcomes in order to determine the best possible course of treatment in future instances. this means that the case presented may not be generalizable for clinicians seeking to care for a patient with a similar injury over a longer course of time. further research is required to determine the best practices for managing an acutely strained abductor digiti minimi in a patient who requires above average dexterity to complete their daily activities. overall, the choice of intervention (i.e. local anesthetic injection and compression taping) was acute management of an abductor digiti minimi strain in a collegiate baseball player: a patient-centered case study 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 chosen due to the short timeframe in which the patient had to recover from his injury. had the patient had prospects of playing past the current season, there may have been other considerations when determining the course of treatment. additionally, if the patient had been required to continue typing for his academic work there may have been a need for other interventions, including discussions with instructors of alternate methods for the patient to complete his assignments. ultimately, the patient’s symptoms were able to resolve with cessation of activity, and no adverse outcomes were reported. clinical bottom line within the scope of clinical practice, it is entirely possible for clinicians to encounter injuries and conditions that are not well described in the literature. in these instances, clinicians must rely on their expertise along with patient-reported measures and values. when relying on these facets of clinical care, evaluation and reevaluation of the clinician’s treatment and rehabilitation plan are crucial to achieving optimal patient outcomes. when prescribing a course of treatment for patients in a competitive setting, it is paramount that clinicians take into account patient-centered values. while the goal of clinicians should be to provide patientcentered care, they must also incorporate patient education as much as possible. by providing a patient with as much information as possible regarding potential outcomes of a chosen treatment program, the clinician can hopefully mitigate at least some of the potential conflicts of interest that may occur in such a scenario. if there is no risk of significant, long-term injury, clinicians should attempt to provide patients with the means to participate in activities if they should desire. references: 1. schmidt ul. surgical anatomy of the hand. 1st ed. new york, ny: thieme medical publishers, inc; 2003. 2. usyal ac, alagoz ms, tuccar e, sensoz o, tekdemir i. the vascular anatomy of the abductor digiti minimi and the flexor digitorum brevis muscles. j hand surg am. 2005;30(1):172-176. https://doi.org/10.1016/j.jhsa.2004.06.00 1 3. meathrel ke, thoma a. abductor digiti minimi involvement in dupuytren’s contracture of the small finger. j hand surg am. 2004;29(3):510-513. https://doi.org/10.1016/j.jhsa.2004.01.01 6 4. al-qattan mm. ulnar nerve compression at the wrist by the accessory abductor digiti minimi muscle: wrist trauma as a precipitating factor. j hand surg. 2004;9(1):79-82. https://doi.org/10.1142/s021881040400 1899 https://doi.org/10.1016/j.jhsa.2004.06.001 https://doi.org/10.1016/j.jhsa.2004.06.001 https://doi.org/10.1016/j.jhsa.2004.01.016 https://doi.org/10.1016/j.jhsa.2004.01.016 https://doi.org/10.1142/s0218810404001899 https://doi.org/10.1142/s0218810404001899 introduction disablement model case study 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 the mulligan concept in the treatment of anterior knee pain karla s. judge, dat, lat, atc1; alan nasypany, ed.d., lat, atc2; russell t. baker, phd, lat, atc2; and james may, dat, lat, atc2 1idaho state university, pocatello id; 2university of idaho, moscow, id abstract the purpose of the disablement model case study was to describe the case of a collegiate basketball player suffering from anterior knee pain (akp). the patient had been experiencing akp while participating in pre-season basketball related activities (playing, weight lifting, and conditioning) for approximately six weeks. as the intensity increased, the pain became intolerable. previously, the patient had missed a significant amount of off-season workouts due to surgery for an upper extremity injury sustained during the competitive season. the patient reported tenderness at the inferior pole of the patella, and at the tibial tuberosity. there was no joint line tenderness, swelling, tissue temperature change, crepitus, or joint locking identified during the initial assessment. manual muscle testing revealed decreased strength and pain at the inferior pole of the patella and the tibial tuberosity with the long sitting straight leg raise, as well as seated knee extension. patient reported outcome measures were used to establish a baseline of pain and function. the disability of the physically active scale, the numeric pain rating scale, and the patient specific functional scale were used to identify patient-centered, as well as clinician-centered changes produced by the treatment intervention. recording of outcome measures took place at the initial assessment, after the initial treatment intervention, two days after the initial intervention, and one and two weeks after the initial intervention. outcome measures reflected a positive result for the decrease of pain with basketball activities, as well as activities of daily living. evidence supports the use of mobilizations to treat tendinopathies, joint positional faults, and neuromuscular motor control. while evaluating and treating patients with the mulligan concept mwm, the clinician receives immediate feedback regarding the efficacy and potential success of the intervention strategy. the purpose of this case study was to describe the application of the mulligan mwm philosophy and tibial internal rotation (tir) technique while treating a patient complaining of akp in an intercollegiate athletic training clinic. key phrases manual techniques, patient-reported outcomes, mulligan concept, sub-therapeutic dose correspondence dr. karla judge, idaho state university, 921 south 8th ave, pocatello, id, 83209 email: judgkarl@isu.edu full citation judge ks, nasypany a, baker rt, may j. the mulligan concept in the treatment of anterior knee pain. clin pract athl train. 2019;2(3):48-57. https://doi.org/10.31622/2019/0003.5. submitted: november 29, 2018 accepted: october 18, 2019 introduction anterior knee pain (akp) is a common complaint in athletics.1 multiple conditions can produce pain at the anterior knee and an accurate assessment is necessary to direct proper treatment. patellar tendinopathy, patellofemoral pain syndrome, quadriceps tendinopathy, chondromalacia, synovial plica, bursa and meniscal lesions can all present as akp.1 poor motor control of the hip, pelvis and knee has also been identified as a possible cause of akp.1-7 ultimately, loss of efficient motor control of hip abductors, adductors, extensors and knee flexors may lead to poor joint kinematics, resulting in akp. 2-7,12,14,15 the mulligan concept (mc) was developed on a positional fault theory, which is based on the belief that minor malalignment of joint surfaces may be present, resulting in swelling, stiffness, and pain.12-18 the mobilization with movement (mwm) may address this minor joint malalignment, as well as help create a more ideal neurophysiological environment for improved motor control and pain-free movement strategies.15 a mwm has been defined as a “sustained passive accessory force/glide to a joint while the patient actively performs a task that was previously painful”.15 the force is applied parallel to the treatment plane and should be a light, gentle force, just enough to improve motion and reduce pain. during assessment, the clinician will identify the direction of the force applied to the joint line in order to produce a positive outcome. https://doi.org/10.31622/2019/0003.5 the mulligan concept in the treatment of anterior knee pain 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 two acronyms help guide and define proper application of the mc mwm.12-18 first, identified in table 1 is the pill acronym. pain free, immediate, and long lasting identifies the desired result of the mobilization technique. the most important part of the pill acronym is the pain free aspect of the mobilization. if pain is not eliminated, then small changes in direction (addition of a minor rotation) or force (increase or decrease) can be made to improve symptoms. an immediate improvement of pain-free range of motion (rom) is expected at the time of the mobilization. if the results are not long lasting, changes should be made regarding the number of sets or repetitions used during the mobilization.15 table 1. the mulligan concept pill acronym for performing a mobilization with movement12-18,21 p pain free: the immobilization should be pain free i immediate: reduction of pain and increase of functional activity ll long lasting: the result of the mobilization should have a long lasting effect in reduction of pain second, table 2 identifies the crocks acronym, “contraindications, repetitions, overpressure, communication, knowledge, sustain/sense/skills/success”, which guides the technique and expectations of the mobilization for both the clinician and patient.12-18 the clinician should possess knowledge of the indications and contraindications of joint mobilization techniques, in general, as well as specific knowledge regarding the mwm technique to ensure a safe intervention.12-18 joint health and any underlying pathology also need to be clearly understood to avoid exacerbating any existing condition, such as fractures, rheumatoid arthritis, or poor skin integrity. sets and repetitions may vary depending on treatment area, length of dysfunction, and treatment calendar.12-18 for example, spinal manipulations are treated with fewer repetitions than peripheral joints or in patients presenting in severe pain.12-18 one set of three repetitions would be used for the first intervention for a spinal mobilization, while a peripheral joint may be treated with three sets of six to ten repetitions.12-18 overpressure added to the end of the active mobilization is believed to aid in providing optimal recovery.12-18 communication between the clinician and the patient is imperative. the clinician must explain the process of the mobilization, and the patient must be able to communicate if any pain is experienced during the mobilization.12-18 finally, a clinician possessing proper skills will sustain the mobilization through the entire rom in order to have a successful treatment intervention.12-18 a common mobilization used for akp is the tibial internal rotation (tir) mwm. the tir mwm is often the first technique clinicians will utilize to treat reported pain and/or dysfunction at the knee.12-15, 17, 18 the tir mwm technique includes a clinician-directed rotational mobilization force added to the patient-directed flexion and extension movement across the treatment plane (the tibial plateau).12-15 the tir mwm can be reinforced with a tape application that may be worn until the patient’s return to the clinic in 24-48 hours (standard precautions for tape application must be considered).12,14,15 the desired effect of the tape is to sustain the mobilization effect and table 2: mulligan concept “crocks” acronym for guidelines and expectations of a mobilizations with movement.12-18,21 c contraindications: do any conditions exist that would limit the use of joint mobilization r repetitions: three sets of ten repetitions are used for treating the extremity joints o overpressure: passive overpressure is applied by either the patient or the clinician at the end range of movement c communication: between the clinician and the patient about the treatment, techniques and expectations before the intervention begins. during the intervention the patient should report any pain. k knowledge: the clinician should possess knowledge of joint planes of motion being treated s sustain, sense, skills, and success: using common sense and clinical skills, the mobilization should be sustained throughout the movement in order to attain success. the mulligan concept in the treatment of anterior knee pain 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 apply continual neurological input for more ideal motor control.15 the mobilization and tape application are intended to enable pain free movement and motor control by addressing the malalignment of tibial external rotation, decreasing medial hamstring inhibition, and decreasing pain.15 short term re-training of motor control can have a prolonged positive effect on pain and therefore is important to facilitate pain free movements, while treating painful and restricted joints.7 the mc mwm can also be incorporated into the patient assessment as well as an intervention tool.15 along with observation, palpation, functional and special tests, the application of a single set of six repetitions (“sub-therapeutic dose”) of the mwm can provide valuable information. a decrease of pain during the subtherapeutic dose of mwm can indicate to the clinician that the mwm could produce a successful outcome.15 a decrease of pain with the knee flexion movement will indicate the mwm is clinically indicated to treat the akp and assist in re-establishing joint alignment and motor control. patient information the patient was a 19-year old male intercollegiate basketball player. he was a 6’1”, point guard weighing 205 pounds. during the past off-season, this patient had undergone surgery for an upper extremity injury which limited his ability to participate in summer conditioning activities. he reported to the athletic training clinic with a primary complaint of intermittent akp pain for approximately six weeks. low level knee pain began shortly after the start of fall semester workouts. initially, the patient had been able to participate in basketball activity, weight lifting, and conditioning. as the intensity of conditioning increased, the patient became unable to participate in basketball-related activities. the patient had been self-treating with patellar strapping and ice, which is a treatment he used previously when he experienced akp. differential diagnosis and evaluation the patient presented with point tenderness to palpation at the tibial tuberosity and the inferior pole of the patella with his knee resting in extension. the patient denied complaints of tenderness, locking, or popping of the joint line. the patient also denied any previous osgoodschlatter or sinding-larson-johansson diagnosis by a medical professional. no crepitus was present. there was no point tenderness or temperature changes along the length of the patellar tendon. all passive and active rom were within normal limits (wnl) at the hip, knee, and ankle bilaterally. trunk flexion, extension, and rotation motions were wnl and pain free. bilateral lower extremity manual muscle testing resulted in 3/5 with pain reported at the inferior pole of the patella during the long sitting straight leg raise and seated knee extension, while all other muscle tests resulted in 5/5. the patient presented with normal patellar alignment, and both clarke’s sign for patellofemoral irritation and the patellar apprehension tests were negative. at the completion of the assessment, the differential diagnosis included: patellar tendinopathy, dysfunctional patellar tracking, hoffa’s fat pad irritation. body structure and function the long sitting straight leg test was used as the client specific impairment measure (csim).15 the csim is a baseline test that is easily and safely reproducible in the clinic, prior to any functional or dynamic movement based testing. the csim is used to assess the treatment effects regarding pain or function. the test should be patientcentered and meaningful to the patient.15 the long sitting straight leg test was used for the csim for this patient due to the painful result of the manual muscle testing during the initial assessment. after completion of the functional and special tests, the clinician included a “sub therapeutic dose” (1x6 repetitions) of the mc tir mwm to the mulligan concept in the treatment of anterior knee pain 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 identify if the joint mobilization could produce a positive effect on the patient reported pain.15 incorporating a sub-therapeutic dose of the mobilization into the assessment allows the clinician to determine if a mwm is clinically indicated.15 during the sub-therapeutic dose, the patient reported a pain-free mwm and immediate decrease in painful knee flexion. as the sub-therapeutic mwm dose matched the pill response, the clinician determined the mc tir mwm was clinically indicated to treat the patient’s akp. the patient had been self-treating his akp over the preceding four days with no improvement of symptoms. he experienced pain at 110˚ of knee flexion, as well as seated knee extension and while performing a straight leg raise. after the positive result of the sub therapeutic dose of tir mwm, the clinician was encouraged to proceed with a full intervention before scheduling further diagnostic testing. prior to the examination, three patient-oriented outcome measures were administered to establish a baseline to measure the effect of patient care. first, the disability of the physically active scale (dpas)23 was used to identify physical impairments, functional limitations, and quality of life changes that have taken place due to the injury.23 it has been designed to provide descriptive themes that are clinically meaningful to athletes. the dpas has shown to be reliable, valid and responsive in the evaluation and monitoring of physically active patients.24 second, the patient rated his pain on a 0-10 scale “least pain to most pain” using the numeric pain rating scale (nrs).25 the nrs has shown to be a sensitive and valid instrument in detecting changes in pain.25 third, the patient completed the patient specific functional scale (psfs)26 to identify movements that are important to him in daily or sport activities (descending stairs, single leg landing, weight lifting, kneeling). the patient graded his ability to perform each activity on a scale of 0-10 “poor ability to best ability”. the psfs has shown to have excellent test-retest reliability and is sensitive to changes.26 the treating clinician compared initial and follow-up scores at pre-determined intervals (initial, two days, one week, two weeks). the results at the initial and follow-up intervals are listed in table 3. table 3: initial assessment and follow-up scores of akp initial 2 days 1 week 2 weeks dpas 19 8 0 0 nrs 5 0 0 0 psfs: 1)descending stairs 4 9 9 10 2)single leg landing 4 9 9 10 3)weight lifting 4 10 10 10 4)kneeling 4 8 8 10 dpas-disability of physically active scale; nrs-numeric pain rating scale; psfs-patient specific functional scale results of the outcome measures were used to assess if changes have met minimal clinically important difference (mcid) standards.27 an mcid is considered the minimum change that takes place as a result of the intervention that is important to both the patient and the clinician.27 to be considered mcids, changes include a pain decrease of six points for chronic pain (pain present for more than 6 weeks) or nine points for acute pain (pain present for less than 6 weeks) on the dpas, a decrease of two points on the nrs and a three point change on the psfs.23-27 activity and participation the patient had been participating in pre-season individual workouts, weight lifting, conditioning, and playing unsupervised basketball for four weeks with akp until the pain became unbearable the day prior to reporting for assessment. the patient did not feel the akp was affecting his the mulligan concept in the treatment of anterior knee pain 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 personal relationships or limiting his social activities. environmental and personal factors the patient was, however, very concerned about missing more team activities, as he had been unable to participate in any activities during the summer months. he had been the starting point guard and was anxious that he would lose his role on the team. his akp was also affecting his ability to sit in class comfortably and to walk up and down stairs to his apartment. intervention to perform the mwm, the patient’s left foot was placed on a non-rolling stool with the knee and hip flexed to 90˚. a chair may be placed near the patient for balance if he/she feels uncomfortable standing on unaffected limb. figure 1 illustrates the starting position for the mwm. prior to the mobilization, the patient reported 7/10 pain at the tibial tuberosity with the knee flexed to 110˚. to complete the mwm, the clinician placed one hand medially around the superior tibia close to the joint line without contacting the tender tibial tuberosity and the other hand grasped the lateral portion of the proximal tibiofibular joint. figure 2 illustrates the starting hand position to perform the tir mwm. the clinician applied internal rotation of the tibia and maintained the rotation throughout the entire rom as the patient moved through available pain-free knee flexion and returned to the starting position (figure 3). during the mwms, the clinician communicated with the patient regarding any discomfort that may have occurred guided by the crocks acronym. the intervention continued with two more sets of the mwm, following the treatment recommendation of three sets of 10 repititions.1119 after the completed treatment, the patient reported 0/10 pain at both the inferior pole of the patella or tibial tuberosity. the csim, long sitting straight leg raise, was also reassessed with the patient reporting a nrs score of 0/10 (mcid for pain) and the mmt was assessed as 5/5. pain scores and knee flexion rom changes are described in table 4. table 4: pain level and rom available prior to, during and after the mwm was performed test intervals nrs knee flexion rom before mwm 7 110˚ after subtherapeutic dose of mwm 4 110˚ after 1st set of mwm 4 120˚ after 3rd set of mwm 0 128˚ nrs-numeric pain rating scale; rom-range of motion the mc guidelines recommend applying tape to reinforce the mobilization, assisting proprioceptive accommodations to the length and load of the new joint position created through the mwm intervention.12-15,17,18 the tape application is intended to mimic the mwm as the patient goes about their daily activities. while standing, the knee is placed in slight flexion (10˚) and full internal tibial rotation. the clinician applies the tape by starting laterally at the proximal fibular head, matching the mwm direction and force, and crossing to the medial aspect of the tibia in a spiral fashion. the tape application continued superiorly, on the posterior knee to the lateral thigh.12-15, 18 the patient reported the tape application resulted in the same joint position sensation as the hands-on mobilization. figure 4 illustrates the completed tape application. outcomes body structure and function the mulligan concept in the treatment of anterior knee pain 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 the patient returned after the weekend (two days after the initial intervention) for a follow-up visit to assess the changes to the mwm and the pill figure 1: starting position for tir mwm figure 2: clinician’s hand placement to perform tir mwm. right hand is encompassing the head of the fibula while the left hand contacts the medial tibia. both hands avoid contacting the tender tibial tuberosity. figure 3: maintaining manual contact throughout the mobilization figure 4: tape application following tir mwm. small wrinkles of the tape may arise as the skin shifts under the adhered tape. the mulligan concept in the treatment of anterior knee pain 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 response, as well as monitor any adverse effects the tape may have had on his skin. 12-20 at the first follow-up, the patient reported 0/10 pain during daily activity over the preceding two days, and reported a score of eight on the dpas (mcid). the clinician repeated bilateral manual muscle testing resulting in 5/5 for all motions, including seated knee extension, which had previously been recorded at 3/5 with pain at the inferior pole of the patella. the clinician performed another intervention of 3x10 mobilizations followed by a new tape application and the patient was advised to return to the athletic training clinic for follow-up care as needed. to continue to collect patient centered outcomes, the patient was asked to return at one week intervals, unless there was a return of painful activity sooner. at the first one week interval, the patient reported 0/10 tenderness at the inferior pole of the patella and at the tibial tuberosity. a tir mwm was not performed at the one week interval due to the patient reporting pain-free activity. at the final outcome collection two weeks after the initial intervention, the patient remained pain-free. both the patient-reported dpas and nrs were recorded at 0/10, while the psfs activities all were recorded at 10/10. due to the patient reported responses on the outcome measures, tir mwm was not performed at the second week follow-up visit. the patient was discharged with the understanding he should return to the athletic training clinic if there was a return of either pain or dysfunction. activity and participation the patient had not participated in any physical activity for two days following the initial intervention. he reported pain-free activities of daily living, which included walking up and down stairs and sitting in class. at the follow up visit two days after the initial intervention, the clinician recommended modified return to basketball activity, suggesting he participate in individual workouts, weight lifting and half the volume of each running workout as pain permitted. the patient determined that he would increase his activity as long as he was pain free and had returned to full basketball activities and reported 0/10 pain with all activity. environmental and personal factors the patient was very anxious to return to activity due to his extended time away previously. his non-basketball painful activities (descending stairs and sitting in class) had decreased immediately and were completely eliminated within two days. while it was recommended he slowly return to activity through modified workouts, he felt he could fully participate as he remained pain free. he reported for follow up visits as scheduled, was truthful about his activity level and was responsive to completing the patient-based outcome forms. discussion anterior knee pain is a common complaint with many causative factors including acute injury, congenital malalignment, poor motor control of the hip, pelvis, knee and core, as well as poor foot posture.1-7 poor motor control of the hip, knee and pelvis may result in an internally rotated femur, with an accompanying externally rotated tibia, creating joint dysfunction.2-5,14,15 utilization of the mc mwm in this specific case study produced positive results which are consistent with results found in a review of the tenets and prescription of mwm by hing, bigelow and bremner in the november, 2008 new zealand journal of physiotherapy.13 the common significant results were reduced pain levels, increased strength and functional improvements when compared to placebo.13 the application of an internal rotation force on the tibia as the patient moved the knee through flexion and extension resulted in decreased pain and a change of faulty joint arthrokinematics. the mc tir mwm is a gentle, pain-free intervention strategy for addressing symptoms associated with the mulligan concept in the treatment of anterior knee pain 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 akp.11-15,17 proper application of a subtherapeutic dose within the initial assessment indicated the mwm could be clinically effective due to the production of the pill effect.15 the tape application is believed to prolong the mobilization effect by providing a constant stimulus on the joint proprioceptors.12-15 the clinician must be well-versed in the contraindications for joint mobilization before applying any mobilizing force on a joint surface, with a complete understanding of arthrokinematics and skills to sense changes in joint mobility. application of a mwm allows the patient to provide feedback to the clinician throughout the treatment. if the patient reports pain, the clinician should pause at the starting point, reposition the hands, making sure hand placement, direction, and pressure is comfortable to the patient, however, if the patient reported pain persists, the mwm would be discontinued. following the mc guidelines, a mwm treatment intervention should be pain-free and the reduction of pain should be immediate.11-19,22 utilization of patient-reported outcome measures can provide the clinician with information regarding the patient’s pain and function, along with the identification of the patient’s quality of life that may be overlooked if not specifically assessed throughout the patient care process. making a concerted effort to appreciate how the injury is impacting the patient’s daily life outside their sport (e.g., transportation, food preparation, attending classes, personal relationships, completing school work) provides the clinician with a higher level of understanding of the patient’s overall well-being. pain and disability scales provided information regarding improvements that were important to the patient (pain-free basketball, climbing stairs to apartment), as well as to the clinician (decreased pain and increased range of motion).23-27 identifying and testing a csim prior to and after an intervention is effective in determining if important changes have taken place that are relevant to both the clinician and the patient.15 continued monitoring of pain and dysfunction through patient-reported outcome measures is important to determine the immediate and lasting effect of the mwm intervention. while the outcome measures were collected for only two weeks until the patient was released to full activity, he was monitored daily for any return of pain or dysfunction. prolonged outcome collection would have produced a more viable conclusion to the efficacy of the tir mwm technique. clinical bottom line this case study was produced in an effort to highlight a successful intervention for one patient reporting akp. the mc mwm is a treatment intervention guided by easy to follow acronyms for the desired outcome (pill) and the technique of each intervention (crocks). the technique allows the patient and clinician to communicate throughout the mobilization to ensure a pain-free intervention, and the importance of the pain-free aspect of the mobilization cannot be understated. if the pill effect had not been produced during the sub-therapeutic dose, the mwm would not have been clinically indicated.11-17 the tape application was used to prolong the mobilization and provide continued neurophysiological input to aid in the success of the intervention. careful assessment and clinical reasoning must take place in order to determine the proper intervention for each patient. this patient had symptoms consistent with those of patellar tendinopathy which had not improved with his treatment of ice and rest. he did report positive initial results during the assessment with the subtherapeutic dose of the mc tir mwm. the improvement in pain scale and muscle testing results are subjective from both the patient and the clinician, and may be a limitation of this case study. a change in joint arthrokinematics is believed to directly affect both pain and strength results of the mc tir mwm.12-15,17-18,22 further case studies and controlled trials are needed to the mulligan concept in the treatment of anterior knee pain 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 further investigate clinical efficacy. the incorporation of the mc mwm into an athletic training practice can be a powerful treatment paradigm that may produce positive results. references 1. coppack r, etherington j, will a. the effects of exercise for the prevention of overuse anterior knee pain. am j sports med. 2011;39.(5):940-948. https://doi.org/10.1177/0363546510393 269 2. nguyen a, schultz s, schnidtz r, luecht r, perrin d. a preliminary multifactorial approach describing the relationships among lower extremity alignment, hip muscle activation & lower extremity joint excursion. j athl train. 2011;46(3):246-256. https://doi.org/10.4085/1062-605046.3.246. 3. powers c, landel r, perry j. timing and intensity of vastus muscle activity during functional activities in subjects with ad without patellofemoral pain. phys ther. 1996;76(9):946-955. https://doi.org/10.1093/ptj/76.9.946 4. mcconnell j. management of a difficult knee problem. man ther. 2013;18:258-263. https://doi.org/10.1016/j.math.2012.05.01 8 5. bolga l, malone t, umberger b, uhl t. hip strength and hip and knee kinematics during stair descent in females with and without pfps. j orthop sports phys ther. 2008;38(1):12-18. https://doi.org/10.2519/jospt.2008.2462 6. willy r, scholz j, davis i. mirror gait retraining for the treatment of patellofemoral pain in female runners. clin biomech. 2012;27:1045-1051. https://doi.org/10.1016/j.clinbiomech.2012 .07.011 7. willy rw, davis is. the effect of a hipstrengthening program on mechanics during running and during a single-leg squat. j orthop sports phys ther. 2011;41:625-632. https://doi.org/10.2519/jospt.2011.3470. 8. kaltenborn, f. the spine: basic evaluation and mobilization techniques.2nd edition. 1993. banta isg, minneapolis mn. 9. klafs, c and arnheim, d. modern principles of athletic training. 2nd edition. 1969. c.v. mosby company. st. louis mo. 10. kaminski t, hertel j, amendola n, docherty c, dolan m, hopkins j, nussbaum e, poppy w, richie d. national athletic trainer’s association position statement: conservative management and prevention of ankle sprains in athletes. j athl train. 2013;48(4):528-545. https://doi.org/10.4085/1062-605048.4.02 11. professional education council of the national athletic trainer’s association. 2011. athletic training competencies. 5th edition. 12. mulligan, br. manual therapy, nags, snags, mwms etc. 6th edition. orthopedic physical therapy products 13. hing w, bigelow r, bremner t. mulligan’s 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(2011). mobilization with movement: the art and science. elsevier, sydney. 15. hing, w hall, t rivett, d vicenzino, b mulligan, b. (2015).the mulligan concept of manual therapy: textbook of techniques. elsevier. australia. 16. baker r, nasypany a, seegmiller j, baker j. the mulligan concept: mobilizations with movement. international journal of athletic training and therapy. 2013;18(1):30-34. https://doi.org/10.1123/ijatt.18.1.30. 17. vicenzino b, paungmali a, teys p. mulligan’s mobilization with movement, positional faults and pain relief: current concepts from a critical review of literature. man ther. 2007;12:98-128. https://doi.org/10.1016/j.math.2006.07.01 2 18. mulligan concept founder’s profile. www.bmulligan.com. official international website. 19. collins n, teys p, vicenzino b. the initial effects of a mulligan’s mobilization with movement technique on dorsiflexion and pain in sub-acute ankle sprains. man ther. 2004;9(2):77-92. https://doi.org/10.1016/s1356689x(03)00101-2 https://doi.org/10.1177/0363546510393269 https://doi.org/10.1177/0363546510393269 https://doi.org/10.4085/1062-6050-46.3.246 https://doi.org/10.4085/1062-6050-46.3.246 https://doi.org/10.1093/ptj/76.9.946 https://doi.org/10.1016/j.math.2012.05.018 https://doi.org/10.1016/j.math.2012.05.018 https://doi.org/10.2519/jospt.2008.2462 https://doi.org/10.1016/j.clinbiomech.2012.07.011 https://doi.org/10.1016/j.clinbiomech.2012.07.011 https://doi.org/10.2519/jospt.2011.3470. https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.1179/jmt.2009.17.2.39e https://doi.org/10.1179/jmt.2009.17.2.39e https://doi.org/10.1123/ijatt.18.1.30 https://doi.org/10.1016/j.math.2006.07.012 https://doi.org/10.1016/j.math.2006.07.012 https://doi.org/10.1016/s1356-689x(03)00101-2 https://doi.org/10.1016/s1356-689x(03)00101-2 the mulligan concept in the treatment of anterior knee pain 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 20. hubbard tj, hertel j. anterior positional fault of the fibula after sub-acute lateral ankle sprains. man ther. 2008;13(1):63–67. https://doi.org/10.1016/j.math.2006.09.00 8 21. hsieh cy, vicenzino b, yang ch, hu mh, yang c. mulligan’s mobilization with movement for the thumb: a single case report using magnetic resonance imaging to evaluate the positional fault hypothesis. man ther. (2002);7(1):4449. https://doi.org/10.1054/math.2001.0434 22. takasaki h, hall t, jull g. immediate and short-term effects of mulligan mobilization with movement on knee pain and disability associated with knee osteoarthritis: a prospective case series. physiother theory pract. 2013;29(2):87-95. https://doi.org/10.3109/09593985.2012. 702854 23. vela l, haladay d, denegar c. transient disablement in the physically active with musculoskeletal injuries, part i: a descriptive model. j athl train. 2010;45(6):615-629. https://doi.org/10.4085/1062-605045.6.615 24. vela i, denegar c. the disability in the physically active scale, part ii: the psychometric properties of an outcomes scale for musculoskeletal injuries. j athl train. 2010;45(6):630-641. 25. ferreira-valente m, pais-ribeiro j, jenson m. validity of four pain intensity rating scales. pain. 2011;(152):2399-2404. https://doi.org/10.1016/j.pain.2011.07.00 5 26. chatman a, hyams s, neel j, binkley j, stratford p, schomberg a, stabler m. the patient-specific functional scale: measurement properties in patients with knee dysfunction. phys ther. 1997;77:820-829. https://doi.org/10.1093/ptj/77.8.820 27. farrar j, portenoy r, berlin j, kinman j, strom b. defining the clinically important difference in pain outcome measures. pain. 2000;(88): 287-294. https://doi.org/10.1016/s03043959(00)00339-0 https://doi.org/10.1016/j.math.2006.09.008 https://doi.org/10.1016/j.math.2006.09.008 https://doi.org/10.1054/math.2001.0434 https://doi.org/10.3109/09593985.2012.702854 https://doi.org/10.3109/09593985.2012.702854 https://doi.org/10.4085/1062-6050-45.6.615 https://doi.org/10.4085/1062-6050-45.6.615 https://doi.org/10.1016/j.pain.2011.07.005 https://doi.org/10.1016/j.pain.2011.07.005 https://doi.org/10.1093/ptj/77.8.820 https://doi.org/10.1016/s0304-3959(00)00339-0 https://doi.org/10.1016/s0304-3959(00)00339-0 manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 it’s time for intraprofessional practice kenneth e games, phd, lat, atc indiana state university, terre haute, in key phrases collaborative practice, boc standards of practice, change correspondence dr. kenneth games, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: kenneth.games@indstate.edu twitter: @gameskenneth full citation games ke. it’s time for intraprofessional practice. clin pract athl train. 2018;1(2): 1-3. https://doi.org/10.31622/2018/0002.1 submitted: october 27, 2018 accepted: october 30, 2018 editorial by now we have all heard about interprofessional and collaborative practice (ipcp), also called interprofessional practice (ipp) or interprofessional education (ipe). what about intraprofessional practice? when was the last time that you effectively practiced in a team-based setting with other athletic trainers? i am not just talking about sharing patients. i am talking about deliberately and intentionally co-facilitating patient care using each individual athletic trainer’s strengths to create a “super provider” capable of delivering the best patient care possible to the populations we treat. are you pausing…thinking this seems impossible? it is already being done in other healthcare professions. nursing has been engaging in intraprofessional practice for years and currently has multiple iterations of best practice guidelines for intraprofessional collaborative practice.1 through a framework to create a collaborative workplace, nursing has effectively created a system that maximizes health and wellness for nursing and delivers the best possible outcomes for patients.1 i see a future where we, as athletic trainers, fundamentally shift our practice models to create environments of intraprofessional collaboration, and that future is closer than you think! i know what you may be thinking…“this will never work” or “athletic training is different” or even “it may work in some settings, but not all.” if these are your initial reactions, you aren’t alone. this radical shift requires new ways of thinking and framing our work in ways we have rarely done in the past. intraprofessional practice can work in any setting. to demonstrate this, imagine with me as i describe an alternative reality than that which currently exists in most secondary school settings. imagine a world where athletic trainers from “rival” high schools provided care to patients at both schools collaboratively based on each athletic trainer’s specialty areas. the athletic trainer from high school a is a specialist in orthopedics, while the athletic trainer from high school b is a specialist in neurotrauma, and both residency trained in their respective areas. a patient from high school a comes into the athletic training facility reporting the signs and symptoms of a concussion. after appropriate evaluation and diagnosis of a concussion, the athletic trainer from high school a determines that intraprofessional referral is necessary and refers the patient to the athletic trainer at high school b for treatment and rehabilitation from the concussion. both athletic trainers keep the patient at the center of the care team and keep their egos out of the health, safety, and wellness of patients. they seamlessly exchange documentation in accordance with federal regulations and together, return the patient to activity with better short, medium, and life-long outcomes. this could be as simple as practitioner to practitioner consultation, as traditional as the patient receiving care at the rival high school, or as advanced as telemedicine to reduce the burden on the patient and provider. try to hold off on that instinct…“well, that’s not my team!” remember that the boc standards of https://doi.org/10.31622/2018/0002.1 it’s time for intraprofessional practice 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 – october 2018 professional practice indicate that the athletic trainer “takes no action that leads to or may lead to improper influence of the outcome or score of an athletic contest or event” (code of professional responsibility, professional responsibility 3.10).2 the standards also state that the athletic trainer “practices in collaboration and cooperation with others involved in a patient’s care when warranted; respecting the expertise and medicolegal responsibility of all parties” (code of professional responsibility, professional responsibility 3.3).2 just consider…this is possible now! are there some structural barriers we must overcome? yes. are their going to be unexpected setbacks? absolutely. but we must start to shift our mindset to be ready to take advantage of opportunities for change when they come. too often, and by too often i mean almost always, the biggest barrier to substantial change and progress in anything (including athletic training) is ourselves. we can no longer believe that we are healthcare providers within the sport and physical activity industry. we are healthcare providers in the healthcare industry providing services to the sport and physical activity industry. this foundational shift in mindset is the first step in opening up a world where intraprofessional collaborative practice becomes the norm, not the exception. the benefits of intraprofessional practice may include the benefits we see with team-based care across healthcare such as improved communication and partnerships among providers and patients;3,4 better response processes in addressing the determinants of health;4 improved coordination of care;3 high levels of satisfaction on healthcare delivery;3,5 and the effective use of resources.6 there could even be more benefits of effective intraprofessional practice in athletic training than we can imagine, due to our unique role in the healthcare industry, but we must take the first step in this change. i’m asking each and every athletic trainer to take a moment and imagine a future of intraprofessional practice in their individual setting. what opportunities do you see? what challenges can you expect? what beliefs that you have about athletic training and your role in healthcare are limiting you and your patients? what will you do to overcome those limiting beliefs? the responsibility is on us. to change the industry we serve, we must change our practice, and before we change our practice, we must shift our mindset. let’s shift our mindset and start imagining and have conversations about intraprofessional practice in athletic training today. references: 1. registered nurses’ association of ontario (rnao). intra-professional collaborative practice among nurses: second edition. registered nurses’ association of ontario. toronto, ontario. 2016. 2. board of certification (boc). boc standards of professional practice: version 3.1. board of certification, inc. 2017. 3. kates n, ackerman s, eds. shared mental healthcare in canada: a compendium of current projects. ottawa: canadian psychiatric association; and mississauga: college of family physicians of canada collaborative working group on shared mental health. 2002. 4. nolte j. enhancing interdisciplinary collaboration in primary healthcare in canada. ottawa: enhancing interdisciplinary collaboration in primary health initiative. 2005. 5. marriott a, marble j. sharing the learning: the health transition fund synthesis series: primary healthcare. ottawa: health canada. 2002. 6. task force two. a physician human resource strategy for canada: innovation service it’s time for intraprofessional practice 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 – october 2018 models in canada database. ottawa: government of canada. 2005. manuscript type point-of-care (practice characteristics) research 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training ashley j. reeves, dat, at*; russell t. baker, phd, dat, at, cmp, prt-c*; scott w. cheatham, phd, dpt, pt, ocs, at, cscs†; and alan nasypany, edd, at* *university of idaho, moocow, id †california state university dominguez hills, carson, ca abstract tendon pathology has been studied across healthcare professions but remains poorly understood. imaging and clinical findings have been used to diagnose tendon pathology, but these findings are discrepant. it is vital that clinicians use sound clinical judgment to determine the most accurate clinical diagnosis and treatment options given documented clinical findings. the purposes of this study were to assess athletic trainers’: 1) documented clinical findings for patients presenting with tendon pain, 2) use of documented findings to inform clinical diagnosis of tendon pathology, and 3) change in tendon pathology classification when presented with a novel diagnostic term. a total of 430 patients (20.70 ± 7.35y) from a multisite research database were included in the study. pain at the site of injury was documented in 95.8% of cases (n = 412). pain during exercise that changed activity (n = 274, 63.7%), and an identified tender point (n = 259, 60.2%) were also present in almost two-thirds of cases. of the patients diagnosed with tendinitis, 35.0% had pain as the only documented inflammatory sign. of the initial set of clinical diagnosis options, tendinopathy was the most commonly (n = 290, 67.4%) selected. there was a 46.0% and 15.0% decrease in the number of tendinopathy and tendinitis diagnoses, respectively, when ‘tendinalgia’ was an option as a diagnostic classification term. there does not appear to be adequate clinical evidence to label tendon pathology as either inflammatory or degenerative. furthermore, clinicians either appear to be: 1) relying on few symptoms to identify a diagnosis or 2) not at first fully considering all clinical findings when diagnosing a patient. according to these findings, tendinalgia seems to be the most appropriate term to describe tendon pain, to help clinicians understand tendon pathology as a pain condition rather than as inflammatory or degenerative. key phrases diagnostic testing, upper extremity, tendinopathy, clinical reasoning correspondence dr. ashley reeves, university of idaho, 875 perimeter drive ms 2401 moscow, id 83844. e-mail: reevesa@uidaho.edu full citation reeves aj, baker rt, cheatham sw, naypany a. point-ofcare research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training. clin pract athl train. 2020;3(2):33-44. https://doi.org/1031622/2020/0002.5. submitted: august 1, 2019 accepted: march 2, 2020 introduction tendon pathology is a common problem among physically active individuals, but is poorly understood by researchers and clinicians alike.1-3 previously, pain at a tendon has been termed tendinitis or tendinosis, describing either an inflammatory or degenerative condition, respectively.3-6 tendinitis involves signs and symptoms of inflammation, which include heat, redness, pain, swelling, and decreased function.39 clinicians grade tendinitis from first to third degree based on the severity and consistency of the patient’s symptoms.10 generally, symptoms become progressively more persistent as the condition worsens, advancing from pain noted only after activity to more consistent pain and decreased performance.10 even though tendon pain is often referred to as tendinitis, tendinosis may be a more correct description, as evidenced by the lack of inflammatory markers in histological studies.3,6,11 in contrast to tendinitis, which describes a primarily inflammatory condition, tendinosis describes changes in tissue integrity (i.e., degeneration) without signs of active inflammation.3-6,12,13 tendinosis is categorized according to the assumed severity of the condition, with stage i correlating to transient pathology and stage ii correlating with more lasting changes to less than half of the tissue structure.14 imaging studies (e.g., magnetic resonance imaging [mri] and diagnostic ultrasound) provide further https://doi.org/1031622/2020/0002.5 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 evidence of the potential inaccuracy of a tendinitis diagnosis, in which imaging findings are often uncorrelated to patient symptoms.3,15-23 for example, in a sample of 253 healthy, asymptomatic individuals ages 13-89 years old, 65% of individuals had tissue abnormalities of the proximal hamstring tendon on mri (13% unilateral, 52% bilateral).23 of note, none of the participants had a history of hamstring pathology.23 in a second study, which involved ultrasound examination of 51 asymptomatic males, 96% had some form of pathological change to the rotator cuff.20 of those individuals with positive findings, 75% had rotator cuff pathology, with the most commonly affected structure being the supraspinatus tendon (65% of total; 5 full thickness tears, 12 partial-thickness tears).20 these findings indicate that pathological changes to the tissue may not be the actual cause of a patient’s symptoms, if asymptomatic individuals have the same tissue abnormalities on imaging studies that would typically only be expected in symptomatic patients.3,15-23 due to these discrepancies, imaging has not been advocated as the most accurate form of assessment, nor does it increase the limited understanding of tendon pathology.3,15-23 most often, tendon pathology is diagnosed clinically based on the patient’s pain narrative, previous history, and outcomes of pain provocation tests.3,10,24,25 palpation may also identify pain, increased tendon thickness, and/or crepitus.3,25-29 pain upon palpation has been found to be reliable across multiple studies when identifying tendon pathology, especially when moderate to high levels of pain upon palpation are present.26,27,29 however, when moderate to high pain levels upon palpation and patient-reported symptoms were considered together, these findings were not an adequate predictor of positive imaging findings (p > 0.05).26 these findings again reinforce the idea that symptoms and tissue pathology are not always congruent.3,15-23,26 as the uncertainty surrounding tendon pathology continues to increase across healthcare despite extensive research, alternate diagnostic classification terms, such as tendinopathy and tendinalgia, have been introduced.3,30,31 tendinopathy is an generic term to describe tendon pathology that presents with tendon pain and increased tendon thickness.3 tendinopathy, as opposed to the previously used tendinitis or tendinosis, implies some type of tissue-based tendon pathology, without specifying a particular cause, reflecting the inconsistencies between imaging, histological, and clinical findings.3,11,15-23 the newest term, tendinalgia, is an expansion of the term lateral epicondylalgia, originally coined by waugh to describe pain at the anatomical location (i.e., lateral epicondyle) without indicating that abnormal changes in the tissue are the cause of the symptom presentation.30,31 patient outcomes further support the notion that actual tissue changes may not be the underlying cause of a patient’s symptoms. with respect to tendon pain, eccentric loading, which aims to create changes in tissue structure, is often incorporated into rehabilitation.3 however, according to a recent literature review, the use of eccentric exercise, though helpful for patient symptoms, did not result in a concomitant improvement in tendon thickness on imaging studies.32 if tendon pathology was primarily due to a tissue abnormality, eccentric exercise should have resulted in both a change in patient symptoms and tissue structure. these discrepancies give reason to question the traditional classifications of tendon pathology, many of which imply tissue-related causes of pain (e.g., tendinitis, tendinosis). although treatments such as eccentric exercise may be effective for reducing patient symptoms, it does not appear that these treatments are having the hypothesized effect (i.e., change in tissue structure).3,32 this may indicate that tendon pain is actually due to a pain processing dysfunction rather than actual tissue pathology.3,33 using a more general term like tendinalgia would free the clinician to treat the source of pain as a processing dysfunction rather than a tissue pathology. due to the lack of consensus among imaging studies and patient outcomes, clinical assessment remains the primary strategy for evaluation and point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 diagnosis.3,15-24 however, limited data exists on healthcare providers’ evaluation findings. most studies regarding tendon pathology have involved physical therapists and orthopedic surgeons, but the evaluation has often been standardized as part of a controlled study.26,27,29 moreover, there is little literature regarding the evaluation practices and reported findings of athletic trainers with respect to tendon pathology, even though tendon conditions are common in physically active individuals.1,2 despite evidence negating the validity of imaging, and therefore the emphasis on clinical evaluation, it is unknown what athletic trainers are reporting from their clinical evaluations of patients with tendon pain. by extension, it is also unknown if athletic trainers are matching their clinical diagnoses to their reported clinical findings based on the current evidence and recommendations for tendon pathology. in order to maximize the likelihood of positive treatment outcomes for patients presenting with tendon pain, it is important to gain a better understanding of the current practices of athletic trainers to identify practices that facilitate optimal treatment choices and areas needing improvement. therefore, the purposes of this study were to assess athletic trainers’: 1) documented clinical findings for patients presenting with tendon pain, 2) use of documented findings to inform clinical diagnosis of tendon pathology, and 3) change in tendon pathology classification when presented with a novel diagnostic term. methods this study was a retrospective descriptive analysis of a research database created and stored in qualtrics (provo, ut, 2002). athletic trainers currently pursuing their doctorate in athletic training contributed to the database for this multisite research study. clinicians were practicing in a wide range of clinical settings and working with patient populations of various physical activity levels. participating clinicians were asked to input de-identified patient data into the database for later analysis. before entering data, patients signed an informed consent form to allow for the inclusion of de-identified information in the research database. the study protocol was approved by the university of idaho institutional review board. procedures the database contained open-ended, multiple choice, and multiple select items pertaining to each portion of a standard clinical evaluation. to be included in the present study for retrospective analysis, patients had to present to the intake clinician with: 1) involvement of a specific muscle or tendon, 2) localized tendon pain, and 3) point tenderness over the involved tendon, as pain is one of the primary clinical symptoms that serve as a focus of treatment10,14,25 due to the nature of the study, evaluations were not standardized. clinicians were encouraged to perform their typical evaluation, which allowed for an authentic picture of typical athletic training practices in the evaluation of suspected tendon pathology. clinicians were asked to enter data regarding patient history, which included, but was not limited to: 1) age, 2) patient sport or occupation, and 3) pain scores rated on the 0-10 numeric pain rating scale (nrs; i.e., current pain, pain at best within the past 24 hours, pain at worst within the past 24 hours, pain at onset, and pain at rest). clinicians also described pain characteristics based on the classifications set forth by nirschl and ashman regarding tendinosis and any objective findings (e.g., swelling, changes in tissue appearance, palpation findings, special tests performed, etc.) from the evaluation.14 it should be noted that although the classifications defined by nirschl and ashman are meant to describe the severity of pathology, and are therefore ordinal in nature, clinicians were allowed to choose more than one category based on patient presentation.14 at the completion of the evaluation, clinicians identified a working clinical diagnosis based on their documented findings under two separate conditions. first, they chose from a list of traditionally recognized tendon pathologies (i.e., first-, second-, or third-degree tendinitis; first or second stage tendinosis; or tendinopathy). a point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 second question then asked them to classify the same tendon pain with tendinalgia, a more general term, added as a classification option to the previous list. the definition of all diagnostic terms, including tendinalgia, had been previously operationally defined and provided to the clinicians involved in the study. data analysis data were analyzed in statistical package for social sciences (version 25.0, ibm, armonk, ny) and microsoft excel (version 16.16.10, microsoft, redmond, wa). patient cases with missing clinical diagnoses were excluded from analysis to keep sample sizes equal across analyses and to facilitate comparisons across the data. if the text entry from an open-ended response was unclear, the data was classified as “unknown”. means and standard deviations were calculated for patient age and pain scores. frequencies and percentages were calculated for all other data to derive comparisons across documented clinical findings. results patient demographics a total of 430 patient cases involving a primary complaint of tendon pain were extracted from the database. on average, patients were 20.7 ± 7.3 years old (range: 14-62 years old) and participated in over 20 different sports and/or activities. the five most common sports or activities included basketball (n = 75, 17.4%), track and field (n = 48, 11.2%), soccer (n = 45, 10.5%), football (n = 44, 10.2%), and baseball (n = 42, 9.8%). reported clinical findings documented clinical findings are presented in tables 1a-c. pain at the site of injury was the most commonly documented clinical finding during evaluation (n = 412, 95.8%), followed by pain that changes activity (n = 274, 63.7%). the most commonly documented tissue changes included the presence of a tender point (n = 259, 60.2%), changes in tissue tension (n = 60, 14.0%), and changes in tissue thickness (n = 53, 12.3%), as determined from the clinician’s evaluation. overall, 87.2% of patients (n = 375) had two or fewer documented signs of inflammation (i.e., pain, loss of function, local swelling, redness, and/or heat).7-9 a total of 103 individuals were diagnosed with some degree (i.e., first, second, or third) of tendinitis. of these 103 individuals, 35.0% (n = 36) had pain at the site of injury as their only documented sign of inflammation. furthermore, pain and loss of function were the only documented signs of inflammation in 10.7% (n = 11) of these 103 cases. finally, clinicians reported using at least one orthopedic special test (e.g., tests for structural integrity of the ligaments, joint capsule, musculotendinous unit, etc.), 76.7% (n = 330) of the time. table 1a. prevalence of reported inflammatory signs sign/symptom frequency (n) percent (%) pain 412 95.8 heat 45 10.5 redness 23 5.3 swelling 98 22.8 loss of function 101 23.5 table 1b. prevalence of reported tissue changes sign/symptom frequency (n) percent (%) spasm 34 7.9 trigger point 44 10.2 tender point 259 60.2 change in tissue tension 60 14.0 change in tissue texture 40 9.3 change in tissue tone 25 5.8 change in tissue thickness 53 12.3 change in sensation 17 4.0 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 pain descriptions using the pain characteristics defined by nirschl and ashman, clinicians documented that 63.7% (n = 274) of patients experienced pain that changed their activity, and patients reported that their pain after activity resolved within 24 hours in 34.4% (n = 148) of cases.14 pain scores were also recorded for each patient. the ‘worst’ pain ranged from 2/10 to 10/10 for all patients, with the average worst pain being 6.7 ± 1.7 points. current pain across the entire sample averaged 3.2 ± 2.2 points, and overall average pain (i.e., averaged current, best, and worst scores) ranged from 0.7 to 9.0, with a sample average of 4.0 ± 1.5 on the nrs. descriptive statistics for nrs scores are provided in table 2. classification of tendon pathology clinician classifications of tendon pathology based on reported clinical findings are presented in table 3 and figure 1. without tendinalgia as a classification option, the most common clinical diagnosis was tendinopathy (n = 290, 67.4%), with the second most common being some degree (i.e., first, second or third) of tendinitis (n = 103, 23.9%). when tendinalgia was added as a classification option, there was a 46.0% decrease in the number of cases classified as tendinopathy, and tendinalgia instead became the most common diagnosis (n = 272, 63.3%). of the 103 patients originally diagnosed with some degree of tendinitis, 51.5% (n = 53) of those diagnoses were switched to tendinalgia when this was an option. furthermore, of the 290 (67.4%) cases originally diagnosed with tendinopathy, 125 individuals (43.1%) were given a final diagnosis of tendinalgia. table 1c. prevalence of reported pain patterns sign/symptom frequency (n) percent (%) pain post-exercise resolves in <24 hours 148 34.4 pain post-exercise resolves in >24 hours 83 19.3 pain post-exercise resolves with warm-up 31 7.2 pain during exercise does not alter activity 101 23.5 pain during exercise does alter activity 274 63.7 pain with heavy adls 126 29.3 pain with light adls but intermittent at rest 116 27.0 constant pain at rest that disturbs sleep 38 8.8 categories adapted from nirschl and aschman15 table 2. pain scores pain score mean ±sd minimum maximum onset 4.8 2.1 0.0 10.0 rest 1.8 1.8 0.0 8.0 current 3.2 2.2 0.0 10.0 best 2.0 1.9 0.0 8.0 worst 6.7 1.7 2.0 10.0 averagea 4.0 1.5 0.7 9.0 aaverage = avg(current,best,worst) table 3. classification of tendon pathology with and without tendinalgia as an option without with classification frequency (n) frequency (n) tendinitis 103 38 first degree 78 27 second degree 23 9 third degree 2 2 tendinosis 37 28 stage i 28 17 stage ii 9 11 tendinopathy 290 92 tendinalgia n/a 272 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 clinical application through the analysis of patient data included in a broader patient outcomes database, the frequency of various documented clinical findings in patients presenting with tendon pathology in athletic training clinics was assessed. this study also aimed to evaluate the clinical diagnoses chosen by athletic trainers based on these findings. finally, changes in clinical diagnosis were evaluated with the introduction of the term tendinalgia, which has been proposed as an alternate term to account for the discrepancies currently surrounding tendon pathology.3,11,1523,30,31 in the present study, the three most frequently documented clinical signs and symptoms were all related to pain (i.e., pain at site, 95.8%; pain that changes activity, 63.7%; tender point, 60.2%). theoretically, because localized pain over the involved tendon was part of the inclusion criteria for the present study, pain at the site of injury should have been reported for all patients, rather than only 95.8%. these inconsistencies could be due to: 1) different interpretations of the definitions between inclusion criteria and clinical findings, 2) failure to evaluate for the presence of pain at the site of injury, or 3) clinician error in reporting findings. regardless of the reason, a primary finding of pain is consistent with the tendency for individuals to continue activity despite pain, only seeking treatment as the condition worsens to the point that they can no longer participate in physical activity at their desired level.3,6,24 the average reported pain scores from the present study (current pain: 3.2 ± 2.2; worst pain: 6.7 ± 1.7) also support this pattern. pain scores at initial evaluation (i.e., current) were high enough to allow for a decrease of at least one minimal clinically important difference on the nrs (i.e., 2 points), meaning patients would be able to identify a difference in pain after treatment, thereby giving them reason to seek care.34 point tenderness and the general pain characteristics found in the present study were 0.0 67.4 2.1 6.5 0.5 5.3 18.1 63.3 21.4 2.6 4.0 0.5 2.1 6.3 0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 tendinalgia tendinopathy tendinosis stage ii tendinosis stage i tendinitis third degree tendinitis second degree tendinitis first degree percent (%) with tendinalgia without tendinalgia figure 1. classification of tendon pathology from reported clinical findings point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 representative of clinical presentations outlined in the literature, but clinical diagnoses did not always align with documented signs and symptoms.3,6,10,13,14,28 for example, tendinitis was the second most common diagnosis when tendinalgia was not given as an option, and over one-third of patients had pain as the only documented inflammatory sign of the five cardinal signs of inflammation. however, pain by itself does not indicate a primarily inflammatory condition. patients with tendon pathology often present with pain, but histological and imaging studies do not always support the presence of inflammation within the tissues.3,6,10,11,14,24-27 therefore, pain – without other key signs or symptoms of inflammation – cannot conclusively indicate an inflammatory condition. loss of function was the second most documented sign of inflammation. however, because pain can affect movement, loss of function may be a notable finding regardless of the nature of the pathology (e.g., inflammatory, degenerative, etc.).35 just over 10% of individuals diagnosed with tendinitis had pain and loss of function as their only signs of inflammation. therefore, the accuracy of many of the tendinitis diagnoses in the present sample is questionable, though it could be argued that clinicians were aware of this possibility. two-thirds of patients originally diagnosed with tendinitis were eventually diagnosed with tendinalgia when this was an option. it seems clinicians may not be using their documented findings to inform their clinical diagnoses when using a common, generic term like tendinitis or tendinopathy. this disconnect is a potential problem because if clinicians label a condition as inflammatory, they should also be choosing treatments that directly affect the inflammatory process, but the patient may not optimally benefit from treatment if the tendon pain is not truly inflammatory in nature.3,11,24,25 it is also important to ask why clinicians, who originally diagnosed their patients with tendinitis but then changed their diagnosis to tendinalgia, did not originally choose tendinopathy, as tendinopathy is at least a more general term.3 in identifying tendinalgia as their final diagnosis, it could be argued that clinicians demonstrated their understanding of the obscurities of tendon pathology described in the literature.3,11,15-23,30 under this premise, tendinopathy would have been a more representative term given the first group of diagnostic options (i.e., without tendinalgia).3 these discrepancies could be due to: 1) clinician error in data entry, 2) failure to report clinical findings that were actually present, and/or 3) failure to consider the implications of all reported clinical findings. if clinicians are not considering the interrelatedness of all documented findings, diagnoses could be misled, again increasing the risk for ineffective treatment.24,25 similar arguments could be made for the observed number of tendinosis diagnoses in relation to reported signs and symptoms. increased tissue thickness was documented 12.3% of the time, but stage i and stage ii tendinosis were only diagnosed in 8.6% of cases. because the presence of tissue thickening was less than the number of tendinosis diagnoses, clinicians may, in this case, have considered this one sign in conjunction with the rest of their clinical findings, rather than considering it in isolation. in contrast, nirschl and ashman have also identified that lateral elbow tendinosis is most common in individuals in their thirties to fifties, but the majority of the patients included in the present study were younger.14 therefore, the likelihood of true tendinosis in the present study is less probable, given the average age was just over 20 years old. considering the average age of individuals in this study, along with the fact that imaging studies were not performed, ultimately bring into question the accuracy of the tendinosis diagnoses, and instead reinforce the use of terms tendinopathy or tendinalgia. despite the patterns noted previously in clinicians’ classifications of tendon pathology, with 67.4% of patients being diagnosed with tendinopathy, point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 diagnoses generally seemed to reflect the lack of understanding of tendon pathology described in the literature.3,11,15-23,30 moreover, when the term tendinalgia was added, there was a 46.0% decrease in the number of tendinopathy diagnoses, and a 15.0% decrease in tendinitis diagnoses. specifically, 178 total classifications were switched from tendinitis or tendinopathy to tendinalgia. the large shifts in clinical classification to tendinalgia may reflect the lack of accurate understanding of tendon pathology. or, it may indicate that clinicians are not effectively using their clinical findings to inform their initial working diagnosis. under the assumption of the former, this could imply that tendinopathy may even be misleading in both describing the nature of tendon pathology and determining treatment choices. of note, 125 of the 290 original tendinopathy cases were changed to tendinalgia when this term was included as a possible diagnosis. perhaps the use of the term tendinalgia more accurately describes the current level of knowledge and primary findings regarding tendon pathology. specifically, these findings suggest that tendon pain is the only consistent finding, and clinicians must perform more through examinations to determine the root cause of the tendon pain. this exploratory study has several implications for clinical practice. there is a need for comprehensive evaluation of tendon pathology if clinicians are to more fully understand how these types of conditions manifest clinically and what causes, other than local tissue inflammation or degeneration, may be the cause of the patient’s root dysfunction. according to numerous imaging studies, tissue changes can often occur without symptoms.3,15-23 for patients presenting with pain, this indicates that degenerative or inflammatory changes noted with imaging may not actually be the cause of a patient’s symptoms. moreover, if observable changes in tissue structure that appear on imaging studies do not match a patient’s symptoms – or lack of symptoms – then clinical findings, which indirectly indicate the nature of pathology through observation of inflammatory signs and pain provocation, may not give clinicians much further information about a patient’s pain.3,15-25 this idea was supported in the present study, with many clinicians ultimately diagnosing their patients with tendinalgia, simply indicating pain at the tendon.30,31 these findings reinforce the need for detailed evaluation to determine local and regionally interdependent causes of pain and dysfunction that may result in localized tendon pain instead of treating local tissue pathology alone.24,25,35,36 thus, more general terms, such as tendinalgia, may be more appropriate when classifying and labeling tendon pain. the lack of understanding of the nature of pathology, and the possibility that clinical diagnoses do not accurately represent these pathologies, is not uncommon. there is evidence that the same is true for lateral ankle sprains, range of motion limitations, and meniscal lesions, in which tissue is the supposed cause of the dysfunction.36-38 the tissue model hypothesis has not been supported across any of these pathologies because the time to discharge, change in function, and/or resolution of pain was faster than the time that would be necessary for true tissue healing and/or changes to have occurred.36-39 while the present study did not include a treatment component, similar questions could be raised about the actual cause of tendon pain. in a case study performed by baker et al., a patient presenting with reactive tendinopathy of the proximal biceps tendon was pain-free and discharged after three days of manual therapy treatment, with no return of symptoms after resuming physical activity.30 if the patient had reactive tendinopathy, which implies pathological tissue changes, it should have taken longer for symptoms to be eliminated, and would have most likely required intermittent rest during training to avoid the return of symptoms.25,39 therefore, at this point in time, it does not seem appropriate for clinicians to confidently label tendon pathology based on the tissue model hypothesis. instead, it point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 seems most acceptable to describe suspected tendon pathology as pain manifesting near a tendon, which is best captured with the term tendinalgia. at the very least, clinicians should acknowledge the limitations in the clinical understanding of tendon pathology, and subsequently treat patients accordingly. terms such as tendinalgia may help remind clinicians to treat the patient’s pain as it presents, rather than treating under the assumption of an inflammatory or degenerative condition without evidence to support these notions. limitations while the limited understanding of tendon pathology that exists across healthcare has been reinforced, the present study does have limitations. several possible patterns were not assessed, including how patients may differ in clinical presentation based on sport or occupation, age, or sex, nor how clinicians may differ in their clinical diagnoses based on years of experience or other factors. additionally, data analyzed within the database did not allow for assessment of whether or not the sign or symptom was assessed. it is possible that a sign or symptom was assessed but was not reported because it either was not present or was not documented by the clinician inputting the examination. therefore, limitations and inaccuracies may exist within the data due to clinician error. however, the goal of the present study was to assess everyday clinical practice. thus, completely accurate results with solely clinician judgment will be difficult to obtain no matter the nature of the study, so long as researchers and clinicians are only analyzing daily clinical practice without confirmation from imaging or other histological studies. in the future, it would be beneficial to assess: 1) patient presentation stratified by various demographic factors, 2) factors that affect clinician choice in diagnosis, and 3) the relationship between clinical diagnosis and treatment. gaining a better understanding of the clinical presentation of tendon pain and clinical reasoning may subsequently lead to improved treatment decisions and patient outcomes. conclusion according to the present study, the most frequent symptom of tendon pathology appears to be the presence of pain (e.g., at the site of injury, during activity, etc.). given the discrepancies in tendon pathology diagnosis and imaging results, clinicians must critically analyze patient presentation to identify an appropriate clinical diagnosis and subsequent treatment plan. understanding of the term tendinalgia, like the previously introduced term of lateral epicondylalgia, may be more relevant to clinicians to improve the documentation of clinical findings, diagnostic classification, and the matching of treatments to address causes of pain. specifically, patient outcomes may be improved if clinicians operate under the premise that tendon pathology is a pain-related condition, rather than treating from the perspective that there are inflammatory or degenerative changes within the tissue. references 1. zwerver j, bredeweg sw, van den akkerscheek i. prevalence of jumper's knee among nonelite athletes from different sports: a cross-sectional survey. am j sports med. 2011;39(9):1984-1988. https://doi.org/10.1177/0363546511413 370. 2. scott a, ashe mc. common tendinopathies in the upper and lower extremities. curr sports med rep. 2006;5(5):233-241. https://doi.org/10.1007/s11932-0060004-5. 3. scott a, docking s, vicenzino b, et al. sports and exercise-related tendinopathies: a review of selected topical issues by participants of the second international scientific tendinopathy symposium (ists) vancouver 2012. br j sports med. 2013;47(9):536-544. https://doi.org/10.1136/bjsports-20130923299. 4. andres bm, murrell ga. treatment of tendinopathy: what works, what does not, https://doi.org/10.1177/0363546511413370 https://doi.org/10.1177/0363546511413370 https://doi.org/10.1007/s11932-006-0004-5 https://doi.org/10.1007/s11932-006-0004-5 https://doi.org/10.1136/bjsports-2013-0923299 https://doi.org/10.1136/bjsports-2013-0923299 point-of-care research: retrospective analysis of the evaluation and 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https://doi.org/10.2214/ajr.11.6971 https://doi.org/10.2519/jospt.2015.5941 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 sports med. 2000;28(5):634-642. https://doi.org/10.1177/0363546500028 0050301. 23. thompson sm, fung s, wood dg. the prevalence of proximal hamstring pathology on mri in the asymptomatic population. knee surg sports traumatol arthrosc. 2017;25(1):108-111. https://doi.org/10.1007/s00167-0164253-4. 24. kaux jf, forthomme b, le goff c, crielaard jm, croisier jl. current opinions on tendinopathy. j sport sci med. 2011;10(2):238-253. 25. cook jl, purdam cr. is tendon pathology a continuum? a pathology model to explain the clinical presentation of load-induced tendinopathy. br j sports med. 2009;43(6):409-416. https://doi.org/10.1136/bjsm.2008.05119 3. 26. cook jl, khan km, kiss zs, purdam cr, griffiths l. reproducibility and clinical utility of tendon palpation to detect patellar tendinopathy in young basketball players. br j sports med. 2001;35(1):65-69. https://doi.org/10.1136/bjsm.35.1.65. 27. maffulli n, kenward mg, testa v, capasso g, regine r, king jb. clinical diagnosis of achilles tendinopathy with tendinosis. clin j sports med. 2003;13(1):11-15. https://doi.org/10.1097/00042752200301000-00003. 28. feilmeier m. noninsertional achilles tendinopathy pathologic background and clinical examination. clin podiatr med surg. 2017;34(2):129-136. https://doi.org/10.1016/j.cpm.2016.10.00 3. 29. hutchison am, evans r, bodger o, et al. what is the best clinical test for achilles tendinopathy? foot ankle surg. 2013;19(2):112-117. https://doi.org/10.1016/j.fas.2012.12.006. 30. baker rt, van riper m, nasypany am, seegmiller jg. evaluation and treatment of apparent reactive tendinopathy of the biceps brachii. int j athl ther train. 2014;19(4):14-21. https://doi.org/10.1123/ijatt.2014-0023. 31. waugh ej. lateral epicondylalgia or epicondylitis: what’s in a name? j orthop sports phys ther. 2005;35(4):200-202. https://doi.org/10.2519/jospt.2005.0104. 32. färnqvist k, pearson s, malliaras p. adaptation of tendon structure and function in tendinopathy with exercise and its relationship to clinical outcome. 2020;29(1):107-115. j sport rehabil. https://doi.org/10.1123/jsr.2018-0353. 33. plinsinga ml, brink ms, vicenzino b, wilgen cpv. evidence of nervous system sensitization in commonly presenting persistent painful tendinopathies: a systematic review. j orthop sports phys ther. 2015;45(11):864875. https://doi.org/10.2519/jospt.2015.5895. 34. farrar jt, young jr. jp, lamoreaux l, werth jl, poole rm. clinical importance of changes in chronic pain intensity measured on an 11point numerical pain rating scale. pain. 2001;94(2):149-158. https://doi.org/10.1016/s03043959(01)00349-9. 35. cook g. movement: functional movement systems: screening, assessment, corrective strategies. santa cruz, ca: on target publications; 2010. 36. gamma sc, baker rt, iorio s, nasypany a, seegmiller jg. a total motion release warm-up improves dominant arm shoulder internal and external rotation in baseball players. int j sports phys ther. 2014;9(4):509-517. 37. hudson r, baker rt, may j, reordan d, nasypany a. novel treatment of lateral ankle sprains using the mulligan concept: an exploratory case series analysis. j man manip ther. 2017;25(5):251-259. https://doi.org/10.1080/10669817.2017. 1332557. 38. hudson r, richmond a, sanchez b, et al. an alternative approach to the treatment of meniscal pathologies: a case series analysis of the mulligan concept “squeeze” technique. int j sports phys ther. 2016;11(4):564-574. 39. lee ac, quillen ws, magee dj, zachazewski je. injury, inflammation, and repair: tissue mechanics, the healing process, and their impact on the musculoskeletal system. in magee do, zachazewski je, quillen ws, eds. scientific foundations and principles of practice in musculoskeletal https://doi.org/10.1177/03635465000280050301 https://doi.org/10.1177/03635465000280050301 https://doi.org/10.1007/s00167-016-4253-4 https://doi.org/10.1007/s00167-016-4253-4 https://doi.org/10.1136/bjsm.2008.051193 https://doi.org/10.1136/bjsm.2008.051193 https://doi.org/10.1136/bjsm.35.1.65 https://doi.org/10.1097/00042752-200301000-00003 https://doi.org/10.1097/00042752-200301000-00003 https://doi.org/10.1016/j.cpm.2016.10.003 https://doi.org/10.1016/j.cpm.2016.10.003 https://doi.org/10.1016/j.fas.2012.12.006 https://doi.org/10.1123/ijatt.2014-0023 https://doi.org/10.2519/jospt.2005.0104 https://doi.org/10.1123/jsr.2018-0353 https://doi.org/10.2519/jospt.2015.5895 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.1080/10669817.2017.1332557 https://doi.org/10.1080/10669817.2017.1332557 point-of-care research: retrospective analysis of the evaluation and classification of tendon pathology in athletic training 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 rehabilitation. st. louis, mo: saunders elsevier; 2007:1-22. manuscript type clinical outcomes research 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 assessing lower extremity injury risk in a mid-atlantic drum corps using the weight bearing lunge test nicolás c merritt, dat, scat, atc, ns1 and cameron j powden phd, lat, atc2 1furman university, greenville, sc; 2indiana state university, terre haute, in abstract with athletic training’s expansion into non-traditional settings, it is important to assess if screening tools can provide value in range of settings. currently, there is a dearth of information regarding specific models for injury risk assessment in drum corps patients. the weight bearing lunge test (wblt) has been used to evaluate those at risk for suffering a lower extremity injury (lei) in a traditional athletic population. this practice-based research is an attempt to apply current evidence of injury risk assessment use in the traditional settings to performing arts. the purpose of our investigation was to determine the effect of wblt motion on lei in drum corps. all participating drum corps members were measured using the wblt during the preseason screening process. injury record keeping was completed through electronic medical records (emr) and all lei were recorded over two consecutive, 85-day seasons. the average of the maximal distance in centimeters of the great toe from the wall indicated the wblt average (wbltav). wblt asymmetry (wbltasy) was the absolute difference between limbs. t-tests were used to determine if there was a significant difference between those who sustained a lei (injured) and those who did not (uninjured) for wbltav and wbltasy. for dependent measures associated with significant group differences, receiver operator characteristic curves (roc) were performed to examine injury risk using area under the curve (auc). lastly, cut-off scores that produced the maximal values of sensitivity and specificity were identified. alpha level was set a priori at p<0.05. drum corps patients with lower wbltav (<11.47cm) or higher wbltasy (>0.75cm) measures were more likely to sustain a lei during a competitive drum corps season. these data demonstrates that the wblt could be viable as a screening tool in the marching arts and provides initial cut-off values. key phrases injury risk reduction, injury surveillance, performing arts correspondence dr. nico merritt, furman university, timmons arena, 3300 poinsett highway, greenville, sc 29613. e-mail: nico.merritt@furman.edu twitter: @bostonandbeyond full citation merritt nc, powden cj. assessing lower extremity injury risk in a mid-atlantic drum corps using the weight bearing lunge test. clin pract athl train. 2018;1(2):37-41. https://doi.org/10.31622/2018/0002.6 submitted: september 13, 2018 accepted: october 15, 2018 introduction a modern drum and bugle corps is a musical marching ensemble consisting of brass instruments, percussion instruments, synthesizers, and color guard. drum and bugle corps are considered marching music’s major league. these groups practice for over 10 hours a day, on their feet, and have high incidence of lower extremity injury (lei). lei is more common to occur in marching ensembles than injury to the upper extremity.1 the most common injuries are medial tibial stress syndrome, achilles tendonitis, and ankle sprain. the commonality of these injuries in combination with their impact on heath and participation signifies the need to develop lei preventative practices in this population to enhance patient safety.1 the first step to injury prevention is identifying those individuals that may be most at risk. in order to accomplish this, clinicians need efficient and effective screening tools. screening tools usually examine range of motion, balance, strength, and/or other modifiable risk factors as potential injury risk predictors. there are many tools that may be effective in assessing injury risk in populations with high incidence of lei.2-6 ankle dorsiflexion range of motion (drom) is a simple measure that has a lot of supportive research in relation to lei risk.2-6 drom has been used with basketball, volleyball, gymnastics, and other various sports and activities.7 the weight bearing lunge test (wblt), specifically, is a common quantification technique that measures drom in a https://doi.org/10.31622/2018/0002.6 assessing lower extremity injury risk in a mid-atlantic drum corps using the weight bearing lunge test 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 weight bearing position. research has demonstrated that the wblt can be used to quantify drom and predict lei.7 additionally, the wblt has been associated with measures of dynamic movement8 and balance9 which have also been associated with injury risk in physically active populations.10 dfrom has been shown to have utility to predict individuals at risk of lei in sports populations. this method, however, has not been conducted with the drum corps population. therefore, the purpose of this study is to determine the effect of drom on lei risk within a mid atlantic drum corps by assessing drom using the wblt. patients: two hundred thirty-eight patients from a drum corps international group from the mid-atlantic region that competes seasonally (male=173, female=65, age=19.49± 1.05yrs) were screened as part of the pre-participation exam prior to the 2016 and 2017 seasons. patients with current lower extremity injury at the time of data collection did not participate and were not included in the study. patients who were included in this study were then monitored throughout the competitive season for lower extremity injury (lei). intervention: the wblt was used to measure weight bearing dorsiflexion rom bilaterally in all patients. assessment of the wblt measurement in a systematic review suggested strong evidence that the inter-clinician reliability (icc=0.80-0.99, mdc 4.6° or 1.6cm) and the intra-clinician reliability (icc=0.65-0.99, mdc 4.7° or 1.9cm) were good.11 the wblt was performed using the knee-to-wall principle (figure 1).10,11 patients were in a standing position facing a wall with the test foot parallel to and on top of a measuring tape. the measuring tape was secured to the floor with athletic tape or an equivalent. the second toe, heel, and knee of the test foot were perpendicular to the wall during the testing session. while maintaining a single leg stance, patients were instructed to perform a lunge towards the wall by flexing the knee while keeping the heel of the test foot firmly fixed to the testing surface and without letting the knee sway medially or laterally. the opposite limb of the test foot was allowed to be suspended in knee flexion and non-weight bearing while the test foot went through the proper motion. patients were able to place their hands on the wall for balance if desired. the test foot was progressed away from the wall in one centimeter (cm) increments and repeated until the knee or heel of the test limb lost contact with the wall and/or floor respectively. the foot placement was then adjusted in smaller increments in order to have the foot the farthest point away from the wall while maintaining knee and heel contact and maximum lunge distance was recorded. the final successful trial was recorded for statistical analysis. wblt measurements were completed by four individuals, two athletic trainers with 1-2 figure 1. weight bearing lunge test (wblt). assessing lower extremity injury risk in a mid-atlantic drum corps using the weight bearing lunge test 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 years of experience and two athletic training students. outcome measures: injury electronic medical records were stored in a password protected, hipaa compliant, online spreadsheet (g suitetm by google©) and was used to keep track of the number of lower extremity injuries sustained over the two 85 day seasons. each patient injury was recorded into the online spreadsheet; patients sustaining multiple injuries were included in the analysis for their first lei only. the definition of a lower extremity injury was an injury that caused removal from activity and loss of practice time for a total of four or more cumulative hours (one practice block). analyses were completed using a statistical software program (ibm corp. released 2015. ibm spss statistics for windows, version 23.0 armonk, ny: ibm corp). means and standard deviations of wblt, average, and asymmetry measures were calculated for injured and noninjured patients. the average of the maximal distance in centimeters of the great toe from the wall indicated the wblt average (wbltav). wblt asymmetry (wbltasy) was the absolute difference between limbs. t-tests were used to determine if there was a significant difference between those who sustained a lei (injured) and those who did not (uninjured) for wbltav and wbltasy. for dependent measures associated with significant group differences, receiver operator characteristic curves (roc) were performed to examine injury risk using area under the curve (auc). lastly, cut-off scores that produced the maximal values of sensitivity and specificity were identified. alpha level was set a priori at p<0.05. results: lei occurred in 87 of 238 patients during the 2016 and 2017 drum corps regular seasons (table 1). the normalized wbltav and wbltasy for injured and uninjured patients are presented in table 2. the injured wbltav was significantly less compared to the uninjured (p=0.005). the injured wbltasy was significantly greater compared to the uninjured (p=0.015). the auc from the roc analysis (figure 2) for wbltav and wbltasy was 0.596 and 0.601 respectively. a wbltav cutoff score of 11.47cm was associated with a sensitivity of 0.678 and a specificity of 0.510. a wbltasy cutoff score of 0.75cm was associated sensitivity of 0.552 and a specificity of 0.629. this data demonstrates that if a drum corps individual has a wbltav measure less than 11.47cm, they are 40% more likely to sustain an lei; if a drum corps individual has a wbltasy measure greater than 0.75cm, then they are 49% more likely to sustain an lei (figure 2). figure 2. receiver operator curve: a) wblt average and b) wblt asymetry. clinical outcomes research 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 discussion: the purpose of this study was to determine if a relationship exists between drom and lei risk in the drum corps population. slightly over one-third of the patients sustained an lei during the 170 days of participation. this study demonstrate that individuals with greater measures of average weight bearing drom (wbltav > 11.47cm) are less likely to become injured and individuals with a greater asymmetry of weight bearing drom (wbltasy > 0.75cm) between limbs are more likely to become injured. these findings are the stepping stone to say that weight bearing drom may be a predictor of injury in the drum corps population. the results of this practice-based research identified wbltav (p=0.005) and wbltasy (p=0.015) differences between those that sustained a lei and those that did not. to further analyze the utility of the wblt, cutoff scores were calculated. while our findings indicated relatively low predictive accuracy overall, as signified by moderate auc values (0.596 and 0.601), each measure fared well at either ruling in or out injury. this was indicated by wbltav sensitivity and wbltasy specificity values of almost 0.70. in terms of positive and negative likelihood ratios, this indicates that a drum corps member who have less than a 11.47cm wbltav are about 40% more likely to sustain a lei than a member over that value (lr+ = 1.38). additionally, if a member has greater than 0.75cm wbltasy, then they are 49% more likely to sustain a lei than an individual with less asymmetry. overall, the results of this study indicate that the wblt is a feasible screening method that does demonstrate useful data for a clinician to determine a drum corps member’s lei risk. these findings are similar to previous literature on lei risk in traditional athletic populations.2-6 furthermore, due to drom’s nature as a modifiable risk factor, injury prevention programs could be implemented to reduce an individual’s risk of lei. we propose that this method of screening can be completed prior to the season, and could allow clinicians to identify at risk individuals and ultimately decrease the overall frequency of lei for the season once these individuals have modified their weight bearing drom through prevention programs. at this time however, there is a need to evaluate the best practices for increasing drom in a prophylactic manner. we experienced a number of obstacles during the implementation of the wblt, however, we determined how to overcome these obstacles in the future. the implementation of the wblt screening with multiple individuals in a short time span could have resulted in possible error. the wblt takes approximately thirty seconds to one minute to perform with one patient. therefore, it is suggested for future studies to either increase the number of trained individuals administering the screening, or increase the amount of time available to complete the screening with the drum corps members. an athletic training student was trained and completed practice sessions, but since the wblt was a new procedure for the athletic training student, this inexperience may have compromised the ability to record accurate measurements. in order to reduce error, it is recommended that individuals who are properly trained and who have previous experience should administer the screening. the number of participants participating in the study may have been too low to provide accurate data for analysis. additional participants may be needed in future studies. this can be accomplished by introducing multiple drum corps groups to the screening and conducting data on all the groups combined, not just one corps for two seasons. additionally, the definition of lei included any injury distal to the hip. although drom can be associated with injuries proximal to the ankle, it is not the only correlating factor. these factors may have produced inaccurate measurements causing a misrepresentation of the studied population. additional research in this area could explore other modifiable risk factors such as knee and hip posture/range of motion, as well as factors such as sex and instrument type, as these could play a contributing role to injury risk within drum corps. assessing lower extremity injury risk in a mid-atlantic drum corps using the weight bearing lunge test 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 clinical implications: little research has been conducted regarding injury prevalence and injury risk factors within the performing arts athlete population, specifically drum corps. our study provides an initial look into potential risk factors for lei. clinicians could utilize this data and the wblt within the drum corps population to screen for lei risk and identify individuals with higher risk of lei. cutoff scores of greater than 0.75cm wbltasy and less than 10.40cm wbltav should be used to identify drum corps members that may be at greater risk of sustaining a lei. with this information, healthcare providers can identify at-risk individuals and prescribe preventative measures in order to mitigate the potential injury during the drum corps season. in conclusion, our research study provides a starting point for prevention research in this unique population. however, additional research studies are needed regarding risk factors that predispose performing arts athletes to injury. such studies can indicate how to best provide prevention strategies for the performing arts athletes in order to increase health related quality of life. references 1. moffit dm, russ ac, mansell jl. marching band camp injury rates at the collegiate level. med probl perform art. 2015;30(2):96. https://doi.org/10.21091/mppa.2015.201 6 2. tabrizi p, mcintyre w, quesnel m, howard a. limited dorsiflexion predisposes to injuries of the ankle in children. j bone joint surg brit. 2000;82(8):1103-1106. https://doi.org/10.1302/0301620x.82b8.0821103 3. pope r, herbert r, kirwan j. effects of ankle dorsiflexion range and pre-exercise calf muscle stretching on injury risk in army recruits. aust j physiother. 1998;44(3):165-172. https://doi.org/10.1016/s00049514(14)60376-7 4. willems tm, witvrouw e, delbaere k, mahieu n, de bourdeaudhuij i, de clercq d. intrinsic risk factors for inversion ankle sprains in male subjects: a prospective study. am j sports med. 2005;33(3):415-423. https://doi.org/10.1177/0363546504268 137 5. . willems tm, witvrouw e, delbaere k, philippaerts r, de bourdeaudhuij i, de clercq d. intrinsic risk factors for inversion ankle sprains in females–a prospective study. scand j med sci sports. 2005;15(5):336-345. https://doi.org/10.1111/j.16000838.2004.00428.x 6. malliaras p, cook jl, kent p. reduced ankle dorsiflexion range may increase the risk of patellar tendon injury among volleyball players. j sci med sport. 2006;9(4):304-309. https://doi.org/10.1016/j.jsams.2006.03.0 15 7. kaminski tw, hertel j, amendola n, et al. national athletic trainers' association position statement: conservative management and prevention of ankle sprains in athletes. j athl train. 2013;48(4):528-545. https://doi.org/10.4085/1062-605048.4.02 8. barrett a cb. weight-bearing dorsiflexion is associated with sagittal plane kinematics during gait. j sports med phys fitness. 2009;39(10):a20. https://doi.org/10.23736/s00224707.17.07348-0 9. hoch mc, staton gs, mckeon po. dorsiflexion range of motion significantly influences dynamic balance. j sci med sport. 2011;14(1):90-92. https://doi.org/10.1016/j.jsams.2010.08.0 01 10. hoch mc, mckeon po. normative range of weight-bearing lunge test performance asymmetry in healthy adults. man ther. 2011;16(5):516. https://doi.org/10.1016/j.math.2011.02.01 2 11. powden cj hj, hoch, mc. reliability and minimal detectable change of the weightbearing lunge test: a systematic review. man ther. 2015;20(4):524-532. https://doi.org/10.1016/j.math.2015.01.00 4 https://doi.org/10.21091/mppa.2015.2016 https://doi.org/10.21091/mppa.2015.2016 https://doi.org/10.1302/0301-620x.82b8.0821103 https://doi.org/10.1302/0301-620x.82b8.0821103 https://doi.org/10.1016/s0004-9514(14)60376-7 https://doi.org/10.1016/s0004-9514(14)60376-7 https://doi.org/10.1177%2f0363546504268137 https://doi.org/10.1177%2f0363546504268137 https://doi.org/10.1111/j.1600-0838.2004.00428.x https://doi.org/10.1111/j.1600-0838.2004.00428.x https://doi.org/10.1016/j.jsams.2006.03.015 https://doi.org/10.1016/j.jsams.2006.03.015 https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.23736/s0022-4707.17.07348-0 https://doi.org/10.23736/s0022-4707.17.07348-0 https://doi.org/10.1016/j.jsams.2010.08.001 https://doi.org/10.1016/j.jsams.2010.08.001 https://doi.org/10.1016/j.math.2011.02.012 https://doi.org/10.1016/j.math.2011.02.012 https://doi.org/10.1016/j.math.2015.01.004 https://doi.org/10.1016/j.math.2015.01.004 clinical outcomes research 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique lucas bianco, dat, lat, atc1; james may, dat, lat, atc2; alan nasypany, edd, lat, atc2 1biokinetix, chicago, il; 2university of idaho, moscow, id abstract hamstring injuries have an occurrence rate of 3.05 per 1000 athlete exposures in intercollegiate athletics. current clinical practice recommendations for rehabilitation of hamstring injuries are based on pathoanatomical muscle tissue healing timeframes. the purpose of this study was to examine the effects of modulating the nervous system with primal reflex release technique (prrt) in patients clinically diagnosed with functional neuromuscular hamstring muscle-related disorder (fnhd). in this a priori case series, prrt was utilized in four patients participating in intercollegiate, national collegiate athletic association division ii, athletics to evaluate numeric pain rating scale (nrs) for current pain, disablement of the physically active (dpa) scale, modified patient specific functional scale (psfs), and active knee extension test (aket). the initial pre-treatment to post-treatment average difference for nrs (3.25±2.5 points) and aket (11±2.16°) improved by an amount that satisfied mcid and mcd respectively. the pre-treatment to one-week follow-up average difference for nrs (5.5±2.3 points), psfs (4.75±2.5 points), and aket (20.5±14°) improved by an amount that satisfied mcid or mcd. the average timeline for discharge to full unrestricted activity was 2.75 days. in the four patients classified with a functional neuromuscular muscle disorder (fnmd), prrt was utilized as the only manual therapy intervention. through modulation of the nervous system, the outcomes reported by the patients were both meaningful and clinically significant. based on the results and the current standard of care for similar patients, the need for further research into this paradigm is warranted. hamstring injuries continue to be a significant clinical injury in the athletic patient population. a thorough evaluation and appropriate classification of muscle injury can help clinicians decided an effective treatment for the patient. clinicians seeking to improve patient outcomes may benefit from considering a paradigm that modifies the neural allostatic loads. key phrases autonomic nervous system, patient-reported outcomes, clinician-rated outcomes correspondence dr. lucas bianco, 3205 street lynchburg, va 24501. e-mail: lucasbianco4915@gmail.com full citation bianco l. a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique. clin pract athl train. 2019;2(1):19-31. https://doi.org/10.31622/2019/0001.5. submitted: december 9, 2018 accepted: february 26, 2018 introduction hamstring injuries are a common pathology within physically active patient populations.1-6 injury to the hamstring muscle complex can present as tissue damage leading to pain and functional limitations.1-4,5-8 structural damage, ranging from micro-trauma to macro-trauma, can occur when the force placed on the hamstring muscle is greater than the mechanical limits of the tissue.9,10 functional limitations, not structural damage, are frequently used to classify a patient with a hamstring injury, and determine treatment parameters based on recommendations of tissue healing timeframes.68,11 it is possible that a portion of these injuries have minimal or no structural damage and are fnmds, thus they do not need to adhere to the recommended tissue healing timeframes. hamstring injuries are prevalent in the intercollegiate athletic population, with a rate of 3.05 per 1000 athlete exposure.12 the goals of hamstring rehabilitation include decreasing pain, restoring function, and returning to the prior level of sports performance with minimal risk of reinjury.1,2,7,11 previous research on hamstring treatment and return to play programs has been completed for patients classified with hamstring injury. however, the re-injury rates for this clinical significant injury have been consistent over the past 20 years.1,2,4,8,11-13 with an increased risk of re-injury rate in intercollegiate athletics, further research is required to determine more effective interventions and treatment theories to decrease pain, restore range of motion (rom), and improve function following classification of a hamstring injury. a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 the pathoanatomical evaluation is recommended as the means for assessing a patient with a possible hamstring injury.1,2,7,8,10,14 the widely used, o’donoghue muscle injury classification system correlates tissue damage to loss of function.15 based on this classification system, patients who present with pain and decreased function would be classified with a grade i or ii hamstring strain. a recent consensus statement on muscle injuries in sport provides a new comprehensive classification system.16 the munich muscle injury classification system (figure 1) was used by the treating clinician (tc) to sub-classify these patients. based on this new classification system, patients treated in this case series would be classified as having a fnmd. the neural component of a musculoskeletal injury can easily be overlooked as it is not commonly associated or treated under the tissue model.17 as rehabilitation theories evolve to meet the progressive neurophysiologic research, clinicians may desire interventions purposed to create ideal function of the neurological system, rather than protocols encompassing the myopic muscle tissue healing model. figure 1. munich muscle classification16 patients with hamstring injuries in this study were classified with a type 2a muscle-related neuromuscular muscle disorder and treated with prrt, an innovative neurophysiological approach to treatment patients with hamstring injuries in this study were classified with a type 2b muscle-related neuromuscular muscle disorder and treated with prrt, an innovative neurophysiological approach to treatment. a. indirect muscle injury/ disorder functional muscle disorder type 1: overexertionrelated muscle disorder type 1a: fatigue-induced muscle disorder type 1b: delayed-onset muscle soreness type 2: neuromuscular muscle disorder type 2a: spine-related neuromuscular muscle disorder type 2b: muscle-related neuromuscular muscle disorder strucual muscle injury type 3: partial muscle tear type 3a: minor partial muscle tear type 3b: moderate partial muscle tear type 4: (sub)total tear subtotal complete muscle tear tendinous avulsion b. direct muscle injury contusion laceration a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 the central nervous system (cns) and peripheral nervous system (pns) are directly related, and function in unison to provide appropriate sensory information to the brain to maintain a state of allostasis throughout the body.18-20 allostatic modulations in loading of the muscle tissue are often due to facilitated neurons and/or inhibited neurons creating abnormal function.20 neurophysiologist, sir charles sherrington, introduced the law of reciprocal innervation which is used in therapeutic techniques, such as proprioceptive neuromuscular facilitation, to relax the agonist muscle via reflexive stimulation of the antagonist muscle.21 the use of reciprocal innervation may be an effective treatment when the nervous system is in need of a modulating external stimulus.22 expanding on this theory, withdrawal and startle reflexes that lead to muscle spasm and possibly pain can be due to mal-adaptation or abnormal stimulation of the nervous system.19 as a result of trauma (e.g., high speed running or agility movements), the nervous system may remain “up-regulated” and unable to restore a state of more ideal allostasis. in this up-regulated state, the use of an external stimulus to reset the cns can resolve pain and restore function instantly.19,23 the creator of prrt, john iams, recognized that reflex responses to startling and/or painful events may persist in the form of facilitated or inhibited muscles, which leads to compensatory patterns, pain, dysfunction.23 through modulating the cns through the pns, prrt, an innovative treatment paradigm, can help reset the nervous system to a more ideal allostatic load following a traumatic incident such as a mechanism of injury leading to a hamstring injury. the use of prrt in clinical practice has been demonstrated in the literature.24-26 the purpose of this study was to examine the effects of modulating the nervous system with prrt in patients classified with functional neuromuscular hamstring musclerelated disorder (fnhd). patients four patients (3 males and 1 female) averaging (19.75±1.5 years of age) actively participating in intercollegiate athletics (table 1) reported to the athletic training clinic with posterior thigh pain. all four patients were evaluated by a certified athletic trainer and met criteria to be included in this study. each patient was classified with fnmd and treated by the same athletic trainer with four years of clinical practice experience who had completed, the primal reflex release technique™ home study course, and the primal reflex release technique™ livetraining seminar. based on the a priori design, the patients were not treated with any other therapeutic interventions. patient-oriented evidence (poe) and clinician-oriented evidence (coe) outcome measures were collected for each patient over the course of treatment. the numeric pain rating scale (nrs) for current pain, disablement of the physically active (dpa) scale, and modified patient specific functional scale (psfs) were all included as poe. the coe classified measure was the, active knee extension test (aket), and hamstring manual muscle test (mmt). the institutional review board (irb) of the two universities involved in this study approved the collection and dissemination of outcomes. all participants provided written table 1. demographics and evaluation information patient age gender sport location of pain in posterior thigh involved side 1 18 female cross country lateral distal third right 2 19 male soccer middle third left 3 21 male basketball lateral middle third left 4 21 male basketball medial proximal third left a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 consent to have their non-identifiable information included in this study. at the time of initial evaluation, each patient reported pain with a decrease in active rom and function in the affected extremity compared bilaterally. due to the short time period from onset of injury to evaluation of the patient (within 1-2 days), lack of structural damage diagnosis, and munich muscle injury classification each patient was determined to have sustained a neuromuscular muscle disorder. one patient selfreported a previous “hamstring strain” on his contralateral side, while the other patients reported no previous hamstring pathology. following the evaluation, poe and coe measures were completed. patients were included if they had the following outcome scores; nrs of ≥2/10, aket measurement of ≤70˚ on involved side, and a psfs score of ≤8/10 (table 2). intervention the initial prrt treatment session was completed immediately following the initial evaluation and collection of baseline patient outcome measures. the patient was positioned supine on a treatment table for all treatments. then the tc provided a tactile stimulus the patient’s muscle bellies and tendons, or a quick movement the patient’s limb to create a reflexive response. the stimulus activates proprioceptors in the local tissue through reciprocal innervation that can lead to a more ideal allostatic load in the nervous system.21-23 starting with the involved side, each technique was completed for approximately 12 seconds, followed by the intervention on the contralateral limb. four prrt treatment techniques in the same sequence were utilized on each patient. the intervention consisted of the following sequence: hamstring down-regulate (dr) (figure 2), gastrocnemius reset (figure 3), medial knee/ sacroiliac (si) joint reset (figure 4), and si bilateral release (figure 5), and was completed bilaterally, for a total of 2-3 minutes per session. after completion of the treatment, the patient stood up and then walked the length of the clinic two times, a total of approximately 60 feet. then aket and psfs were reassessed, along with the nrs, at the conclusion of the initial treatment session. outcome measures the nrs, psfs, mmt, and aket were assessed at the following time-points: preand post-initial treatment session, discharge, one-week, and sixweek follow-up assessment. the dpas was collected at the pre-initial treatment session, oneweek, and six-week follow-up assessment. following the evaluation and collection of initial outcome measures, each patient received the prrt sequence described below. total number of treatments and days to discharge were tracked for each patient. numeric rating scale & disablement of the physically active the nrs and dpas patient-reported outcomes assessments measured each patient’s perception of pain and disablement. the nrs is an 11-point pain scale where 0 is “no pain” and 10 is “the worst pain imaginable.” scores reported for the nrs represent patient reported current pain in a weight bearing position (i.e. standing) at the time of assessment. a change of 2 points or greater is considered a minimal clinically important difference (mcid) for the nrs.27 the dpas was designed and validated for assessing disablement in physically active individuals. a 64-point scale with 16 possible identifiers of disablement individually scored on a 5-point likert scale where zero is “no issues” and 4 is a “severe” issue. for acute conditions, a mcid is reached with a 9-point difference in scores.28 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 figure 2. hamstring down-regulate (dr).22-23 patient rests foot on the tc’s shoulder while stimulation is applied to the patella tendon and each hamstring (semitendinosus, semimembranosus, and biceps femoris) muscle bellies. figure 4. medial knee/sacroiliac (si) joint reset.23 stimulation is provided to the adductor magnus muscle superior to the knee and pes anserine inferior to the knee. figure 3. gastrocnemius reset.23 patient maintains hip and knee flexion and ankle dorsiflexion while the tc applies stimulation to the patella tendon and ankle dorsiflexors (tibialis anterior, and extensor digitorum longus). figure 5. si bilateral release.22 the tc provided an external rotation stimulus into external hip rotation which the patient reacted against activating his/her internal hip rotators. table 2. inclusion and exclusion criteria inclusion exclusion acute, sudden posterior thigh pain nrs of ≥2/10 moi: acceleration or deceleration during running tender area to palpate on hamstring weakness compared bilaterally with knee flexion <5/5 mmt asymmetrical range of motion >5˚ involved side aket measurement of <70˚ modified psfs ≤8/10 gross deformity visible ecchymosis previous hamstring strain within 6 months no specific moi a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 range of motion (rom) to objectively assess rom, the aket was completed. the aket is completed with the patient lying supine. first, the clinometer phone application (plaincodetm, stephanskirchen, germany) was utilized to position the angle of hip flexion at 90° by placing the device on the posterior aspect of the thigh. once in 90° of hip flexion the patient was advised to straighten at his/her same knee while the patient maintained a fixed 90° hip flexion position.29,30 the clinometer was then moved to the anterior tibial shaft to assess the amount of knee extension which was recorded as the aket measurement, a straight knee was considered 90° of movement. the standard error of measurement (sem) has been reported at 3.8°.29,30 the minimal detectable change (mdc) has been recorded between 9.7° and 10.5°.29,30 strength testing manual muscle tests were included to grade muscular strength during evaluations.31 each patient was positioned prone and queued to flex his/her knee through the full rom. if the patient could not move through the full rom against gravity a grade of 2 was documented. no patients had a trace amount of movement, grade 1. when full rom accomplished against gravity with no pain and the same rom compared bilaterally a grade of 3 was documented. next, the tc placed force on the posterior aspect of the calcaneus while the patient’s knee was flexed to 90° and then asked the patient to resist. if the patient was able to resist the same force bilaterally a grade of 5 was recorded, grade of 4 was provided when full rom was obtained but one side was unable to resist the same force as the contralateral side.31 patient specific functional scale for assessment of perceived function, a modified psfs was implemented for uniformity between patients and the a priori design. the psfs classified each activity on an 11-point scale with 10 defined as, able to perform the same as before injury. an mcid is established for the psfs when a score for a single activity changes by 3 points.32 for the single activity, the patient was asked to stand with his/her feet about an inch apart and then cued to “bend forward and touch your toes”. following completion of the task the patient was asked to score the task on the 11-point scale. results four patients were evaluated and treated by the tc and were discharged to full unrestricted activity in an average of 2.75 days from the start of treatment (table 3). during the treatment sessions, poe and coe outcomes were collected to assess the patient’s pain and function. immediately following the initial treatment all the patients reported a decrease in pain that met mcid standards and three out of the four patients had an increase aket measurement that was greater than the mdc (table 4). prior to returning to full unrestricted activity (i.e. competitive event) the patients had decrease in nrs, as well as increases in psfs, mmt and aket (table 5 & table 6). at the one-week assessment all the patients reported a mcid for nrs and dpas while all but one had a mcid recorded for psfs (table 6). the aket measures for each patient were all greater than the mdc at the six-week follow-up assessment (table 5). at the six-week follow-up after discharge each patient reported no re-injury and maintained outcome scores. discussion the initial treatment of prrt resulted in immediate improvements on the nrs and aket for all four patients classified with a fnhd (table 4). applying the prrt hamstring treatment sequence to these patients paired with appropriate activity progression (restricted to a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 table 3. course of treatment timeframe patient # time from injury to tx (days) number of tx sessions limited participation in sport (days) discharged from tx (days) unrestricted activity (days) 1 1 3 2 4 3 2 <1 2 1 3 3 3 <1 3 2 3 3 4 <1 2 1 2 2 tx = treatment table 4. initial pre-intervention to post-intervention outcome scores patient # pre-tx nrs post-tx nrs pre-tx psfs post-tx psfs pre-tx aket post-tx aket pre-tx mmt pre-tx mmt 1 4 2 a 5 8a 55 67b 2/5 3/5 2 8 6 a 2 4 23 31 2/5 2/5 3 5 3a 7 8 52 65b 3/5 3/5 4 7 0a 5 5 62 73b 3/5 3/5 tx = treatment; a= mcid, b= mdc table 5. outcome measurements discharge to 6-week follow up patient # discharge mmt 1 week mmt 6 week mmt clinician oriented outcome measures manual muscle testing 1 4/5 4+/5 5/5 2 4+/5 5/5 5/5 3 5/5 5/5 5/5 4 4/5 5/5 5/5 active knee extension test 1 67a/65 66/66 72/75 2 64a/68 68/70 63/64 3 70a/74 78/77 85/85 4 73a/77 78/78 71/73 patient oriented outcome measures numeric rating scale 1 0b 0 0 2 2b 1 0 3 0b 0 0 4 0b 0 0 disablement of the physically active 1 18b 0 2 0b 0 3 6b 4 4 19b 0 patient specific functional scale 1 10b 8 10 2 10b 10 10 3 9 9 8 4 9b 8 10 aket = affected limb/unaffected limb; a= mdc from discharge to unrestricted activity; b= mcid from discharge to unrestricted activity a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 unrestricted activity) assisted the patients in returning to pre-injury participation levels. the focus of the four prrt treatment techniques was on modifying the nervous system rather than a muscle tissue healing model which is commonly followed after the classification of an acute hamstring injury. treating hamstring injuries with neurophysiological based interventions can have positive effects on pain, rom, and function of the patient. the results of this case series support the use of intervention theories to modulate the cns to assist patients classified with fnhd return to normalized allostatic loads demonstrated by outcomes improving before expected muscle tissue healing timeframes. the classification of fnhd was based on the munich muscle injury classification system. this system takes into account past classification systems based on structural damage and systems that explored functional deficits. by adding increased specifications for muscle injury, the munich muscle injury classification system supports the use of a more patient-centered intervention approach. in patients that do not have structural muscle damage a fnmd guides clinicians to consider the neurological mechanisms of injury, which are often overlooked. the goals for a patient following a hamstring injury is to decrease pain followed by restoring normal rom, strength, and function, while minimizing injury recurrence rates.1,2,7,11 pain management is the initial goal of any rehabilitation program. pain could be the prolonged symptom that needs to be addressed before function can be fully restored.6,11,33,34 decreasing pain is commonly achieved through heat, ice, ultrasound, electrical stimulation, mechanical therapies, and rest.1,2,13,33-35 following a decrease in pain, rom must be restored before strength and functional activities can improve.35-38 clinicians assess musculoskeletal injuries in this manner based on a hypothesized correlation with severity of signs and symptoms. rehabilitation is progressed based on decreased signs and symptoms assumed to be associated with tissue healing.7,14,36,37 new classification systems are warranted as ekstrand et al., found that patients classified with structural injuries through clinician evaluation only had evidence of mri diagnosed muscle tear in 29% of patients.39 no diagnostic imaging was completed during this case series. through an innovative treatment used with these patients to modify neural allostatic loads, immediate changes in pain and function occurred leading to discharge criteria being achieved faster than the traditional timeframes associated the muscle tissue healing. each patient in this study reported immediate decreases in pain at an amount that satisfied a mcid and increased rom greater than a mdc at the oneweek follow-up for each patient (table 5 & table 6). immediate changes in pain and rom are useful to clinicians and further research should be completed on treatments that have similar effects. hamstring injury and re-injury rates have been consistent for the past 20 years and have been associated with prolonged symptoms in physically active populations.3-5, 12 most traditional treatments for acute hamstring injuries have been studied in physically active populations and include stretching techniques paired with strengthening (e.g., eccentric) exercises, and trunk stabilization and agility drill progressions.13,34, 38 most of these stretching techniques are time consuming and rely on tissue change that may not restore neuromuscular connections that are also responsible for functional deficits. range of motion increases have been linked to sensory perception instead of the commonly cited mechanical theories to increase muscle extensibility.17,40 currently, the best recommendations do not recommend clinicians to consider modifying the neural allostatic loads following an acute hamstring injury.1,2,13,35-38 to improve on the hamstring injury and re-injury rates new innovative treatments should be explored. treatments that a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 attempt to adjust dysregulated neural allostatic loads created during a mechanism of injury/trauma need to be considered in future research, as well as implemented into clinical practice. sherry et al., reported that re-injury occurs in one-third of patients within two weeks of returning to unrestricted activity from a stretching and strengthening hamstring injury treatment program.13 none of the patients in the current case series suffered re-injury upon returning to full team activities at six-week follow-up which supports the effectiveness of prrt in a short-term period. the nervous system is sophisticated from the reflex circuits that occur at the spinal level to the descending motor pathways that control voluntary movement. following injury or even perceived tissue damage the nervous system reacts with reflexes (e.g., flexor reflex, autogenic inhibition reflex, myotatic reflex).19,20 each of these movements are facilitated by an external stimulus and provide sensory information to the neurons within the spinal cord which result in motor neurons being activated to diffuse the external stimulus. when the reflex circuit is functioning appropriately the nervous system is effective at recognizing and responding to potentially dangerous external stimuli. however, in some cases external stimuli cannot be managed solely by the reflex circuit.40,41 the sensory information travels through the spinal cord to the brainstem and forebrain, which then sends a signal through the descending motor pathway to respond to the stimulus.19,20,40 if addition sensory information continues to ascend to the cns, the allostatic load will remain increased thus leading to hypersensitivity of the nervous system. through modulation of the cns, reflexes can be stimulated to modify the allostatic load which would potentially result in immediate changes at the local site of musculoskeletal injury.22 there are several programs that are available to guide the treatment of acute hamstring injury. sherry et al., provided an outline of differential diagnosis, prognosis, and return to play protocol for acute hamstring injury.11 this protocol recommends 3 phases over eight weeks to progress a patient to return-to-activity. the return-to-activity was based on pain-free palpation over the injury site, full muscle strength, full muscle endurance, and no kinesiophobia. patients classified with acute hamstring strain return-to-play in a range of 6-22 days.4,7,13 gibbs et al., assessed 31 patients classified with grade i hamstring strain. fourteen of the patients had normal mri and returned to full team activities at an average of 6 days while 17 patients averaged 20 days to return to full team activities.7 comparatively, the patients in this current study were discharged to return to full unrestricted activity and able to complete full team activities at 2.5 days. with no peer-reviewed articles specific to the treatment of patients classified with acute hamstring injury, prrt has been found to have a positive effect on pain and function when implemented in other areas of the body. hansberger et al. reported a decrease pain in patients with chronic and acute plantar fasciitis in an intercollegiate athletic training clinic.24 the current study employed treatment procedures that were similar in design and time for intervention to the case series by hansberger. hansen-honeycutt et al., reported an immediate decrease in musculoskeletal pain in three patients using prrt and breathing reflex triggering exercises in a intercollegiate athletic training clinic.25 after utilizing these techniques, each patient reported a decrease in tenderness to palpation over his/her tender areas or with primary musculoskeletal complaint.25 the samples for both studies were patients in intercollegiate athletic training clinics.24,25 a third study was a case report on a patient with shoulder impingement syndrome treated with prrt which resulted with immediate reduction of poe for pain, disablement, and perceived function.26 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 these examples of prrt decreasing or resolving pain in 1 to 3 treatments warrants further investigation of this technique in other musculoskeletal disorders such as acute hamstring injury. based on outcomes recorded in the current study, treatments focused on modulating the cns warrant further investigation in both clinical and laboratory settings that utilize randomized controlled methods. as expressed by the results, the intervention, prrt, used in the current case series may have been effective at creating ideal function of the nervous system instead of a healing the tissue based on a myopic muscle tissue healing model. future studies should incorporate a larger sample size of patients with acute hamstring injury treated and assess the effectiveness of prrt in patients with and without mri evaluated hamstring injuries. to expand on the effectiveness of prrt, cohort studies comparing prrt versus other treatment interventions for acute hamstring injury would help support if the effects of this study were due to the use of prrt. the case series presented was the first to report the outcomes of prrt for treating acute hamstring injury. some of the limitations include a small sample size, and no clinician reliability. the tc was a novice practitioner with one year of clinical application of prrt and therefore had not become an expert at the technique through years of practice. the tc providing the treatment also obtained measurements (e.g. mmt, rom) and was not blind to results. the patients were young, physically active intercollegiate athletes therefore the effects may be expected in the same population. clinical application through the case series performed by a certified athletic trainer in an athletic training clinic, the results of prrt to treat patients with fnmd were reported. in this isolated case series patients, had an immediate change in pain and rom following treatment sessions. treating patients classified with fnmd with prrt led to immediate and short-term changes in the poe and coe outcomes along with successful return-to-activity. the use of prrt possibly modified the neural allostatic load of the patient, which could explain the improved patient outcomes in the current study. the standard of care for hamstring muscle injuries is guided by the goal of creating a tissue change to decrease pain, restore function, improve strength, and limit reinjury.1,2,7,11 in the current study, coe and poe outcomes were positively affected in a shorter amount of time compared to pathoanatomic healing timeframe for similar patients classified with grade 1 hamstring strain. the available research on prrt supports, through clinic practice outcomes, a neurophysiological approach to treatment of acute hamstring injury. based on the outcomes of the study, clinicians looking to improve patient outcomes may benefit from considering a paradigm that modifies the neural allostatic loads during treatment prior to or in conjunction with other techniques rather than relying solely on the pathoanatomical theory of tissue healing. references 1. clanton to, coupe kj. hamstring strains in athletes: diagnosis and treatment. j am acad orthop surg. 1998;6: 237-248. 2. opar da, williams md, shield aj. hamstring strain injuries. sports med. 2012; 42: 20926. https://doi.org/10.2165/11594800000000000-00000. 3. malliaropoulos n, papacostas e, kiritsi o, rad pm, papalada a, gougoulias n, maffulli n. posterior thigh muscle injuries in elite track and field athletes. am j sports med. 2010;38: 1813-9. https://doi.org/10.1177/0363546510366 423. 4. elliott mc, zarins b, powell jw, kenyon cd. hamstring muscle strains in professional https://doi.org/10.2165/11594800-000000000-00000 https://doi.org/10.2165/11594800-000000000-00000 https://doi.org/10.1177/0363546510366423 https://doi.org/10.1177/0363546510366423 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 football players a 10-year review. am j sports med. 2011;39: 843-50. https://doi.org/10.1177/0363546510394 647. 5. ekstrand j, gillquist j, möller m, oberg b, liljedahl so. incidence of soccer injuries and their relation to training and team success. am j sports med. 1983;11: 63-7. https://doi.org/10.1177/0363546583011 00203. 6. askling c, saartok t, thorstensson a. type of acute hamstring strain affects flexibility, strength, and time to return to pre-injury level. br j sports med. 2006;40: 40-4. https://doi.org/10.1136/bjsm.2005.01887 9. 7. gibbs nj, cross tm, cameron m, houang mt. the accuracy of mri in predicting recovery and recurrence of acute grade one hamstring muscle strains within the same season in australian rules football players. j sci med sport.2004;7(2):248-58. https://doi.org/10.1016/s14402440(04)80016-1. 8. chan o, del buono a, best tm, maffulli n. acute muscle strain injuries: a proposed new classification system. knee surg sports traumatol arthrosc. 2012;20(11):2356-62. https://doi.org/10.1007/s00167-0122118-z. 9. morgan dl. new insights into the behavior of muscle during active lengthening. biophys j. 1990;57: 209-21. https://doi.org/10.1016/s00063495(90)82524-8. 10. schuermans j, van tiggelen d, danneels l, witvrouw e. biceps femoris and semitendinosus—teammates or competitors? new insights into hamstring injury mechanisms in male football players: a muscle functional mri study. br j sports med. 2014;48: 1599606. https://doi.org/10.1136/bjsports2014-094017. 11. sherry ma, johnston ts, heiderscheit bc. rehabilitation of acute hamstring strain injuries. clin sports med. 2015;34(2):26384. https://doi.org/10.1016/j.csm.2014.12.009 . 12. dalton sl, kerr zy, dompier tp. epidemiology of hamstring strains in 25 ncaa sports in the 2009-2010 to 20132014 academic years. am j sports med. 2015;43: 2671-9. https://doi.org/10.1177/0363546515599 631. 13. sherry ma, best tm. a comparison of 2 rehabilitation programs in the treatment of acute hamstring strains. j orhto sports phys ther. 2004;34(3):116-25. https://doi.org/10.2519/jospt.2004.34.3.1 16. 14. schneider-kolsky me, hoving jl, warren p, connell da. a comparison between clinical assessment and magnetic resonance imaging of acute hamstring injuries. am j sports med. 2006; 34:1008-1015. https://doi.org/10.1177/0363546505283 835. 15. o'donoghue dh. treatment of injuries to athletes. philadelphia, pa: wb saunders company; 1984. 16. mueller-wohlfahrt hw, haensel l, mithoefer k, ekstrand j, english b, mcnally s, orchard j, van dijk cn, kerkhoffs gm, schamasch p, blottner d. terminology and classification of muscle injuries in sport: a consensus statement. br j sports med. 2012;47(6): 342-50. https://doi.org/10.1136/bjsports2012-091448. 17. weppler ch, magnusson sp. increasing muscle extensibility: a matter of increasing length or modifying sensation? phys ther. 2010;90: 438. https://doi.org/10.2522/ptj.20090012. 18. panjabi mm. the stabilizing system of the spine. part i. function, dysfunction, adaptation, and enhancement. clin spine surg. 1992;5: 383-9. https://doi.org/10.1177/0363546510394647 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https://doi.org/10.2522/ptj.20090012 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 19. yeomans js, li l, scott bw, frankland pw. tactile, acoustic and vestibular systems sum to elicit the startle reflex. neurosci & biobehav rev. 2002;26: 1-1. https://doi.org/10.1016/s01497634(01)00057-4. 20. noakes td, peltonen je, rusko hk. evidence that a central governor regulates exercise performance during acute hypoxia and hyperoxia. j exp biol. 2001;204: 3225-34. 21. sherrington cs. on reciprocal innervation of antagonistic muscles. third note. j r soc med. 1896;60: 414-7. https://doi.org/10.1098/rspb.1907.0026. 22. sharman mj, cresswell ag, riek s. proprioceptive neuromuscular facilitation stretching. sports med. 2006;36: 929-39. https://doi.org/10.2165/00007256200636110-00002. 23. iams j. what is the primal reflex release technique for pain relief? 2012. available at http://www.theprrt.com/what-is-the-primalreflex-release-technique-for-pain-relief.php. accessed december 6 2016. 24. hansberger bl, baker rt, may j, nasypany a. a novel approach to treating plantar fasciitis–effects of primal reflex release technique: a case series. int j sports phys ther. 2015;10(5): 690-9. 25. hansen-honeycutt j, chapman eb, nasypany a, baker rt, may j. a clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: part 2, a case series. int j sports phys ther. 2016;11(6): 971-79. 26. carnahan k. inclusion of primal reflex release technique (prrt) plan of care for shoulder pain: a case study. nd. retrieved from http://theprrt.com/files/prrtpatientcase-study.pdf. 27. farrar jt, young jp, lamoreaux l, werth jl, poole m. clinical importance of changes in chronic pain intensity measured on an 11‐ point numerical pain rating scale. pain. 2001;94: 149‐158. 28. vela li, denegar c. the disablement in the physically active scale, part ii: the psychometric properties of an outcomes scale for musculoskeletal injuries. j athl train. 2010;45: 630‐641. https://dx.doi.org/10.4085%2f10626050-45.6.630. 29. hamid ms, ali mr, yusof a. interrater and intrarater reliability of the active knee extension (ake) test among healthy adults. j phys ther sci. 2013;25: 957-61. https://dx.doi.org/10.1589%2fjpts.25.957. 30. reurink g, goudswaard gj, oomen hg, moen mh, tol jl, verhaar ja, weir a. reliability of the active and passive knee extension test in acute hamstring injuries. am j sports med. 2013;41: 1757-61. https://doi.org/10.1177/0363546513490 650. 31. kendall fp, mccreary ek, kendall ho. muscles, testing and function: testing and function. philadelphia, pa: lippincott williams and wilkins; 1983.32. 32. horn kk jennings s richardson g vliet dv hefford c abbott jh. the patient‐specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. j orhto sports phys ther. 2012;42: 30‐42. https://doi.org/10.2519/jospt.2012.3727. 33. mason dl, dickens v, vail a. rehabilitation for hamstring injuries. cochrane database syst rev. 2012;12:cd004575. https://doi.org/10.1002/14651858.cd004 575.pub3. 34. mendiguchia j, brughelli m. a return-to-sport algorithm for acute hamstring injuries. phys ther sport. 2011;12: 2-14. https://doi.org/10.1016/j.ptsp.2010.07.00 3. 35. copland st, tipton js, fields kb. evidencebased treatment of hamstring tears. curr sports med reports. 2009;8: 308-14. https://doi.org/10.1249/jsr.0b013e3181c 1d6e1. https://doi.org/10.1016/s0149-7634(01)00057-4 https://doi.org/10.1016/s0149-7634(01)00057-4 https://doi.org/10.1098/rspb.1907.0026 https://doi.org/10.2165/00007256-200636110-00002 https://doi.org/10.2165/00007256-200636110-00002 http://www.theprrt.com/what-is-the-primal-reflex-release-technique-for-pain%09relief.php http://www.theprrt.com/what-is-the-primal-reflex-release-technique-for-pain%09relief.php http://www.theprrt.com/what-is-the-primal-reflex-release-technique-for-pain%09relief.php http://theprrt.com/files/prrtpatient-case-study.pdf http://theprrt.com/files/prrtpatient-case-study.pdf https://dx.doi.org/10.4085%2f1062-6050-45.6.630 https://dx.doi.org/10.4085%2f1062-6050-45.6.630 https://dx.doi.org/10.1589%2fjpts.25.957 https://doi.org/10.1177/0363546513490650 https://doi.org/10.1177/0363546513490650 https://doi.org/10.2519/jospt.2012.3727 https://doi.org/10.1002/14651858.cd004575.pub3 https://doi.org/10.1002/14651858.cd004575.pub3 https://doi.org/10.1016/j.ptsp.2010.07.003 https://doi.org/10.1016/j.ptsp.2010.07.003 https://doi.org/10.1249/jsr.0b013e3181c1d6e1 https://doi.org/10.1249/jsr.0b013e3181c1d6e1 a novel approach to treating acute hamstring functional neuromuscular disorder-effects of primal reflex release technique 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 36. järvinen ta, järvinen tl, kääriäinen m, äärimaa v, vaittinen s, kalimo h, järvinen m. muscle injuries: optimising recovery. best pract res clin rheumatol. 2007;21: 317-31. https://doi.org/10.1016/j.berh.2006.12.00 4. 37. de vos rj, reurink g, goudswaard gj, moen mh, weir a, tol jl. clinical findings just after return to play predict hamstring reinjury, but baseline mri findings do not. br j sports med. 2014;48: 1377-84. https://doi.org/10.1136/bjsports-2014093737. 38. wangensteen a, tol jl, witvrouw e, van linschoten r, almusa e, hamilton b, bahr r. hamstring reinjuries occur at the same location and early after return to sport: a descriptive study of mri-confirmed reinjuries. am j sports med. 2016;44: 2112-21. https://doi.org/10.1177/0363546516646 086. 39. kilcoyne kg, dickens jf, keblish d, rue jp, chronister r. outcome of grade i and ii hamstring injuries in intercollegiate athletes a novel rehabilitation protocol. sports health. 2011;3: 528-33. https://doi.org/10.1177/1941738111422 044. 40. ekstrand j, askling c, magnusson h, mithoefer k. return to play after thigh muscle injury in elite football players: implementation and validation of the munich muscle injury classification. br j sports med. 2013. https://doi.org/10.1136/bjsports2012-092092. 41. kingsley re. concise text of neuroscience. 2nd ed. baltimore, md: lippincott williams & watkins; 2000. motor systems iii: the basal ganglia; 285–310. 42. siegelbaum sa, hudspeth aj. principles of neural science. kandel er, schwartz jh, jessell tm, editors. new york city, ny: mcgraw-hill; 2000. 43. turl se, george kp. adverse neural tension: a factor in repetitive hamstring strain? j orhto sports phys ther. 1998;27: 16-2. https://doi.org/10.2519/jospt.1998.27.1.1 6. https://doi.org/10.1016/j.berh.2006.12.004 https://doi.org/10.1016/j.berh.2006.12.004 https://doi.org/10.1136/bjsports-2014-093737 https://doi.org/10.1136/bjsports-2014-093737 https://doi.org/10.1177/0363546516646086 https://doi.org/10.1177/0363546516646086 https://doi.org/10.1177/1941738111422044 https://doi.org/10.1177/1941738111422044 https://doi.org/10.1136/bjsports-2012-092092 https://doi.org/10.1136/bjsports-2012-092092 https://doi.org/10.2519/jospt.1998.27.1.16 https://doi.org/10.2519/jospt.1998.27.1.16 disablement model case series 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report alli z. powell, dat, at1 & russell t. baker, phd, dat, at2 1colorado mesa university, grand junction, co; 2university of idaho, moscow, id abstract scapular dyskinesis is an abnormal movement of the scapula due to poor motor control of the surrounding musculature and can lead to other glenohumeral pathologies. the pathology results in the lateral tilting of the scapula during many glenohumeral joint movements and weight-bearing activities of the upper extremity (i.e., plank). the typical conservative treatment protocol focuses on strengthening surrounding musculature and is often a lengthy protocol. a weakness of strengthening protocols is the failure to address the motor function of targeted muscles at the level of the central nervous system (cns) to restore dynamic stability and motor control. reactive neuromuscular stabilization (rns) is a novel treatment that targets the cns to address motor control impairments to restore the normal muscular and joint stability and function. purpose: the purpose of this case study was to demonstrate the efficacy and the outcomes of using rns as a treatment for dysfunctions such as scapular dyskinesis. a 20-year-old female intercollegiate swimmer presented with significant mid-back pain that failed to resolve without treatment. the patient was diagnosed with scapular dyskinesis as well as presented with a number of postural concerns, trigger points, and pain with multiple activities. the initial protocol for treatment for this patient was a standard conservative treatment protocol focused on strengthening. after six weeks of treatment without improvement, the clinician modified care to include rns. following three treatments across seven days, the patient’s symptoms decreased significantly and the patient met discharge criteria. at an eleven-month follow-up, the patient’s improvements were maintained. the patient in this case report demonstrates the effectiveness of rns while treating scapular dyskinesis and the importance of recognizing the cause of the dysfunction early within the evaluation. key phrases diagnostic testing and physical examination, upper extremity, patient-reported outcomes, manual techniques correspondence dr. alli powell, colorado mesa university, 1100 north ave. grand junction, co. e-mail: azeigel@gmail.com full citation powell a & rusty bt. treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report. clin pract athl train. 2019;2(3):35-47. https://doi.org/2019/0003.3. submitted: february 21, 2019 accepted: october 21, 2019 introduction scapular dyskinesis (sd) is defined as irregular motion of the scapula.1-2 scapular dyskinesis is often evaluated visually by the clinician from a posterior view with the patient performing active glenohumeral (gh) motions.1-5 the scapula provides stability to the gh articulation through the contraction of the surrounding muscles to centralize the rotation of the gh joint.1-2 the position of the scapula adjusts to overhead activity by moving in the following motions: protraction, retraction, elevation, depression, and rotation. when the scapula fails to move synergistically with the gh joint, compensatory and dysfunctional movement patterns are created.1 most abnormal movement patterns of the scapula have been suggested to result from poor functioning of the stabilizing muscles of the scapula.1,3 increased protraction at the medial border of the scapula during gh motion, such as horizontal adduction, flexion, and abduction are some of the most common signs of sd.3 the abnormal movement, when not caused by long thoracic nerve damage, is typically thought to result from hyper-activation of the upper trapezius in conjunction with decreased activation of the lower trapezius and serratus anterior.6 though nerve damage to the long thoracic and spinal accessory nerves may result in decreased muscular function, the commonality of these pathologies as the cause of the dyskinesis is less than 5%.1 other common causes include thoracic kyphosis, clavicular fracture nonunion, high-grade ac joint instability, or soft tissue inflexibility.2 conservative treatment is the most commonly recommended course of action in cases of sd; https://doi.org/2019/0003.3 treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 however, if nerve damage is present, surgical intervention may be indicated.4 most nonoperative rehabilitation includes mobility exercises of the thoracic spine and shoulder (e.g., stretching, joint mobilizations, thoracic mobility exercises), closed and open chain strengthening exercises (e.g., push up plus, serratus anterior ceiling punches), and other reactive exercises (e.g., catching and throwing) targeting the improvement of motor control. a few concerns with conservative rehabilitation of sd is lengthy treatment protocols (i.e. weeks to months); and a primary focus on strengthening only the surrounding musculature of the shoulder girdle instead of focusing on neuromuscular reeducation and the restoration of dynamic stability and functional movement patterns.7 as a proposed cause for sd is poor motor control and a loss of dynamic stability, along with over activation of related musculature, a neuromuscular re-patterning technique such as reflexive neuromuscular stabilization (rns) seems appropriate. this technique was derived from a treatment called reactive neuromuscular training (rnt). the concept of rnt is to restore dynamic stability and motor control post-injury with rehabilitation techniques which target the central nervous system (cns). as the cns reacts to a stimulus to create joint stability, there is a conversion from conscious thought to unconscious.8 rather than cue the patient verbally and have discussions regarding what they are doing incorrectly, the goal of rnt is to exacerbate the dysfunctional movement with an external stimulus to bring a more clear perception to the patient of the error that is occurring.9 when using rnt, a clinician applies an external stimulus to the patient’s body to promote an unconscious response by the cns to produce the appropriate motor response and correct the faulty movement pattern.10 where rns deviates from rnt is modification to make the process more ‘reflexive’ than ‘reactive’ to enhance the unconscious and reflexive response that a physically active patient needs to produce during activity to maintain dynamic stability.11 let us take for an example, when a patient performs a squat they have a significant valgus collapse. when using rnt we may utilize an elastic band around the patient’s knees as a constant force that they are pushing against as they squat to force the patient to engage appropriate knee and hip stabilizers throughout the movement. in contrast, when switching to an rns mindset of treatment, the clinician would apply the valgus force at the patient’s knees with varying amounts of force and at unexpected times to force the patient’s reflexes to initiate and correct the faulty movement pattern with their reflex to the stimulus. again, the largest difference is having a constant and known force they are reacting to versus and changing and unexpected force their reflexes must engage in to correct the movement pattern. currently, there are no studies regarding the application of rns and sd and only a few studies have been published on the application of rns or rnt; thus, little is known about the application of these techniques in patient care. therefore, the purpose of this case study was to report the outcomes of incorporating rns into the rehabilitation program of an intercollegiate swimmer diagnosed with sd who had failed to improve using traditional conservative methods. the patient gave informed consent to participate in the study as well as was informed that the data collected would be submitted for publication. this study was approved by the institutional review board. patient information patient the patient was a 20-year-old female division i intercollegiate swimmer who presented with right upper back pain and no known mechanism of injury. she described experiencing her current pain for approximately six months. her pain was isolated to the right medial border of the scapula with a gradual onset and no known treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 mechanism of injury. when the symptoms initially began, her primary complaint was experiencing pain at the end of inhalation. when the pain started, the patient was home for the summer (i.e. between spring and fall semesters) and used self-treatment consisting of three months of complete rest from activity and occasional superficial heat without resolution of her symptoms. the patient reported to the athletic training clinic after four months of unresolved symptoms for the start of the fall semester. the initial examination revealed pain along the medial aspect of the right scapula during inhalation, while sitting in good posture, or while wearing a backpack. the patient did not reveal any red flags for cancer, chronic illnesses, or family history of illnesses. she had experienced pain in the upper right back eight months previously when she was lifting weights, however, the pain resolved without treatment. she reported the current episode as “feeling different” and unrelated to the current condition. she was not taking any medication for the discomfort and had no other reports of treatment. her reported worst pain on the numerical pain rating scale (nprs) was a seven out of ten when sitting erect and at the end of an inhalation. a zero on the nprs is classified as no pain, whereas a ten is classified as the worst pain imaginable.12 disability was measured using the disablement in the physically active (dpa) scale, which is scored from zero (no disability) to 64 (maximum disability).13-14 the patient reported a disability score of 28 on the dpa scale on the initial evaluation. the patient specific functional scale (psfs) was utilized to identify activities within her daily life that were causing pain. this scale utilizes a score between zero (cannot perform) to ten (no problem performing).15 her three primary painful activities were breathing (4 out of 10), sitting up straight (4 out of 10) and wearing a backpack (6 out of 10). the examination did not reveal signs of inflammation, ecchymosis, or deformities surrounding the area of pain. her natural posture was forward head, forward shoulder, and increased kyphosis. the postures were exacerbated in a seated position. in a seated position, visual evaluation of the patient’s breathing revealed all of the motion for inhalation stemming from the chest rather than from the diaphragm. to test breathing functionality, the clinician used a modification of the manual assessment of respiratory motion (marm) test.16 the modification of the marm test was done via palpation and observation to assess the 3-dimensional movement of the trunk and chest during inhalation and exhalation. the clinician placed their hands along the patient’s mid to low back with the thumbs parallel to the spine and fingers splaying laterally (figure 1). while the patient completed normal inspiration/expiration, the clinician felt for the motion of breathing to either be lateral, superior, anterior, and/or posterior. a normal pattern consists of lateral, anterior, posterior, and limited superior motion.17 this patient revealed a primary upward motion in breathing, with absent posterior and lateral motions with inhalation. tender points (tps) at the middle portion of the insertion of the rhomboid minor, superior portion of the insertion of the rhomboid major, middle figure 1. hand positioning for modified marm test treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 trapezius superior portion of the insertion and superolateral muscle belly, and serratus posterior superolateral muscle belly were identified with palpation. differentiation of the musculature was determined through active contractions of the muscles. in addition to reporting tps, the patient stated that she generally felt “tighter” on the right medial aspect of the scapula, compared bilaterally. the patient also reported tenderness to palpation at the first and second ribs with a superior to inferior pressure posterior to the clacivle and on the posterior aspect of the eleventh and twelfth ribs in a supine position. range of motion testing was performed and revealed no limitations or pain with any of the following active range of motions (arom) at the shoulder: flexion, extension, internal rotation (ir) at a 90-90 position, external rotation (er) at a 90-90 position, abduction, horizontal adduction, or horizontal abduction. observation during arom testing revealed the patient had substantial sd on the right side that was most prominent with flexion, abduction, and horizontal adduction (figure 2). the following passive ranges of motion (prom) at the shoulder were equal bilaterally, within normal limits, and nonpainful: flexion, extension, ir, er, horizontal adduction, abduction and horizontal abduction. strength testing of the rotator cuff muscles, deltoid, pectoralis major, biceps brachii, and triceps brachii were all 5/5 and non-painful when compared bilaterally. the right rhomboids had decreased strength, 4/5, when compared bilaterally. the patient displayed a positive sulcus sign bilaterally and sd on the right when in a push up plus position both in non-weight bearing and weight bearing positions. based on the lateral scapula slide test (lsst), the patient met the established threshold, 1.5cm to be a positive test, of difference during 90 degrees of abduction and was .2cm and .3cm from the threshold in the positions with hands on hips and at 90 degrees horizontal adduction while standing to indicate sd (table 1).1,18-19 each measurement was taken from the spinous process even with the inferior angle of the scapula for each motion. the lsst was performed with the patient’s hands by her side, progressed to hands on the hips, and 90 degrees of abduction. though the lsst is designed exclusively for those three motions, the clinician also measured the differences when the patient completed horizontal adduction. the apprehension and relocation, empty can, and gerber lift off tests were negative. neurological screening and function was within normal limits. based upon these findings, the patient was classified with right sd and conservative rehabilitation was initiated without limitation in activity levels. intervention the first six weeks of treatment and rehabilitation consisted of a combination of moist heat packs (mhp), positional release therapy (prt), breathing retraining, primal reflex release techniques (prrt), instrument assisted soft tissue mobilization (iastm), massage, strengthening, and stretching. treatment sessions began with mhps to stimulate blood flow to the affected area, and to help increase patient relaxation and comfort. after the application of figure 2. scapular dyskinesis pretreatment disablement model case series 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 table 1. measurements taken in the scapular slide test (cm) left right left right arm position day 1 day 3 down by sides 9.5 9.5 9.5 9.5 hands on hips 8.9 10.2 8.9 8.9 90 degrees abduction 10.2 7.6 10.2 10.2 90 degrees horizontal adduction 12.7 14 12.7 12.7 the mhps, prt was used to release the tps present during the initial evaluation. following prt, breathing retraining exercises were used to restore normal diaphragmatic breathing. the techniques utilized were a combination of breathing exercise developed by michael grant white20 and pprt techniques developed by john iams, and were selected because of positive clinical outcomes experienced by the treating clinician during previous patient care.21 the breathing exercise was similar to the traditional “clam shell” exercise for hip external rotator strengthening (figure 3 and figure 4). however, the breathing component required the patient to attempt maximal exhalation (i.e., “blow all your air out”) and then move through full hip external rotation with the top leg while holding their breath throughout the motion. once the knees returned to the starting position, the patient was cued to inhale. the length of the count varied by the patient’s ability to hold her breath. when the patient returned to the starting position, the required response was to have the patient take a “gasping” breath, meaning the patient felt as if she could not hold her breath any longer, thus taking a large reflexive inhalation. the prrt technique was then used to address the patient reported rhomboid tightness. initially, a facilitation technique was used on the rhomboids due to the forward shoulder posture of the patient; however, the technique did not produce improvement, so the clinician then inhibited the rhomboids in an attempt to decrease pain and tightness. next, iastm and massage were used to reduce remaining tps on the affected side rhomboid major, rhomboid minor, upper and middle trapezius, and serratus posterior, as well as to restore function and rom. therapeutic exercises were used to improve muscular control and strength of the serratus anterior and lower trapezius muscles to improve scapular stabilization within a functional movement pattern (table 2). finally, a stretching regimen was used to release tight anterior musculature and improve posture. over the first six weeks of therapy, the patient would complete this therapy protocol 1 time per figure 3. starting and ending position of the “clam shell” exercise figure 4. “clam shell” exercise motion disablement model case series 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 day and four days per week, on average. during this time, the patient reported short-term pain relief and tp reduction. the patient typically reported a decrease in pain following each treatment session; yet, the pain and tps returned without any substantial improvement by the end of a two-hour swim practice or by her next visit. when a treatment was provided prior to practice, the patient reported a resolution of her complaint, but it would only remain resolved through 50 to 75% of the practice period (~2 hours). treatment provided on non-training days followed a similar pattern, but usually increased the duration of her pain resolution from approximately 90 minutes to 3 hours. during these six weeks, discernible improvements in the patient’s strength and dyskinesis were recorded (table 4). due to the lack of consistent and long-lasting patient-reported or disease-oriented improvement, the clinician re-evaluated the patient and decided to add rns to her established rehabilitation protocol. the clinical reasoning for this choice focused on the belief the patient’s functional motor patterns (i.e., stability) were not being addressed at the subconscious level, and a more reflexive neuromuscular intervention was needed to normalize movement patterns and postures at the subconscious level. the initial treatment goal for utilizing rns was to decrease sd during standing horizontal adduction because this was the most difficult movement for the patient and movement with the most sd. the patient continued to use mhp prior to beginning exercises because she felt the mhp helped to decrease pain and increase her mobility. the treatment protocol was mhp, rns with horizontal adduction in standing, i’s, y’s, t’s in a prone position on two of the days, push up plus on a bosu ball on one day, while the patient also continued to stretch the pectoralis muscles in a doorway as she had been doing daily. the clinician first applied an anterior to posterior stimulation for rns to various places on the anterior aspect of the patient’s body (i.e., upper 1/3 of the sternum, middle of the sternum, xiphoid process, upper abdomen, lower abdomen, and bilateral asis) as the patient was standing and performing horizontal adduction. while the clinician applied the anterior to posterior force via hand pressure, the patient was instructed to close her eyes and not allow the clinician to push her backwards. the response the clinician was testing for was the largest decrease in the sd during one repetition of horizontal adduction with the external stimulation. once the location of pressure that was the most responsive in decreasing sd the patient was found, she was asked to continue to table 2. frequency and duration of each rehabilitative exercise performed exercise times per week* weeks performed duration low row/ scapula pinches with a red resistance band 2-3 2 3x8-10 supine scapular retraction 1-5 2 2x8 standing scapular retraction against exercise ball 1-5 3 2x10 scapular control exercises (patient holding a weighted ball and moving into flexion, horizontal adduction, horizontal abduction & abduction) 2-3 4 3x30 seconds push up plus on bosu 2 3.5 3x8 i’s, y’s, t’s 2 3.5 2x8 horizontal adduction with 3lb weighted ball with rns 2 1.5 3x10 *times per week varied weekly based on availability and travel treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 keep her eyes closed, to react to the stimulus without anticipation, and told to not let the clinician push her backwards. once the patient reacted, she then performed the active horizontal adduction while the stimulus was sustained (figure 5). on the first day of treatment with rns, the patient performed two sets of ten repetitions with the pressure in the middle of her sternum. a third set was completed with the patient closing her eyes and imagining the pressure on her chest before completing the movement. when the patient imagined the pressure, the elimination of dyskinesis was consistent with the clinician applied force. days two and three of rns consisted of the same treatment, but on these days, the patient performed one set of ten repetitions with clinician generated force, while the second and third sets were done with the imagination of the pressure. the nprs was collected pre and post each treatment, psfs was collected pretreatment, and the dpa scale was collected at day one, at discharge (day three), and eleven-months post-discharge. the patient denied taking any medications for pain and maintained her activity level throughout the course of the new treatment protocol. the patient was treated two consecutive days, then 6 days later for the third treatment. she responded well to treatment without increased pain during and after treatments. the patient did not return to the clinic until 6 days following the third treatment. at this time, the patient reported near resolution of symptoms, was able to swim throughout an entire practice without pain returning, had an improved physical exam (e.g., no tender points, improved scapular positioning, negative special tests), and met established discharge criteria. discharge criteria had been previously established as the ability to maintain normal scapular stabilization throughout functional movements (without rns), an average nprs score of one out of ten or below,22 and a psfs of a nine out of ten or higher23 with intercollegiate swimming and conditioning activity. results prior to using rns as a treatment, the patient had received 26 days of treatment over six weeks without substantial or lasting improvements then after just three treatment sessions with rns involved in the treatment protocol the patient met established discharge criteria (table 3 and table 4). at this time, a full re-evaluation was performed, intake data was collected, and no treatment was performed. the physical exam revealed the scapular slide test was equal bilaterally. the patient’s primary chest breathing pattern was still present in a seated position, but diaphragm activation was now present measured through modified marm test. the tps on the insertion of the rhomboid major and insertion, muscle belly of the middle trapezius, and eleventh and twelfth ribs were no longer present during palpation. the tp at the middle portion of the rhomboid major was still present, but the patient reported tenderness to be mild (2/10) figure 5. scapular dyskinesis was eliminated when pressure was applied to mid sternum disablement model case series 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 table 3. patient reported outcomes prior to rns with horizontal adduction tx day 1 tx day 11 tx day 21 nprs current 8 7 4 nprs best 5 7 4 nprs worst 8 7 5 nprs average 7 7 4.33 nprs –post 6 6 3 dpa scale 28 15* psfs 7.75 7 7.6 *clinically significant difference; abbreviations: dpa scaledisability of the physically active scale; psfs patient specific functional scale (0=unable to perform, 10= fully able to perform); nprsnumeric pain rating scale at current, best within past 24 hours, worst within last 24 hours, average of current, best and worst (0=no pain, 10=worst pain); pre-tx: pre-treatment; post-tx. post-treatment; n/a: not applicable table 4. outcome measurements after rns with horizontal assuction rns tx 1 rns tx 2 rns tx 3 6 day f/u 2 wk f/u 11 mon f/u dpa scale 22 n/a 16 n/a n/a 4 psfs 8 n/a 7 9.5* n/a 10 nprscurrent pre-tx 4 4 4 1 2 0 nprs-current post tx 2 3 2 n/a n/a n/a nprschange 2* 1* 2* n/a n/a n/a scapular slide test horizontal adduction 1.3 cm n/a n/a n/a 0 cm 0 cm *clinically significant difference; dpa scaledisability of the physically active scale; psfspatient specific functional scale (0=unable to perform, 10= fully able to perform); nprsnumeric pain rating scale at current, best within past 24 hours, worst within last 24 hours, average of current, best and worst (0=no pain, 10=worst pain); pre-tx: pre-treatment. post-tx. post-treatment; scapular slide testhorizontal adduction: number is different between affected and unaffected; n/a: not applicable compared to initial measures (4/10). the patient also continued to experience tenderness at the first and second ribs. the patient’s natural sitting posture was still forward head, forward shoulder, and increased kyphosis; however, these postures were not as noticeable as those found during the initial exam. the patient also reported it was easier to maintain good posture, and she could now do so without experiencing pain. additionally, the previous sd that was noted with flexion, abduction, horizontal adduction, and in a push up plus position was no longer present. based on the physical exam and patient outcome findings, the patient was released to full activity (i.e., swimming, dryland training, and weight lifting) without further treatment, but was monitored throughout the remainder of the swim season. follow-up measurements were collected at 2 weeks and 11 months post-discharge (table 4). detailed evaluation of patient outcomes utilizing rns treatment revealed the patient demonstrated a change in pain that met the minimal clinically important difference (mcid) on the nprs after day 1, but it took 3 visits for this change to be maintained between treatment sessions (table 4).24 functional improvement followed a similar pattern based on psfs scores. the patient did not report sustained functional improvement until after the third treatment. however, once this was reached, the patient retained her functional improvement all the way through the 11 month post-discharge follow-up. additionally, the patient’s scapular winging improved. at the initial exam, the patient treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 displayed a 1.3 cm difference side to side of scapular winging with horizontal adduction; at discharge, the patient had an even distance from medial border of the scapula to spinous process with active horizontal adduction (table 1). as with the other measures, this improvement was maintained at the 11-month follow-up visit. discussion rehabilitation for sd commonly targets the decreased activation of the serratus anterior and middle trapezius.25 worsley et al.26 used a general rehabilitation program to retrain scapular stabilizers over a course of ten weeks. the researchers found the serratus anterior and lower trapezius could successfully be retrained over ten weeks, and scapular motion was nearly equal to a healthy population after the protocol was completed.26 the long-term benefits of this program are unknown as data was collected prior to intervention and immediately post the ten week protocol.26 in this case study, the initial focus was on relieving pain through soft tissue treatments, and improving scapular motion through increased strength and muscle activation of the parascapular musculature. after minimal improvement, the intervention shifted towards restoring optimal movement patterns of the scapula using a reflexive neuromuscular approach. unlike exercise-based therapy, rns may be beneficial from an evaluative and treatment standpoint because of the immediate restoration of a functional movement pattern when the clinician applies an external force.27 if the functional movement pattern is not restored, either the wrong force is being applied (e.g., not enough force, wrong location) or rns is not indicated.9,27 the location or amount of force may vary from patient to patient; though, when indicated, the treatment should produce an instantaneous, noticeable, and long-lasting improvement in movement.27 the proposed theories behind the success of rns are based on influencing the central nervous system (cns) with subconscious and reflexive movement which restores motor control and dynamic stability. reflexive neuromuscular stabilization was derived from the term rnt, which was first proposed by voight and cook.28 the primary objective of the treatment is to trigger the subconscious process of recruiting the appropriate musculature to establish a proper movement pattern(s).8,10,28 when using an rns treatment, the external stimulus is provided in varying forces at varying times throughout a dysfunctional movement. with rns, the goal remains to recruit the cns to establish appropriate recruitment strategies of involved musculature in particular movements or activities by reflexively re-patterning the neuromuscular system. in this case study, the treatment was applied to the sternum with a varying amount of force and frequency, requiring the patient to react more reflexively to an unexpected stimulus, as opposed to anticipating a consistent resistance, which helps the reaction to become subconscious. borsa et al.29 also explained when a motion or stimulus is repeated, the brain stores these movements or stimuli, and then has the ability to access the response unconsciously. through applying rns, restoring the functional movement, then having the patient go through the functional movement over a number of repetitions that functional movement can now be maintained without conscious thought. currently, there are no published studies or case reports on utilizing rns for sd; however, there are published reports on the use of rnt or rns to address other dysfunction or pathology. the ability to functionally complete a previously poor motor pattern without conscious thought was elicited in a case study using rnt for apparent hamstring tightness.27 the patient in this case was tested on a variety of hamstring extensibility measurements and was classified with hamstring treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 tissue extensibility dysfunction (ted). after one treatment of rnt during multi-segmental flexion, for the patient experienced substantial improvements in all rom measurements immediately following the intervention. not only were the gains in all rom testing improved, but the gains in motion were enough to be within the normative ranges for each rom measurement tested after a single intervention.27 the patient also maintained the improvements, which exceeded the gains expected from the stretching literature, at the five-week follow-up without further intervention.27 similarly, in another case study, rns was used in conjunction with the mulligan concept for a young patient with multidirectional instability of the shoulder, who had recently sustained a subluxation.11 in this case, the clinician performed a mulligan concept mobilization with movement followed by rns to restore full pain-free rom after one visit. the patient was discharged in 6 visits, returned to football activities, and did not suffer a re-injury during that season.11 additionally, rnt has been reported to be beneficial in a case report on anterior cruciate ligament (acl) deficiency.28 over the course of eight visits, the patient experienced a large increase in strength that could only be explained by neuromuscular adaptations as opposed to true strength increases.28 traditional strength gains require several weeks to occur, whereas neuromuscular adaptations within the body occur during the first six weeks of training.28 further, when movement patterns changes, or the abolition of patient complaint, occur immediately with rns application during a treatment session, it seems most likely that the mechanism of action is drive by a neurological change. thus, of the intreatment session changes and the overall improvement over eight treatment sessions, indicate rapid neuromuscular adaptations as opposed to traditional drivers of strength improvements from exercise.28 while these three cases suggest rns may be an effective intervention, reports on the effectiveness of rns on sd could not be identified in the literature. in the current case, applying rns required a contraction of anterior chain muscles, in particular the abdominal muscles, to initiate stabilization before the patient tried to move the arm. the reflexive contraction, and subsequent stabilization, corrected faulty stabilization patterns allowing for more ideal functional movements (e.g., shoulder horizontal adduction). the serratus anterior and lower trapezius are typically the muscles not activating appropriately with sd.6 it is hypothesized that activating a reflexive stabilization pattern (e.g., spinal stabilization) with rns created the proper stability for the serratus anterior and lower trapezius to be properly coordinated to stabilize the scapula properly. throughout the three days of treatment with rns, the application of rns immediately produced improvement (e.g., pain, scapular positioning), but it took until after the third treatment for the motor pattern to become ingrained enough for the patient to maintain her improvement during and after activity. due to the paucity of research on rns, the ideal treatment parameters (e.g., number of treatments, sets, repetitions) required for the best treatment results are unknown. in addition, ideal locations for stimulus during rns, or any variance across different areas of the body, functional movements (e.g., are complex movement patterns more difficult to restore), or pathology are also unknown. it is quite possible that different pathologies or movement patterns will require different parameters (e.g., differences in treatment time, frequency, duration) to produce effective patient outcomes. for example, multisegmental flexion, a uniplanar motion, required only one treatment to produce maintained resolution of a patient who present with a hamstring ted.27 in contrast, a patient with a deficient acl completed eight days of treatment with rnt, and may have needed more, to fully resolve the patient’s condition. in this case, the patient did not only have one dysfunctional motion, but instead needed to restore functional movement through multiple complex movement treatment of scapular dyskinesis with reflexive neuromuscular stimulation: a case report 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 patterns. though the motions that needed restoration were complex, only three treatments of rns were necessary for a case of sd to meet discharge criteria and maintain these improvements at 11-month follow-up (table 4). the presented case provides preliminary evidence that rns may be an effective treatment option, at least as an adjunct therapy, for patients with sd. future research needs to be completed on rns to determine the effectiveness of the treatment as an adjunct or individual treatment. additionally, future research should be performed to determine the appropriate dosage of rns to restore and maintain functional movement patterns. clinical bottom line the results of this case study provide initial evidence of the potential benefit of utilizing rns. the reflexive nature of rns, and the description of its use in this case study, may help clinicians utilize the technique to inform their clinical decision-making in determining when or how to use rns or rnt in therapeutic rehabilitative programs. in this case, after adjusting the treatment protocol to include rns as the primary intervention, the patient reported clinically significant improvement in pain and function. the patient reported clinically significant improvement and did not believe she needed additional treatment after three days of rns treatment. she remained fully functional and with reduced pain 2 weeks and 11-months post conclusion of the treatment after a multi-modal conservative rehabilitation program had failed to produce meaningful improvement over 6 weeks. based on these results, further research on the use of rns with sd is warranted to determine effectiveness, but this case may serve as a clinical guide for incorporating rns into patient care. references 1. kibler wb. the role of the scapula in athletic shoulder function. am j sports med. 1998;26(2):325-337. https://doi.org/10.1177/03635465980 260022801. 2. kibler wb, ludewig pm, mcclure pw, michener la, bak k, sciascia ad. clinical implications of scapular dyskinesis in 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rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 24. hefford c, abbott jh, arnold r, baxter gd. the patient-specific functional scale: validity, reliability, and responsiveness in patients with upper extremity musculoskeletal problems. j orthop sports phys ther. 2012;42(2):56-65. https://doi.org/10.2519/jospt.2012.395 3. 25. huang ts, ou hl, huang cy, lin jj. specific kinematics and associated muscle activation in indiciduals with scapular dyskinesis. j shoulder elbow surg. 1995;24:1227-1234. https://doi.org/10.1016/j.jse.2014.12.0 22. 26. worsley p, warner m, mottra s, et al. motor control retraining exercises for shoulder impingement: effects on function, muscle activation, and biomechanics in young adults. j shoulder elbow surg. 2013;22:e11-e19. https://doi.org/10.1016/j.jse.2012.06.0 10. 27. loutsch ra, baker rt, may jm, nasypany am. reactive neuromuscular training results in immediate and long term improvements in measures of hamstring flexibility: a case report. int j sports phys ther. 2015;10(3):371-377. 28. cook g, burton l, fields k. reactive neuromuscular training for the anterior cruciate ligament-deficient knee: a case report. j athl train. 1999;34(2):194-201. 29. borsa pa, lephart sm, kocher ms, lephart sp. functional assessment and rehabilitation of shoulder proprioception for glenohumeral instability. j sport rehabil. 1994;3:84-104. https://doi.org/10.1123/jsr.3.1.84. https://doi.org/10.2519/jospt.2012.3953 https://doi.org/10.2519/jospt.2012.3953 https://doi.org/10.1016/j.jse.2014.12.022 https://doi.org/10.1016/j.jse.2014.12.022 https://doi.org/10.1016/j.jse.2012.06.010 https://doi.org/10.1016/j.jse.2012.06.010 https://doi.org/10.1123/jsr.3.1.84 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, patientcentered 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 wholeperson 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 clinicianrated 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 patientrated 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 17 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 easyto-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 patientspecific 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 19 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 11point 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 postintervention, 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 20 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 21 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 15, 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 5point 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 22 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 readministered 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 selfreported 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 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 references 1. deyo ra. using outcomes to improve quality of research and quality of care. j am board fam pract. 1998;11(6):465–473. https://https://doi.org/.org/10.3122/jabfm .11.6.465 2. slover jd, karia 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https://catalyst.nejm.org/implementing-proms-patient-reported-outcome-measures/ 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 manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 thank you for your service! lindsey e. eberman, phd, lat, atc indiana state university, terre haute, in thank you for your service! the editorial board wants to thank all those who serve or have served clinical practice in athletic training, this year. as we continue to evolve, we have had several section editors move on, while we are honored to welcome new section editors. let us first thank brian vesci, esther nolton, and alison o’connor sutherland for their service to the journal. thank you for your continued support, contributions, and dedication to clinical practice research. and, a great welcome to tim nicollelo (disablement model case studies and reports), s. andrew cage (validation case studies and reports), kim barber foss (point-of-care research), and nick pfeifer (quality improvement reports). we continue to evolve as a journal and we are happy to announce dr. zachary winkelmann will be joining the senior editorial board and dr. matthew drescher and ms. kelcey granger will be joining the team as staff editors. we are hopeful that these small changes will help better support section editors, reviewers, and authors. below we recognize our section editors and reviewers who have contributed to the journal over the past year: section editors: disablement model case studies and reports tim nicollelo, ms, lat, atc -st. luke's health system validation case studies and reports s. andrew cage, med, lat, atc university of texas tyler point-of-care research kim barber foss, ma, lat, atc -cincinnati children's hospital clinical outcomes research jj wetherington, ms, lat, atc st. luke’s sports medicine quality improvement reports nick pfeifer, edm, atc boston university preceptor case studies zachary dougal, dat, lat, atc ball state university evidence-to-practice reviews cameron powden, phd, lat, atc indiana state university clinical expertise commentary hollie walusz, ma, atc, pes boston university patient-centered-care commentary mark laursen, ms, atc, boston university reviewers: nicholas c merritt, dat, atc, scat – furman university skye livermore-brasher mpa, lat, atc – columbus state university samantha jane atkielski ms, lat, atc, ces university of wisconsin milwaukee thank you for your service! 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3issue 2 – june 2020 kevin michael schroeder, dat, atc – university of new mexico connor burton, dat, lat, atc – indiana state university zachary k winkelmann, phd, scat, atc – university of south carolina justin tatman, ms, lat, atc – tria orthopedic center danielle colegrove – northwestern university vicky graham, dat, atc – xavier university jamie nikander, dat, lat, atc – west olympia sports medicine emily gibb, ma, atc – boston university lucas bianco, ms, lat, atc – university of lynchburg sara j. brown, ms, atc – boston university daniel walen, dat, at, atc – western michigan university thomas abdenour, dhsc, atc, ces retired adam babiarz, dat, lat, atc – ati physical therapy nicholas dephillipo, ms, atc, otc, cscs – the steadman clinic kelcey granger ms, lat, atc – indiana state university chyrsten gessel ms, lat, atc – mariette college savannah katelyn bailey, lat, atc – united states marine corps alli zeigel powell, dat, at – colorado mesa university steve middleton, dpt, atc william woods university mccall christian, dat, lat, atc – missouri state university richelle williams, phd, atc – drake university kim mace, dat, atc – boston university katie knappenberger, ms, rd, cssd, atc – northwestern university nancy uriegas, ms, scat, atc – university of south carolina manuscript type patient-centered care commentary 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 creating a lgbtq+ inclusive culture in the athletic training facility sean m. rogers, dat, atc 1 ; ashley k. crossway, dat, atc 2 ; patricia a. aronson, phd, lat, atc3 1california state university, northridge, northridge, ca; 2 nazareth college, rochester, ny; 3 lynchburg college, lynchburg, va key phrases emotional wellness and mental health, preparticipation exams and screening, cultural competency, health care disparities correspondence dr. sean rogers, california state university, northridge department of kinesiology, 18111 nordhoff street, northridge, ca 91330-8287. e-mail: sean.rogers@csun.edu twitter: @datsearog full citation rogers sm, crossway ak, aronson pa. creating a lgbtq+ inclusive culture in the athletic training facility. clin pract athl train. 2018;1(1):11-14. https://doi.org/10.31622/2018/0001.3 submitted: may 15, 2018 accepted: may 25, 2018 commentary lesbian, gay, bisexual, transgender, and queer individuals often fall under the umbrella acronym lgbtq+ and are represented as a community. however, each individual letter represents a distinct population with its own identity, challenges, and unique obstacles with regards to equity.1 in recent years, there has been significant advancements in civil rights legislation and overall social acceptance of the lgbtq+ community. hallmark legislative victories including the right to marriage2 and to openly serve in the armed forces3 have resulted in long overdue legal protections for the lgbtq+ community. despite these advances, lgbtq+ individuals still disproportionately suffer from health disparities arising from stigmatization, oppression, and discrimination.4,5 one significant societal barrier still adversely affecting the healthcare of lgbtq+ individuals is the lack of healthcare providers that are both knowledgeable and capable of delivering culturally competent and inclusive patient care.5 creating an inclusive environment welcoming lgbtq+ individuals in the clinical setting is vital to healthcare of those within the community. this paper serves to address inclusion of lgbtq+ patients through patient centered care in the athletic training facility. current literature suggests that one of the most predominant health disparities among the lgbtq+ community is dissatisfaction and avoidance of healthcare as a whole, which directly leads to suboptimal patient outcomes.5,6 recent trends in healthcare promote practitioners utilizing a patientcentered approach focusing on the identity of a patient, and how it relates to overall health related quality of life (hrqol).7 adherence to this approach better serves and respects the identity of patient populations.7,8 the theoretical framework of contemporary disablement models, such as the nagi model, challenges clinicians to simultaneously address multiple aspects of health and wellbeing for overall improved patient outcomes.9 in order for healthcare practitioners to provide quality patient care, and achieve appropriate patient outcomes for individuals of many diverse backgrounds, cultures, and identities, it is imperative to use a patient-centered approach. the importance of identity and patient centered care utilizing a patient-centered approach requires the clinician to consider the patient’s identity and how it contributes to the overall disability and societal implication of the injury or pathology.7,8 the identity of lgbtq+ patients, as with all patients, is multidimensional and includes the interests, goals, dreams, and desires derived from the intricacies of patients’ past experiences. utilization of a disablement model in conjunction with an understanding of a patient identity helps the practitioner create targeted interventions to best address the etiology of the injury or illness being treated. this practice in healthcare is what is known as patientcentered care. patient-centered care is an approach to healthcare that focuses on the unique qualities of each individual patient.7,8 mailto:sean.rogers@csun.edu https://doi.org/10.31622/2018/0001.3 creating a lgbtq+ inclusive culture in the athletic training facility 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 this approach to healthcare is driven by active patient participation and less by cliniciandominated dialogues.7,8 the patient-centered approach creates a clinician-patient relationship that is rooted in trust, empathy, understanding, and collaboration with respect to the patient’s identity.7,8 in practice, a patient-centered approach to healthcare has been found to increase efficiency of care, improve patient outcomes, increase hrqol, reduce patient discomfort, and more adequately address patient concerns regarding healthcare.8,10 healthcare disparities of lgbtq+ individuals specific to the lgbtq+ community, patientcentered care can mean the difference between an individual feeling comfortable enough to seek care and avoiding healthcare all together. a recent study published in the, journal of homosexuality, found that 37% of lgbtq+ young adults do not disclose their identity to healthcare providers due to concerns over potential discrimination, internalized stigmas, fear of rejection, or a belief that health and lgbtq+ identity are not related.6 apprehension towards seeking healthcare either in part by not feeling comfortable disclosing personal information, or in full by complete avoidance of seeking healthcare can be detrimental to the hrqol of lgbtq+ individuals. apprehension of lgbtq+ individuals in seeking healthcare can be especially problematic for athletic trainers (ats) particularly those practicing in traditional sports-focused settings at the professional, collegiate, or secondary school levels. while organizations such as the national collegiate athletic association (ncaa) have made a concerted effort to create a more inclusive environment in sports, ideologies supporting homonegativity are still prevalent in all competitive levels of sport subculture in western society.11 athletic trainers, especially in the aforementioned settings, are often the point of care for a disproportionately large number of patients. given the close proximity with athletics, an ideology of homonegativity can either intentionally or unintentionally permeate into the clinic climate. consciously or unconsciously supporting and reinforcing a homonegative ideology in an athletic training facility can substantiate lingering societal stigmas of lgbtq+ individuals.9 such an environment can prevent lgbtq+ patients from seeking care from an at, or disclosing pertinent information to the at. through being an active champion and advocate in identifying and addressing blatant bias and discrimination in athletic training facilities, ats can focus on more patient-centered and equitable practice. creating an inclusive facility environment in order for a shift towards more equitable patient care to occur ats must first take inventory of their own clinical practice, implicit biases, and communication styles in addition to the clinical setting in which they practice. one of the most difficult and perhaps tedious aspects of affecting change is awareness of not only systemic faults, but also personal weaknesses and areas of improvement. on an individual level, ats must recognize their own verbal and non-verbal reactions when interacting with patients of diverse backgrounds. inappropriate or incorrect language, body positioning, facial expression, or mannerisms, whether intentional or unintentional can cause the practitioner to appear as closed off or unwelcoming.12,13 these verbal and non-verbal cues, when intentionally exhibited towards underserved populations such as the lgbtq+ community, are an example of demeaning micro aggressions.12,13 adjustments to personal practice should be reinforced through the creation of facility or institution-wide policies that ensure discriminatory language, micro aggressions, and inappropriate behavior are addressed.12 in addition to an analysis of personal practice and athletic training facility policies, specific attention should be given to maintaining an inclusive clinic environment. in order to create a welcoming inclusive environment for lgbtq+ individuals an athletic training facility can present visible representation supporting equality such as safe space ally stickers and posts of non-discrimination policies, and provide access to gender neutral restrooms as well as brochures or information addressing health concerns specific to the lgbtq+ population.12,13 this development of an inclusive facility culture is especially pertinent for ats, given the close relationship and proximity between practitioner and patient in the multiple creating a lgbtq+ inclusive culture in the athletic training facility 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 different settings ats practice. as such, it is important to create an inclusive facility culture before the first lgbtq+ patient seeks care. creating and maintaining an equitable and culturally competent practice in athletic training is a difficult endeavor for any practitioner. in order to facilitate this development of a model practice, there are many training programs such as safe space and ally training that provide sensitivity training to become cognizant of lgbtq+ concerns, while simultaneously learning how to identify and address internal bias.5,12,13 these types of instructional trainings are an excellent way to bridge individual practitioner development, while at the same time addressing clinic or institutional areas of cultural weakness.12,13 in addition to the aforementioned changes, another impactful adjustment that can be made to improve a facility’s culture is the creation and utilization of inclusive documentation forms. while documentation forms, such as a pre-participation exam, are important for an athletic training facility to gather legal names and biological sex, it is equally important that the patient have the opportunity to self-report demographic information such as preferred name, gender, and gender identity. the most effective way to gather this information from the patient without being insensitive is by simply asking open-ended questions.13 this technique allows the patient to respond in whatever manner is appropriate, while also conveying that the practitioner respects the identity of the patient. furthermore, utilizing an open-ended questioning technique allows the practitioner to collect pertinent demographic information, such as relationship status and appropriate pronouns, which are important when considering the hrqol of lgbtq+ patients and can be utilized in future patient interactions.7,12,13 an inclusive approach to patient interaction and documentation sets an important precedence that any patient, regardless of his-her-zir identity, is welcomed and will be treated with the upmost respect and fairness. special attention, however, must be placed on avoiding ambivalent or neutral attitudes towards practicing in an equitable manner in order to maintain an inclusive athletic training facility environment. while not being an active participant in creating an equitable practice might seem innocuous, inaction in addressing areas of weakness related to equity can be just as harmful to lgbtq+ individuals as outright discrimination. conclusion major societal advancements in recent years have provided recognition and legal protections for lgbtq+ individuals. these advancements, coupled with more exposure and access to competitive sports, have created a prominent need for ats in all settings to ensure their practice is welcoming, inclusive, and culturally competent. through the process of intentional reflection and analysis of athletic training facility culture, coupled with tangible changes, ats can create an environment in which all patients, regardless of their identity, can feel comfortable seeking care. references 1. lev ai, sennott sl. clinical work with lgbtq parents and prospective parents. in: ae goldber, kr allen, eds. lgbt-parent families: innovations in research and implications for practice. new york, ny: springer; 2013:241-60. 2. masci d. supreme court’s doma decision driving same-sex marriage efforts in states. fact tank: new in the numbers: pew research center, 2013. http://www.pewresearch.org/fact tank/2013/10/21/supreme-courts-domadecision-driving-same-sex-marriage-effortsin-states/. accessed: may 1, 2018. 3. frank n. the president's pleasant surprise: how lgbt advocates ended don't ask, don't tell. j homosex. 2013;60(2-3):159213. https://doi.org/10.1080/00918369.2013 .744666 4. institute of medicine. the health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. washington, dc: national academies press, 2011. 5. mckay b. lesbian, gay, bisexual, and transgender health issues, disparities, and information resources. med ref serv q. http://www.pewresearch.org/facthttp://www.pewresearch.org/facthttps://doi.org/10.1080/00918369.2013.744666 https://doi.org/10.1080/00918369.2013.744666 creating a lgbtq+ inclusive culture in the athletic training facility 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 2011;30(4):393-401. https://doi.org/10.1080/02763869.2011 .608971 6. rossman k, salamanca p, macapagal k. a qualitative study examining young adults’ experiences of disclosure and nondisclosure of lgbtq identity to health care providers. j homosex. 2017;64(10):1390-410. https://doi.org/10.1080/00918369.2017 .1321379 7. weiner sj, schwartz a, sharma g, et al. patient-centered decision making and health care outcomes: an observational study. ann intern med. 2013;158(8):57379. https://doi.org/10.7326/0003-4819158-8-201304160-00001 8. epstein rm, street rl. the values and value of patient-centered care: ann fam med. 2011;9(2)100-103. https://doi.org/10.1370/afm.1239 9. snyder ar, parsons jt, valovich mcleod tc, curtis bay r, michener la, sauers el. using disablement models and clinical outcomes assessment to enable evidence based athletic training practice, part i: disablement models. j athl train. 2008;43(4):428-36. https://doi.org/10.4085/1062-605043.4.428 10. oates j, weston ww, jordan j. the impact of patient-centered care on outcomes. fam pract. 2000;49(9):796804. 11. anderson e, magrath r, bullingham r. out in sport: the experiences of openly gay and lesbian athletes in competitive sport: new york, ny: routledge; 2016. 12. mcclain z, hawkins la, yehia br. creating welcoming spaces for lesbian, gay, bisexual, and transgender (lgbt) patients: an evaluation of the health care environment. j homosex. 2016;63(3):38793. https://doi.org/10.1080/00918369.201 6.1124694 13. mcnair rp, hegarty k. guidelines for the primary care of lesbian, gay, and bisexual people: a systematic review. ann fam med. 2010;8(6):533-41. https://doi.org/10.1370/afm.1173 https://doi.org/10.1080/02763869.2011.608971 https://doi.org/10.1080/02763869.2011.608971 https://doi.org/10.1080/00918369.2017.1321379 https://doi.org/10.1080/00918369.2017.1321379 https://doi.org/10.7326/0003-4819-158-8-201304160-00001 https://doi.org/10.7326/0003-4819-158-8-201304160-00001 https://doi.org/10.1370/afm.1239 https://doi.org/10.4085/1062-6050-43.4.428 https://doi.org/10.4085/1062-6050-43.4.428 https://doi.org/10.1080/00918369.2016.1124694 https://doi.org/10.1080/00918369.2016.1124694 https://doi.org/10.1370/afm.1173 manuscript type quality improvement reports 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes devon serrano, dat, lat, atc, nremt* & velyn wu, md† *sweet briar college, sweet briar, va; †university of florida, gainesville fl abstract a concussion return-to-participation protocol specific to equestrian is critical in the safe return of athletes to their respective discipline. when the care of the hunter/jumper equestrian teams became the responsibility of the sports medicine staff at sweet briar college, a return-toparticipation concussion management policy was needed to ensure the safety of the equestrian student-athletes. a quality-improvement project focusing on the development of a “return-to-ride” protocol was started in the fall semester of 2016. the sports medicine staff collaborated with the sweet briar college riding center to create and ensure compliance of the protocol. the intended aim of developing this protocol was to create a guideline for concussion management of the equestrian student-athlete that would standardize care across sports and between providers. at the time of this quality improvement cycle, no specific concussion management protocol had been adopted or approved for any discipline of equestrian. due to the differences between equestrian sports, changes would be need to be made in order to best serve the athlete(s) affected. using a traditional five-day return-to-play program as an example, the returnto-ride (rtr) protocol is seven days of gradual riding for equestrian athletes. this protocol accounts for the specific physical demands and vestibular disruptions associated with equestrian. this plan, do, study, act (pdsa) cycle was conducted during the fall semester of 2016 to the fall semester of 2019. the purpose of this pdsa cycle was to provide athletic trainers and other healthcare providers with insight on the development and outcomes of a concussion return to participation protocol for equestrian athletes. key phrases policy and procedure development, risk management and mitigation, professional standards correspondence dr. devon serrano, sweet briar college, 134 chapel rd., sweet briar, va 24595. e-mail: dserrano@sbc.edu twitter: @devonserrano full citation serrano d & wu v. implementation of a novel return-toride concussion management policy for collegiate hunter/jumper equestrian athletes. clin pract athl train. 2020;3(2): 15-30. https://doi.org/10.31622/2020/0002.4. submitted: october 15, 2019 accepted: june 14, 2020 current model in 2017, the sport science institute (ssi) of the national collegiate athletic association (ncaa) released updated recommendations on concussion safety management in intercollegiate athletics.1 the concussion safety protocol checklist and diagnosis and management of sport-related concussion best practices interassociation consensus documents serve as the standard to which colleges and universities associated with the ncaa hold their concussion safety management programs.1 athletic trainers often serve as the management personnel of student-athletes with concussions from initial evaluation to return to activity.2 in order to best serve athlete populations, concussion management recommendations state that return-to-play (rtp) protocols must include sport-specific exercise.1 in august 2016, equestrian was granted full access to the sports medicine clinic at sweet briar college. the sports medicine staff had limited knowledge regarding the demands of the sport, especially when it came to sport-specific activities for concussion management. a rtp protocol specific to equestrian did not exist. presently, no aspects of equestrian are considered champion sports in the ncaa, though it has been considered an emerging sport for women at division i and ii since 2002.3-5 as of september 2019, the ncaa committee on women’s athletics voted in favor of a proposal to add equestrian to the ncaa emerging sports for women program at the division iii level.5 a vote by the division iii membership on the proposal, conducted in january 2020, was narrowly defeated.5 in order to be considered a champion sport and have mailto:dserrano@sbc.edu https://doi.org/10.31622/2020/0002.4 implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 recognized competitive seasons that end with a championship, 40 programs must declare intent to have a varsity program.3 for collegiate programs, the options for competition associations include the intercollegiate horse shows association (ihsa) and national collegiate equestrian association (ncea).6.7 at the time of publication, membership in the ncea extends over all three ncaa divisions with 17 schools in division i, five in division ii and three in division iii.8 the ihsa membership extends to 48 states and canada with over 10,000 participating student-athletes from 577 member schools.6 no specific concussion management protocol has been adopted or approved by either organization, leaving each member school to manage concussions individually.6,7 the availability of a concussion management protocol specifically for equestrians would allow for a consistent level of care among member schools within an association. the purpose of the following document is to describe the use of a quality improvement process in developing an equestrian-specific return-toride (rtr) concussion management protocol for a collegiate equestrian program. the aim was to develop and implement a guideline for concussion management of the equestrian student-athlete that would standardize care provided by all members of the sports medicine team to the same level given to all other existing sports managed by the sports medicine department. the process for the development and implementation of a sport-specific concussion management protocol, challenges and barriers and outcomes will be discussed. pdsa cycle plan the first step of the development phase was determining individuals who would be critical in a successful creation of a protocol. the primary writer on the protocol in this instance was the director of sports medicine for sweet briar, with input and direction from the team physician for sweet briar athletics and the director of riding at the college. equestrian access to sports medicine services varies on the institution. according to the ihsa 2018-2019 rulebook and ncea rulebook (revised in february 2019), a qualified medical professional must be on site for all schooling sessions and the entire length of a performance or show.10,12 a qualified medical professional is listed as a certified and/or licensed emergency medical technician, paramedic, physician or nurse who is trained in pre-hospital trauma.10,12 at the collegiate level, access to sports medicine services vary based on the school’s distinction of the team, whether it be club or varsity status. further research and advocacy is currently being conducted to propose the creation of a standard by which collegiate equestrian teams receive access to sports medicine services and the allowance of athletic trainers to be deemed qualified medical professionals by ihsa and ncea standards. researching the specific demands, physical and mental, is needed for the creation of sport-specific policies. although created and initially implemented using hunter/jumper athletes, the goal of the protocol was to allow for adjustments to fit the needs of all equestrian athletes based on the demands of the sport. this included development of skill session parameters for traditional five-phase policies.1 there were several physical demands that needed to be met in order to have the protocol be successful. hunter/jumper equestrian is about the relationship between the rider and the horse. the two are teammates and the success of one is equally dependent on the success of the other.9 due to the changes in pace (walk, trot, canter and/or gallop) and height variations, there are also vestibular disruptions that must be accounted for. jumps in collegiate competition in the ncea and ihsa can range from two feet six inches to three feet six inches in height.8,10 theses demands on the rider were discussed with the sports medicine staff by implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 the riding center staff, including physical demands (particularly on the hip, back, shoulder and lower leg) and vestibular disruptions throughout the pace and height variances.9,11 do the sweet briar college return-to-ride protocol was developed for hunter/jumper equestrian athletes in the fall semester of 2016. the protocol (appendix a), was created in conjunction with the director of the harriet howell rogers riding center at sweet briar college in sweet briar, virginia. the protocol was designed to slowly increase the rider’s control over the horse, cardiovascular intensity, musculoskeletal involvement and changes in vestibular disruption. the purpose of the protocol was to outline an equestrian-specific return to participation for student-athletes competing on the college’s competitive equestrian teams. it also served as a way to build a rapport and relationship with the college’s equestrian program’s student-athletes and coaches. prior to the 2016-2017 academic year, there had been no significant interaction between the equestrian program and the sports medicine team. the rtr protocol was designed in compliance with the ncaa interassociation consensus: diagnosis and management of sport-related concussion practices.13 at the initial conception of the rtr protocol, a five-phase policy was proposed to the director of riding at sweet briar (table 1) after discussing with the director the demands placed on equestrian athletes as they return after any injury. table 2 outlines the sections present in the rtr policy and procedure document that were developed using best-practice guidelines. the proposed protocol followed the standard fivephase outline as expected by the ncaa.1 the purpose of the original five-phase protocol was to serve an outline for all three members of the creation team to follow and work from as well as giving the director of riding an idea as to the types of activities that might be needed in a final version of a protocol. the decision to extend the protocol from five days to seven days was jointly made by the director of sports medicine, the team physician, and the director of riding. one of the concerns when a five-phase protocol was proposed was that the athlete might not have enough time to gain confidence on the horse and manage the fine and gross motor control demands put on the body as well as vestibular disruptions. the extension of the rtr protocol to seven days also accounted for the addition of the horse as part of the studentathlete’s full participation in equestrian events. because the horse is a significant part of the sport, it was important to involve use of a horse in the protocol to allow for the student-athlete to work on gaining control in gradual monitored steps. a rtr protocol completion sheet was created with the return to ride phases and places for instructor sign-off after completion of each phase. this sheet was created to track rider progression throughout the protocol. the rtr protocol consists of seven days of gradual increases in riding under the participation direction of a coach and medical direction of a certified athletic trainer. athletes are able to proceed to the next phase if they are asymptomatic at the satisfaction of the current phase and the subsequent 24 hours.2 if symptoms occur during activity, the athlete is removed from activity and instructed to rest for 24 hours prior to considering starting from the previous level that did not produce symptoms. symptoms that were exacerbated at this progression stage must dissipate prior to attempting the previous stage. per the recommendation of the national athletic trainers’ association (nata) position statement, final clearance for full participation following completion of the protocol is required from a medical doctor.2 during the creation of the policy and procedure, several audiences had to be considered including student-athletes, coaches, horse trainers, and stakeholders. as access to sports medicine services varies across secondary school, collegiate, and implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 private settings, it is important to educate coaches and horse trainers on the impact of concussions and the importance of progressionbased concussion management in the return of a student-athlete to activities of daily living, academics and riding participation.13 this also serves as an opportunity to educate stakeholders on the value of athletic trainers and their possible collaboration when working with student-athletes who compete in equestrian sports. the final policy and procedure document as updated in september 2019 (appendix a) outlines the purpose of concussion management for student-athletes as well as the full policy for pre-participation examinations, return-to-learn (rtl) progression, and rtr policy (table 3). table 1. original proposed five-phase return-to-ride protocol phase 1: light aerobic exercise 20 minutes stationary bike at 70% maximum heart rate phase 2: moderate aerobic exercise interval bike ride: 10 sets of 30 second sprints/30 seconds recovery body weight circuit: squats/push-ups/sit-ups: three sets of 20 each phase 3: sportspecific exercises 60 yard shuttle run plyometric circuit (examples): 10 yard bounding/10 medicine ball throw/10 vertical jumps; three times each 15 minutes of walking on a horse with trotting (based on the rider’s abilities) phase 4: fullcontact practice limited participation in full contact practice and monitoring of symptoms inclusion of jumping small obstacles (based on the rider’s abilities) phase 5 full participation in practice table 2. sections of the return to ride policy and procedure document education mandatory educational session for all student-athletes and coaches, informational document provided to all student-athletes and coaches, acknowledgement of concussion understanding for all student-athletes and coaches pre-participation assessment completed annually for all student-athletes and includes the competition of the most current version of the sport concussion assessment tool (scat) with full balance error scoring system (bess) test. all history questions must be completed as part of the scat assessment. post-concussion management immediately upon suspicion of concussion: • removal from participation • completion of scat test with balance (bess or tandem walk as available) • evaluation of head and cervical spine • initiation of emergency action plan if necessary • serial evaluation and monitoring for deterioration post-injury. • home instructions with discharged from medical care return to academics a four-phase stepwise progression that works to allow student-athletes to increase in their workload and class attendance safely with multiple evaluations with the managing athletic trainer with communication with members of the academic community necessary for the student-athlete’s success. return to activity utilized in initial recovery, return to learn (rtl) progression and return to play/ride progression return to play termed “return to ride” for equestrian athletes in this policy and procedure. appendix a. implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 table 3. seven-day return-to-ride protocol phase 1 • mount/dismount/lead in hand/walk undersaddle (mounted) • mount/dismount, lead for five minutes (complete two times) • mount, walk undersaddle for 15 minutes • dismount and put the horse away phase 2 • mount and walk for 10 minutes • trot two laps around the indoor arena • walk five minutes • trot two laps around the indoor arena • walk for 10 minutes • dismount and put the horse away phase 3 • mount and walk for 10 minutes • trot four laps around the indoor arena o walk two minutes • trot four laps around the indoor arena • walk for 10 minutes • dismount and put the horse away phase 4 • mount and walk for 10 minutes • trot four laps around the indoor arena o walk two minutes • trot four laps around the indoor arena • walk for one minute • canter a lap in each direction • walk for 10 minutes • dismount and put the horse away phase 5 • mount and walk for 10 minutes • work at the trot and canter for 15 minutes with periods of walk • finish with walk for 10 minutes • dismount and put the horse away phase 6 • repeat phase 5 • add jumping small obstacles phase 7 • full participation in practice or lesson without restrictions study the rtr protocol was created, developed and implemented at the beginning of the fall 2016. the first equestrian related concussion occurred in spring 2017. to determine how the rtr protocol compared to the rtp protocol, the following items were collected: • date of injury • date of evaluation • number of days from injury to rtl phase 4 (rtl 4) • dates each phase of the student’s respective return to participation protocol was completed • number of days from the date of injury to date of protocol completion all the collected dates were placed in a password protected spreadsheet and updated daily throughout the athlete’s recovery. the average number of days from injury to rtl4 and from injury to concussion resolution were collected for all athletes in sports managed by the sweet briar college sports medicine department. this included athletes who completed any of the three concussion return to participation protocols (rtp, rtr or a combination protocol). any observations were documented on the athletes’ concussion evaluation for that day and/or in the notes section of the athlete’s injury in the electronic medical record system. at the time of submission, the protocol had been completed a total of 16 times with collegiate hunter/jumper equestrian athletes. as with all student-athletes, they were required to also complete their four-phase rtl protocol prior to the rtr protocol. since the introduction of the rtr protocol in september 2016, a total of 85 return to participation protocols for all sports at sweet briar college were completed (69 rtp and 16 rtr) (figure 1). a total of seven ncaa varsity programs and two competitive equestrian teams used the appropriate return to activity protocol. five concussion management cases (four rtp and one rtr) were not included in this analysis implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 because the return to participation protocol was not completed for reasons such as medical withdrawal, athlete non-adherence, athlete transfer to another institution and graduation from the institution. concussions included in this analysis were categorized as incoming (occurred prior to enrollment at sweet briar college), athletic mechanism of injury or non-athletic mechanism of injury. in this analysis, the average number of days lost to concussion recovery was followed (figure 2). this was defined as the time frame from the date of injury evaluation to the date of full athletic return. it is important to note that the averages from the fall 2018 semester were higher due to several protocols implemented over winter break and being completed at the start of the spring 2019 semester. in both the spring 2018 and spring 2019 semesters, protocols were delayed due to spring break and were completed when the student-athlete(s) returned to campus. overall as of september 30, 2019 the seven-day rtr protocol presented similar averages of days lost to concussion as its five-day rtp counterpart. due to the additional two days in the rtr protocol, it was surprising to see that the averages of days lost was as close as they were. a major success was the quick adaption of the protocol by the equestrian staff. the coaches and instructors were open to the use of the protocol and served as advocates for the athletes if an injury (concussion or other) occurred as well as encouraging them to seek medical attention. they were receptive to education relative to concussions and were willing to assist in concussion management when needed and necessary. as in any setting with a new possible policy, there were challenges to implementation of the new concussion policy with procedures. the rtr protocol was designed for use with collegiate hunter/jumper equestrian student-athletes who had limited to no prior access to an athletic trainer either at the institution or at their high school and/or private barn. the initial challenge was working with the student-athletes to gain their buy-in into being able to use an athletic trainer, not just for concussion management, but also for general athletic health care. cooperation from the student-athletes began with an introductory meeting at the beginning of the year to introduce the athletic trainer and explain offered services with locations and available times. this introduction is now offered annually as part of the onboarding experience for both new and returning student-athletes. another step towards buy-in of the policy was meeting with studentathletes at the barn and campus arenas. this was a time for both the athletic trainer and studentathletes to ask questions. this allowed for the athletic trainer to speak with the coaching staff and build relationships with them as to how to best utilize the athletic trainer for their student-athletes. at the beginning of the research phase of writing this protocol, the majority of student-athletes were very open to explaining the sport of hunter/jumper equestrian and the psychological connect they have with the barn, as well as the importance of the barn to their personal identify. a second challenge was that no specific training with the sports medicine team or equestrian coaches was conducted on the implementation of the protocol. the athletic trainer met with the equestrian coaches to discuss the new protocol, athlete evaluations, completion of phases and how to respond if an athlete reports symptoms at any point (during recovery or return to ride phase). act for clinicians in settings where they are building new relationships, it is important to learn about the sport they are working with. this includes understanding the physical competitive aspects of the sport as well as the psyche of the athletes and how their sport impacts their lives. in terms of understanding the sport, it is important that policies reflect sport participation and serve as a implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 figure 1. number of return to participation protocols completed from august 2016 to september 2019 academic term number of rtp protocols completed number of rtr protocols completed fall 2016 22 0 spring 2017 7 5 fall 2017 20 3 spring 2018 6 1 fall 2018 10 4 spring 2019 3 2 fall 2019 (as of september 23, 2019) 1 1 total number completed 69 16 figure 2. average days lost from evaluation to completion of designated return to participation protocol academic term average days from evaluation to rtp 5 average days from evaluation to rtr 7 fall 2016 20.4 spring 2017 16.2 16.8 fall 2017 20.7 24.3 spring 2018 20.0 32.0 fall 2018 48.1 21.25 spring 2019 19.0 27.0 fall 2019 (as of september 30, 2019) 12.0 12.0 average number of days lost 22.3 25.4 guide to clinical practice. this creates a standard for patient care and protects the clinician legally. when creating a new policy and procedure, especially when working with a new program or a program that has had little to no interaction with an athletic trainer, policy development serves as a good opportunity to learn about the sport and build strong relationships with coaches and other stakeholders. one potential barrier to implementation of the rtr protocol is how the protocol needs to be adjusted when an athlete only rides two to three times per week. a lesson-based schedule can delay the completion of an athlete’s protocol so adjustments might be necessary to keep the protocol from being completed over several weeks. this barrier can be overcome by working with the equestrian coaches and instructors to allow the athlete to complete supervised rides outside of their designated lesson times. another barrier is the skill level of each athlete. with abilities ranging from beginner walk/trot up to those able to jump three feet six inches, it is important to make sure the athlete can complete their protocol safely and in their own skill range. in the event an athlete does not canter and/or jump, it may be necessary to modify the protocol phase to make sure the intensity is increased without putting the athlete at risk due to lack of skill. implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 an opportunity for further research includes applying the rtr protocol to all equestrian athletes such as those who compete in eventing (dressage, jumpers, and cross country), fox hunting, polo, competitive trail riding, endurance riding, western styles (pleasure, reining, cutting, team pinning, working cow horse, trail class, halter), and rodeo events. this protocol was written to serve as a general outline for other competitive sanctions of equestrian so testing and utilization in those sanctions would be needed to determine how effective the policy is in return-toride participation for equestrian athletes. further research is also needed to determine the psychological effects of concussion on the psyche of equestrian athletes and is currently in the initial stages of development. clinical bottom line equestrian currently is working towards becoming recognized as an emerging sport within the ncaa and over 10,000 students participate in the sport at the collegiate level annually. therefore, more research and policy development is needed to ensure that sport-specific policies are created to fit the needs of the athletes competing and participating. steps in this process include researching statements from the ncaa and sport’s governing bodies to determine how one’s current policies align with the expectations and standards set forth. it is important to involve important stakeholders in policy creation, editing and implementation. this allows for them to understand the standards expected of the policy as well as give valuable input on needed changes or recommendations. education and evaluation by staff members and stakeholders are both part of the development and implementation processes. as equestrian continues to rise in status and participation numbers, it is important to develop policies that are sport-specific and align with standards of the sport’s governing bodies, nata, and ncaa. creation, evaluation and improvement of policies allow for improved patient care that is specific to the needs of athletes and their sport. references 1. national collegiate athletic association. concussion educational resources. sport science institute, national collegiate athletic association, indianapolis, in. 2017. available at: http://www.ncaa.org/sportscience-institute/concussion-educationalresources. accessed july 2018 and september 2019. 2. broglio sp, cantu rc, gioia ga, guskiewicz km, kutcher j, palm m, et al. national athletic trainers’ association position statement: management of sport concussion. j athl train. 2014; 49(2):245-265. https://dx.doi.org/10.4085%2f10626050-49.1.07. 3. national collegiate athletic association. sports. national collegiate athletic association, indianapolis, in. 2017. 4. stark-mason r. still in the saddle: equestrian association working to rally support for the sport. ncaa champion magazine. december 2015. available at: http://www.ncaa.org/champion/still-saddle. accessed july 2018 and september 2019. 5. stark-mason, r. committee on women’s athletics supports division iii equestrian proposal. national collegiate athletic association. national collegiate athletic association, indianapolis, in. 2017. available at: http://www.ncaa.org/about/resources/medi a-center/news/committee-women-s-athleticssupports-division-iii-equestrian-proposal. accessed september 2019. 6. intercollegiate horse show association. about: general information. intercollegiate horse show association. 2018. available at: https://www.ihsainc.com/about-us/generalinformation. accessed july 2018 and september 2019. http://www.ncaa.org/sport-science-institute/concussion-educational-resources http://www.ncaa.org/sport-science-institute/concussion-educational-resources http://www.ncaa.org/sport-science-institute/concussion-educational-resources https://dx.doi.org/10.4085%2f1062-6050-49.1.07 https://dx.doi.org/10.4085%2f1062-6050-49.1.07 http://www.ncaa.org/champion/still-saddle http://www.ncaa.org/about/resources/media-center/news/committee-women-s-athletics-supports-division-iii-equestrian-proposal http://www.ncaa.org/about/resources/media-center/news/committee-women-s-athletics-supports-division-iii-equestrian-proposal http://www.ncaa.org/about/resources/media-center/news/committee-women-s-athletics-supports-division-iii-equestrian-proposal https://www.ihsainc.com/about-us/general-information https://www.ihsainc.com/about-us/general-information implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 7. national collegiate equestrian association. about. national collegiate equestrian association, waco, tx. 2018. available at: https://collegiateequestrian.com/sports/201 9/4/3/_131987884238679712.aspx. accessed july 2018 and september 2019. 8. national collegiate equestrian association. schools. national collegiate equestrian association, waco, tx. 2018. available at: https://collegiateequestrian.com/sports/201 9/5/2/equest_0502195449.aspx. accessed july 2018 and september 2019. 9. pilato m. a new view: bringing sports medicine to the equestrian athletes. american medical equestrian association safe riders foundations news. american medical equestrian association safe riders foundations, albuquerque, nm. winter 2005-2006. accessed september 2019 10. intercollegiate horse show association. 2018-2019 ihsa rulebook. intercollegiate horse show association. 2019. accessed september 2019 11. nelson de, pivara fp, condie c, smith sm. injuries in equestrian sports. phys sportsmed. 1994: 22 (10); 53-60. https://doi.org/10.1080/00913847.1994. 11710501. 12. national collegiate equestrian association. rulebook. national collegiate equestrian association, waco, tx. 2019. 13. national collegiate athletic association. ncaa interassociation consensus: diagnosis and management of sport-related concussion practices. sport science institute, national collegiate athletic association, indianapolis, in. 2017. available at: https://www.ncaa.org/sites/default/files/ss i_concussionbestpractices_20170616.pdf. accessed september 2019. https://collegiateequestrian.com/sports/2019/4/3/_131987884238679712.aspx https://collegiateequestrian.com/sports/2019/4/3/_131987884238679712.aspx https://collegiateequestrian.com/sports/2019/5/2/equest_0502195449.aspx https://collegiateequestrian.com/sports/2019/5/2/equest_0502195449.aspx https://doi.org/10.1080/00913847.1994.11710501 https://doi.org/10.1080/00913847.1994.11710501 https://www.ncaa.org/sites/default/files/ssi_concussionbestpractices_20170616.pdf https://www.ncaa.org/sites/default/files/ssi_concussionbestpractices_20170616.pdf implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 appendix a: return-to-ride protocol management of a concussion in sport can be challenging, as there are no universal standards on concussion care and return to play guidelines. the following document is a concussion policy and management plan that specifically outlines the role of the sweet briar college sports medicine health care providers. the goal of this protocol is to give athletic trainers and physicians dealing with concussions a common student-athlete concussion management program. this policy is for the concussion care and management of student-athletes in the competitive programs of sweet briar college athletics and riding. the sports medicine staff will provide concussion healthcare through baseline testing, education, injury diagnosis, management and rehabilitation. in order to return to participation, the studentathlete must complete the return to learn and return to play/ride protocols through the sports medicine staff and be cleared to return to participation by the team physician or their designee. education sweet briar college will present all student-athletes with the ncaa concussion fact sheet for studentathletes. student-athletes are required to sign a student-athlete acknowledge statement annually stating that they received, read and understand the ncaa concussion fact sheet. this document on concussions includes the definition of a concussion, how to reduce the risk of concussions, symptoms of concussions, and how to report any concerns for themselves or a teammate regarding a concussion. student-athletes are required to attend a preseason brief session with the athletic trainer prior to participation. concussion education is also included in this meeting. coaches at sweet briar college will receive the ncaa concussion fact sheet for coaches annually. they are required to sign the coach acknowledge statement annually prior to the start of their season. additional educational opportunities in relation to concussions is available upon request, as needed and/or when new information regarding concussions becomes available. members of the sports medicine staff will receive a copy of the ncaa concussion fact sheet for coaches and student-athletes annually to have as reference. in addition, all members of the sports medicine staff will participate in concussion education annually including a review of the concussion management policy during the emergency action plan annual review. baseline testing upon enrollment at sweet briar college and before the first day of practice/tryouts, every student-athlete will undergo baseline testing. baseline testing must occur annually prior to the student-athlete’s first day of their first season for the academic year. if a student-athlete sustains a concussion during the academic year, a new baseline will be completed prior to their return to participation. in compliance with the arrington settlement and as implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 recommended by the ncaa, and the sweet briar college athletic conference the baseline assessment for all sweet briar college student-athletes will consist of the following: • sport concussion assessment tool5th edition (scat5) • balance error scoring system (bess) test • impact computerized concussion test (baseline) concussion the sweet briar college sports medicine staff will determine whether or not a concussion has occurred, realizing that each concussion and each student-athlete is different, and individual treatment plans are necessary. a concussion is a brain injury that may be caused by a blow to the head, face, neck or elsewhere on the body from an impulsive force transmitted to the head. concussions can also be a result from contact with another player, hitting a hard surface such as the ground, or being hit by a piece of equipment such as a bat, basketball or softball. a concussion may present differently from one student-athlete to another. a concussion can happen even if the athlete does not lose consciousness. following a concussion, a student-athlete may exhibit the following signs and symptoms: physical symptoms cognitive symptoms emotional symptoms headache vision difficulty nausea and/or vomiting dizziness and/or lightheadedness balance difficulties light sensitivity noise sensitivity fatigue slurred/incoherent speech ringing in the ears loss of or altered consciousness vacant stare loss of bowel control loss of bladder control seeing bright lights or stars memory loss attention disorders concentration problems confusion disorientation irritability sadness nervousness sleep disturbances personality changes feeling of being stunned depression when a student-athlete exhibits signs, symptoms or behaviors consistent with a possible concussion, they shall be removed from practice or competition and evaluated by the certified athletic trainer and/or team physician. signs and symptoms of a concussion can take up to seven (7) days to present fully. it is important that student-athletes be truthful and forthcoming about signs and symptoms of a concussion as soon as they present. the student-athlete will be evaluated and monitored to determine their status as it relates to being concussed. once a student-athlete has been diagnosed with having a concussion, they shall be removed from physical activity for the remainder of that day, and not allowed to participate in implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 academic activities for the remainder of that day. the student-athlete, or their parent, guardian or roommate (as needed depending on the needs and requests of the student-athlete), will be provided with instructions on further care and the home concussion information sheet upon discharge. the student-athlete will be monitored for progression of symptoms during the ongoing course of their concussion by the sweet briar college sports medicine staff. immediately following injury, the studentathlete will be placed on cognitive brain rest for 24-48 hours unless noted by the athletic trainer and/or team physician. the sweet briar college sports medicine staff will use the scat5 and bess tests daily, along with other examinations deemed necessary during the evaluation of the concussed studentathlete until the symptoms have subsided and/or have been resolved. all of these evaluations will be compared to the baseline scores of the student-athlete and will aid in the return to learn and return to play/return to ride progressions. once the student has sustained a concussion, the athletic trainer will set up an appointment for evaluation with the team physician during their the next sports medicine clinic day. when the student-athlete is either approaching the end of return to learn phase 1 or enters return to learn phase 2, the athletic trainer will notify the director of academic resource center so they can arrange a meeting with the student-athlete to create a plan for post-injury academic success. with permission for release of information from the student-athlete, the academic resource center will be notified and updated on the condition of the student-athlete after they suffer a concussion in order for the dean’s office to notify professors. notifications include: • the office of the dean (dean and secretary) • team physician • dean of students • director of the academic resource center • athletic director • riding director (in the event the injured student-athlete is on an equestrian team) • head coach(es) of the team(s) the injured student-athlete is a member of the dean of students, the office of the dean and director of the academic resource center will be notified during the student-athlete’s return to learn protocol. once the student-athlete progresses out of return to learn and into return to play and/or return to ride, they will no longer receive email updates as the student will be returned to full academic participation at this point. student-athletes will complete the impact test as part of their concussion recovery plan. they will take the test a total of three times: 48 hours post-injury, at the completion of return to learn phase 4 (rtl 4) and at the completion of return to play day 5 (rtp 5) or return to ride day 7 (rtr 7). implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 it is important to note that all return-to-learn, return-to-play, return-to ride, and return-to-play/returnto-ride combination protocols are individualized on a case-by-case basis, allowing for the student-athlete to receive the best available and most accurate care to aid in their recovery. return to learn (rtl) the sweet briar college athletic training staff, team physicians, and the academic resource center will work together to determine return to learn status of a post-concussed student-athlete. the office of the academic dean will inform the student-athlete’s professors and any accommodations that may be necessary in their return to the classroom and activities that are associated with their full academic return. once a student-athlete has been diagnosed with having a concussion, they shall be removed from physical activity for the remainder of that day and not allowed to participate in academic activities. the office of the academic dean will be notified of the status of the student-athlete. following a concussion, the student-athlete will be seen daily by a sweet briar college athletic training staff member prior to the start of their first academic class. at that time, the decision will be made if the student-athlete’s symptoms have progressed to allow them to attempt to attend class, study hall, and tutoring sessions that day. the office of the academic dean will then convey the status of the studentathlete to their professors. if a student-athlete is allowed to return to class, they will be evaluated that afternoon in order to complete an updated scat5, to aid in determining how the day of learning progressed. this is repeated until the student-athlete successfully completes rtl 4; then they will be seen once per day until the completion of their designated return to participation protocol. guidelines for progression • student-athlete proceeds to the next level only if asymptomatic at the current level of progression. • following a recovery phase, if they are symptom-free for 24 hours they will progress to the next level. o if symptoms occur, they rest until they are symptom-free and return to the previous stage that did not produce symptoms. • during recovery, it is important for the student-athlete’s work and assignments to be prioritized so they can make up all missed work without inducing additional stress and emotional distress. • phases of recovery o phase 1: complete physical and cognitive rest  no school attendance  strict limitations on technology usage and reading  rest o phase 2: return to school with academic accommodations  initiated once student-athlete reports four or less symptoms with a total severity score of four or less  continue limits on technology usage implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020  avoid heavy backpacks  no tests/exams/quizzes/reading/homework, athletics, band or chorus  monitor symptoms  rest at home o phase 3: continue academic accommodations  attend school full-time if possible  increase workload gradually (testing, homework, etc)  monitor symptoms  rest at home o phase 4: full return to academics  attend school full-time  self-advocate at school (meet due dates, etc)  resume normal activities in any concussion case when a student-athlete needs or requests counseling, the sports medicine staff will assist in referring them to a counselor, located at on the second floor of protho hall in student life. return to play (rtp) the gradual exertion return to play process is designed to allow for a gradual increase in exercise volume and intensity during the return to play process. guidelines for progression • student-athlete proceeds to the next level only if asymptomatic at the current level. • if symptoms occur during activity: stop activity, rest for 24 hours and begin at the previous level that did not produce symptoms. • levels of progression o phase 1: light aerobic exercise  20 minutes stationary bike at 70% maximum heart rate o phase 2: moderate aerobic exercise  interval bike ride: 10 sets of 30 second sprints/30 seconds recovery  body weight circuit: squats/push-ups/sit-ups: three sets of 20 each o phase 3: sport-specific exercises  60 yard shuttle run  plyometric circuit (examples): 10 yard bounding/10 medicine ball throw/10 vertical jumps; three times each  15 minutes of sports-specific non-contact drills o phase 4: full-contact practice  limited participation in full contact practice and monitoring of symptoms o phase 5: full participation in practice return to ride (rtr) implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 the gradual exertion return to ride process is designed to allow for a gradual increase in exercise volume and intensity during the return to ride process. guidelines for progression • student-athlete proceeds to the next level only if asymptomatic at the current level. • if symptoms occur during activity: stop activity, rest for 24 hours and begin at the previous level that did not produce symptoms. • due to the nature of the aerobic and anaerobic demands of the sport of equestrian, each phase increases in the demand of those systems on the body during sport-specific controlled activity. • levels of progression o phase 1  mount/dismount, lead for five minutes (complete two times)  mount, walk undersaddle for 15 minutes  dismount and put the horse away o phase 2  mount and walk for 10 minutes  trot two laps around the indoor arena  walk five minutes  trot two laps around the indoor arena  walk for 10 minutes  dismount and put the horse away o phase 3  mount and walk for 10 minutes  trot four laps around the indoor arena  walk two minutes  trot four laps around the indoor arena  walk for 10 minutes  dismount and put the horse away o phase 4  mount and walk for 10 minutes  trot four laps around the indoor arena  walk two minutes  trot four laps around the indoor arena  walk for one minute  canter a lap in each direction  walk for 10 minutes  dismount and put the horse away o phase 5  mount and walk for 10 minutes  work at the trot and canter for 15 minutes with periods of walk  finish with walk for 10 minutes  dismount and put the horse away o phase 6  repeat phase 5  add jumping small obstacles o phase 7  full participation in practice or lesson without restrictions implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 return to play/return to ride combination in the case of students who are both considered student-athletes for both an ncaa team and a competitive equestrian team, they will complete a combination of the return to play and return to ride protocols. completion of this combination protocol will be considered sufficient in allowing them to return to both activities. this protocol is a guideline and can be adjusted by the director of sports medicine and designated team physician to best accommodate the recovery of the student-athlete and their participation schedules. • student-athlete proceeds to the next level only if asymptomatic at the current level. • if symptoms occur during activity: stop activity, rest for 24 hours and begin at the previous level that did not produce symptoms. • levels of progression o phase 1: return to ride phase 1  mount/dismount/lead in hand/walk undersaddle  mount/dismount, lead for five minutes (complete two times)  mount, walk undersaddle for 15 minutes  dismount and put the horse away o phase 2: return to play phase 2  interval bike ride: 10 sets of 30 second sprints/30 seconds recovery  body weight circuit: squats/push-ups/sit-ups: three sets of 20 each o phase 3: return to play phase 3  60 yard shuttle run  plyometric circuit (examples): 10 yard bounding/10 medicine ball throw/10 vertical jumps; three times each  15 minutes of sports-specific non-contact drills o phase 4: return to ride phase 5  mount and walk for 10 minutes  work at the trot and canter for 15 minutes with periods of walk  finish with walk for 10 minutes  dismount and put the horse away o phase 5: return to play phase 5  full participation in practice o phase 6: return to ride phase 6  repeat phase 5 • mount and walk for 10 minutes • work at the trot and canter for 15 minutes with periods of walk • finish with walk for 10 minutes • dismount and put the horse away  add jumping small obstacles o phase 7: return to ride phase 7  full participation in practice or lesson without restrictions no student-athlete will be allowed to return to full activity or competition until they are asymptomatic in limited, controlled, and full-contact activities. any student-athlete diagnosed with a concussion must be medically cleared by a team physician before returning to implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 competition. this includes any student-athlete who arrives to sweet briar college with a pre-existing concussion, and/or have continuing symptoms from a resolved concussion. the return-to-learn, return-to-play, return-to-ride and return-to-play/return-to-ride combination protocols are different and can be completed at different times. return-to-learn will be initiated before return-to-play, return-to-ride and return-to-play/return-to-ride combination. they can also occur simultaneously. for student-athletes who also participating in the equestrian program, they must complete the return-to-play/return-to-ride combination protocol. it is important to note that the listed progression timelines can take place over a period of days, weeks, or months. it could potential result in medical disqualification from participation in sweet briar college athletics and equestrian for a season or indefinitely. athletes with multiple concussions the sweet briar college athletic training staff and team physicians have the right to review all student-athlete’s medical history, both previous and current, and reserve the right to withhold from participating in college sponsored athletic events (i.e., practices, game, weight-lifting, conditioning, shows, competitions, travel, etc). travel with athletes recovering from a concussion the ability of a student-athlete recovering from a concussion to travel to athletic or equine competitions or trainings with their team is at the discretion of the sweet briar college athletic training and sports medicine staff. the sweet briar college athletic training staff and team physicians have the right to forbid travel for a student-athlete recovering from a concussion until they are cleared for full athletic, equine and academic participation. returning to work in the case that a student-athlete sustains a concussion, they will be recommended to refrain from work (on or off campus) while in the initial phases of recovery. once a student-athlete has completed return to learn phase 4 (rtl 4), they can consider returning to work. if a student-athlete is on work-study at the college, a member of the human resources team will be put on the student-athlete’s release and notified of the student-athlete’s injury as well as when they are permitted to return to work. returning to drive when a student-athlete sustains a concussion, they be recommended to refrain from driving a motorized vehicle. this includes but it not limited to a car, trunk, motorcycle, motorized scooter, gator, golf cart. they will also be recommended to refrain from riding in a motorized vehicle driven by another person, unless in implementation of a novel return-to-ride concussion management policy for collegiate hunter/jumper equestrian athletes 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 the case of an emergency. once a student-athlete completes return to ride or return to play day 3 (rtr 3 or rtp 3), they consider returning to driving and riding in motorized vehicles. annual review in accordance with the ncaa, this policy will be reviewed annually by the institution’s athletic health care administrator (ahca). the ahca is a designated health provider within the athletic department who oversees the administration and delivery of healthcare for the institution’s student-athletes. clinical outcomes research 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes r ross dexter, ms, mkin, at, lat, cscs1,3; terylan k loftis, ms, at, lat, prt-c®2; russell t baker, phd, dat, at, cmp, prt-c®3; timothy e speicher, phd, at, lat, cscs, prt-c®2 1grtiman medical center, moscow, id; 2positional release therapy institute, ogden, ut; 3university of idaho, moscow, id abstract healthy athletes commonly engage in pre-participation warm-up strategies designed to physiologically and mechanically prepare the body for training and competition. alterations in rotational range of motion (rom) of the dominant shoulder in overhead athletes, resulting in total rotation rom loss, correlate with performance deficit, injury risk, and lost training time. researchers have suggested that interventions using total motion release® (tmr®) increase shoulder rom more effectively than traditional warm-up methods. a randomized pre-test post-test trial was used to explore the effects of a regionally interdependent application of tmr® via a forward flexed trunk twist (fftt) and seated straight leg raise (slr) compared to a traditionally designed athletic warm-up on active shoulder internal rotation (ir) and external rotation (er) in healthy overhead athletes measured with the clinometer© smartphone application. participants included twenty-two ncaa division i, iii, club, and secondary school senior student-athletes (9 javelin, 7 volleyball, 6 baseball; 13females, 9-males; age= 19.3±1.1 years; height= 178±11.4 cm; weight= 76.4±11.2 kg), randomly assigned to tmr® (tmrg; n=11) and traditional warm-up (twg; n=11) groups. the tmrg performed 3 sets of fftt and slr, each held for 20 seconds to the side of ease. the twg completed a traditionally designed athletic warm-up including running, athletic drills, and dynamic and static stretching. the tmrg experienced significantly greater increases in dominant shoulder ir, non-dominant shoulder ir, and non-dominant shoulder er (mean change =+9.5°, +7.5o, +4.7o), than the twg (+1.7°, -6.7°, -4°) respectively. intervention time to completion was also different between groups (tmrg = 7mins twg = 25mins). this study indicates that an indirect tmr® application produces efficient meaningful changes in rotational active range of motion (arom) of the shoulder in overhead athletes. key phrases injury risk reduction, performance exercise, throwing athletes correspondence r ross dexter, 875 perimeter dr, moscow, id 83843, 208-885-6111. e-mail: dext8778@vandal.uidaho.edu full citation dexter rr, loftis tk, baker rt, speicher te. regionally interdependent application of total motion release® and active rotational shoulder range of motion in overhead athletes. clin pract athl train. 2019;2(2): 20-36. https://doi.org/10.31622/2019/0002.4. submitted: august 31, 2018 accepted: february 18, 2019 introduction dynamic, forceful, and repetitive movement of the shoulder among overhead athletes may cause osseous and soft tissue adaptations as well as kinematic changes within the joint and surrounding musculature.1-8 as a result, overhead athletes may present with increased external rotation (er) and decreased internal rotation (ir) of the dominant shoulder.1,3-7 range of motion (rom) adaptations, via the reduction of total rotational rom, may elevate risk of shoulder injury, result in lost training and competition time, and raise the potential for decreases in performance via common injury patterns.9,10 researchers suggest the goals of performance readiness be accomplished via the progressive sequencing of warm-up activities including lowintensity aerobic exercise, stretching, high load dynamic drills, and sports specific exercises.11-13 it is recommended that this sequence elevate the heart rate, increase peripheral tissue temperature, address specific aims such as increasing rom through static or dynamic stretching, and then incorporate specific skill based drills required by the training or competitive environment of the participant.12,13 interventions to improve shoulder rom and increase performance readiness are employed https://doi.org/10.31622/2019/0002.4 regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 21 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 by athletes regardless of ability and health status. these often include static stretches that have traditionally focused on local structures.1,7,8,12,14 though these types of interventions are regularly employed, improvements in shoulder ir are often found to be less than 5°.14-16 while immediate increases in shoulder rom have been found, static stretching has often not been found to produce lasting changes in rom or increase performance in athletic populations.12-16 despite these findings, researchers have traditionally advocated that both healthy and at risk individuals engage in daily stretching programs, often as part of warm-up activities, in order to improve or maintain shoulder rom.4,12,14-17 focusing on specific tissues and localized areas of the body, while ignoring the complexity of the neuromuscular system, may reduce the efficacy of traditional warm-up protocols.18-21 instead, heeding the interconnected nature of the neuromuscular and fascial systems may be the key to producing meaningful injury prevention and performance enhancement strategies. researchers have established that alterations in one region of the body affect not only local outcomes, such as positional changes in joints, tension dynamic changes across soft tissues, and alterations in stability,22-24 mobility,25-27 and motor control,28,29 but invariably produce adjustments in other, interdependent, body regions.26,27,30-32 the term regional interdependence (ri) is used to describe this phenomenon.32 while the ri model is primarily concerned with musculoskeletal factors, it may also involve neurophysiological effects.31,32 therefore, neuromuscular adaptation is of particular interest when movement is the primary driver of intervention, as is the case during therapeutic exercise or warm-up programs prior to training or competition. total motion release® (tmr®), a movement based orthopedic intervention, utilizes ri, potentially via cross education,22-25 neural coupling,28 and the common core hypothesis,29 as well as the fascial interconnectedness of the trunk and upper limbs,33-35 to produce changes in rom, pain, and dysfunction, through targeted pain-free movement.30 the tmr® system is based on the theory that pain alters motor control, movement patterns adapt to dysfunction created by pain, and that the body seeks symmetry and will correct dysfunctional movement patterns in the absence of pain.30 participants using tmr® are asked to perform movements bilaterally and then self-rate to compare the motions on a scale of 0-100.30 on this scale, 0 represents an absence of pain, dysfunction, or strength deficit, and equal quality and quantity of rom. in contrast, a score of 100 represents extreme pain, complete dysfunction or unilateral strength deficit, or substantial loss of quality or quantity of rom.30 once these selfdetermined ratings have been established, the motion with the highest rating (i.e., the most ‘dysfunctional’ movement or ‘bad side’) is addressed by performing the same motion to the side of ease (i.e., ‘good side’) through set and repetition schemes determined by the clinician or based on patient comfort.30 the movement is completed so long as the motion is not bilaterally painful or dysfunctional, which would be a contraindication to use that movement within the tmr® system.30 the use of tmr® may have benefits as a performance readiness and injury prevention strategy due to the proposed effects regarding increased rom,26,27 and may help patients/athletes achieve symmetry in paired movement patterns.26 although tmr® research is scarce, its use has been found to quickly increase shoulder rom in baseball players when using arm raise and trunk twisting motions.26,27 however, tmr® as an regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 22 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 intervention strategy, is often applied in a regionally interdependent fashion.30 therefore, further research is warranted to determine the effects of tmr® as an intervention for increasing shoulder rom in overhead athletes. specifically, it is necessary to assess if these positive changes in rom are the result of direct application of tmr® movements at the upper extremity. therefore, the purpose of this study was to explore the regionally interdependent effects of an indirect application of tmr® using forward flexed trunk twist (fftt) and active straight leg raise (slr) techniques on shoulder arom compared to a traditional athletic warm-up among healthy overhead athletes. patients with the approval of a university institutional review board, a non-blinded randomized control trial design was utilized to examine and compare the effects of an indirect tmr® intervention and a traditionally designed warmup. all participants were informed of the risks and benefits of the investigation prior to signing informed consent documents and were aware that they could withdraw their participation at any time. a total of 22 student-athletes were recruited from ncaa division i university volleyball and track and field teams, a ncaa division i university club baseball team, a ncaa division iii track and field team, and secondary school baseball and volleyball teams. gender and sport differences between groups are presented in the consort flow chart (figure 1). participants were included if they were between the age of 18 and 25, could complete all warmup activities and rom testing procedures, were a member of a secondary school, junior/community college, naia, ncaa i, ii, iii, club baseball, baseball, volleyball, or track and field team, and had been competitive in their discipline for at least 3 years. participants were excluded from this study if they had had any orthopedic surgery three months prior to data collection at the hip, knee, ankle, spine, shoulder, or elbow. individuals with orthopedic injuries older than three months that remained symptomatic were also excluded. participants were also excluded from this study if they were found to be unable to complete shoulder rom testing or had painful motion with both left and right trunk rotation or left and right straight leg raise as these are contraindication within the tmr® system.30 all participants were also able to complete a full traditionally designed athletic warm-up. if the participant was being advised by their medical or coaching staff not to take part in such activity, was unable to complete any portion of the traditional warm-up, or wished for their rom or demographic information to not be utilized, withdrawal from participation was accepted. all volunteers met the pre-screened inclusion criteria with no participants dropping or being excluded once data collection had begun. interventions the study was conducted in a single session for each participant. all interventions were performed before any sport-specific or warm-up activities had occurred for the day. randomization was accomplished by using a first generator by randomization.com, participants randomly assigned to either the tmr® group (tmrg; n=11) or the traditional warm-up group (twg; n=11). a certified strength and conditioning specialist (cscs) collected all measurements and data in their second year studying in a masters of science in athletic training program. all measurements and interventions were conducted indoors in athletic training facilities and gymnasiums. pretest measurements range of motion changes in female elite swimmers throughout a competitive season 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 figure 1. consort diagram showing the breakdown of participants by intervention, gender, and sport. assessed for eligibility (n = 22) excluded (n = 0) included (n = 22) male (n = 9) female (n = 13) sport breakdown: baseball (n = 6) randomized (n = 22) allocated to tmrg (n = 11) received allocated intervention (n = 11) a llo ca tio n allocated to twg (n = 11) received allocated intervention (n = 11) br ea kd ow n male (n = 6) female (n = 5) sport breakdown: baseball (n = 4) volleyball (n = 4) male (n = 3) female (n = 8) sport breakdown: baseball (n = 2) volleyball (n = 3) analyzed (n = 11) excluded from analysis analyzed (n = 11) excluded from analysis a na ly si s range of motion changes in female elite swimmers throughout a competitive season 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 of active shoulder ir and er were measured on the dominant and non-dominant sides before performing either intervention. following baseline arom measurements, the participants in the tmrg performed one seated straight leg raise (slr) (figure 2) with each leg and one fftt (figure 3) with the arms across the chest placing the palmar surface of the hand at the anterior axilla, the hips slightly flexed as if performing a dead lift, and the torso at an angle which caused no discomfort in the lumbar region to each side. hip angle, depth, and postural control were not controlled for as the tmr® system asks for the participant to reach their perceived end range requiring changes in joint angles during intervention.30 the participant then determined which side or motion provided the most rom, best quality of motion, was pain free, or free of restriction.30 figure 2. seated straight leg raise starting position and ending position. figure 3. forward flexed trunk twist movement. total motion release® group (tmrg intervention) participants in the tmrg established a side of ease for both the seated tmr® slr and fftt through self-determination. after the easier side had been determined, participants performed the seated slr (3 sets of 20-second static holds at end range) and the fftt (3 sets of 20-second static holds) in the direction of the side of ease beginning with the most dysfunctional of the two patterns. after each set, there was a 30-second rest interval. static holds of 20 seconds at end range were chosen to mitigate the fatigue associated with completing multiple high-volume repetition and set schemes as part of this intervention.36 participants in the tmrg were given instruction by a level 3 tmr™ trained investigator and were cued to ‘sit back, rotate, and breathe’ throughout the fftt and ‘to lift the foot up and breathe’ during the slr. following the intervention, arom measurements were reassessed. each participant accomplished the tmrg intervention, including testing on the side of ease, in approximately 7 minutes. traditional warm-up group (twg intervention) researchers suggest that a pre-training or precompetition warm-up should include sequential phases designed with the specific goals of elevating the heart rate and increasing peripheral tissue temperature, addressing mobility and rom through static or dynamic stretching, and incorporating specific skill based or sport specific drills.11,13 the twg in this study followed a protocol fashioned after these recommendations using static stretches shown in the literature to increase ir and decrease posterior capsular tightness at the shoulder.14,15 static stretching was done in the terminal phase, as increases in rotational rom was the end goal of the twg.37 the twg completed the warm-up protocol (table 1) after baseline arom measurements were assessed. following the intervention, arom measurements were reassessed. each participant completed the twg intervention in approximately 25 minutes. to complete the range of motion changes in female elite swimmers throughout a competitive season 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 table 1. traditional warm-up protocol warm-up exercise repetitions phase i jog 3min at 25% phase ii walking knee hug 10m alternating forward lunge w/ rotation 10m alternating reverse lunge w/ rotation 10m alternating walking quadriceps stretch 10m power skips 10m alternating lateral lunges 10m walking dynamic forward overhead arm circles 10m walking dynamic reverse overhead arm circles 10m walking horizontal cross body arm swings 10m phase iii sprint (50%) 2 x 30m sprint (75%) 2 x 30m sprint (90%) 2 x 30m phase iv alternating seated cross body stretch 3 x 30s each alternating seated upper trapezius stretch 3 x 30sec each alternating side lying sleeper stretch 3 x 30sec each protocol, each participant in the twg completed a 4-phase warm-up. phase i consisted of a 3minute steady state jog.11 phase ii was comprised of a series of dynamic full body warm up drills with upper and lower extremity dynamic stretches, dynamic movements in all three planes of motion, and a focus on full range shoulder motion.11,12 phase ii was completed in three continuous rounds with a 30-second rest interval. phase iii included two rounds of 30 meter runs at 50%, 75%, and 90% of perceived max intensity, each done with a 30-second rest interval.11 phase iv was comprised of 3 rounds of 30-second alternating static stretches for the shoulder done to produce a 30-second rest interval on the uninvolved side while the involved side was stretched.11-14 static stretches included a seated cross body stretch, a seated upper trapezius stretch, and a side lying sleeper stretch with the arm at 90 degrees of adduction, 90 degrees of shoulder flexion, and 90 degrees of elbow flexion.14,15 outcomes measures active shoulder ir and er were measured using the clinometer© digital smartphone application (plaincode software solutions, stephanskirchen, germany) which is accurate to 0.1°. a smartphone was affixed to the participant's forearm just proximal to the wrist, utilizing an ailkin running sports armband for droid turbo™ android smartphone by motorola© to make use of the clinometer© digital application (figure 4). shin et al 38 demonstrated the clinometer© app to have high intra-rater reliability when measuring active shoulder er (icc=0.98, 95% confidence interval [ci]=0.95-0.99 and ir (icc=0.96, 95% ci=0.96-0.99) among evaluators. significantly correlation with goniometer measurement have also been shown through pearson correlation coefficient (pcc) evaluation for both active shoulder er (pcc=.95) and ir (pcc=.92).38 interobserver reliability was comparable to goniometry as well for both active er (icc= 0.87, 95% ci=0.79-0.92) and active ir (icc=0.67, 95% ci=(0.43-0.82).38 regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 26 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 figure 4. ailkin running sports armband for droid turbo™ android smartphone by motorola© the examiner stood opposite the desired movement, near the head during active ir and at the torso during active er to allow the examiner access to the functional use of the smartphone clinometer©.38 each participant was asked which arm they primarily used during their competitive activity to determine dominance. for er and ir measurements, the participant was instructed to lie supine on a table. an adjustable belt was placed across each participant’s chest at the level of the sternoclavicular joint to limit trunk compensation into extension, rotation, or flexion during rom testing (figure 5).39 participants were positioned with the shoulder abducted to 90°, the elbow flexed to 90°, and the forearm supinated with support from the table along the proximal 50% of the humerus (figures 6 & figure 7). once positioned, the participant was instructed to either internally or externally rotate the arm, making sure to minimize excessive scapular and trunk motion by maintaining contact with the table at the humerus and posterior trunk. the measurement was recorded when the participant verbally confirmed reaching perceived end range.38 all measurements occurred in the same order, beginning with dominant shoulder ir, dominant er, non-dominant ir, and finally non-dominant er. before completing this study, intra-rater reliability pilot testing was conducted using the clinometer© application, armband, and chest strap. the examiner measured shoulder ir and er five times with the smartphone application and averaged the values. the examiner placed the smartphone in the correct position for measurement and positioned the participants for proper measurement. measurements were conducted on each participant (n=10) twice over a 5-day period. a two-way mixed effects model intraclass correlation (icc) was used to assess intra-rater reliability for the investigating clinician responsible for data collection using the clinometer© application. the standard error of the mean (sem) values were calculated for shoulder ir and er using the formula (sem = sd√1icc). where sd is the standard deviation from the test.40 minimal detectable change (mdc) was calculated using the formula (mdc=sem×1.96× √2).2, 22 the icc, sem and mdc values were excellent for both measurements, and comparable table 2. intra-rater reliability for shoulder internal & external rotation using the clinometer application (n = 10). active range of motion (arom) intraclass coefficient (icc) standard error measurement value (sem) minimal detectable change value (mdc) shoulder internal rotation 0.99 0.32 0.87 shoulder external rotation 0.96 0.80 2.22 regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 27 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 to previously research by shin et al. for active er (sem=3.01, mdc=2) and active ir (sem=1.86, mdc=3) (table 2).38,40,39 statistical analysis all data were analyzed using the statistical package spss version 21 (ibm corp. armonk, ny, usa). normality was confirmed using the shapirowilk test. levene's test for homogeneity of variances was non-significant for dominant ir (p=.504), non-dominant ir (p=.376), and nondominant er (p=.696). a one-way anova was used to determine the difference between groups for change in shoulder ir and er from pre-to postintervention, to calculate effect size and observed power, and to assess group means comparisons. a priori α level of p ≤ .05 was utilized for all statistical analyses. effect size calculations were completed using partial eta-squared. partial eta squared values lower than 0.0099 were considered small, while 0.0588 was the benchmark for medium, and values greater than 0.1379 were considered large effect sizes.42 results all of the 22 participants recruited for the study met inclusion criteria and completed the study in its entirety. analyses of variables at baseline testing did not reveal any significant differences between groups in age (p=.349), weight (p=.188) (table 3), pre-intervention dominant shoulder ir (table 4), non-dominant shoulder ir (table 5), pre-intervention dominant shoulder er (table 4), or non-dominant shoulder er (table 5). however, there was a significant difference between the mean height of participants in both groups ( p=0.003) (table 3). table 6 shows the differences in shoulder ir and er pre-intervention. on average female participants had greater ir figure 5. adjustable belt used to stabilize patient. figure 6. internal rotation measurement starting and ending position. figure 7. external rotation measurement starting and ending position. regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 28 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 table 4. dominant shoulder range of motion by group active rom ir pre ir post er pre er post tmrg 96°±16.2° 106.4°±17.2° 117.7°±6.5° 120.1°±8.7° twg 101.8°±14.3° 103.5°±12.9° 114.5°±15.8° 117.1°±8.7° p value p=0.384 p=0.169 p=0.012 p=0.935 (ir) internal rotation, (er) external rotation, (tmrg) total motion release group, (twg) traditional warm-up group table 5. non-dominant shoulder rom by group active rom ir pre ir post er pre er post tmrg 101.5°±16.1° 108°±14.7° 107.63°±13.2° 112.5°±12.4° twg 108.8°±9.5° 103°±11.9° 110.9°±10.4° 106.8°±13.2° p value p=0.068 p=0.176 p=0.773 p =0.824 (ir) internal rotation, (er) external rotation, (tmrg) total motion release group, (twg) traditional warm-up group table 6. range of motion differences by gender gender dom ir pre dom er pre non dom ir pre non dom er pre male 88.6°±16.09° 110.5°±9.26° 96.1°±14.45° 101.7°±10.91° female 105.7°±9.02° 119.4°±12.91° 111.6°±9.3° 115°±12.08° (dom) dominant shoulder, (non dom) non-dominant shoulder, (ir) internal rotation, (er) external rotation table 3. descriptive statistics height (cm) age (years) weight (kg) participants 178±11.4 19.3±1.1 76.2±10.9 tmrg 184.7±10.4 19.5±1.3 79.3±10.8 twg 171.6± 7.6 19±0.9 73.1±10.7 (tmrg) total motion release group, (twg) traditional warm-up group range of motion changes in female elite swimmers throughout a competitive season 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 and er for both dominant and non-dominant shoulders. among the tmrg, a statistically significant increase in dominant shoulder ir (f(1,21)=6.623, p=0.044), non-dominant shoulder ir (f(1,21)=20.52, p<0.001), and non-dominant shoulder er ((f(1,21)=9.108, p= 007) was observed after the intervention compared to the twg (table 7). a significant group difference was not observed for dominant shoulder er (f(1,21)<0.001, p=0.982) and the variable did not meet the assumption for homogeneity of variance. the differences between groups represented a large effect size (η2 >0.138) for the increases found in dominant shoulder ir, nondominant shoulder er, and non-dominant shoulder ir.42 discussion while examining the effects of a regionally interdependent application of tmr® in healthy overhead athletes, members of the tmrg experienced significant increases in dominant shoulder ir when compared to participants who completed a traditional warm-up. the dominant shoulder ir and er improvements found in the current study were not as large as those produced in previous tmr® shoulder rom investigations.26,27 however, in the current study, 9 out of the 11 members of the tmr® group experienced an increase in ir greater than 5° on the dominant shoulder without performing any upper extremity activity or warm-up. interestingly, non-dominant shoulder ir and er arom increased significantly in the tmrg compared to the twg, a result not identified in previous research utilizing tmr®.26,27 the improvements in dominant and non-dominant shoulder ir following the tmr® intervention used in this study exceeded shoulder rom gains reported in much of the stretching literature, while the traditional warm-up protocol achieved similar rom alterations cited in previous research.14,16,26,27,43 participants in the twg of the current study experienced similar changes in dominant shoulder ir (mean=1.7°± 7°) to laudner et al.14 (3.1°), oyama et al.43 (3.8°), and gamma et al.'s 26 findings (2.2°). in contrast, gamma et al.’s 27 follow-up study found greater gains in the warm-up group (6.2°) than previous research, but this increase was still below the improvement experienced by the tmr® group for both dominant shoulder ir (mean=9.5°) and nondominant shoulder ir (mean=7.5°) in the current study. the faul’s stretching routine,16 which incorporates 3-7 second static stretches of shoulder flexion, extension, and er, has produced gains in dominant shoulder rom more similar to our tmr® findings. sauers et al.16 reported the faul’s stretching routine increased baseball players’ er by an average of 7.6° and ir 9.2°, table 7. change in shoulder internal and external rotation from pre to post-intervention between groups change from baseline tmrg twg p value effect size (η2) observed power dom ir +9.5°±9.6° +1.7° ± 7° p = .044 η2 = .188 .534 dom er + 2.5° ± 5.3° +2.5° ± 11.9° p = .982 η2 = .000 .05 non dom ir +7.5° ± 5.7° -6.7° ± 9.7 p < .001 η2 = .468 .99 non dom er +4.7° ± 6.2° -4° ± 7.5° p = .007 η2 = .313 .819 (dom) dominant shoulder, (non dom) non-dominant shoulder, (ir) internal rotation, (er) external rotation, (tmrg) total motion release group, (twg) traditional warm-up group regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 30 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 but we do not know if this protocol results in rom improvements in the non-dominant arm as was found with the application of tmr® in the current study. while non-dominant er improvement was found, the result do not suggest that this application of tmr® will significantly increase dominant shoulder er in overhead athletes. methodological differences between studies may explain differences in the magnitude of rom change when compared to previous research on tmr® and shoulder rom.26,27 while the length of time to complete the tmr® or traditional warm-up interventions was similar to previous research 26 (7 vs. 25 min), the application of tmr® was different.26,27 in previous studies 26,27 examining the effect of tmr® on shoulder rom, researchers combined a trunk twist motion with the arm raise, while the seated straight leg raise replaced the arm raise in the current study. it is possible that the use of the tmr® arm raise, even when performed on the non-dominant side, is more effective than the leg raise in producing changes in shoulder rom. the arm raise may have either a contralateral or direct effect on shoulder motion and may be more effective than the slr for increasing shoulder ir or er due to the crosseducation effect, or in the case of dominant side of ease, direct shoulder neuromuscular training paired with the indirect effects of the fftt. in addition to differences in tmr® application, other methodological differences were present in participant inclusion criteria. in the first gamma et al.26 study, participants presented with less baseline dominant ir (66°±12.06°) and dominant er (82.4°±11.33°) than was found in the present study (baseline=96°±16.2°of ir and 117.7°±6.5° of er). the current results could also be affected by gender and sport differences as the previous studies included only male baseball players,26,27 while the current study included both male and female participants and participants who competed in a variety of overhead sports. it is important to note that our methods for shoulder ir and er measurement did not call for the control of scapular motion via pinning of the scapula or visual inspection (i.e. stopping the measurement when the scapula begins to rotate and tilt anteriorly).46-48 measurement of this type accounts for scapulothoracic function and glenohumeral rom providing a more integrated and performance driven active measure. thus, shoulder complex rom was measured in place of strict glenohumeral rom. researchers have compared passive rom measurements with humeral head stabilization, scapular stabilization, visual inspection, and without stabilization and found that measurement without stabilization increased shoulder ir means by 8-30°.46,47 as a result, when stabilization methods are accounted for, our ir measurements fall closer to normative values. additionally, our study features 13 female participants while previous shoulder ir research has been largely conducted in male participant populations.14,16,26,27,43,46 multiple studies support our findings suggesting that females have greater ir and er on average than males regardless of the measuring method (table 6).47,48 furthermore, passive measurements of shoulder ir and er rom often produce values greater than active by approximately 4 degrees for males and females.48 despite the different methodology, the low mdc values for our measurement methods indicate that changes in rom are unlikely due to measurement error. generalization of this study is limited due to the sample size (n=22) and use of collegiate and secondary school athletes. additionally, neither the examiner nor the participants were blinded to the intervention or measurements. the investigating clinician, while trained in tmr®, was a relative novice using the intervention. a more experienced tmr® clinician may have achieved regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 31 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 different alterations in rom. additionally, no follow-up measures were recorded, so it is unknown how long the rom gains in either group remained. in spite of such limitations, the significant improvement in bilateral shoulder ir and non-dominant shoulder er, and strong effect sizes, suggests the results of this study are clinically and practically meaningful. thus, future research on tmr® is warranted. the time to completion differences between our intervention groups merits exploring interventions that are of a similar duration. additionally, the duration of rom improvement following tmr® intervention, along with assessing if multiple interventions produce more meaningful results, should be established. further research efforts should also focus on single method interventions within the tmr® system and explore the tmr® intervention principle of addressing the side of ease versus the side of restriction. finally, electromyographic study of activation patterns during trunk rotation may yield information regarding neuromuscular changes following tmr® intervention. considerations regarding tmr® mechanisms our findings, when compared with those in the current literature, 14,16,26,27,43 suggest that indirect ri interventions produce superior increases in rom for overhead athletes bilaterally compared to a traditional direct methods, and require less time for completion. the findings, when combined with previous work, 26,27 support a hypothesis that increases in shoulder rotational rom may be able to be driven by interventions directed at the core, which may be related to reducing rom asymmetries of the trunk. the use of a trunk twist to improve shoulder rom supports ri research linking the relationship between thoracic spine function and trunk stabilization to shoulder pain, mobility, and motor control.5,31,32,49 weakening of muscles that attach to the thoracolumbar fascia may have profound effects on the spine as the fascial structures provide for spinal integrity and mechanical function.49 loss of stiffness and mechanical function at the spine places greater stress upon the glenohumeral joint and rotator cuff in throwing athletes as the force needed to accelerate and decelerate the limb is initiated and increasingly dispersed through the glenohumeral joint during forceful overhead power production and deceleration.49 insufficient core stability also correlates with a higher incidence of scapular dyskinesis, which is a risk factor for shoulder injuries in volleyball players.5 the literature supports evidence of the importance of activation sequencing of the deep core musculature and trunk stabilization through the thoracic cage in counter rotation prior to movement at the upper extremity in overhead athletes.5,26,27,32,49 extremity function during forceful counter rotation, acceleration, and deceleration is dependent on the sequential and reciprocal relationship between core stiffness and rotatory control, providing a stable platform at the trunk.5,18-21,32,49 the fftt may have had a greater effect on rom changes than the slr in the tmrg due to the principle of proximal trunk stability predicating distal limb mobility. neurological activity through the interconnected tissues of the posterior fascial chain and deep arm fascial chain during the fftt also likely contributed to significant alterations in shoulder arom.33 trunk twist motions can be performed in a variety of positions including seated, standing, and with the hips hinged or the trunk flexed when utilizing tmr®. placing the spine in a position of angular shear force during the hip hinge portion of the fftt utilized in this study forces the trunk to stabilize and protect the spine reflexively. as the trunk stabilizes the spine, a more rigid platform is created throughout the lumbopelvic and thoracolumbar regions, potentially resolving regionally interdependent applications of total motion release® and active rotational shoulder range of motion in overhead athletes 32 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 june 2019 stability and motor control dysfunctions at the core, glenohumeral joint, and scapulothoracic articulation.18-21 when considering ri interventions like tmr® as neurophysiological processes, ri may be a combined function of three interrelated neuromotor principles: cross education,22-25 neural coupling,28 and the common core hypothesis.29 currently, it is understood that neuromuscular control and strength production relies on stimuli received and communicated throughout the whole body for optimal function during complex integrated movements.22,23,28,29 short term strength gains are due to increased neurological activity, not muscular hypertrophy, and are not dependent on local training effects in tissues.22-28 additionally, contralateral strength gains are due to increased motor neuron output rather than muscular fiber adaptations as ipsilateral motor neurons and branched spinal fibers project bilaterally.22,25 therefore, repeated or sustained contractions can induce adaptations in the untrained limb.23,24,28 such contralateral enhancement of motor control may serve as the fundamental basis of tmr®. instead of reinforcing the painful, restricted, or dysfunctional movement, tmr® use may allow participants to adapt motor neurons of the spinal cord to the motor pattern perceived as non-threatening, which then ‘spills over’ to the other side of the body.22 clinical application the use of tmr® in our study led to significant improvements in bilateral shoulder ir and nondominant shoulder er in overhead athletes. these findings are significant as ir deficit of the dominant shoulder is often associated with reduced performance and injury risk in overhead athletes. based on the results of this study, the tmr® fftt and slr are more effective at immediately increasing bilateral shoulder ir, as well as non-dominant shoulder ir and er, in overhead athletes than a traditionally designed athletic warm-up protocol. several factors may contribute to a lack of increase in dominant shoulder er. commonly, adaptations in the dominant shoulder of overhead athletes include reductions in ir accompanied by increased er.6,44,45 such paired adaptations in rom of the shoulder in overhead athletes often contribute to asymmetries correlated with patterns of increased injury risk, performance deficit, and potentially to pathological circumstances such as glenohumeral internal rotation deficit (gird) in overhead athletes.1-10,44,45 as such, it is plausible that increasing ir without paired increases in er, moving rom toward a state of symmetry, is a beneficial adaptation in healthy populations for injury prevention. for overhead athletes, this means that tmr® may potentially prepare the shoulder for throwing, spiking, and serving far better than static and dynamic stretching through rapid increase of shoulder ir through motor neuron adaptation, via increases in trunk stability, rotatory control, and ri alterations throughout the shoulder girdle. the tmr® protocol was completed in less than one third of the time of the traditional warm-up indicating that the incorporation of the tmr® fftt and slr can increase shoulder arom to a larger degree in a shorter amount of 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https://doi.org/10.1177/0363546510384223 https://doi.org/10.1177/03635465020300011701 https://doi.org/10.1177/03635465020300011701 https://doi.org/10.1177/1941738108331201 https://doi.org/10.1177/1941738108331201 https://doi.org/10.1053/apmr.2002.34815 https://doi.org/10.1186/1758-2555-4-33 https://doi.org/10.3233/bmr-1996-7103 enrollment manuscript type clinician expertise commentary 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 specialization in athletic training: a natural evolution jj wetherington, ms, atc, otc st. luke’s sports medicine, boise, id key phrases emerging settings, organizational and personal outcomes, public health, residency, advanced practice correspondence mr. jj wetherington, st. luke’s sports medicine, 600 robbins road suite 401, boise, id 83709 e-mail: jjwetherington@gmail.com twitter: @jj_atc full citation wetherington j. specialization in athletic training: a natural evolution. clin pract athl train. 2018;1(1):33-36. https://doi.org/10.31622/2018/0001.7 submitted: may 4, 2018 accepted: may 29, 2018 commentary the skill set of the athletic trainer, like the skills of other allied health professionals, has evolved to match the changing demands of patient populations. as the skill set of the athletic trainer has grown, so has the settings that this skill set has been utilized. no longer are athletic trainers only recognizable in the interscholastic and professional sports arenas. the value of the athletic trainers’ skillset has resulted in the proliferation of the profession into settings such as physician practice, industrial, public safety, military, and research. as the practice of athletic training has evolved to meet these growing workplace demands, some individuals have developed specialized skills and knowledge that has allowed them to thrive in these emerging settings. specialization was first recognized by adam smith and immortalized in his seminal publication the wealth of nations.1 as with the labor sector, specialization in medicine has characterized progression for nearly two decades.2 the catalyst for specialization in medicine can be traced to the publication of the, 1910 flexner report. after this report healthcare delivery, specifically medical education, radically changed.3 flexner’s call for educational reform emphasized more research/evidence-based education and advocated for the pursuit of greater knowledge.3 as practitioners devoted their intellectual endeavors to furthering their understanding about increasingly narrower topics, practitioners started to differentiate themselves into specific areas of expertise or focus which led them to dedicate their time in training to those specific areas.2 the first medical specialty to create its own assessment board was ophthalmology in 1917.2 in 1933, the four specialties of dermatology, obstetrics and gynecology, otolaryngology, and ophthalmology created a federation called the american board of medical specialties (abms). because of the emergence of these specialties, a national system of standards was created for recognizing specialists and providing information to the public. by 1970, there were 20 specialties. with the most recent addition of genetics and genomics in 1991; there are currently 24 specialties recognized by the abms.4 specialization is not exclusive to physicians, but also evolved in physical therapy, occupational therapy, and nursing. no matter the profession, specialization in medicine is driven primarily by 3 factors: innovation in medical science and technology, professional preferences, and economic considerations.5 education innovation in medicine is correlated to increasing knowledge about a particular field.6 as knowledge increases, advancements in technology inevitably follow, which leads to more complex technological skills and intellectual competencies among practitioners.6 increases in knowledge place new and major burdens on professionallevel preparation which can neither teach all the new information, nor quickly revise curricula to exclude the outdated information.6 to ensure that all this new knowledge is included, professional programs must sacrifice depth. what results is a generalist preparation, which often requires those passionate few who choose to devote their intellectual energies to understanding specific areas of this new knowledge base to seek postprofessional education to develop specialized expertise. the profession of athletic training, similar to other professions in medicine, has struggled to balance https://doi.org/10.31622/2018/0001.7 specialization in athletic training: a natural evolution 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 and evolve educational system to meet the growing knowledge base in our field. athletic training education and accreditation of athletic training programs progressed from being controlled by the member organization of the national athletic trainers’ association (nata) to being independently run by the commission on accreditation of athletic training education (caate). along with structural changes, the way that education was delivered has radically changed over that period.7 athletic training evolved from an internship driven-model to a curriculum-driven model. most recently, the caate announced that by 2022 professional programs must transition to the master’s level. the educational elevation has inspired an expansion in the breadth of the practice of athletic training. expanding education is truly the only way to widen scope and demonstrate in a practice analysis that this new knowledge base includes the responsibilities required of the profession. a worry of some surrounding the change in professional degree requirements is that the education for athletic training is becoming too watered down and athletic trainers are lacking depth in their entry-level knowledge base. this is a common worry amongst the athletic training community and is also a concern for other medical professions. for example, this was also a fear of general practitioners, as their knowledge base has widened considerably since its creation. as more and more athletic trainers advance their practice into new and narrower fields, the knowledge base that athletic trainers are expected to know is reaching a critical mass. this increase in knowledge base is placing an increased burden on athletic training educators to teach all the new knowledge without sacrificing depth. as educators spend the majority of their time in the classroom with students teaching the expanding scope of practice, there is even less time for them to clinically practice and evolve their own skills. the lack of time for educators makes it even more difficult for them to teach and provide meaningful experience-based mentorship for their students. this tipping point has happened in other professions and resulted in the creation of formalized specialist training to further clinical skill sets. along with the athletic training educational requirements changing, so is the practice of athletic training. athletic trainers are not only increasing their knowledge base and clinical practice skill set, they have expanded their footprint into settings outside of the interscholastic and professional sports arenas. this expansion of practice into new arenas has required athletic trainers to deepen their current skill set, as well as develop new skills. these new skills are not transferrable to all athletic training practice. residencies organically developed to meet the need for athletic trainers to deepen their current skills, and learn new skills to help them thrive. the residency model is well known in medicine and is intended to build upon the generalist education that all receive. the caate, recognizing the growing trend in specialized training, developed standards for residency programs to ensure that students were receiving advanced preparation through a planned program of clinical and didactic education in specialized content areas. the caate has initially recognized eight specialty areas: prevention & wellness, urgent & emergent care, primary care, orthopedics, rehabilitation, behavioral health, pediatrics, and performance enhancement.7 the caate has acknowledged that this list is not all encompassing, and has laid out steps to propose new specialties areas as they arise. these are all great steps for our the profession that will continue to help the profession advance. specializations may narrow even further, or occur when specialties are combined to develop subspecialties (e.g., pediatric neurology).6 as subspecialties develop, so will the need for training through fellowships training. the fellowship is seen in medicine, and is intended to deepen a practitioner’s focus on a specific topic to the level of content expert. athletic training has not reached this point yet, but it is not too far off in the future. similar to physicians, athletic trainers are starting to subspecialize by patient population or body part. in orthopedics alone there are athletic trainers who have subspecialized their practice to pediatrics, trauma, total joint and adult reconstruction, foot and ankle, spine, hand, and/or upper extremity. these ground breaking athletic trainers will be the ones to foster the growth of fellowship training in the field of athletic training. professional practice specialization in athletic training: a natural evolution 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 specialization is an organic evolution of medical practice, but specialized practitioners cannot reach their full potential without support and backing from the profession. as the few innovative professionals devise and test these advanced skills, the profession must perfect who should be utilizing these skills.6 not all of these advanced skills can be performed by all practitioners, and in these cases specialization is often needed to support these particular practices.6 the idea of specialization is not always meet with resounding support. athletic training is no different than other medical professionals who have worried about fragmentation of their profession and the loss or under valuing of the generalist skillset.2 physicians had these same concerns, and specialization was seen as a benefit for the generalist practice, as it allowed for the strengthening, focusing, and reinvestment of the generalist practice and education. another concern of specialization is the misrepresentation of unqualified practitioners.2 the creation of board certification of specialty status was seen as an ingenious way for professions to control the concerns of specialization. in response to the growth of optometry as a separate discipline, the american medical association, and the american ophthalmological society created an independent board of specialists. this board was tasked with creating standards that would recognize physicians whose knowledge and skills demonstrated expertise in identifying and treating disorders of the eye.2 physicians created the ambs as an independent board to maintain the standards for physician certification.4 proposals for new specialties initially come from professional societies and are exhaustively vetted by the board.2 the profession of athletic training should follow this blueprint by creating an independent board of specialties who does not seek to create specialties, but instead focus on the maintenance of quality for the specialty certification. the creation of the specialty certification should come from the specialty practice societies who can properly recognize the specific patient populations, the highly focused knowledge required to treat such patients, and the skills that need to be obtained beyond that of the generalist practice for that specialty field of practice. in addition, these specialty societies should determine the qualifications required to sit for the certification examination. specialization does not end with satisfactory performance on a single examination. practitioners need to remain competent throughout their careers. the practice of athletic training has evolved significantly in a short amount of time, and for some athletic trainers this is within the life of their whole career. it has been demonstrated that skills decay and innovation happens, so once a specialty certification is obtained it needs to be maintained.2 recertification requirements are just as vital to the success of the specialty development as initial certification.2 economic considerations in the age of healthcare delivery changes and quality movement, consumers are demanding more from health care. consumers as well as healthcare organizations are demanding more transparency and higher standards to ensure their providers have the knowledge and skills required for positive patient outcomes.2 board certifications of specialty training is one of the frequent criteria used to ensure competence.2 when the public identifies an area of need or an aspirational goal develops, new areas of specialization tend to arise.6 initially these new fields usually have a great shortage of professionals who have both the interest and the specific expertise to address to these problems.6 as known from the law of supply and demand, as the supply decreases the demand and cost of the product goes up. even without specialty certification, the economic benefit of specialty skill set has already being seen. research has demonstrated that athletic trainers who report performing seven or more specialized skills indicated that they earn significantly higher yearly salaries than those who did not.8 however, a proliferation of specialties without adequate reasoning may confuse the public and healthcare organizations, thus minimizing the positive impact of the profession. the value of specialty certification should be undeniable, but most people do not understand what criteria that certification represents, or fully appreciate that different kinds of organizations can offer certificates that represent varying degrees of rigor and clinical relevance. specialization in athletic training: a natural evolution 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 conclusions specialization should be difficult to obtain and just as hard to maintain. it is not meant to degrade or diminish the work of the generalist practitioner. it is, in fact, the recognition that within a generalist discipline it is becoming increasingly difficult to keep up with the depth of knowledge needed for this type of practice, especially when including technical, clinical, and managerial skills. the intended goal of specialization is to promote and foster the growth of the profession. specialization is not something to be feared. it is something that should be embraced and cultivated. if properly done it can be a huge step forward in the evolution of athletic training. if poorly managed it could mean even more stagnation as the profession is presented with the changing landscape of healthcare delivery. references 1. smith a. inquiry into the nature and causes of the wealth of nations. london: w. strahan and t. cadell; 1776. 2. cassel ck, reuben db. specialization, subspecialization, and subsubspecialization in internal medicine. new engl j med. 2011;364(12):1169-1173. https://doi.org/10.1056/nejmsb1012647 3. flexner a. medical education in the united states and canada: a report to the carnegie foundation for the advancement of teaching. bulletin no.4. new york: carnegie foundation for the advancement of teaching, 1910. 4. abms history of improving quality care. american board of medical specialties web site. http://www.abms.org/aboutabms/history/. accessed april 16, 2018. 5. detsky as, gauthier sr, fuchs vr. specialization in medicine: how much is appropriate. j am med assoc. 2012;307(5):463-464. https://doi.org/10.1001/jama.2012.44 6. peplau h. specialization in professional nursing. clin nurse spec. 2003;17(1):3-9. https://doi.org/10.1097/00002800200301000-00002 7. residency programs. commission on accreditation of athletic training education web site. https://caate.net/residencyprograms/. accessed april 16, 2018. 8. hassell j, wetherington j, kitano j, scharer k, paturzo m. the roles and responsibilities of athletic trainers working the physician practice. poster session presented at: big sky athletic training sports medicine conference; 2018; big sky, montana. https://doi.org/10.1056/nejmsb1012647 https://doi.org/10.1001/jama.2012.44 https://doi.org/10.1097/00002800-200301000-00002 https://doi.org/10.1097/00002800-200301000-00002 commentary manuscript type abstract presentation 64 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 the presentation of adhesive capsulitis of the hip: a case study patrick e. jurewicz, ms, scat, atc*; ryan c. berlinrut, pa-c†; frank k. noojin iii, md†; zachary k. winkelmann, phd, scat, atc* *university of south carolina, colombia, sc; †prisma health orthopedics, lexington, sc full citation jurewicz pe, berlinrut rc, noojin fk, winkelmann zk. the presentation of adhesive capsulitis of the hip: a case study. clin pract athl train. 2021;4(1): 64-65. https://doi.org/10.31622/2021/0004.1.10. presented at the 4rd annual athletic trainers in the physician practice society meeting and conference, february 26-27, 2021. abstract a 47-year-old female patient employed as a nurse in a mental health facility working 10-hour shifts reported to the sports medicine clinic for an initial orthopaedic examination after she twisted and fell out of bed causing direct compressive forces on her right hip. she has a history of an underdeveloped right hip, a non-steroidal antiinflammatory drug (nsaid) allergy, and low back pain (oswestry score: 41/50, nprs: 8/10) and is classified as a heavy smoker for 30 years. after initial onset, the patient’s pain increased with all motions. the patient also described a ‘catching sensation’ in her hip. the patient used crutches for one month until her pain was intolerable, and she began to utilize a wheelchair to ambulate for daily activities. the differential diagnoses included acetabular labrum tear and asis tendonitis with additional considerations given to iliac spine avulsion fracture and lumbar radiculopathy. the initial examination included xray which showed no abnormalities and a magnetic resonance imaging scan which identified asis tendonitis with a possible symptomatic acetabular labrum tear. the patient’s last full day of work was december 31st, 2019. due to past medical history, the traditional management of nsaid use was ruled out and this patient was prescribed other pain medications. in addition, other interventions included an ultrasound guided intra-articular corticosteroid injection (csi) and physical therapy with no positive response from the patient, however, minor relief was noted with oral steroid use. preoperative blood work showed elevated levels of inflammatory markers, prompting a rheumatology referral. patient reported feelings of anxiety, emotional stress, and depression on her health history questionnaire after three months of pain. the sports medicine clinic healthcare team ordered surgery of the acetabular labrum tear, which was delayed for five months due to the covid-19 pandemic. the patient’s increasing pain and decreased ambulatory status forced her to remain out of work for the totality of the case presentation which spanned 8 months. finally, in august 2020, an arthroscopy of her right hip was completed which confirmed a final diagnosis of an acetabular labrum tear and adhesive capsulitis of the right hip (ach). post-surgery, the patient reported that her pain is improving and that she can ambulate using crutches. adhesive capsulitis of the hip (ach) is an extremely rare clinical diagnosis with very little literature written on the topic. currently there are no specific special tests for the identification of ach. however, ach can present with similar indications as adhesive capsulitis of the shoulder such as chronic onset, decreased and painful ranges of motion, and synovial inflammation. due to the uncommon nature of this ailment, traditional differential diagnoses are ruled out prior to consideration of ach using diagnostic imaging. traditional management of ach includes oral anti-inflammatories, csi, and physical therapy. https://doi.org/10.31622/2021/0004.1.10 the presentation of adhesive capsulitis of the hip: a case study 65 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 once other pathologies are ruled out, arthroscopy can be performed to confirm the presence of ach which is similar to this case presentation. providers should consider ach when a patient presents with hip pain that is non-specific in terms of mechanism of injury, inflammatory markers, and pain location. correspondence patrick e jurewicz, university of south carolina, 1300 wheat st, columbia, sc 29208 email: jurewicp@email.sc.edu mailto:jurewicp@email.sc.edu manuscript type clincal outcomes research 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 short term effects of a pectoralis minor positional release in collegiate swimmers: a case series jonathan roman, ms, atc and noelle m selkow, phd, atc illinois state university, normal, il abstract a tight pectoralis minor correlates to abnormal scapular kinematics, which can cause pain, loss of range of motion and even loss of function, due to the change in scapular position. with these muscular imbalances causing forward scapular posture, the pectoralis minor is a key component to address in the prevention and treatment of shoulder impingement and scapular dyskinesis. this study investigated the effectiveness of a single positional release therapy (prt) treatment of the pectoralis minor on scapular posture in collegiate swimmers immediately and 24 hours post intervention. seventeen division iii collegiate swimmers (7 males and 10 females) volunteered to participate, with only one shoulder being excluded due to recent injury (n=33). researchers measured resting pectoralis minor muscle length, forward shoulder posture and scapular elevation of both shoulders. data were collected a total of 3 times; prior to the prt intervention, right after the intervention and again 24 hours post intervention. each shoulder was treated with a single session of prt on the pectoralis minor. there was a significant difference for resting pectoralis minor length immediately post-intervention compared to baseline (p=.016). scapular positioning at 0° abduction had a statistically significant improvement in position from immediate post-intervention to 24 hours postintervention (p=.014). scapular positioning at 90° of abduction also had a statistically significant increase in position from baseline to immediate post-intervention (p=.042). for forward shoulder posture, there was a statistically significant improvement in position from baseline to immediate postintervention (p≤.001). the results of this case series show that a single treatment of prt has an immediate effect in reducing resting pectoralis minor muscle length and decreasing rounded shoulder posture. however, this single treatment of prt was not enough to maintain these effects after 24 hours, and should be combined with other manual therapies or rehabilitation protocols to address scapular positioning in collegiate swimmers. key phrases manual techniques, injury risk reduction, college and university patient population correspondence dr. noelle m selkow, illinois state university, school of kinesiology and recreation, cmaous box 5120, normal, il, 61761. e-mail: nselkow@ilstu.edu twitter: @docselkow full citation roman j, selkow nm. short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. clin pract athl train. 2018;1(2):42-48. https://doi.org/10.31622/2018/0002.7 submitted: august 29, 2018 accepted: october 15, 2018 introduction there is a consistently growing population of collegiate swimmers within division i, ii, and iii institutions totaling around 486,000 swimmers in the 2015-16 academic year.1 competitive swimming athletes are at risk for shoulder injury due to an excessive amount of shoulder revolutions that can cause the anterior shoulder musculature to hypertrophy.2 during the freestyle, butterfly, and backstroke of competitive swimming, the athlete is consistently applying adduction and internal rotation forces from the shoulder in order to propel themselves through the water, which may lead to an imbalance of agonist-antagonist muscles.3 this muscular imbalance often leads to scapular dyskinesis, which is defined as abnormal movement patterns causing alteration of optimal scapular kinematics.4,5 the pectoralis minor specifically has been related to shoulder pain in swimmers,2 and scapular dyskinesis due to its shortened muscle length.6,7 a tight pectoralis minor can be either a primary or secondary cause of shoulder pain,8 and the diminished muscle length prohibits proper scapular upward rotation, posterior tilting and external rotation.9-11 often times swimmers with bilaterally tight pectoralis minor muscles develop forward scapular posture, which has been described as a forward head and rounded shoulders position, and contributes to shoulder impingement.2,9,12 previous studies have stated that the pectoralis minor muscle tightness is typically due to adaptive changes in the muscle belly from repetitive motions that involve scapular https://doi.org/10.31622/2018/0002.7 short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 protraction and anterior tilting and/or by maintaining a static shortened position over time.8,9 with these muscular imbalances causing forward scapular posture, the pectoralis minor is a key component to address in the prevention and treatment of shoulder impingement and scapular dyskinesis.9,11,13,14 manual therapies such as stretching,13-15 muscle energy technique (met),16 and myofascial trigger point17 have shown to be effective in treating shoulder impingement symptoms. previous research articles have addressed the need for interventions that can increase the pectoralis minor resting length in shoulder rehabilitation protocols.2,7,11,12 positional release therapy (prt), under the umbrella of strain–counterstrain,18 is similar to myofascial trigger point.19 strain-counterstrain addresses dysfunctional tissue by putting them in a slacked position to decrease activity from proprioceptors.20 however, prt uses tender points and a position of comfort to resolve the associated dysfunction, instead of attempting to stretch the muscle.21,22 unlike myofascial trigger points that are hyperirritable bands of tissue, tender points are discrete areas of tissue tenderness that can occur anywhere in the body.21,22 prt treatment begins by identifying a tender point, the clinician positioning the patient in a position of comfort that is typically obtained by shortening tissues around the tender point while a slight touch monitors the position.23,24 this position is then held for 90 seconds, and then slowly returning the patient to normal resting position.22,23 although this technique has been around for many years,25 and there has been some evidence of its clinical usefulness,26-28 further research on the effects of prt are still needed.21,22,29-31 the purpose of this study was to investigate the effectiveness of a single prt treatment of the pectoralis minor on scapular posture in collegiate swimmers immediately and 24 hours post intervention. the hypothesis is that the prt intervention will lengthen the pectoralis minor, decrease the forward scapular position and increase scapular upward rotation in the group of collegiate swimmers. methods design this design of this investigation was a case series, where the athletic trainer for the swim team performed all prt treatments and measurement. the athletic trainer was certified for 1.5 years. the athletic trainer attended a prt course for the upper extremity and was trained in the technique utilized in this study. all participants received the intervention on both shoulders, unless excluded. there was no true control group, as the athletic trainer and coach wanted all swimmers to receive a potentially beneficial treatment. hence, this was a sample of convenience. the independent variables were intervention (prt to the pectoralis minor) and time (baseline, immediately post intervention, and 24-hours post intervention). the dependent variables were pectoralis minor length (cm), forward shoulder posture as measured with the double square (cm), and scapular position in 0°, 45°, and 90° of shoulder abduction (cm). participants participants included 17 division iii collegiate swimming athletes (7 males and 10 females; age: 20.0 ± 1.4 years; height: 170.9 ± 8.6 cm; mass: 69.3 ± 12.8 kg). shoulders of swimmers that had a recent history (past 6 months) of upper extremity injury or any history of upper extremity surgery were excluded from the study only one participants’ shoulder was not measured due to recent injury (n=33). all participants were in the post season at the time of data collection. both left and right shoulders were used for data collection. the institutional review board at the university approved this study and all participants signed informed consent. resting pectoralis minor length measurement participants were instructed to lie supine with arms at their side in a relaxed position. the measurement landmarks were from the medial inferior angle of the coracoid process to the anterior-inferior edge of the 4th rib, 1 finger width lateral to the sternum.32 using the pectoralis minor index (pmi),9 each shoulder was measured in centimeters then divided by the participants short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 height in centimeters and multiplied by 100 to account for limb height. (figure 1) forward shoulder posture measurement after palpating the anterior tip of the acromion process on the participants shoulder, the location was marked on the participant’s skin with a permanent marker. the participant was then instructed to move backwards towards the wall until their heels and back touched the wall. the examiner then positioned the double square instrument over the shoulder being examined. with one square flush against the wall, the other square adjusted until it touched the tip of the acromion process marked previously measured in centimeters (cm).33 (figure 2) scapular positioning we measured the participant’s scapular mobility using the lateral scapular slide test (lsst).34 the examiner used a cloth measuring tape to determine the distance from the inferior angle of the scapula to the nearest spinous process in 3 different shoulder positions in centimeters (cm). the first position was with their arms relaxed at their sides (0° abduction). the second was with the participant’s hands on their hips with their fingers on the anterior side and thumbs on the posterior side of their waist, with about 10° of shoulder extension (45° abduction). the third position is with their arms at 90° of shoulder elevation with their thumbs pointed downward. (figures 3-5) positional release therapy for the pectoralis minor the participant was placed supine on the table. using one hand to palpate for tender points, the examiners other hand grasped the forearm of the treatment side. upon finding a tender point, the examiner monitored the palpation and began to move the treatment arm across the body towards the opposite hip, and then applied a distraction force with internal rotation to fine tune the position so that the fasciculation response was most prominant.22 the fasciculation response is a continuous small amplitude twitch, similar to a pulse, where the tender point is located and examiner’s fingers are located. the position of comfort was painless and allowed the participant to relax. the examiner held this position for 90 seconds (figure 6) and then slowly returned the arm to neutral and re-evaluated the tender point. a successful treatment was determined by a decrease in pain on the tender point as indicated by the patient. the examiner repeated the procedure for all tender points located on the involved pectoralis minor muscle. no other interventions were used. procedures data measurements were collected a total of 3 times on each participant. they were measured prior to the prt intervention, right after the intervention and again 24 hours post intervention. during the length of the study (24 hours), the participants were not to participate in any physical activity. statistical analysis separate paired-samples t-test were conducted to evaluate the effect of prt for the pectoralis minor on pectoralis minor length, scapular positioning, and forward shoulder posture. cohen’s d effect sizes were calculated for significant findings. alpha was set a priori at α=0.05. ibm spss statistics 25 (chicago, il) was used for statistical analysis. results means and standard deviations, along with pvalues and effect sizes are presented in table 1. the only significant finding with an effect size that did not cross zero was for forward shoulder posture. forward shoulder poster decreased immediately after the prt intervention, but the results were not maintained 24 hours postintervention. discussion due to the nature of the sports, repetitive motions of the shoulder tend to cause muscular imbalances and can lead to injury.2,3 because of this, clinicians and health care professionals utilize a variety of manual techniques to address the over active anterior muscles that may contribute to injury. short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 although prt is becoming more popular among clinicians, there is no previous research using prt on the pectoralis minor in swimmers. this case series has indicated that there is merit to prt, when used to address the pectoralis minor in asymptomatic swimmers, to decrease rounded shoulders posture after a single treatment session. a tight or shortened pectoralis minor has been correlated to abnormal scapular kinematics, causing the rounded shoulder posture observed in most swimming athletes.2,6,12,15,16 the increased anterior tilting, internal rotation and downward rotation of the scapula is partly due to the line of pull of the pectoralis minor,9 along with other muscles, such as the pectoralis major and scapular retractors.35 from our findings, prt seems to influence forward shoulder posture immediately after intervention to the pectoralis minor. clinicians can utilize this technique during a rehabilitation session to help position the scapula in more neutral position before strengthening exercises are implemented. therefore, the muscles around the scapula will be strengthened in a more optimal position. strengthening exercises alone may take as long as 8 weeks to correct scapular positioning.36 compared to other manual therapy treatments, muscle energy technique has been shown to increase pectoralis minor length and decrease forward shoulder posture after a 6-week intervention,16 although it is unknown what changes would occur after 1 session of muscle energy technique. with limited research on manual therapy for forward shoulder posture, prt seems to be a good option when initially addressing this condition. there were some limitations to this study that could attribute to the results that were found. the prt treatment session was altered from the current treatment protocol of holding the position of comfort until fasciculation decreases significantly table 1. means, sd, and p-values of clinical outcomes. effect sizes for significant p-vales provided baseline postintervention postintervention to baseline p value 24 hrs postintervention 24 hrs postintervention to postintervention p value 24 hrs postintervention to postintervention p value pectoarlis minor length (cm) 18.02±1.14 18.38±1.25 p=.016 es=.36 (-.12 -.85) 18.06±1.17 p=.016 es=.26 (-.22 -.75) p=.813 scapular position 0° (cm) 9.40±1.53 9.47±1.67 p=.701 9.76±1.89 p=.014 es=.18 (-.31-.66) p=.098 scapular position 45° (cm) 10.18±1.44 10.18±1.48 p=.955 10.26±1.45 p=.162 p=.441 scapular position 90° (cm) 10.53±1.84 10.23±1.71 p=.042 es = -.17 (-.65-.32) 10.79±1.82 p≤.001 es = .35 (-.13-.84) p=.172 forward shoulder posture (cm) 15.81±1.55 14.85±1.5 p≤.001 es = -.67 (-1.16– -.17) 15.64±1.42 p≤.001 es = -.54 (-1.03– -.05) p=.379 short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 or ceases, to holding for a set time of 90 seconds, to help standardize the treatment for all participants in this study.21,22,31 furthermore, when using prt to treat injuries of the shoulder, such as shoulder impingement or scapular dyskinesis, multiple muscles need to be identified and treated over multiple sessions to correct the problem.22,31 lastly, the single prt session was done by a clinician with novice training, and not a full certified prt clinician. for future research studies a full prt treatment involving multiple targeted muscles should be performed as outlined by speicher.22 the treatment should be performed by a prt certified clinician, and there needs to be more than one treatment session. furthermore, more measurements should be taken, such as a visual analog pain rating scale, humeral abduction rom and humeral horizontal abduction rom. also, future research should look into seeing if dominant arm and breathing side plays a role in rom restrictions in each swimmer. clinical application this case series was used to identify if prt was an effective treatment method to influence scapular posture in collegiate swimmers. the results of this case series show that a single treatment of prt may have an immediate effect in reducing resting pectoralis minor muscle length and decreasing rounded shoulder posture. however, this single treatment of prt was not enough to maintain these effects after 24 hours, and should be combined with other manual therapies or rehabilitation protocols to address scapular dyskinesis in collegiate swimmers. references 1. irick e. ncaa sports sponsorship and participation rates report 1981-82 – 201516. indianapolis, in: national collegiate athletic association; 2016. 2. kluemper m, uhl t, hazelrigg h. effect of stretching and strengthening shoulder muscles on forward shoulder posture in competitive swimmers. j sport rehabil. 2006;15(1):58-70. https://doi.org/10.1123/jsr.15.1.58 3. troup jp. the physiology and biomechanics of competitive swimming. clin sports med. 1999;18(2):267-285. https://doi.org/10.1016/s02785919(05)70143-5 4. kibler wb, ludewig pm, mcclure p, uhl tl, sciascia a. scapular summit 2009: introduction. july 16, 2009, lexington, kentucky. j orthop sports phys ther. 2009;39(11):a1-a13. https://doi.org/10.2519/jospt.2009.0303 5. kibler wb, ludewig pm, mcclure pw, michener la, bak k, sciascia ad. clinical implications of scapular dyskinesis in shoulder injury: the 2013 consensus statement from the 'scapular summit'. br j sports med. 2013;47(14):877-885. http://dx.doi.org/10.1136/bjsports-2013092425 6. ludewig pm, cook tm. alterations in shoulder kinematics and associated muscle activity in people with symptoms of shoulder impingement. phys ther. 2000;80(3):276291. 7. mcclure p, greenberg e, kareha s. evaluation and management of scapular dysfunction. sports med arthrosc. 2012;20(1):39-48. https://doi.org/10.1097/jsa.0b013e3182 4716a8 8. morais n, cruz j. the pectoralis minor muscle and shoulder movement-related impairments and pain: rationale, assessment and management. phys ther sport. 2016;17:1-13. https://doi.org/10.1016/j.ptsp.2015.10.00 3 9. borstad jd, ludewig pm. the effect of long versus short pectoralis minor resting length on scapular kinematics in healthy individuals. j orthop sports phys ther. 2005;35(4):227238. https://doi.org/10.2519/jospt.2005.35.4.2 27 10. muraki t, aoki m, izumi t, fujii m, hidaka e, miyamoto s. lengthening of the pectoralis minor muscle during passive shoulder motions and stretching techniques: a cadaveric biomechanical study. phys ther. https://doi.org/10.1123/jsr.15.1.58 https://doi.org/10.1016/s0278-5919(05)70143-5 https://doi.org/10.1016/s0278-5919(05)70143-5 https://doi.org/10.2519/jospt.2009.0303 http://dx.doi.org/10.1136/bjsports-2013-092425 http://dx.doi.org/10.1136/bjsports-2013-092425 https://doi.org/10.1097/jsa.0b013e31824716a8 https://doi.org/10.1097/jsa.0b013e31824716a8 https://doi.org/10.1016/j.ptsp.2015.10.003 https://doi.org/10.1016/j.ptsp.2015.10.003 https://doi.org/10.2519/jospt.2005.35.4.227 https://doi.org/10.2519/jospt.2005.35.4.227 short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 2009;89(4):333-341. https://doi.org/10.2522/ptj.20080248 11. lee jh, cynn hs, yi ch, kwon oy, yoon tl. predictor variables for forward scapular posture including posterior shoulder tightness. j bodyw mov ther. 2015;19(2):253-260. https://doi.org/10.1016/j.jbmt.2014.04.01 0 12. hibberd ee, oyama s, spang jt, prentice w, myers jb. effect of a 6-week strengthening program on shoulder and scapular-stabilizer strength and scapular kinematics in division i collegiate swimmers. j sport rehabil. 2012;21(3):253-265. 13. rosa dp, borstad jd, pogetti ls, camargo pr. effects of a stretching protocol for the pectoralis minor on muscle length, function, and scapular kinematics in individuals with and without shoulder pain. j hand ther. 2017;30(1):20-29. https://doi.org/10.1016/j.jht.2016.06.006 14. turgut e, duzgun i, baltaci g. stretching exercises for subacromial impingement syndrome: effects of 6-week program on shoulder tightness, pain and disability status. j sport rehabil. 2018;27(2):132-137. https://doi.org/10.1123/jsr.2016-0182 15. williams jg, laudner kg, mcloda t. the acute effects of two passive stretch maneuvers on pectoralis minor length and scapular kinematics among collegiate swimmers. int j sports phys ther. 2013;8(1):25-33. 16. laudner kg, wenig m, selkow nm, williams j, post e. forward shoulder posture in collegiate swimmers: a comparative analysis of muscle-energy techniques. j athl train. 2015;50(11):1133-1139. https://doi.org/10.4085/1062-605050.11.07 17. bron c, de gast a, dommerholt j, stegenga b, wensing m, oostendorp ra. treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. bmc med. 2011;9:8. https://doi.org/10.1186/1741-7015-9-8 18. jones lh. spontaneous release by positioning. aao journal. 2012;22(1):54-61. 19. segura-ortí e, prades-vergara s, manzaneda-piña l, valero-martínez r, polotraverso ja. trigger point dry needling versus strain-counterstrain technique for upper trapezius myofascial trigger points: a randomised controlled trial. acupunct med. 2016;34(3):171-177. http://dx.doi.org/10.1136/acupmed-2015010868 20. jones l, kusunose r, goering e. jones straincounterstrain. boise, id: jones straincounterstrain, inc; 1995. 21. speicher te, draper do. top-10 positionalrelease therapy techniques to break the chain of pain: part 1. athletic therapy today. 2006;11(5):60-62. 22. speicher te. clinical guide to positional release therapy. champaigne, il: human kinetics; 2016. 23. chaitow l. positional release techniques. 3rd ed. philadelphia: churchill livingstone elsevier; 2007. 24. d’ambrogio k, roth g. positional release therapy: assessment and treatment of musculoskeletal dysfunction. st. louis: mosby; 1997. 25. jones l. strain-counterstrain. indianapolis: jones strain-counterstrain inc; 1995. 26. meseguer a, fernandez-de-las-penas c, navarro-poza j, rodriguez-blanco c, bosca gandia j. immediate effects of the straincounterstrain technique in local pain evoked by tender points in the upper trapezius muscle. clinical chiropractic. 2006;9:112118. https://doi.org/10.1016/j.clch.2006.06.003 27. dardzinski ja, ostrov be, hamann ls. myofascial pain unresponsive to standard treatment: successful use of a strain and counterstrain technique with physical therapy. j clin rheumatol. 2000;6(4):169-174. https://doi.org/10.1097/00124743200008000-00001 28. kelencz ca, tarini va, amorim cf. trapezius upper portion trigger points treatment purpose in positional release therapy with electromyographic analysis. n am j med sci. 2011;3(10):451-455. https://doi.org/10.4297/najms.2011.3451 29. wong ck. strain counterstrain: current concepts and clinical evidence. man ther. https://doi.org/10.2522/ptj.20080248 https://doi.org/10.1016/j.jbmt.2014.04.010 https://doi.org/10.1016/j.jbmt.2014.04.010 https://doi.org/10.1016/j.jht.2016.06.006 https://doi.org/10.1123/jsr.2016-0182 https://doi.org/10.4085/1062-6050-50.11.07 https://doi.org/10.4085/1062-6050-50.11.07 https://doi.org/10.1186/1741-7015-9-8 http://dx.doi.org/10.1136/acupmed-2015-010868 http://dx.doi.org/10.1136/acupmed-2015-010868 https://doi.org/10.1016/j.clch.2006.06.003 https://doi.org/10.1097/00124743-200008000-00001 https://doi.org/10.1097/00124743-200008000-00001 https://doi.org/10.4297/najms.2011.3451 short term effects of a pectoralis minor positional release in collegiate swimmers: a case series. 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 2012;17(1):2-8. https://doi.org/10.1016/j.math.2011.10.00 1 30. wong ck, abraham t, karimi p, ow-wing c. strain counterstrain technique to decrease tender point palpation pain compared to control conditions: a systematic review with meta-analysis. j bodyw mov ther. 2014;18(2):165-173. https://doi.org/10.1016/j.jbmt.2013.09.01 0 31. speicher te, draper do. top-10 positionalrelease therapy techniques to break the chain of pain: part 2. athletic therapy today. 2006;11(6):56-58. 32. borstad jd. measurement of pectoralis minor muscle length: validation and clinical application. j orthop sports phys ther. 2008;38(4):169-174. https://doi.org/10.2519/jospt.2008.2723 33. peterson de, blankenship kr, robb jb, et al. investigation of the validity and reliability of four objective techniques for measuring forward shoulder posture. j orthop sports phys ther. 1997;25(1):34-42. https://doi.org/10.2519/jospt.1997.25.1.3 4 34. kibler wb. the role of the scapula in athletic shoulder function. am j sports med.1998;26(2):325-337. https://doi.org/10.1177/0363546598026 0022801 35. ludewig pm, reynolds jf. the association of scapular kinematics and glenohumeral joint pathologies. j orthop sports phys ther.2009;39(2):90-104. https://doi.org/10.2519/jospt.2009.2808 36. paulson g, selkow nm, begalle rl. the effects of a shoulder strengthening program on scapular positioning in collegiate swimmers. j ath train. 2018; 6 (53):s42. https://doi.org/10.4085/1062-605053.6s.s1 https://doi.org/10.1016/j.math.2011.10.001 https://doi.org/10.1016/j.math.2011.10.001 https://doi.org/10.1016/j.jbmt.2013.09.010 https://doi.org/10.1016/j.jbmt.2013.09.010 https://doi.org/10.2519/jospt.2008.2723 https://doi.org/10.2519/jospt.1997.25.1.34 https://doi.org/10.2519/jospt.1997.25.1.34 https://doi.org/10.1177/03635465980260022801 https://doi.org/10.1177/03635465980260022801 https://doi.org/10.2519/jospt.2009.2808 https://doi.org/10.4085/1062-6050-53.6s.s1 https://doi.org/10.4085/1062-6050-53.6s.s1 manuscript type disablement model case study 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel therapy cody inskeep, ms, lat, atc1; todd olin, md, mscs2; robert arthur ms, lat, atc, cscs3 1biotix health, centennial, co; 2pediatric exercise tolerance center, denver, co; 3indiana state university, terre haute, in abstract a 23-year-old male division i distance runner presented with several years of exertional stridor (high-pitched inspiratory noise caused by airflow obstruction), previously diagnosed as exercised-induced laryngeal obstruction (eilo), a condition formerly known as vocal cord dysfunction and exercisedinduced paradoxical vocal fold motion. over the course of roughly 3 years, the patient had previously failed conventional and invasive respiratory therapies for eilo including respiratory retraining, inspiratory muscle training, reflux suppression, allergy suppression, amitriptyline, performance psychology, and injection of botulinum toxin to the larynx. at a referral center that specializes in the treatment of eilo, the patient's diagnosis was confirmed through the use of a new procedure called continuous laryngoscopy during exercise. he underwent three sessions of therapeutic laryngoscopy during exercise (which relies on real-time laryngoscopy footage as biofeedback during exercise) and concurrently learned novel breathing techniques to address the problem. it is common to misdiagnose exercise induced respiratory problems based on patients-described symptoms alone. athletic trainers should be able to recognize eilo cases and feel comfortable contacting and collaborating with expert providers on appropriate treatment. this case is also important in that it documents a treatment failure of laryngeal injection of botulinum toxin for eilo, something not previously reported in the literature. key phrases exercise induced laryngeal obstruction, vocal cord dysfunction, respiratory correspondence cody inskeep, briotix health, 9000 e nichols ave #104, centennial, co 80112 e-mail: cody.inskeep@briotix.com twitter: @codyi85 full citation inskeep c, olin t, arthur r. exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel therapy. clin pract athl train. 2019;2(2):37-44. https://doi.org/10.31622/2019/0002.5.1. submitted: march 3, 2019 accepted: june 10, 2019 introduction exercise-induced shortness of breath is common in athletes, with up to 70% of athletes reporting a degree of respiratory distress during exercise.1,2 while asthma, a disease of the small airways, is the most commonly-identified respiratory disease among athletes, between 5% and 8% of all adolescents and young adults struggle because they are experiencing airway obstruction at the level of the larynx (video 1), a condition different than asthma.3 this upper airway obstruction is known as exercise-induced laryngeal obstruction (eilo), a condition previously referred to as vocal cord dysfunction and paradoxical vocal fold motion. it is characterized by airway obstruction that occurs at a glottic or subglottic level only during exercise (video 2), often causing shortness of breath that can be visualized by athletic trainers.4,5 among athletes, eilo has been often misdiagnosed as asthma, whereby in a cohort of 91 athletes referred for asthma symptoms, 31 (35.2%) were actually diagnosed with eilo.5 at presentation, eilo symptoms often mimic those of exercise-induced asthma (eia) with patients commonly complaining of “wheezing” in association with their dyspnea (despite the field observations that they are experiencing inspiratory stridor).6,7 eilo may be clinically distinguished from eia by the time course of symptoms. eilo generally is characterized by symptoms that are isolated to high intensity exercise and rapidly resolve.8 in contrast, eia generally develops over several minutes and requires up to an hour to resolve.9 in clinical settings, the physical examination of patients with mailto:cody.inskeep@briotix.com https://doi.org/10.31622/2019/0002.5 https://vimeo.com/clinat/review/344404886/2102213062 https://vimeo.com/clinat/review/344405909/6548cdbac3 exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 38 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 eilo and eia are generally normal.10 the similarities between asthma and eilo and the common practice of relying solely on clinical history to differentiate the conditions may lead to misdiagnosis, inappropriate management, and ineffective interventions.7 however, identification of ineffective therapeutic trials with bronchodilators such as albuterol (almost universally used in the treatment of eia) can be helpful in directing athletic trainers and other healthcare providers towards alternative diagnoses such as eilo. the mechanisms of eilo are still unclear and current models hypothesize a variety of possible disease contributors. these factors may include laryngeal mechanical insufficiency, neural dysfunction, and a psychological component.7 continuous laryngoscopy during exercise (video 3), a procedure which features endoscopic visualization of the larynx throughout an entire bout of intense exercise, is currently the gold standard for diagnosis of eilo because characteristic upper airway obstruction can be visualized while field symptoms are reproduced in the exercise lab.11-13 other methods to identify the condition indirectly including post-exercise laryngoscopy and exercise flow volume loop analysis are used in practice, but present serious limitations to eilo identification.10 standard treatment algorithms do not currently exist for eilo although a number of therapies are used in practice.10 removal of irritants and triggers from the athlete’s environment, speech therapy, psychological interventions, pharmacological interventions, botulinum toxin injections, supraglottic surgery, and inspiratory muscle training have mixed results with no single treatment or combination of treatments showing consistent effectiveness.10 the most common treatments appear to be traditional breathing techniques taught in speech therapy. however, traditional breathing techniques often do not provide relief from exertional dyspnea and are often difficult to perform during high-intensity exercise.10 therapeutic laryngoscopy during exercise (tle) is a newly developed procedure that features laryngeal visualization during respiratory retraining that occurs simultaneous to exercise.12 it has also been found that after the application of traditional breathing techniques, inappropriate glottic adduction still exists during therapeutic laryngoscopy (tle) treatments.14 in response to the observation of inconsistent success with traditional therapies and lack of treatment protocols, novel and alternative treatment techniques should be explored. the eilo biphasic inspiration (eilobi) techniques represent such a novel and alternative treatment. they were developed through observations made during tle and designed for use in highintensity exercise.15 the eilobi techniques help trigger laryngeal abduction which reduces the degree of upper respiratory obstruction in athletes with eilo.16 the following case describes a patient who was unresponsive to many common treatments for eilo, including botulinum toxin injections, and found the greatest symptom relief with the eilobi technique this case is important because relief from traditional therapies may not yield the most relief and alternative methods provide better results. consulting a specialist is the best avenue for patient care. patient information a 23-year-old male ncaa division i distance runner (cross-country, 3k steeplechase, 5k) with a history of childhood asthma, allergic rhinitis, and supraventricular tachycardia status post ablation presented to the healthcare team (primary care physician, immunologist, performance psychologist, ear nose and throat specialist, pulmonologist) with several years of exertional dyspnea. several months after an initial diagnosis of and treatment for asthma, he continued to experience exertional dyspnea. in the context of characterizing the dyspnea as stridor and the response to treatment as minimal, he was diagnosed with eilo. in addition to eilo, a few potential disease contributors were identified. he was found to have https://vimeo.com/clinat/review/344406522/e29b93bf25 https://vimeo.com/clinat/review/344406522/e29b93bf25 exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 39 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 gastroesophageal reflux (gerd) and was treated with acid suppression medication and an inlet patch procedure. he was also found to struggle with anxiety and was treated by a local performance psychologist. despite appropriate treatment of hypothesized disease contributors (allergic rhinitis, gastroesophageal reflux, and anxiety) and conventional treatment for eilo (respiratory retraining) with speech and language pathologists, he continued to struggle with exertional stridor for several months. for this reason, he was also treated with inspiratory muscle training with a powerbreathe®, amitriptyline, and laryngeal botulism toxin injections on 3 occasions. a powerbreathe® is an inspiratory muscle training device used for improving the strength and endurance of the muscles used to breathe in; amitriptyline is a prescription drug used to treat depression, anxiety, and nerve pathologies; and botulism toxin injections are used to reduce excess muscle activity caused by dystonia. despite these interventions which were sequentially introduced over several months, the patient continued to struggle with the primary symptom of exertional stridor through the time of his presentation at the final referral center roughly 5 years after symptoms began. activity and participation patient reported occasional “wheezing” while running which progressed into full breathing attacks during his junior and senior years of high school that reduced his ability to run during races to a jog. over time, these symptoms increased in terms of frequency and severity. when symptom free, which often occurred during practice, he was able to complete a mile in slightly more than 4 minutes. when symptoms occurred, he was often unable to complete races. differential diagnosis and evaluation the differential diagnosis of exertional stridor includes all causes of fixed and dynamic intrinsic and extrinsic obstruction of the upper airway. eilo occurring at a glottic or supraglottic level is the most likely lesion. additionally, laryngeal webs, subglottic and tracheal stenosis, and compression from large vessels or masses can cause stridor. prior to presentation at the pulmonologist computed tomography of the chest and swallow evaluations excluded extrinsic compression. previous exercise testing excluded exertional hypoxemia. continuous laryngoscopy during exercise at the final referral center confirmed the diagnosis of eilo affecting both glottic and supraglottic structures. body structure and function the patient was usually asymptomatic at the time of evaluation by athletic trainers in the clinic. the patient described periodic symptoms commonly associated with eia or eilo, mainly “wheezing” with dyspnea. the few times athletic trainers were able to evaluate the patient during an episode, he presented with stridor, difficulty breathing, and altered voice pitch. these symptoms subsided within minutes of ceasing activity. environmental and personal factors the patient comes from an affluent, supportive family who encouraged and modeled being physically active. he had goals to serve in a special-forces unit since he was a child. the student-athlete has a history of seeking treatment for anxiety that was relatively successful. interventions after diagnosis confirmation with continuous laryngoscopy during exercise, the patient performed three sessions of therapeutic laryngoscopy during exercise (tle), described below. during the sessions, the patient learned one version of the eilobi (eilo biphasic inspiratory) breathing techniques as well as a framework for managing some of the cognitive behavioral contributors to eilo. exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 40 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 outcomes although intermittent results were noticed with traditional respiratory therapy interventions, the patient noticed significant improvements after the series of therapeutic laryngoscopy during exercise sessions and with the eilobi techniques. he routinely uses them during all of his runs. he’s no longer a collegiate athlete but still averages 50 miles per week. the patient still has symptoms albeit they’re less frequent and severe from a respiratory perspective if his gerd is controlled but has periods of respiratory distress. he does note, however, that if he misses a day of gerd medication his breathing while running is difficult for reasons related to pain. discussion we present a case of an elite male athlete with eilo who struggled with delays in diagnosis and poor responsiveness to conventional and invasive therapies for eilo including traditional respiratory retraining with trigger suppression and botulinum toxin injections to the larynx. this is an important case because it highlights that the eilobi breathing techniques can result in successful treatment of eilo in elite athletes previously unresponsive to therapy. secondarily, although previous literature seems to suggest a very high success with botulinum toxin injections, this report underscores a concern for treatment failures.17 this patient made major improvements with the use of the tle procedure. in this procedure, patients are able to visualize their upper airway during intense exercise, with the ability to use the images as biofeedback during respiratory retraining teaching sessions (figure 1). additionally, the procedure enables thoughtful discussion about cognitive behavioral features which may be suspected in the event that eilo episodes trigger at somewhat unusual times. the procedure naturally enables complex teaching necessary to learn the eilobi breathing techniques.8 figrure 1: therapuetic laryngoscopy during exercise. the eilobi breathing techniques feature a high resistance and low resistance phase of inspiration that can be performed rapidly.15 the techniques were discovered fortuitously during the endoscopic evaluation of patients who had previously not responded to conventionally used breathing techniques. many of the conventional respiratory retraining strategies focus on slow breathing in the use of the diaphragmconcepts not compatible with the high respiratory rates and engagement of abdominal muscles that accompany intense exercise with athletes.15 the techniques are challenging yet important to learn and require a thoughtful teaching strategy. nonetheless, in appropriately selected patients, like ours, that demonstrated a high degree of motor coordination, the techniques can minimize or eliminate symptoms. clinical bottom line it is common to diagnose and treat exerciseinduced respiratory problems based on patientsdescribed symptoms alone which may lead to misdiagnosis as asthma with subsequent inappropriate management, and ineffective interventions. athletic trainers have a very unique perspective because they may be present during events with the opportunity to visually distinguish inspiratory stridor from other respiratory phenomena. observation of characteristic field events or videos of characteristic episodes can exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 41 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 be helpful in terms of raising suspicion of eilo. continuous laryngoscopy during exercise can provide definitive diagnosis of eilo. traditional breathing techniques learned from speech therapists often do not provide relief from exertional dyspnea and are difficult to perform during high-intensity exercise. the eilobi breathing techniques were designed specifically to address these concerns. after this case presentation, athletic trainers should be able to recognize their very unique perspective on events that can occur in the field, clinically suspect eilo cases based on inspiratory stridor, and feel comfortable contacting and collaborating with expert providers on appropriate treatment. patient perspective my breathing problems began during my sophomore year of high school. i had been a tennis player who occasionally ran until i took up running full time during my freshman year of high school where i was able to make it to the state regional meet. i had been a diagnosed asthmatic since i was 8 years old and occasionally used an inhaler during wheezing episodes. despite wheezing at times, i was still a competitive tennis player who was ranked in the top 5 in the state. at the conclusion of my freshman season we wanted more answers so i saw an immunologist. i tested positive for multiple allergens. we were excited for this news as we thought we had found the reason for my breathing issues that were starting to develop. initially i had thought my issues were from pre-race anxiety but the confirmation of having multiple allergies seemed like a more likely cause. i started getting routine allergy shots which led to a sophomore track season where i had very few breathing issues. my junior and senior year of high school were drastically different. i routinely had significant breathing issues during multi-race days, some of which would reduce my pace to a jog with bad wheezing. there was no consistency to causes to these issues; highand low-pressure races, time of year, nothing was consistent. during this time my race anxiety seemed to escalate and i would sometimes puke before or after races. by this time, i had been to the doctor multiple times and had been told i was anemic, had asthma, and was over training. during my freshman year of college in 2013, i had very few breathing attacks early in the season; however, when i did have them they were severe and the severity seemed to be getting worse. as the season progressed the breathing attacks became more frequent, which was a pattern for my entire college career. i can only think of one season where the first real workout of the year didn’t go amazing. i chalked this pattern up to being less stressed coming out of the summer but when i thought about my anxiety levels before a fast workout, there didn’t seem to be any correlation. it seemed as though the more fit i got through the season, the worse and more frequent my attacks would become. by the spring season during my freshman year i was able to run workouts in practice very well but struggled during competition. from the outside it appeared as if i was overtraining and couldn’t handle the pressure while racing. i don’t have any hard feelings for anybody who thought that because it seemed pretty obvious but i knew there was something more to it. it has always torn me apart on the inside trying to prove that i knew i was fit. during this time i became very callused emotionally and really struggled with the fact that i couldn’t push my body to its physical limits although i knew i had more in me. from this point on was the loneliest and toughest part of my life but it didn’t stop me from putting in the work or trying to figure out a solution. starting my sophomore year, the pattern continued where i would run well early in the fall semester and trail off as the season progressed. additionally, early during the fall of 2014 my heartrate was very irregular and high which led to being diagnosed with supraventricular exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 42 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 tachycardia (svt) so i ended up having a cardiac ablation procedure. we had hoped this may have been a contributor to my breathing issues but shortly after i started running again i realized it was unrelated. i made it through the season racing slightly better than my freshman year until the outdoor track conference meet where i had such severe breathing attacks that my pace was reduced to a jog and i finished last in two races. naturally after years of hearing that i’m overtraining and i’m a “head-case”, i started overanalyzing everything i was doing looking for a cause to my running issues. during the summer between my sophomore and junior year of college i came up with a brilliant solutioni would get so fit that i could overpower my breathing problems; unfortunately, that didn’t work either. early during my junior season in 2015 i started having consistent throat pain, so i returned to the immunologist. she suggested i might have vocal cord dysfunction (vcd) which seemed to fit after looking into it on my own. i had unexplained voice cracks during conversations that didn’t align with puberty, i stuttered on and off which developed around the same time as my breathing issues got worse, and i developed a habit cough that would get worse with running at times. i worked with multiple speech pathologists and eventually ended up with a pathologist who worked specifically with athletes. following a speech therapy session there were good and bad days of running still. i ended up being tested for gerd and tested positive. i was super excited for this diagnosis as well since gerd had been linked to causing vcd. unfortunately, treating the gerd didn’t seem to help my breathing attacks much. during the summer of 2016, i ran 100 miles a week for 10 weeks straight and was feeling okay. i was still having breathing attacks but i felt like i had some control over them as i was still using a powerbreathe® device most of the time. like the previous college years, the fall season started out great but went downhill fast. i started seeing a sports psychologist in the fall of 2016 who worked with an nba team in the area as well but this also didn’t seem to have any lasting effect. after the gerd treatment failed to have any real effect, i got a series of three botox injections. at first, i felt like these injections helped but it was very short-lived and also had no lasting effect. during this time, i also started taking amitriptyline which also seemed to have very little effect on the breathing issues. in the spring of 2017 i was referred to the national jewish hospital (njh) in denver, co. due to classes, i ended up scheduling a series of appointments over a ten-day period that summer. by this point the self-doubt and the inability to do what i had dreamed of being the best at were taking a toll on me. it was at this time where i started having breathing difficulties in everyday life. stairs were harder to get up. i would often have to cut off a friend midconversation just to catch my breath after climbing just one flight. i couldn’t talk on long runs anymore because i would mumble and slur my words. these speech difficulties got worse to where i would have difficulty just having conversation while walking long distances across campus. i would often be light-headed and dizzy after long easy runs; i couldn’t wait until denver. during my ten-day stent in denver that summer, i saw a myriad of doctors at njh. three inlet patches were found in my throat. i ended up having ablation therapy on the patches and it was thought that i would be back to running without issue in 2-3 months. in conjunction with the ablation therapy i was also put on nexium which didn’t help much either. there was one physician at njh that was doing research on vocal cord disorders but he was on vacation during this trip so i scheduled to see him in december of 2017. in the fall of 2017, i started my last crosscountry season in college and i was mentally not into it. before i knew it, i was back at njh in exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 43 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 december. i had one more ablation procedure on a small portion of one inlet patch and saw the physician who was researching vocal cord disorders (dr. olin). i went through a series of treatment sessions with dr. olin where i was taught how to breathe during exercise. to this day, this has been the single greatest help to my breathing. the spring of 2018 was a turning point in my life. i began to put life after college as a priority while continuing to run. since then, i have only run a few 100-mile weeks while continually averaging 50 miles per week. there is no doubt that the breathing techniques i learned with dr. olin have helped. i still have breathing issues although they’re not as frequent or severe. i continue to have heartburn, albeit less severe. if i miss a day of taking nexium then i notice my breathing is worse. supplemental videos video 1: example of exercise-induced shortness of breath video 2: visualization of airway obstruction video 3: continuous laryngoscopy during exercise references 1. hull jh, ansley l, robson-ansley p, parsons jp. managing respiratory problems in athletes. clin med (lond). 2012;12(4):351356. https://doi.org/10.7861/clinmedicine.12-4351. 2. lund t, pedersen l, larsson b, backer v. prevalence of asthma-like symptoms, asthma and its treatment in elite athletes. scand j med sci sports. 2009;19(2):174-178. https://doi.org/10.1111/j.16000838.2007.00753.x. 3. christensen pm, thomsen sf, rasmussen n, backer v. exercise-induced laryngeal obstructions: prevalence and symptoms in the general public. eur arch otorhinolaryngol. 2011;268(9):1313-1319. https://doi.org/10.1007/s00405-0111612-0. 4. maat rc, roksund od, halvorsen t, et al. audiovisual assessment of exercise-induced laryngeal obstruction: reliability and validity of observations. eur arch otorhinolaryngol. 2009;266(12):1929-1936. https://doi.org/10.1007/s00405-0091030-8. 5. nielsen ew, hull jh, backer v. high prevalence of exercise-induced laryngeal obstruction in athletes. med sci sports exerc. 2013;45(11):2030-2035. https://doi.org/10.1249/mss.0b013e3182 98b19a. 6. morris mj, christopher kl. diagnostic criteria for the classification of vocal cord dysfunction. chest. 2010;138(5):1213-1223. https://doi.org/10.1378/chest.09-2944. 7. hull jh, hull pj, parsons jp, dickinson jw, ansley l. approach to the diagnosis and management of suspected exercise-induced bronchoconstriction by primary care physicians. bmc pulm med. 2009;9:29. https://doi.org/10.1186/1471-2466-9-29. 8. olin jt, clary ms, fan em, et al. continuous laryngoscopy quantitates laryngeal behaviour in exercise and recovery. eur respir j. 2016;48:1192-1200. https://doi.org/10.1183/13993003.00160 -2016. 9. silverman m, anderson sd. standardization of exercise tests in asthmatic children. arch dis child. 1972;47(256):882-889. https://dx.doi.org/10.1136%2fadc.47.256. 882. 10. halvorsen t, walsted es, bucca c, et al. inducible laryngeal obstruction: an official joint european respiratory society and european laryngological society statement. eur respir j. 2017;50(3). https://doi.org/10.1183/13993003.02221 -2016. https://vimeo.com/clinat/review/344404886/2102213062 https://vimeo.com/clinat/review/344404886/2102213062 https://vimeo.com/clinat/review/344405909/6548cdbac3 https://vimeo.com/clinat/review/344406522/e29b93bf25 https://doi.org/10.7861/clinmedicine.12-4-351 https://doi.org/10.7861/clinmedicine.12-4-351 https://doi.org/10.1111/j.1600-0838.2007.00753.x https://doi.org/10.1111/j.1600-0838.2007.00753.x https://doi.org/10.1007/s00405-011-1612-0 https://doi.org/10.1007/s00405-011-1612-0 https://doi.org/10.1007/s00405-009-1030-8 https://doi.org/10.1007/s00405-009-1030-8 https://doi.org/10.1249/mss.0b013e318298b19a https://doi.org/10.1249/mss.0b013e318298b19a https://doi.org/10.1378/chest.09-2944 https://doi.org/10.1186/1471-2466-9-29 https://doi.org/10.1183/13993003.00160-2016 https://doi.org/10.1183/13993003.00160-2016 https://dx.doi.org/10.1136%2fadc.47.256.882 https://dx.doi.org/10.1136%2fadc.47.256.882 https://doi.org/10.1183/13993003.02221-2016 https://doi.org/10.1183/13993003.02221-2016 exercise induced laryngeal obstruction in a collegiate runner: a case report of a novel approach 44 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 11. heimdal jh, roksund od, halvorsen t, skadberg bt, olofsson j. continuous laryngoscopy exercise test: a method for visualizing laryngeal dysfunction during exercise. laryngoscope. vol 1162006:52-57. https://doi.org/10.1097/01.mlg.00001845 28.16229.ba. 12. tervonen h, niskanen mm, sovijarvi ar, hakulinen as, vilkman ea, aaltonen lm. fiberoptic videolaryngoscopy during bicycle ergometry: a diagnostic tool for exerciseinduced vocal cord dysfunction. laryngoscope. 2009;119(9):1776-1780. https://doi.org/10.1002/lary.20558. 13. olin jt, clary ms, connors d, et al. glottic configuration in patients with exerciseinduced stridor: a new paradigm. laryngoscope. 2014;124(11):2568-2573. https://doi.org/10.1002/lary.24812. 14. olin jt, deardorff eh, fan em, et al. therapeutic laryngoscopy during exercise: a novel non-surgical therapy for refractory eilo. pediatr pulmonol. 2017;52(6):813819. https://doi.org/10.1002/ppul.23634. 15. johnston kl, bradford h, hodges h, moore cm, nauman e, olin jt. the olin eilobi breathing techniques: description and initial case series of novel respiratory retraining strategies for athletes with exercise-induced laryngeal obstruction. j voice. 2018;32(6):698-704. https://doi.org/10.1016/j.jvoice.2017.08.0 20. 16. graham s, deardorff e, johnston k, olin jt. the fortuitous discovery of the olin eilobi breathing techniques: a case study. j voice. 2018;32(6):695-697. https://doi.org/10.1016/j.jvoice.2017.08.0 19. 17. altman kw, mirza n, ruiz c, sataloff rt. paradoxical vocal fold motion: presentation and treatment options. j voice. 2000;14(1):99-103. https://doi.org/10.1097/01.mlg.0000184528.16229.ba https://doi.org/10.1097/01.mlg.0000184528.16229.ba https://doi.org/10.1002/lary.20558 https://doi.org/10.1002/lary.24812 https://doi.org/10.1002/ppul.23634 https://doi.org/10.1016/j.jvoice.2017.08.020 https://doi.org/10.1016/j.jvoice.2017.08.020 https://doi.org/10.1016/j.jvoice.2017.08.019 https://doi.org/10.1016/j.jvoice.2017.08.019 manuscript type clinical outcomes 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 the effect of dynamic balance performance on lower extremity injury in division iii football players brian j. coulombe, dat, lat, atc1; cameron j. powden, phd, lat, atc2 1texas lutheran university, seguin, tx; 2indiana state university, terre haute, in abstract identifying and implementing evidence based prevention programs present a significant challenge for athletic trainers. despite encouraging results in research, individual interventions are often specific to a setting or population and dependent on identifying accurate injury risk factors. this practice-based research is an attempt to apply current evidence in prevention to a population of division three football athletes. the clinical staff reviewed national and site-specific injury data and identified lower extremity (le) injury as the area of focus. evidence was searched to identify modifiable risk factors and valid measurement tools that could be addressed in our setting. dynamic balance has been well documented as a risk factor for le injury and the y balance test (ybt) has been shown to be an accurate measure of balance and increased risk of injury. the purpose of our investigation was to determine if our population exhibited similar injury rates in those with balance deficits as documented in other settings. we chose the football program within our setting due to the high number of athletes and consistent injuries that occur throughout the season. all returning football athletes were measured for dynamic balance using the ybt during the annual screening process. injury record keeping through electronic medical record (emr) system was consistent with current procedures and noncontact le injuries were analyzed to remove non-modifiable risk factors. comparisons were made between ybt results and incidence of injury in 46% of our athletes. statistical analysis revealed no relationship between ybt measurements and le injury. our results are contradictory to those reported in recent studies from differing populations. implementation difficulties and population differences are theorized reasons for our inability to achieve similar results. clinically, our results underscore the need for clinicians to measure interventions within their own settings to determine usefulness and make the best decision for their patients. key phrases injury risk reduction, injury surveillance, prevention correspondence dr. brian columbe, texas lutheran university, 1000 w. court street, seguin, tx 78155 e-mail: bcoulombe@tlu.edu twitter: @bcoulatc full citation columbe bj, powden cj. the effect of dynamic balance performance on lower extremity injury in division iii football players. clin pract athl train. 2018;1(1):15-20. https://doi.org/10.31622/2018/0001.4 submitted: may 3, 2018 accepted: may 25, 2018 introduction athletic trainers are tasked with implementing policies and procedures designed to prevent or mitigate emergent, acute, or chronic injuries and medical conditions1. prevention of injuries before they occur (primary prevention), providing early identification and care (secondary prevention) to limit the extent of an injury, and comprehensive rehabilitation (tertiary prevention) after an injury are all areas in which athletic trainers work to prevent the disabling effects of injury. interventions to prevent injury have historically focused on the individual and specific risk factors to which patients are exposed.2 to maximize primary and secondary prevention interventions it is important that athletic trainers focus their efforts on evidence-based initiatives aimed at specific populations of patients.2 football is a collision sport that has the highest injury rates of all ncaa intercollegiate athletic programs.3 injuries to the lower extremity (le) make up 54% of all injuries. furthermore, the knee (12%), ankle (11.8%), and thigh musculature (10.7%) are the top 3 body parts injured in practice activities.3 one specific institution, a private, liberal arts, ncaa division iii university, has experienced similar injury rates for these types of le injuries. examination of electronic medical records (emr) from the previous academic year revealed 57% of le injuries at the specific institution were the result of non-contact mechanisms. in an effort to improve healthcare services provided to our athletic population, the clinical athletic training staff searched recent evidence to identify modifiable risk factors for le injury. our evidence-based approach also included identifying a le injury prevention program that had been evaluated for feasibility. postural control and dynamic balance are two modifiable risk factors that have been related to le injury.4,5 recent evidence indicates that https://doi.org/10.31622/2018/0001.4 the effect of dynamic balance performance on lower extremity injury in division iii football players 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 impaired balance increases an athlete’s risk of injury.6-10 furthermore, prophylactic balance training programs have demonstrated the ability to decrease injury risk.5,11,12 together these findings highlight the importance of identifying balance deficits during the prevention process. single leg balance tests, like the star excursion balance test (sebt) and the newer y-balance test (ybt), are frequently used tools in lab-based and practical research studies that use single leg reach distance to evaluate dynamic balance and postural control.4-7,13-15 evidence for using the ybt as an injury prediction tool has been encouraging with multiple studies identifying anterior reach asymmetries of over 4cm and composite scores of under 89.9% as strong predictors of injury.7,8,11,15 as our clinical staff reviewed current evidence on the ybt, concerns of replicating results found in previous studies within our own patient population became evident. it was important for us to establish measures at which our athletes experience increased injury before implementing interventions to prevent those injuries. we determined that our first step in improving quality of care in the area of injury prevention started with the collection and analysis of data within a specified population to determine what, if any, interventions may be appropriate. although the ybt has performed well as a predictive measure of injury in ncaa division 1 football, basketball, and soccer athletes, its utility to identify at-risk individuals is unclear within the football population at the specific ncaa division iii institution. the purpose of this practice-based research project was to determine the relationship between the ybt and le injury in football athletes at the institution. our hypothesis was that those experiencing non-contact le injuries would demonstrate significantly greater asymmetries and lower composite scores than the uninjured population. patients one hundred thirty-nine football student-athletes from the same ncaa division iii institution participated in this screening and monitoring program. prior to the start of the 2016 football season, all athletes completed an annual medical screening process of which ybt measurements were included. athletes were given brief information on the purpose of balance assessment as a means to identify risk of le injury before completing measurements. athletes with a le injury at the time of ybt evaluation were excluded from this study. athletes who were included in this study were then monitored throughout the competitive season for le injuries. intervention the fms y balance test (perform better, west warwick, ri) was used to measure balance in athletes. the ybt tool consists of a center platform and three pvc pipes attached in anterior, posteromedial, and posterolateral directions. each directional pipe is labeled in centimeters (cm) and includes a sliding block that an athlete pushes as they reach in a specific direction (figure1). reliability assessments of ybt measurements in multiple studies suggest strong intrarater reliability between icc=0.85-0.93 and interrater reliability between icc=0.91-1.0.5,8,15 the measurement protocol utilized was based on a previous protocol.15 athletes were instructed to stand barefoot on the center platform and reach out in each direction, with the contralateral limb, to slide a block down the directional pipe. trials were repeated if athletes removed hands from hips, failed to return to the start, threw the block, or placed excess weight on the block. athletes completed four practice trials followed by three measurement trials in each direction. the furthest reach in each direction was recorded, normalized to leg length and used for analysis. two examiners monitored the trials to ensure correct procedure and two others recorded reach distances. ybt examiners completed educational sessions to ensure that those measuring ybt understood the process and could obtain reliable measurements. leg length was measured following ybt. leg length was measured from the anterior superior iliac spine to the distal tip of the medial malleolus on both limbs after athletes lifted their hips off of the table and returning to a supine position. all ybt and leg length measurements were completed by the clinical athletic training staff (< 8 years boc certified) or senior level professional athletic training students who completed a training module with measurement practice at the institution. the information was stored in a microsoft® excel spreadsheet to be analyzed with injury data to determine the, if any, relationship exists between balance and le injury. this was an important first the effect of dynamic balance performance on lower extremity injury in division iii football players 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 step in determining the necessity of possible prevention programming. outcome measures injury emr surveillance occurred via sportsware© (computer sports medicine inc. stoughton, ma.) database and lasted the entire fall 2017 season. injuries to the le that resulted from any non-contact mechanism were included if the event required medical care and resulted in time-loss of one or more days of normal football activities. a report was generated through the emr for the stated conditions and ybt values for those injured were matched in microsoft® excel database for analysis. athletes sustaining multiple injuries were included for their first injury only. analyses were conducted using a statistical software program (ibm corp. released 2015. ibm spss statistics for windows, version 23.0. armonk, ny: ibm corp). means and standard deviations were calculated for all reach distances and asymmetries in each leg for injured and uninjured athletes. limb asymmetries were calculated by taking the absolute difference between limbs for each reach direction and composite score. receiver operator characteristic (roc) curves were created to establish a cut-off point at which a difference in scores correlated with an increased chance of le injury. this was done for each reach and composite score asymmetry to determine risk of injury in this population. the p value was set at p < 0.05 a priori. results non-contact le injuries occurred in 62 of 136 athletes who completed the 2017 football season (table 1). the normalized reach distances and composite scores are presented in table 2 for injured and uninjured athletes. non-significant asymmetries (table 3) were noted among injured and uninjured populations (p = 0.382) with mean asymmetries for each direction and composite being within 1% except for the posteromedial reach direction (2%). roc data failed to reach significance in establishing cut off points for reach or composite score asymmetries. table 1. sustaining non-contact le injuries. number percentage no injury 74 54.4 injury 62 45.6 total 136 100.0 the effect of dynamic balance performance on lower extremity injury in division iii football players 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 table 3. ybt asymmetry values for each direction group (n) anterior posteromedial posterolateral composite uninjured (74) 5.8 ± 4.8% 7.5 ± 6.7% 9.1 ± 7.4% 4.3 ± 4.2% injured (62) 6.4 ± 5.6% 9.5 ± 14.1% 9.0 ± 11.7% 5.2 ± 6.2% average (136) 6.1 ± 5.2% 8.4 ± 10.8% 9.1 ± 9.6% 4.7 ± 5.2% note: values are expressed as a percentage difference between limbs table 4. receiver operator characteristic findings discussion the purpose of this study was to determine if a relationship exists between ybt performance and the incidence of le injury in ncaa division iii football players. our results did not find any ybt reach direction that was predictive of le injury. this is in contrast to recent investigations of ybt performance in other populations. using the star excursion balance test (sebt), plisky6 found that high school basketball players with anterior reach asymmetries greater than 4 cm demonstrated a 2.5 times greater injury risk. additionally, female athletes were 6.5 times more likely to sustain injury if their composite reach score was less than 94% of their limb length.6 the relation of anterior reach asymmetry to increased injury risk was corroborated using the ybt in a population of ncaa division 1 athletes from various sports in a 2015 investigation by smith et al. which found that participants with anterior reach differences of over 4 cm were almost 4 times more likely to sustain a le during their competitive season.9 similar ybt procedures have been applied among amateur and professional soccer players finding a 4 cm difference in the posteromedial direction as a risk factor for injury.16 in contrast, another investigation using the ybt among ncaa division i football players was unable to corroborate injury risk in those with anterior reach asymmetries, but did find a 3.5 times higher injury rate in those with composite scores of less than 89% of limb length.8 the combination of these findings highlight the variation in the predictive ability of the ybt/sebt and underscores the importance of continued investigations within multiple populations. before adopting quality improvement interventions, athletic trainers should incorporate evidence from their own patient population along with current research evidence to ensure the usefulness of those interventions. practice-based research and analysis of such data can help focus efforts on the needs of our patients and improve overall outcomes. despite our results, the ybt can still be a useful marker of neuromuscular control in patients after specific injuries. investigations among patients with lateral ankle sprains, chronic ankle instability, anterior cruciate injury, and patellofemoral pain syndrome consistently exhibit significant reach deficits in the directions used in the ybt.4 additionally, rehabilitation focusing on improving balance while reaching in anterior, posteromedial, posterolateral directions has shown improvement within injured populations.4 one such study among those with chronic ankle instability found significant improvement in reach distances after 4 weeks of balance exercise focused on the anterior, posteromedial, and posterolateral directions.10 within our application, baseline asymmetry measure area std. error p value cut off score sensitivity specificity anterior .519 .050 .702 0.1% 61.3% 47.3% posteromedial .532 .050 .526 7.2% 43.5% 67.6% posterolateral .456 .050 .382 1.0% 98.0% 11.0% composite .513 .051 .800 8.4% 19.4% 91.9% the effect of dynamic balance performance on lower extremity injury in division iii football players 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 measurements were used as objective return to play criteria for those injured throughout the season. evidence has established the ybt as an appropriate measure of dynamic postural control, and that interventions focusing on balance and neuromuscular control exercises lead to improved reach scores.17-20 there were a number of challenges experienced in the implementation of the ybt testing procedures, which may have affected measurements collected. a large number of football athletes (139) reported for the preparticipation exam that was scheduled for a 3hour time period. the addition of a balance testing station increased the time required to complete all components of the exam, which created a sense of fatigue in athletes and clinicians. the ybt was a new procedure for staff and professional level students who were conducting measurements. training and practice sessions were employed, but unforeseen challenges during a time-sensitive exam may have compromised the ability to record accurate measurements. additionally, returning players may not have provided maximal effort as this was a new and unexpected task that was seen as a burden. lessons learned through unsuccessful experiences provide valuable information on how to improve procedures and must be addressed in future investigations of the ybt as a predictive assessment of injury. educational sessions for athletes and coaching stakeholders can lead to buy-in and commitment to gathering accurate measurements. further training and experience among those conducting measurements will increase efficiency and accuracy of the measurement process. finally, procedures to limit the number of athletes measured in one session may help with the impatience of athletes and the fatigue of clinicians. the results of this practice-based research did not identify ybt measurements predictive of lower extremity injury. adjustments to implementation policies will be necessary if the ybt will be continued to be used as a predictor of lower extremity injury or an objective rehabilitation measure. one of the benefits that resulted from our investigation was an additional clinical outcome measure to assess return to activity status for those that incur lower extremity injury. comparisons to ybt baseline measures of dynamic balance will be useful information to assist clinical decision making regardless of injury predictive ability. clinical application while identifying and using current evidence to guide clinical practice is an important function of an athletic trainer, implementation of specific interventions designed to prevent injury should be tailored to the individual setting and population being treated. practice based research provides information on potential usefulness of interventions and can provide additional clinician-rated outcomes to improve clinical decision-making. continuous data collection and assessment of interventions is crucial for clinicians to make the best decisions for their patients. references 1. henderson j. the 2015 athletic trainer practice analysis study. omaha, ne: board of certification; 2015. http://www.bocatc.org/system/document_v ersions/versions/24/original/boc-pa7content-outline20170612.pdf?1497279231. access date: may 1, 2018. 2. hoffman m, bovbjerg v, hannigan k, et al. athletic training and public health summit. j athl train. 2016;51(7):576-580. https://doi.org/10.4085/1062-605051.6.01 3. dick r, ferrara ms, agel j, et al. descriptive epidemiology of collegiate men's football injuries: national collegiate athletic association injury surveillance system, 19881989 through 2003-2004. j athl train. 2007;42(2):221-233. 4. gribble pa, hertel j, plisky p. using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. j athl train. 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sports med. 2006;40(7):610-613. https://doi.org/10.1136/bjsm.2005.02435 6 8. butler rj, lehr me, fink ml, kiesel kb, plisky pj. dynamic balance performance and noncontact lower eextremity injury in college football players: an initial study. sports health: a multidisciplinary approach. 2013;5(5):417-422. https://doi.org/10.1177/1941738113498 703 9. smith ca, chimera nj, warren m. association of y balance test reach asymmetry and injury in division i athletes. med sci sport. exerc. 2015;47(1):136-141. https://doi.org/10.1249/mss.0000000000 000380 10. mckeon p, ingersoll c, kerrigan dc, saliba e, bennett b, hertel j. balance training improves function and postural control in those with chronic ankle instability. med sci sports exerc. 2008;40(10):1810. https://doi.org/10.1249/mss.0b013e3181 7e0f92 11. mcguine ta, greene jj, best t, leverson g. balance as a predictor of ankle injuries in high school basketball players. clin j sport med. 2000;10(4):239-244. 12. emery ca, rose ms, mcallister jr, meeuwisse wh. a prevention strategy to reduce the incidence of injury in high school basketball: a cluster randomized controlled trial. clin j sport med. 2007;17(1):17-24. https://doi.org/10.1097/jsm.0b013e3180 2e9c05 13. herrington l, hatcher j, hatcher a, mcnicholas m. a comparison of star excursion balance test reach distances between acl deficient patients and asymptomatic controls. knee. 2009;16(2):149-152. https://doi.org/10.1016/j.knee.2008.10.00 4 14. hertel j, braham ra, hale sa, olmstedkramer lc. simplifying the star excursion balance test: analyses of subjects with and without chronic ankle instability. j orthop sports phys ther. 2006;36(3):131-137. https://doi.org/10.2519/jospt.2006.36.3.1 31 15. plisky pj, gorman pp, butler rj, kiesel kb, underwood fb, elkins b. the reliability of an instrumented device for measuring components of the star excursion balance test. n am j sports phys ther. 2009;4(2):92. 16. gonell ac, romero jap, soler lm. relationship between the y balance test scores and soft tissue injury incidence in a soccer team. int j sports phys ther. 2015;10(7):955. 17. leavey vj, sandrey ma, dahmer g. comparative effects of 6-week balance, gluteus medius strength, and combined programs on dynamic postural control. j sport rehabil. 2010;19(3):268-287. https://doi.org/10.1123/jsr.19.3.268 18. mcleod tcv, armstrong t, miller m, sauers jl. balance improvements in female high school basketball players after a 6-week neuromuscular-training program. j sport rehabil. 2009;18(4):465-481. https://doi.org/10.1123/jsr.18.4.465 19. fitzgerald d, trakarnratanakul n, smyth b, caulfield b. effects of a wobble board-based therapeutic exergaming system for balance training on dynamic postural stability and intrinsic motivation levels. j orthop sports phys ther. 2010;40(1):11-19. https://doi.org/10.2519/jospt.2010.3121 20. filipa a, byrnes r, paterno mv, myer gd, hewett te. neuromuscular training improves performance on the star excursion balance test in young female athletes. j orthop sports phys ther. 2010;40(9):551-558. https://doi.org/10.2519/jospt.2010.3325 https://doi.org/10.7205/milmed-d-13-00222 https://doi.org/10.7205/milmed-d-13-00222 https://doi.org/10.2519/jospt.2006.2244 https://doi.org/10.1136/bjsm.2005.024356 https://doi.org/10.1136/bjsm.2005.024356 https://doi.org/10.1177/1941738113498703 https://doi.org/10.1177/1941738113498703 https://doi.org/10.1249/mss.0000000000000380 https://doi.org/10.1249/mss.0000000000000380 https://doi.org/10.1249/mss.0b013e31817e0f92 https://doi.org/10.1249/mss.0b013e31817e0f92 https://doi.org/10.1097/jsm.0b013e31802e9c05 https://doi.org/10.1097/jsm.0b013e31802e9c05 https://doi.org/10.1016/j.knee.2008.10.004 https://doi.org/10.1016/j.knee.2008.10.004 https://doi.org/10.2519/jospt.2006.36.3.131 https://doi.org/10.2519/jospt.2006.36.3.131 https://doi.org/10.1123/jsr.19.3.268 https://doi.org/10.1123/jsr.18.4.465 https://doi.org/10.2519/jospt.2010.3121 https://doi.org/10.2519/jospt.2010.3325 manuscript type patient-center-care-commentary 32 clinical practice in athletic training volume 1 – issue 2 – october 2018 expanding clinical practice with complementary and integrative health, such as tai chi, as therapeutic interventions connor a. burton, lat, atc indiana state university, terre haute, in key phrases therapeutic exercise, emotional wellness, mental health, tai chi correspondence connor burton, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: cburton24@sycamores.indstate.edu twitter: @cburt105 full citation burton ca. expanding clinical practice with complementary and integrative health, such as tai chi, as therapeutic interventions. clin pract athl train. 2018;1(2):32-36. https://doi.org/10.31622/2018/0002.5.1 submitted: september 1, 2018 accepted: october 23, 2018 commentary the national institutes of health (nih) define complementary and integrative health (cih) as “those health care practices not currently considered an integral part of conventional medicine.”1 when an intervention is used in addition to conventional care, it is deemed as complementary medicine. integrative medicine are those interventions that are used in place of conventional care.1 across the general public, the utilization of cih in western society is growing. a 2012 study of nearly 89,000 americans indicated that 33.2% were utilizing cih.2 within this study, various reasons for utilizing cih included health/wellness improvement, treatment for symptoms related to disease, or to improve side effects from modern medicine.2 some western health care providers have brought cih into their practice, whether it be direct incorporation or referral to another qualified provider. some of these interventions include chiropractic services, massage therapy, relaxation techniques, yoga and tai chi.1 although cih continues to grow in western society as a whole, the utilization of cih copyright © by indiana state university all rights reserved. issn online 2577-8188 in modern health care does not follow a similar trend. in order to provide patients with optimal care and satisfactory outcomes, it is crucial to consider all potential interventions when developing a patient-centered plan of care. acting as the first point of care for the majority of our patient populations, athletic trainers can talk with patients about these unique interventions. in so doing, we play an integral role in starting a movement of holistic health care which provides patients which more options to meet their goals and needs. what is tai chi and how is it implemented into practice? there is a strong body of literature supporting the use of tai chi as an intervention for the mental health of young, physically active individuals.3-5 tai chi is a form of martial art and mind-body exercise which originated in china.5 this technique is commonly described as combining slow-paced, precise, and constant functional movements with controlled breathing.3-5 tai chi can be implemented into clinical practice through one-onone patient care with goals of addressing specific conditions. due to the uniqueness of athletic training as a health care profession, tai chi can also be implemented into clinical practice in group intervention sessions. two examples of this implementation could be facilitation of proper breathing during movement for endurance athletes or promotion of positive mental health. the literature supports the use of tai chi for both orthopedic (balance, agility, postural control, lower extremity strength,3 cardiovascular and respiratory function,7 and pain reduction5) and mental health (anxiety,4,5 depression,4,5 selfesteem,5 and mood.5). across the literature, improvement of outcomes were found regardless of the duration (15 to 60 minute sessions), https://doi.org/10.31622/2018/0002.5 using tai chi as a therapeutic intervention to expand complementary and integrative health in clinical practice 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 frequency of sessions (once per week to daily) and length of patient enrollment in the program (3 to 12 week intervention). as noted, tai chi can serve as an intervention to address causative factors related to mental health, as well as functional limitations. as a clinician, it is important to understand how a technique can be an effective option in patient care. moreover, when aiming to provide patient centered care, it is equally important to educate the patient regarding how each available technique can be an effective component of the patient plan of care. for tai chi, the emphasis of the intervention is placed on incorporating relaxation and deep breathing into functional movements.3-5 a visual aid of what a tai chi intervention could look like is detailed in table 1. this table details notes for the clinician developing and implementing the intervention (left column) in addition to patient education and queues for appropriate integration of breathing with functional movement (right column). indications and considerations for implementing tai chi similar to each therapeutic intervention a clinician uses in clinical practice, it is important to understand the indications, contraindications, and considerations for a technique prior to implementing the technique into a plan of care. like general physical activity there is an adherent risk of injury which must be acknowledged when performing tai chi. individuals who have health conditions which require consultation with a table 1: phase progression of diaphragmatic breathing with basic and advanced movements. phase concepts for clinician examples of cueing diaphragmatic breathing hand placement above/below umbilicus patient should begin diaphragmatic breathing. time spent practicing dependent on dysfunction correct any shoulder elevation and rib expansion during breathing progress patient appropriately supine  sitting  standing “please find a position that is comfortable for you.” (standing, seated, or supine) “please place one hand on your stomach and one hand on your stomach below your belly button.” “breathe in through your nose so that you feel your stomach expand under your hand. breathe out through your nose so that you feel your stomach shrink under your hands.” functional movement with breathing patient continues diaphragmatic with basic movements (single leg squat, arm elevation) maintain proper breathing from phase one with movement. ensure abdomen is moving with inhalations progress patient to advanced functional movement when breathing is controlled and routine “starting in a standing position with feet shoulder width apart, breathe in as you raise your arms straight out in front of you.” “breathe out as you squat down and lower your arms to your side at the same time.” “breathe in as you rise up out of the squat and raise your hands straight in front of you.” “continue to focus on breathing through your belly and not raising your shoulders up or expanding your chest when breathing.” advanced functional movement introduce occupational/sport specific movement with breathing adjust movement speed and intensity according to patient progress and occupational/sport demands (lifting an object repetitively, throwing a pitch, rebounding with contact) “breathe in as you properly squat down to pick up this weighted object and breathe out as you pick the object up.” “breathe in as you enter your wind-up phase and breathe out as you progress through your early cocking and follow-through phases of throwing.” using tai chi as a therapeutic intervention to expand complementary and integrative health in clinical practice 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 physician prior to partaking in physical activity (e.g. heart condition, severe osteoporosis) should take precaution. additionally, individuals with an orthopedic injury that requires modifications to activities of daily living or physical activity should take precaution and consult with their health care provider. to obtain the greatest results, the difficulty of the tai chi exercises should be tailored to the patient’s experience level with the intervention and fitness.6 tai chi can be utilized for any patient who is physically active. for patients who only complete walking and activities of daily living, a clinician can develop a program which revolves around foundational movements, such as mini squats with synchronous arm swings or controlled lunges. for patients who partake in a high level of physical activity, a clinician can develop a program which progresses through foundational movements into advanced movements which resemble free flowing dance movements, or tailor the program to introduce breathing with occupational/sport specific activities. in the realm of athletic training, patients may present with breathing dysfunction caused by a variety of factors such as compensatory movements in the kinetic chain, diaphragmatic dysfunction, thoracic sprain or strain, rib dysfunction, heightened levels of anxiety or stress, or faulty breathing mechanics. inherently, breathing dysfunction can result in a negative impact on health-related quality of life for patients. applying a patient-centered lens to care an important part of effectively providing patient-centered care is understanding more about the patient than just the condition. this understanding must dive deeper than a physical wellness understanding of the individual. there are seven dimensions which are key to understanding the holistic wellbeing of a patient. these dimensions include: social, emotional, spiritual, environmental, occupational, intellectual, and physical.8 when providing care to a patient presenting with a form of breathing dysfunction, that can be defined as a breathing disorder in which respiration patterns change due to chronic factors resulting in dyspnea and other symptoms,9 a holistic approach must be employed to identify the contributing factor(s). examples of how a condition can impact the seven dimensions of wellness can be found in table 2. this is not intended to be an exhaustive list of table 2. implications of impairment on the seven dimensions of wellness. dimension implications social external pressure to continue occupational/sport duties; change or loss of social identity emotional internal pressure to continue occupational/sport duties; internal loss of social identity; stress and/or anxiety associated with pain during physical activity/breathing spiritual dependent on the patient’s spiritual beliefs tai chi can support, conflict, or be indifferent towards patient’s spiritual health environmental increased number of provider visits can increase the impact of on environmental factors (pollution, healthcare system, economic, etc.) occupational pressure to continue meeting the organizational expectations of occupation/sport activity during and after injury intellectual patient education and cultural understanding of impairment is vital for treatment and success of interventions physical patient may experience pain with activities of daily living, pain with occupational/sport specific functions, or decreased level of function using tai chi as a therapeutic intervention to expand complementary and integrative health in clinical practice 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 holistic factors to consider, but is designed to help a clinician understand the frame of mind necessary to apply well-rounded patient care and extent of impairment on these domains. a patient who presents with thoracic, musculoskeletal pain with breathing during exercise and increased levels of stress and anxiety during physical activity many be a patient case worth considering the use of tai chi as a therapeutic intervention. when considering social and emotional wellness, a patient could be experiencing internal or external pressure to perform at a high level. of the examples provided in table 2, some of these factors can result in heightened anxiety and stress, which may result in physiologic changes like increased heart rate and respirations. these changes can alter the intricate function of the respiratory system. conclusion as a cih technique, tai chi can be incorporated into a patient’s plan of care in conjunction with other interventions. as the current literature indicates,3-5 patient outcomes related to mental health and physical impairment significantly improve regardless of the programming parameters for tai chi intervention. due to the fact that guidelines are not specific, a clinician should work with the patient to set a plan of care which best suits the patient’s availability, needs, and preferences. as a clinician it is viable to provide patients with options when establishing a plan of care which aims to address the goals the patient seeks to accomplish while receiving care. in order to best address patient needs and goals, a clinician must not only understand the clinical relevance of all considered interventions, but also recognize the impact a condition and intervention will have on the seven dimensions of patient wellness. references 1. national center for complementary and integrative health. u.s. department of health and human services – national institutes of health. https://nccih.nih.gov/research/camonpu bmed/background.htm. updated sept 24, 2017. access date: june 6, 2018. 2. clarke tc, black li, stussman bj, et al. trends in the use of complementary health approaches among adults: united states, 2002-2012. natl health stat report. 2015;79:1-15. 3. bu b, haijun h, yong l, et al. effects of martial arts on health status: a systematic review. j evid-based med. 2010;3:205219. https://doi.org/10.1111/j.17565391.2010.01107.x 4. sharma m, haider t. tai chi as an alternative and complimentary therapy for anxiety: a systematic review. j evidbased complimentary & altern med. 2015;20(2):143-153. https://doi.org/10.1177/2156587214 561327 5. wang f, othelia lee ek, wu t, et al. the effects of tai chi on depression, anxiety, and psychological well-being: a systematic review and meta-analysis. intl j bev med. 2014; 21:605-617. https://doi.org/10.1007/s12529-0139351-9 6. xiong ky, he h, ni gx. effect of skill level on cardiorespiratory and metabolic responses during tai chi training. eur j sport sci. 2013;13(4):386-391. https://doi.org/10.1080/17461391.20 11.635706 7. polkey mi, qiu zh, zhou l, et al. tai chi and pulmonary rehabilitation compared for treatment-naïve patients with copd: a randomized controlled trial. chest. 2018;153(5):1116-24. https://nccih.nih.gov/research/camonpubmed/background.htm https://nccih.nih.gov/research/camonpubmed/background.htm https://doi.org/10.1111/j.1756-5391.2010.01107.x https://doi.org/10.1111/j.1756-5391.2010.01107.x https://doi.org/10.1177%2f2156587214561327 https://doi.org/10.1177%2f2156587214561327 https://doi.org/10.1007/s12529-013-9351-9 https://doi.org/10.1007/s12529-013-9351-9 https://doi.org/10.1080/17461391.2011.635706 https://doi.org/10.1080/17461391.2011.635706 using tai chi as a therapeutic intervention to expand complementary and integrative health in clinical practice 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 https://doi.org/10.1016/j.chest.2018.0 1.053 8. lyon, k. the seven dimensions of wellness. american medical student association. https://www.amsa.org/the-sevendimensions-of-wellness/. updated july 8, 2015. access date: august 25, 2018. 9. boulding r, stacey r, niven r, fowler sj. dysfunctional breathing: a review of the literature and proposal for classification. eur respir rev. 2016;25:287-94. https://doi.org/10.1183/16000617.00 88-2015 . https://doi.org/10.1016/j.chest.2018.01.053 https://doi.org/10.1016/j.chest.2018.01.053 https://www.amsa.org/the-seven-dimensions-of-wellness/ https://www.amsa.org/the-seven-dimensions-of-wellness/ https://doi.org/10.1183/16000617.0088-2015 https://doi.org/10.1183/16000617.0088-2015 disablement model case study 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study rodrigo e. martinez, dat, lat, atc*; evelyn benitez-lopez, dat, atc†; lindsey larkins, dat, cscs, prt-c‡ * florida international university, miami, fl; †east los angeles college, monterey park, ca; ‡ university of idaho, moscow, id abstract medial tibial stress syndrome (mtss) is a common pathology in physically active people and one of many overuse leg injuries present in weight bearing athletes, with the highest prevalence in runners. researchers have extensively explored treatment for mtss, but a long-lasting and effective treatment option has not been established. this case report aimed to explore the effects of the myokinesthetic systemtm (myk), a form of manual therapy, on two athletes diagnosed with mtss. patient one is a 19-year-old male rugby player with a previous history of mtss, who reported leg pain while running which progressed to constant pain. patient two is a 24-year-old female collegiate soccer patient who reported increasing leg pain while running, with no previous history of mtss. after being diagnosed with mtss, both patients’ posture was evaluated using the myk postural analysis to identify and treat the primary nerve root dysfunction (i.e., s1). each patient received a total of six myk treatment sessions over a two-week period. treatment included manual stimulation via tactile feedback of each muscle innervated by the primary dysfunctional nerve root. treatments were performed bilaterally with alternating patterns of 4-10 passive and active movements. implementation of manual therapy resulted in long-term, full resolution of symptoms without modifying or restricting athletic participation. both patients reported a decrease in pain and an increase in function across six treatment sessions without curtailing activity. manual therapy techniques such as myk may be a suitable treatment option for physically active patients with mtss. the outcomes of this case report suggest that myk may help improve and ultimately resolve mtss pain and dysfunction in patients involved in weight bearing physical activity. future studies should continue to examine the effectiveness of these techniques via randomized clinical trials. key phrases manual techniques, patient-reported outcomes, injury risk reduction correspondence dr. rodrigo e. martinez, florida international university, 11200 sw 8th street, ahc3-331, miami, fl 33199. e-mail: matinr@fiu.edu full citation martinez re, benitez-lopez e, larkin l. the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study. clin pract athl train. 2020;3(3):37-45. https://doi.org/10.31622/2020/000.3.3.6. submitted: january 15, 2020 accepted: april 31, 2020 introduction medial tibial stress syndrome (mtss), also known as “shin splints”, is a lower extremity pathology reported during repetitive weight bearing activities such as running 1-2 and other ballistic sports such as basketball, tennis and track and field.3 signs and symptoms include dull, aching or diffuse pain in the distal 2/3 of the posteromedial tibia.4 pain is usually absent during moments of inactivity, but will increase during physical activity, and palpation of the posteromedial tibia can elicit pain.5 conflicting etiologies and numerous predisposing factors make it difficult to identify a singular root cause.3 differences in pronation, plantar flexion, hip internal and external rotation, when compared bilaterally, are examples of intrinsic risk factors contributing to the development of mtss.3,6 imbalances in any of the aforementioned risk factors can alter mechanics along the lower extremity kinetic chain.3 with these subtle variations in posture, a patient may develop pain and experience decreased function. current conservative interventions (e.g., rest, ice, massage, stretching, strengthening) used to treat mtss address the patient’s local area of pain, but none focus on reducing intrinsic risk factors, specifically those that affect posture. a suggested approach to treatment is to view the body as a whole, emphasizing the need for a global assessment, as opposed to focusing on the local mailto:matinr@fiu.edu https://doi.org/10.31622/2020/000.3.3.6 the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 area of pain.7-8 the myokinesthetic systemtm (myk) is a global manual therapy treatment model developed by dr. michael uriarte. the treatment paradigm is designed to assess and balance the nervous system by treating the muscles innervated by specific nerve pathways.9 the purpose of myk is to evaluate postural imbalances and treat neuromuscular dysfunction as a method to restore allostasis, or homeostasis within reasonable fluctuation.9-10 once postural imbalances are identified, the clinician can provide a patient specific treatment to improve postural dysfunctions, while decreasing pain and restoring function. limited evidence exists on myk, however, previous published works include a comprehensive overview of myk, its positive effects on low back pain,11 disc herniations,12 chronic knee osteoarthritis,13 and mtss.14 identification and implementation of a treatment that not only addresses the physical manifestation of pain, but addresses potential contributing causes is needed. the purpose of this case report is to present two instances of competitive athletes diagnosed with mtss, who were treated successfully with myk. this study was approved by the institutional review board of university of idaho following the helsinki declaration. all participants signed an informed consent prior to their inclusion. patient information patient one a nineteen-year-old male club rugby athlete complaining of bilateral shin pain reported to a musculoskeletal pain clinic. previous history included mtss seven years ago with no other lower extremity injuries or complaints. the prior bout of mtss was of slow onset, aggravated only with repetitive activity (e.g., mile runs). pain subsided when the patient refrained from physical activity and felt no need to seek any other form of treatment. signs and symptoms of the new complaint included bilateral dull and diffused pain over the distal ⅔ posteromedial aspect of the tibia during physical activity and upon palpation. the patient had been experiencing pain for over a month, which progressed slowly from pain with running, to pain during and after activity, and finally to constant pain. upon questioning, the patient reported a gradual increase in physical activity, which included running on turf and concrete. the patient’s pain was measured by utilizing the numeric pain rating scale (nprs). at initial evaluation, the patient reported his worst pain was 7/10 bilaterally while running, best pain 0/10 while seated, and current pain 1/10 while walking. function was measured by the lower extremity functional scale (lefs) and disablement was assessed using the disablement in the physically active (dpa) scale. initial scores were 47/80 and 41/64, on the lefs and dpa scales, respectively. patient two a twenty-four year old female collegiate soccer athlete complaining of bilateral shin pain reported to her athletic trainer. the patient was otherwise healthy without current or past injuries to the lower extremity. the patient did not report a specific mechanism of injury; she stated running produced constant pain for the past four weeks with gradual worsening. the patient attempted to treat her symptoms with ice and stretching, reporting minimal to no improvement. the patient was initially evaluated mid-competition season with signs and symptoms that included aching and diffused pain along the distal ⅔ posteromedial border of both tibia during weight bearing physical activities (i.e., running), and pain with palpation. the patient's pain was measured with the nprs. at intake, her worst pain was 10/10 bilaterally while running, best pain was 0/10 at rest, and current pain 3/10 while walking. function was measured by the lefs and disablement was assessed using the dpa scale. initial scores were 59/80 and 36/64, on the lefs and dpa scales, respectively. intervention each patient was evaluated and treated at their respective clinics by a single clinician for the duration of their care. in both cases, an orthopedic examination was completed to determine the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 diagnosis per established guidelines,4 as outlined in table 1, and to rule out the presence of a stress fracture. physical impairments may result from postural compensations and/or dysfunctions within the nervous system, therefore, the myk postural analysis was used on each patient to assess and identify a primary nerve root dysfunction.9-10 the clinicians performed a static postural assessment by observing the patient’s upper extremities, torso, and lower extremities in standing, seated, and prone positions. the clinicians used the posture assessment chart (table 2) to connect postural imbalances to specific nerve root pathways innervating specific groups of muscles. the nerve pathway containing the greatest number of imbalances was identified as the primary dysfunctional nerve root at the time of assessment. treatment was performed on the primary dysfunctional nerve root as determined through the postural assessment.9-10 at intake, both cases’ postural assessments indicated the s1 nerve root as the primary dysfunction due to it having the highest number of associated imbalanced postures. the administration of one treatment took approximately ten minutes. treatment included manual stimulation of each muscle innervated by the s1 nerve root, applied bilaterally with alternating patterns of 4-10 passive movement repetitions immediately followed by 4-10 active repetitions. in theory, the passive motions (figure 1) are performed to clear muscle memory, followed by active movements (figure 2) to reestablish proper neuromuscular firing patterns.9 stimulation was applied during the passive and active muscle lengthening motions by using light or deep compressions, glides, or cross-friction. the combination of simultaneous movement and tactile feedback stimulates several ascending sensory tracts and improves communication between the cns and the muscles innervated by the corresponding nerve root. during each visit, both patients received a treatment session that consisted of two s1 treatment bouts. after each treatment bout, the patients walked for two minutes to allow the cns to interpret and adjust to the feedback received during treatment. a second s1 treatment was administered immediately following the twominute walk. the session ended with a second twominute walk. this treatment protocol was used at subsequent visits. discharge criteria was met after patients received a total of twelve myk s1 treatments completed in six sessions over two weeks. patients continued their sporting activities while undergoing myk treatments and through the 15-day follow-up. during this time, both patients refrained from additional therapy. outcome measures the myk posture analysis chart (table 2) was utilized to assess and log each patient's posture. additionally, patient reported outcomes measures collected that included the nprs, the lefs, the dpa scale, and the global rating of change (groc) scales. when a minimal amount of change needed to indicate importance to the clinician and patient, also known as the minimal clinical important difference (mcid) achieved, it was noted in table 3. the nprs is an 11-point scale, by which a score of zero indicates no pain and ten represents the worst pain imaginable, as perceived by the patient. a change in two points on the npr scale indicates an mcid.15 the lefs is a 20-item questionnaire used to assess a person’s ability to perform activities of daily living. each item is scored by the patient; a score of 4 indicates no difficulty with the listed task while a table 1. signs and symptoms used for mtss diagnosis (yates & white, 2004) pain history pain with activity lasting hours or days after activity. no history of paraesthesia. location pain along the posteromedial border of the tibia that was spread out over an area of 5 cm. palpation diffuse tenderness over the distal 2/3 posteromedial border of tibia. the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 table 2. the myokinesthetic ™ system postural assessment chart (uriarte, 2010) posture chart head lumbar spine flexed _____ (c1-t1) flexed _____ (l1-l5) extended _____ (c1-c3) extended _____ (l1-l2) rotated _____ (c1-t1) rotated _____ (l1-l5) laterally flexed _____ (c1-t1) laterally flexed _____ (l1-l2) scapula hip elevated _____ (c3-c4) flexed/ant rot _____ (l5-s1) depressed _____ (c3-c5) extended/post rot _____ (l1-l5) protracted (ab) _____ (c3-c5) abducted _____ (l2-l3) retracted (ad) _____ (c5-c8) adducted _____ (l4-l5) upward rotated _____ (c3-c8) laterally rotated _____ (l2-s1) downward rotated _____ (c3-c7) medially rotated _____ (l5-s1) shoulder knee flexed _____ (c5-c8) flexed _____ (l3-l4) extended _____ (c5-c8) extended _____ (s1) depressed (ab) _____ (c5-c8) externally rotated _____ (l2-l3, s1) elevated (add) _____ (c5-c6) internally rotated _____ (s1) medially rotated _____ (c5-c6) laterally rotated _____ (c5-c8) elbow ankle flexed _____ (c7-c8) plantar flexed _____ (l4) extended _____ (c5-c7) dorsiflexed _____ (s1-s2) everted _____ (l4) forearm pronated _____ (l4) supinated _____ (c6-t1) inverted _____ (l5-s1) pronated _____ (c5-c6) supinated _____ (l5-s1) wrist big toe flexed _____ (c6-c8) flexed _____ (l5) extended _____ (c5-t1) extended _____ (s1-s2) radial deviated _____ (c7-c8) abducted/varus _____ (s1-s2) ulnar deviated _____ (c6-c7) adducted/valgus _____ (l5-s1) thumb toes flexed _____ (c7-t1) flexed _____ (l5) extended _____ (c6-t1) extended _____ (s1-s2) abducted _____ (c8-t1) adducted _____ (c6-t1) finger flexed _____ (c6-t1) extended _____ (c7-t1) abducted _____ (c8-t1) adducted _____ (c8-t1) "reprinted from myokinesthetic system: lower body, lumbar, and sacral plexus, 4th edition, micharl uriarte), posture chart, pg. 146, 1998, with permission from elsevier ." the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 score of 0 identifies a task that is impaired. an mcid on the lefs is an increase of nine points.16 the dps scale is a 16-item questionnaire measuring impairments, functional limitations, disability and quality of life. a score ≤ 23 is expected in healthy individuals. an established mcid on the dpa scale of nine for acute injuries and six for persistent injuries is the standard used to indicate meaningful change.17 the groc is a visual 11-point scale used to quantify a patient’s perceived progress over time (e.g., improvements, digressions). an mcid for the groc is an increase of two points.18 outcomes were collected at regular intervals, as outlined in table 3, and patients were considered for discharge when meeting the following criteria: • nprs ≤ 2 average of best, worst, current, forty-eight hours after last treatment • lefs ≥ 70 figure 1: start and end positions for passive dorsiflexion figure 2: start and end positions for active dorsiflexion the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 • dpa scale ≤ 23 within the last forty-eight hours • groc ≥ 4 from intake to twenty-four hours after final treatment results patient one after the first week of treatment (three treatment sessions), the patient achieved mcid for the nprs, lefs, dpa scale, and reported a groc score of 3/5 (table 3). treatment continued for an additional week (three treatment sessions), until the patient experienced resolution of pain and met discharge criteria. minimal clinical important differences were achieved for all nrs, lefs, and dpa scale scores taken between intake and discharge, and a one-point increase on the groc at the time of discharge. at the fifteen-day follow-up, the patient remained pain free and continued to report improvements in function while remaining physically active. the patient reported no pain, no dysfunction, and a groc of five at six-month follow-up. table 3 contains initial, discharge and fifteen-day follow-up results of the postural assessment and how it changed over the course of treatment. patient two after the first week of treatment (three treatment sessions), the patient improved scores for the nprs, lefs, and dpa scale. minimal clinically important difference scores were achieved for both the nprs and dpa scale, and an initial groc score of 3/5 was reported (table 3). treatment continued for an additional week (three treatment sessions), until the patient’s symptoms improved and discharge criteria were met. minimal clinical important differences were achieved for all outcome measures between intake and discharge, and a one-point increase on the groc at the time of discharge. at the fifteen-day follow-up the patient continued to experience decreases in pain and reported improvement in function while remaining physically active and participating in soccer activities. at the six-month follow-up, the patient reported no pain, no dysfunction, and a groc of five. table 3 includes a summary of outcome measures across all time points, and postural assessment results for initial, discharge and fifteen-day follow-up. discussion in this case report, myk was effective in reducing pain and restoring function in an accelerated time frame for two athletes suffering from mtss, without being removed from activity. clinically significant results were achieved in both cases as measured by the nprs, dpa scale and lefs after treating exclusively with this technique. minimal clinically important differences were achieved in both cases across all collected outcome measures within three treatment sessions and again at discharge. minimal clinically important differences were achieved in both cases across all collected outcome measures within three treatment sessions and again at discharge. patient 1 remained pain free and self-reported excellent outcome measures at fifteen-day and six-month follow-ups. patient 2 was fully functional with soccer activities and met discharge criteria with an average nprs score of 1/10 at discharge. at the fifteen-day follow-up her average nprs score was 0.33/10, the patient reported her worst pain (1/10) was re-produced only during particularly vigorous soccer activity. at the six-month follow-up, patient two reported being pain free and fully functional. currently, clinicians have various options to treat patients with mtss. the evidence supporting traditional treatments (e.g., rest, ice, stretching, and strengthening exercises) is not promising, as pain and dysfunction recur with activity.2,19 the use of limited activity in combination with traditional treatments and a gradual return to play progression can take up to one-hundred days for the patient to report resolution of symptoms.19 rest alone can take up to six weeks until a patient is pain free.20 in this case report, two patients experienced significant improvement of symptoms in two weeks without activity limitations, and maintained long-term results. the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 a previous history of mtss has been linked to high recurrence rates.2,21-22 biomechanical, as well as structural abnormalities, are associated with lower extremity injuries causing dysfunctions along the kinetic chain.20, 23-25 a visual observation of standing postures can help detect anomalies such as genu varum, pes planus, hyperpronated foot, increased forefoot and rear foot arch, which has been associated as intrinsic risk factors in patients with mtss.20,25-27 the changes brought about by the myk treatment may have reduced intrinsic risk factors as they relate to posture and movement, resulting in long-term results. the patients experienced clinically significant improvements across all measures (i.e., selfreported pain, disablement, and function) meeting discharge criteria after two weeks of treatment; compared to rest alone that may take up to six weeks.20 at the end of the two-week treatment period, both patients experienced changes in previously dysfunctional postures. within the s1 nerve root, patient 1 corrected two dysfunctional postures and patient 2 corrected four. although patient 1 experienced fewer changes in posture, his pain was still eliminated. in patient 2, some postures within the s1 nerve root remained present at discharge, however enough postures were corrected to contribute to a combined positive effect on the system resulting in decreased pain and increased function. theoretically, the summation of positional variations could have reduced stress loads in the lower kinetic chain. additionally, changes may continue during activity as the cns configures afferent and efferent communication, correcting unbalanced patterns until allostasis has been achieved. corrected patterns may continue to have a positive impact on symptoms as the body table 3. patient outcomes patient one outcome intake 1 week discharge 15 day follow-up 6 month follow-up nprs ave.: worse current best 2.66 7 1 0 1 3 0 0 0 0 0 0 0 0 0 0 0 0 0 0 dpa scale 41 16 2 0 0 lefs 47 64 73 80 80 groc 3 4 5 5 myk posture s1 c5 c6 patient two outcome intake 1 week discharge 15 day follow up 6 month follow up nprs ave.: worse current best 4.33 10 3 0 1.66 3 2 0 1 3 0 0 0.33 1 0 0 0 0 0 0 dpa scale 36 9 6 0 0 lefs 59 66 77 80 80 groc 3 4 4 5 myk posture s1 c7/c8 c7/c8 nprsnumeric pain rating scale; dpa scaledisablement in the physically active scale; lefslower extremity functional scale; grocglobal rating of change; myk myokinesthetic *= minimally clinically important difference the effects of the myokinesthetic system on medial tibial stress syndrome in the physically active: a case study 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 continues to move, even if treatments are no longer administered. several limitations to the study warrant discussion. internal validity may have been compromised as patient 1 reported a self-bias. the patient stated that he did not believe the treatment would resolve his condition, which might have resulted in delayed healing and extended treatment time. external validity is low since these two patients may not be generalized to larger populations. further investigation into the effects of myk with rest on mtss is warranted. a larger-scale trial is needed to explore how postural changes affect the longand short-term effects of mtss. clinical bottom line the exact etiologies of mtss are unknown, but risk factors associated with this syndrome are numerous. conservative treatments focus on the local area of pain and do not address intrinsic risk factors. the myokinesthetic system, in comparison to traditional treatments, addresses postural risk factors to help prevent and/or decrease the signs and symptoms associated with the syndrome. as the number of risk factors decreased in both patients so did pain intensity. the results of this case report provide evidence of the short and long-term effects of myk to decrease pain in two patients presenting with mtss while remaining physically active. through this case report we found that posture indeed may be an outward expression of the nervous system, encouraging clinicians to consider addressing structural compensations. a full-scale investigation of myk is needed to determine its ability to effectively treat and address postural risk factors that lead to mtss. references 1. brewer rb, gregory am. chronic lower leg pain in athletes: a guide for the differential diagnosis, evaluation, and treatment. sport health. 2012; 4(2):121-127. https://doi.org/10.1177%2f19417381114 26115. 2. schulze c, finze s, bader r, lison a. treatment of medial tibial stress syndrome according to the fascial distortion model: a prospective case control study. sci world j. 2014. https://doi.org/10.1155/2014/790626. 3. hubbard tj, mullis carpenter e, cordova ml. contributing factors to medial tibial stress syndrome: a prospective investigation. med sci sport exer. 2009; 41(3):490-496. https://doi.org/10.1249/mss.0b013e3181 8b98e6. 4. yates b, white s. the incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. am j sport med. 2004; 32(3):772-780. https://doi.org/10.1177/0095399703258 776. 5. burrus mt, werner bc, starman js, et al. chronic leg pain in athletes. am j sport med. 2015; 43(6):1538-1547. https://doi.org/10.1177/0363546514545 859. 6. moen mh, bongers t, bakker ew, et.al. risk factors and prognostic indicators for medial tibial stress syndrome. scand j med sci sport. 2012; 22:34-39. https://doi.org/10.1111/j.16000838.2010.01144.x. 7. cook g. movement: functional movement systems: screening assessment, and corrective strategies. santa cruz, ca: on target publications; 2010. 8. total motion release. research & evidence 2018. https://tmrseminars.com/researchevidence. accessed november 19, 2018. 9. uriarte m. myokinesthetic system: lower body lumbar and sacral plexus. 4th ed. 2010. 10. brody k, baker rt, nasypany a, may j. the myokinesthetic system, part i: a clinical assessment and matching treatment intervention. int j athl ther train. 2015; 20(4):5–9. https://doi.org/10.1123/ijatt.2014-0131. 11. brody k, nasypany a, baker rt, may j. analysis of patient outcomes using the myokinesthetic system for the treatment of low back pain: a case series. j chiropr med. 2017; 16(2):111‐121. https://doi.org/10.1016/j.jcm.2017.01.002 . 12. hansen-honeycutt j, nasypany, a, baker, rt. treatment utilizing a muscle energy technique and the myokinesthetic system on patients https://doi.org/10.1177%2f1941738111426115 https://doi.org/10.1177%2f1941738111426115 https://doi.org/10.1155/2014/790626 https://doi.org/10.1249/mss.0b013e31818b98e6 https://doi.org/10.1249/mss.0b013e31818b98e6 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lopez eb, cox rw, et al. exploring treatment of medial tibial stress syndrome via posture and the myokinesthetic system. j bodyw mov ther. 2020; 24(1):82‐ 87. https://doi.org/10.1016/j.jbmt.2019.06.00 4. 15. krebs ee, carey sc, weinberger m. accuracy of the pain numeric rating scale as a screening test in primary care. j gen intern med. 2007; 22(10):1453–1458. https://doi.org/10.1007/s11606-0070321-2. 16. yeung tsm, wessel j, stratford p, macdermid j. reliability, validity, and responsiveness of the lower extremity functional scale for inpatients of an orthopaedic rehabilitation ward. j orthop sports phys ther. 2009; 39(6):468-477. https://doi.org/10.2519/jospt.2009.2971. 17. vela li, denegar cr. the disablement in the physically active scale, part ii: the psychometric properties of an outcomes scale for musculoskeletal injuries. j athl train. 2010; 45(6):630-641. https://doi.org/10.4085/1062-605045.6.630. 18. kamper sj, maher cg, mackay g. global rating of change scales: a review of 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76(2):237-244. 24. neal bs, griffiths ib, dowling gj, et al. foot posture as a risk for lower limb overuse injury: a systematic review and meta-analysis. j foot ankle res. 2014; 7(55). https://doi.org/10.1186/s13047-0140055-4. 25. reinking mf, austin tm, hayes am. exercise related leg pain in collegiate cross-country athletes: extrinsic and in intrinsic risk factors. j orthop sport phy ther. 2007; 37(11):670678. https://doi.org/10.2519/jospt.2007.2534. 26. bennett je, reinking mf, pluemer b, et al. factors contributing to the development of medial stress syndrome in high school runner. j orthop sport phy ther. 2001; 31(9):504510. https://doi.org/10.2519/jospt.2001.31.9.5 04. 27. sommer hm, vallentyne sw. effect of foot posture on the incidence of medial tibial stress syndrome. med sci sports exerc. 1995; 27(6):800-804. https://doi.org/10.1123/ijatt.2016-0013 https://doi.org/10.1016/j.jcm.2016.07.002 https://doi.org/10.1016/j.jcm.2016.07.002 https://doi.org/10.1016/j.jbmt.2019.06.004 https://doi.org/10.1016/j.jbmt.2019.06.004 https://doi.org/10.1007/s11606-007-0321-2 https://doi.org/10.1007/s11606-007-0321-2 https://doi.org/10.2519/jospt.2009.2971 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.1179/jmt.2009.17.3.163 https://doi.org/10.1179/jmt.2009.17.3.163 https://doi.org/10.1186/1758-2555-4-12 https://doi.org/10.1007/s12178-009-9055-6 https://doi.org/10.1007/s12178-009-9055-6 https://doi.org/10.2147/oajsm.s39331 https://doi.org/10.1186/s13047-014-0055-4 https://doi.org/10.1186/s13047-014-0055-4 https://doi.org/10.2519/jospt.2007.2534 https://doi.org/10.2519/jospt.2001.31.9.504 https://doi.org/10.2519/jospt.2001.31.9.504 manuscript type evidence-to-practice review 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review matthew s. panetta, scat, atc; carly j. wilson, scat, atc; and zachary winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract clinical outcomes are influenced by specific physical therapy interventions and several nonspecific factors associated with the healthcare professional, patient, and setting. the relationship built between patients and providers is based on treatment outcomes is referred to as the patient-provider interaction, which is a nonspecific factor. the purpose of this review was to investigate patients’ and clinicians’ perceptions of factors that influence patient-provider interactions. eleven different databases were accessed as potential research sources. thirteen qualitative studies were selected that examined the perceptions of non-specific factors which impact the patient-clinician relationship as well as the perceptions that healthcare providers and patients in musculoskeletal settings. out of these 13 articles, four common themes were found to influence the patient-provider interaction across all the literature selected for this review: clinician interpersonal and communication skills, clinician practical skills, individualized patient-centered care, organizational and environmental factors. articles for this study were only considered for review if they were published in english. this was stated as a limitation of the study, as well as the fact that this review only identified factors that are perceived to be related to patient-provider interactions. the review highlighted that patients and clinicians believe communication, interpersonal and practical skills, individualized care, and appropriate time and flexibility for patient care influence patient-provider interaction in musculoskeletal settings. these factors can serve as facilitators as well as barriers, depending on the level of intensity that they are implemented in the overall patientprovider interaction. athletic trainers, as healthcare professionals, need to be responsible for implementing patient-centered care concepts to encourage a healthy patient-provider interaction. key phrases organizational and personal outcomes & patient education correspondence dr. zachary winkelmann, university of south carolina 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation panetta ms, wilson cj, winkelmann zk. the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review. clin pract athl train. 2020;3(3):18-23. https://doi.org/10.31622/2020/0003.3.4. submitted: april 20, 2020 accepted: september 1, 2020 original reference and summary o'keeffe m, cullinane p, hurley j, leahy i, bunzli s, o'sullivan p, o'sullivan k. what influences patient-therapist interactions in musculoskeletal physical therapy? qualitative systematic review and meta-synthesis. phys ther. 2016;96(5):609–622. summary clinical problem and question sports medicine providers assist a wide range of patients with various degrees of musculoskeletal pain, guiding them through both the physical and psychological aspects of recovery and rehabilitation and often forming strong bonds along the way. healthcare providers who practice from a clinician-driven mindset will focus on identifying the diagnosis and prescribing interventions and rehabilitation for treatment.1 a clinician-driven mindset can often cause the provider to neglect important patient-centered care principles during the patient-provider interaction. the patient-provider interaction is defined as the sense of collaboration, warmth, and support between the patient and the clinician.2 previous research has focused on the impacts that patient-provider relationships have on treatment outcomes. the common theme identified in multiple studies has been a strong mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2020/0003.3.4 the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 bond between the healthcare provider and patient results in improved patient outcomes and recovery.3 positive patient interactions in therapeutic rehabilitation settings have been linked to reduced pain and disability, as well as higher treatment satisfaction.4 however, there is little known about what specific components ultimately help form and facilitate that crucial relationship between the patient and healthcare provider. the primary clinical question of this systematic review was to explore what factors hindered or assisted the relationship formed between sports medicine providers and their patients through the therapeutic rehabilitation process. the research team of this systematic review focused on the term “nonspecific factors”, defined as factors associated with provider, patient, and setting, to differentiate from more clinically related factors such as prescribed interventions. summary of literature previous literature selected for the guiding systematic review2 had to meet specific guidelines based on the clinical question. studies were included if they examined the opinions and viewpoints of patients or physical therapists in regard to the factors that proved to enable or serve as an obstacle to a positive interaction between patients and their provider.2 exclusion criteria was defined as primarily quantitative studies, literature that was not reported in english, studies looking at settings that did not fit musculoskeletal physical therapy or conditions, or measured only the strength of the relationship between healthcare provider and patient rather than the factors that established it in the first place.2 through quality assessment and screening, 13 articles were approved to be included in the systematic review and meta-synthesis with a total of 253 patients and 78 providers being interviewed. the guiding systematic review2 was the first to look at provider and patient perceptions of patient-centered care simultaneously. eight articles investigated clinician’s interpersonal and communication skills, ten articles evaluated clinician practical skills, seven articles examined individualized patientcentered care, and six articles investigated organizational and environmental factors.2 summary of outcomes the authors from the guiding systematic review2 examined the providers’ and patients’ perceptions of factors that influence patient-provider interactions in musculoskeletal settings. the authors examined the thirteen qualitative studies using the critical appraisal skills programme (casp) qualitative research assessment tool. the patient-provider interaction is also referred to as the relationship between patients and healthcare providers on treatment outcomes. the relationship is usually built from a sense of collaboration, warmth, and support between individuals and includes agreement on goals and interventions and overall attitudes among each other.2 this is essentially the basis of patient-centered care: ensuring that high quality, holistic care is being provided that includes the values and goals of the patient. findings and clinical implications from the 13 studies that were included, four themes were reported to influence patientclinician interactions (figure 1). the first theme encompassed clinician interpersonal skills, such as active listening, empathy, friendliness, encouragement, confidence, and nonverbal communication.2 physical therapist practical skills comprised the second theme, which focused on clinician practical skills, which included proficiency, training and ability to explain healthcare concepts to the patient. theme three was individualized patient-centered care, which was assessed by taking the patient’s opinion into consideration and individualizing the treatment. lastly, organizational, and environmental factors, the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 interpersonal and communication skills active listening allow patients to tell their stories without interruption encourgament provide accurate reassurance as a form of emotional support empathy consider how the patient's pain could impact their lives confidence find the balance between confidence and arrogance friendliness integrate a pleasant daily greeting for each patient non-verrbal communication consider your body language and the patien'ts mannerisms practical skills patient education provide simple and clear instructions. tell them the "why" of their treatment plan. clinician expertise and training engage in continuing professional development to keep developing technical abiltiies individualized patientcentered care individualized care make adjustments to each patient's care plan considering patient’s opinions and preferences do not ignore the patient's thoughts about certain exercises organizational and environmental factors time spend more time explaining the injury, illness, or treatment flexibility with patient appointments and care consider a line of communication for the patient to contact you about their home care plan after your evaluation figure 1. main influences of patient-provider interactions in musculoskeletal physical therapy. the first and second column are the main themes and traits from the study. the third column includes clinical bottom lines and suggestions to improving patient-provider interactions. the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 including the time and provider’s flexibility with care and appointments constituted the fourth theme. the four themes found in this study can be incorporated regularly into everyday athletic training clinical practice to enhance patientprovider relationships. theme 1 clinician interpersonal and communication skills there were several interpersonal and communication factors from both the patient and clinician that determined the quality of interactions, such as verbal and nonverbal communicative ability, empathy, and trust. active listening was the most common aspect stated by both patient and clinician.2 active listening is giving one’s undivided attention to the speaker while using appropriate non-verbal communication to assure the patient that they are being understood.2 clinicians who actively listen will reassure the patient that they are valued, which will strengthen the patient-clinician bond.5 the findings also showed a discrepancy between clinician and patient about encouragement for the patient during their appointment. patients that did not receive enough encouragement may feel less motivated to give their best effort during rehabilitation and improvement goals may not be met on time.6 from the thirteen articles included in the guiding review, there were zero reported statements regarding encouragement from the clinician’s stance. athletic trainers should practice active listening with non-verbal communication, along with sincere empathy and encouragement for the patient to optimize patient satisfaction. theme 2 – clinician practical skills the next theme focused on the practical skills of the clinician. healthcare professionals and patients share the belief that healthcare expertise was crucial to the development of a strong patient-clinician relationship.2,6 clinician expertise encourages patients to develop trust and reliance with the clinician, strengthening the patientprovider interaction.2 clinicians stated that continuing education and skill development were important to the maintenance of the patientclinician relationship. patients highly valued a provider who could easily explain the patient’s problem, how the provider could help them, and why the provider was prescribing specific exercises in their rehabilitation.2,7 the concept of patient education can relate directly back to athletic training, where the athletic trainer is on the front lines of sharing and disseminating information to the patient on their diagnosis and rehabilitation plan while avoiding medical jargon. athletic trainers should address health literacy and assist patients in their capacity to process and understand their health conditions. patient education with clear explanations can help the patient feel more comfortable with their rehabilitation protocol and clinician’s decision making.2 athletic trainers share this priority for developing and maintaining clinical competency and have expressed a professional desire for more research to be done in focus group sessions for the prioritized research agenda for the athletic training profession organized by the strategic alliance research agenda task force.8 theme 3 individualized patient-centered care patient-centered care is the practice of being “respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”9 patients highlighted the importance of individualized patient care and taking into consideration patients’ opinions and preferences in regards to the patient-provider relationship2, stating that they found it annoying when their clinician ignored their preferences and felt that it diminished the overall interaction.5 patients appreciated when their clinician made an effort to adjust or adapt their rehabilitation in relation to their inability to complete a task, which positively affected the patient-provider relationship.2 this can easily relate to the the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 profession of athletic training. athletic trainers are providers with the unique opportunity to work with patients from initial injury to final discharge. throughout this process, the athletic trainer should tailor the patient’s rehabilitation to their functional goals and personal preferences to facilitate patient engagement and commitment. theme 4 organizational and environmental factors a healthcare professional’s lack of organization regarding the amount of time given to patients and appointment flexibility created a general dissatisfaction for patients.2 athletic trainers may be limited in their amount of time for patient care. in this guiding review, both patients and providers stated that allowing patients appropriate time to explain their problem and discuss their treatment was essential to maintaining a positive patientprovider interaction.2 it may be beneficial for the provider to be proactive and plan out each patient’s rehabilitation and main points of discussion prior to seeing them, as well as being flexible. however, only one healthcare provider in the guiding review stated that flexibility with patient appointments and care was important, compared to five patient statements. patients expressed appreciation towards clinicians who accommodated patient care and appointment scheduling based on their needs.2 athletic trainers work with a variety of patient populations who also have busy schedules that have to be worked around to fit in rehabilitation appointments. to reduce the feeling of being rushed and increase the patient’s satisfaction, athletic trainers should outline the allotted time available for the patient’s session at the beginning of the appointment.10 by implementing patient-centered care techniques into appointment scheduling, athletic trainers can maximize the use of their time and convey that the patient’s time is just as valued. clinical bottom line the guiding review concluded that healthcare professionals and patients believe that communication and interpersonal skills, practical skills, individualized care, and organizational and environmental factors have influences on the relationship developed during the rehabilitation for musculoskeletal injuries. furthermore, there is a difference between clinicians and patients about the value of patient education. patients rated their own education of their rehabilitation as highly important to the facilitation of the patientprovider interaction, however clinicians rated it low in value. patients primarily felt importance in active listening, patient education, individualized rehabilitation, and encouragement from their clinician. clinicians that take the time to actively listen and provide individualized care are much more likely to develop stronger interactions and relationships that may promote rehabilitation outcomes.2,5-7 scheduling out a block of time during the day for one patient to come in while preventing interruptions from other individuals can show the patient that the clinician has their undivided attention for communication and rehabilitation.5,6,11 patients value their feelings and beliefs regarding their care planning. similarly, athletic trainers’ value their own time and effort that they put into treatment and rehabilitation with their patients. patients in the guiding review reported strong values in education from the clinician. athletic trainers with a sufficient understanding of the injury and patient’s goals can enhance the patientclinician interaction through patient-centered care tactics. gaining patient insight can be accomplished by asking what questions or worries the patient may be having about their rehabilitation process. athletic trainers should also work on creating a habit in providing clear explanations of their responsibilities and duties with the patient when creating goals and decision making with certain interventions. the guiding review also observed that patients reported that encouragement from their clinician was important, the value of patient-provider interactions in orthopedic settings: an evidence-to-practice review 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 even though the clinician did not see any value in this factor. encouraging patients through their rehabilitation exercises demonstrates a deeper level of care and emotional support, which aligns specifically with patient-centered care principles. the evidence from this review supports clinician interpersonal and practical skills, individualized care, and organization factors as influences that can cultivate the patient-clinician relationship. references 1. bensing j. bridging the gap: the separate worlds of evidence-based medicine and patient-centered medicine. patient educ couns. 2000;39(1):17-25. https://doi.org/10.1016/s07383991(99)00087-7. 2. o’keeffe m, cullinane p, hurley j, et al. what influences patient-therapist interactions in musculoskeletal physical therapy? qualitative systematic review and meta-synthesis. phys ther. 2016;96(5):609-622. https://doi.org/10.2522/ptj.20150240 3. rathert c, wyrwich m, boren s. patientcentered care and outcomes: a systematic review of the literature. med care res rev. 2013;70(4):351-379. https://doi.org/10.1177/1077558712465 774. 4. ferreira p, ferreira m, maher c, refshauge k, latimer j, adams r. the therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. phys ther. 2013;93(4):470-478. https://doi.org/10.2522/ptj.20120137. 5. potter m, gordon s, hamer p. the physiotherapy experience in private practice: the patients’ perspective. aust j physiother. 2003;49(3):195-202. https://doi.org/10.1016/s00049514(14)60239-7. 6. gyllensten a, gard g, hansson l, ekdahl c. interaction between patient and physiotherapist in psychiatric care – the physiotherapist’s perspective. adv physiother. 2000;2(4):157-167. https://doi.org/10.1002/pri.156 7. kidd m, bond c, bell m. patients’ perspectives of patient-centeredness as important musculoskeletal physiotherapy interactions: a qualitative study. physiotherapy. 2011;97:154-162. https://doi.org/10.1016/j.physio.2010.08.0 02. 8. eberman le, walker se, floyd r, covassin t, nolton e, valier a, phan k, weiss l, earlboehm j. the prioritized research agenda for the athletic training profession: a report from the strategic alliance research agenda task force. j athl train. 2019;54(3):237-44. https://doi.org/10.4085/1062-6050-37418. 9. richardson w, berwick d, bisgard j, bristow l, buck c, cassel c. crossing the quality chasm: a new health system for the 21st century: institute of medicine. washington: national academy press; 2001. https://doi.org/10.17226/10027. 10. smith r. patient-centered interviewing. 2nd ed. philadelphia: lippincott williams & wilkins, 2002. 11. hills r, kitchen s. satisfaction with outpatient physiotherapy: focus groups to explore the views of patients with acute and chronic musculoskeletal conditions. physiother theor pr.2007;23(1):1-20. https://doi.org/10.1080/0959398060102 3705. https://doi.org/10.1016/s0738-3991(99)00087-7 https://doi.org/10.1016/s0738-3991(99)00087-7 https://doi.org/10.2522/ptj.20150240 https://doi.org/10.1177%2f1077558712465774 https://doi.org/10.1177%2f1077558712465774 https://doi.org/10.2522/ptj.20120137 https://doi.org/10.1016/s0004-9514(14)60239-7 https://doi.org/10.1016/s0004-9514(14)60239-7 https://doi.org/10.1002/pri.156 https://doi.org/10.1016/j.physio.2010.08.002 https://doi.org/10.1016/j.physio.2010.08.002 https://doi.org/10.4085/1062-6050-374-18 https://doi.org/10.4085/1062-6050-374-18 https://doi.org/10.17226/10027 https://doi.org/10.1080/09593980601023705 https://doi.org/10.1080/09593980601023705 manuscript type quality improvement (pdsa) cycles 1 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 optimizing return to learn following a sport-related concussion: a quality improvement project dawn ranns, dat, atc1,2 & tamara valovich mcleod, phd, atc, fnata2,3 1limestone college, gaffney, sc; 2athletic training programs, and 3school of osteopathic medicine in arizona, a.t. still university, mesa, az abstract sport-related concussion (src) has been at the forefront of the sports medicine literature and media; however only recently has return to learn (rtl) been recognized as an important piece of a concussion management plan (cmp). a student’s successful transition back to the classroom following src depends on the support, resources, and effective communication among the multidisciplinary team. this project focused on the assessment of current faculty knowledge, attitudes, and beliefs about concussion, the development of an rtl policy, and implementation of educational resources at a division ii institution. this project ran for 6 months, using 2 cycles of the plan, do, study, act (pdsa) methodology. an initial survey demonstrated faculty have a poor understanding of the behavioral and emotional signs and symptoms of concussion and that there was insufficient communication regarding student-athletes with concussion between faculty, staff, student-athlete, and administration. initially, a rtl plan was developed and added to the existing concussion management plan (cmp), followed by the formation of a multidisciplinary concussion management plan (cmt). finally, a one time in-person concussion education presentation was provided to faculty. quantitative results from the post survey and semi-structured face-to-face interviews revealed improved communication among cmt members. one-hundred percent of faculty believed the brochure and presentation were helpful when managing a student with src. faculty felt more knowledgeable and confident about academic adjustments and communicating with the cmt. similarly, qualitative results from the in-person interviews with 8 faculty members revealed knowledge, confidence, and communication greatly improved; however, participants recommend additional education and a faculty resource page for concussion materials. this project demonstrated improvement in communication and efficiency in notifying faculty following injury minimizing time lag in academic adjustments. the rtl policy and faculty concussion education represents a simplistic, sustainable resource that could be replicated to other colleges. key phrases policy and procedure development, risk management mitigation, collegiate and university patient population, sport-related concussion, return-to-learn correspondence dr. tamara c. valovich mcleod, a.t. still university, 5850 e. still circle, mesa, az 85206. e-mail: tmcleod@atsu.edu twitter: @tamaracvmcleod full citation ranns d & valovich mcleod tv. optimizing return to learn following a sport-related concussion: a quality improvement project. clin pract athl train. 2019;2(3):1-15. https://doi.org/10.31622/2019/0003.1. submitted: may 23, 2019 accepted: july 23, 2019 current model in 2017, the center of disease control reported the incidence of sport-related concussion (src) as 2.5 million a year.1 this injury is most common in persons ages 15-24 with a prevalence rate ranging from 16-24%.2 although src management has significantly improved in the last decade, return to learn (rtl) is a relatively new piece to concussion recovery. presently, only division i institutions are required to submit a formal written concussion management plan (cmp) to the ncaa that includes both rtl and return to play criteria (rtp). to date, rtl protocols have been based on limited consensus driven empirical data and their effectiveness and clinical implementation has not been widely assessed. this quality improvement project took place at a small private college, with an undergraduate enrollment of 2,595 students and approximately 850 student-athletes. the college is located in a suburban area that sponsors intercollegiate athletics at the ncaa division ii level. with large roster sizes, the addition of several new sports in the last five years, and a number of at risk sports including football, men’s and women’s soccer, men’s and women’s basketball, wrestling, acrobatics and tumbling, and men’s and women’s lacrosse, there was an increase number of https://doi.org/10.31622/2019/0003.1 optimizing return to learn following a sport-related concussion: a quality improvement project 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 reported src. in 2015-2016 there were 14 reported src, 2016-2017 12 reported src, 2017-2018 36 reported src, and 2018-2019 58 reported src’s. in the previous cmp, when a student-athlete suffered a concussion, the athletic training staff notified the academic dean who then informed the student-athlete’s professors a concussion had occurred; however, communication was often delayed or omitted either by athletic training staff or by an academic dean’s office. collegiate student-athletes often identify themselves directly by their achievements on the field as well as in the classroom, therefore the faculty perception is vital in identifying the recovery from src.3 faculty have the ability to positively or negatively impact a student’s recovery depending on whether they will provide classroom support. the willingness of the faculty may be subjective by their preexisting knowledge of concussion, cognitively, physically, and behaviorally, and their beliefs about concussion. while there is some evidence to suggest that short-term academic dysfunction occurs following sport-related concussion,4-7 these seem to resolve and not impact long-term academic outcomes, as reported through end of year grade point average.8 specifically, wasserman et al5 noted higher academic dysfunction scores in the initial week following concussion compared to peers with extremity injuries and swanson et al7 reported academic difficulty among students with vision symptoms, hearing difficulty, and concentration issues.7,9 furthermore, surveys of student-athletes found that 27-90%5 of students and parents reported difficulty completing homework or classwork during the recovery time following concussion.5 when recovery is prolonged, there is a greater impact on perceived health status, with adolescent athletes reporting deficits in healthrelated quality of life related to school and cognitive functioning.10 during this quality improvement project the athletic training staff noticed once an initial e-mail was sent to an academic dean following a src there was no further communication with anyone about the academic performance of the studentathlete. during the 2017-2018 academic year there were 36 src reported to the athletic training staff. thirty-three percent (n = 12/36) of student-athletes became ineligible for their sport during the recovery semester and 72% (n = 26/36) had a decrease in grade-point-average from fall 2017 to spring 2018. sixteen percent (n = 6/36) of student-athletes were placed on academic suspension or withdrew from the institution. this data is consistent with the literature.5,11 over the course of the year, no faculty reached out to athletic training staff concerning a student’s concussion or classroom needs. in addition, in reviewing the college policy for concussion management there was no information provided regarding rtl. therefore, an initial survey was conducted of the college faculty in regard to understanding of concussion. when the faculty were surveyed, 40% (n = 22/53) of respondents never received notification when a student-athlete they taught was diagnosed with an src (table 1). this lack of communication between faculty, administration, and/or healthcare providers does not follow best practices. in addition, student-athletes seldom received guidance and resources upon returning to the classroom nor does a healthcare provider follow-up with the student-athletes to assess progress in the classroom. faculty perception of student’s class attendance, quality of class participation or attentiveness, effort put forth on exams and assignments as well as not knowing a student has suffered an src could affect the recovery and the academic success of students. therefore, this quality improvement project focused on the assessment of current faculty knowledge, attitudes, and beliefs about concussion, the development of a rtl policy, and implementation of educational support to all stakeholders involved with the management of a student-athlete following src. optimizing return to learn following a sport-related concussion: a quality improvement project 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 pdsa cycle initially the author assessed the college faculty through the use of the university faculty knowledge, attitudes, and beliefs about academic adjustments for students with concussion survey to identify gaps in faculty knowledge about concussion and the academic adjustments. the survey is a modification from the validated beliefs, attitudes, and knowledge of pediatric athletes with concussion for (bakpac–at).12 written permission was given from the original authors of the survey. the survey was available to the faculty for 19 days, april 23 to may 9, 2018. following the completion of the survey the investigator analyzed the survey data to identify problems with the current system to facilitate the first pdsa cycle. the project team consisted of one author, who was a full-time faculty member of the institution and the faculty athletic representative, with perspectives of key figures academically with the faculty and athletically with the athletic department. following the assessment of the survey the plan was three-fold: 1. develop a standardized institution cmp, 2. develop a multidisciplinary cmt, and 3. disseminate the results of the baseline survey and implement concussion education to the faculty. following the development of standardized form for return to learn, a one-time concussion education presentation was developed for faculty, athletic staff, athletic training staff, student-athletes and the medical director for athletics. for the purposes of this qi project only faculty were assessed following the presentation. a cause and effect diagram illustrated in figure 1 was constructed based on the investigators’ assessment of faculty knowledge from the baseline survey. a process diagram was developed to capture the current table 1. faculty demographics baseline survey n % gender (n=52) male female did not respond 21 26 5 40 50 10 age (years) (n=42) 20-29 30-39 40-49 50-59 60-69 70-79 5 10 10 9 6 1 12 24 24 23 14 2 highest level of education (n=52) bachelor’s degree master’s degree doctoral degree 3 24 23 6 50 46 years of teaching experience (n=43) 0-9 10-19 20-29 30-39 40+ 17 12 6 4 1 40 28 14 9 2 level of schooling taught* (n=50) undergraduate post-baccalaureate – master’s level post-baccalaureate – doctoral level not a teacher 33 7 4 5 66 14 8 10 academic division (n=49) arts and letters social and behavioral science natural sciences professional studies education and physical education 18 11 10 6 4 37 23 20 12 8 additional roles filled (n=24) academic advisor dean department chair coach school counselor 21 1 6 1 1 88 4 25 4 4 *some faculty have taught in multiple levels optimizing return to learn following a sport-related concussion: a quality improvement project 4 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 1. cause and effect (“fishbone”) diagram optimizing return to learn following a sport-related concussion: a quality improvement project 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 concussion management procedure for a studentathlete who suffers a src. an additional process diagram was developed including the ultimate goal of operation following a src and the rtl that is currently used when a student-athlete suffers a concussion. both current and future institutional process diagrams are displayed in figure 2 and figure 3. implementation of the new flow chart in august 2018 has made the process more efficient by streamlining a student-athletes rtl and rtp, ultimately eliminates faculty’s need to reach out to someone at the intuition when a student-athlete returns to the classroom. it was clear by the initial assessment that faculty knowledge on concussion, academic adjustments, and collaboration between faculty and staff is limited. most faculty recognized a concussion is serious; however, they lacked knowledge about cognitive rest and limitations following a src or the ability to provide appropriate academic adjustments for students. it was hypothesized improving faculty communication with various stakeholders and identifying their role on the cmt and providing academic adjustments for students, faculty would be more likely to provide assistance figure 2. previous src flowchart to students and student overall success will improve when returning to the classroom (figure 1). pdsa cycle 1 following the baseline data collection from the initial university faculty knowledge, attitudes, and beliefs about academic adjustments for students with concussion survey and the cause and effect diagram it was identified that faculty lacked overall basic knowledge on concussion and applicable academic adjustments for students returning to the classroom following a src. plan in august 2018, all faculty attended a single concussion education presentation and received a brochure about the new rtl policy for studentathletes following a src. during the fall 2018 semester all student-athlete’s suffering a src reported to the cmt to be assessed for their individual rtl plan. faculty were informed via email of student-athletes who suffered a src within 24-hours of injury on the institutions concussion awareness form. student-athletes reported to the cmt bi-weekly for re-assessment until they are discharged from any rtl classroom adjustments. faculty received updated information via e-mail within 24-hours following each student-athlete’s appointment with the cmt as well as a discharge letter when the student no longer required adjustments in the classroom. from september to october 2018 faculty completed a post survey. preand post-survey results were then compared to asses any changes in the faculty’s knowledge, attitudes, and beliefs of src and academic adjustments. do the initial intervention incorporated a single concussion education presentation and brochure to the faculty that included information related to 1. basic concussion knowledge, 2. appropriate academic adjustments for the classroom, 3. personnel involved in the multidiscipline cmt, and 4. the eight stages of the rtl policy for the institution. in august 2018, all faculty at the optimizing return to learn following a sport-related concussion: a quality improvement project 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 institution were presented the concussion education and a concussion awareness brochure. from september 25 october 12, 2018 faculty completed the survey with modifications to the original university faculty knowledge, attitudes, and beliefs about academic adjustments for students with concussion survey to determine if change occurred. the results were analyzed to evaluate the effectiveness of the educational presentation and brochure. study a total of 157 faculty were e-mailed the survey, 45 responses, and 24 individuals completed the entire survey for a 15% response rate. generalized analysis of results considered only the results of the 24 complete surveys; however, individual question analysis assessed all available information. all faculty agreed the educational presentation was beneficial. a majority of faculty would prefer a variety of alternative education mode such as links associated to concussion, recorded webinars, live webinars, and in-person presentations. oddly, 43.48% (n = 10/23) of faculty would prefer not to receive any more information on concussion. faculty knowledge of symptoms associated with concussion improved in 11 of 22 symptoms, only 4 symptoms scored worse on the post survey. symptoms related to emotions conveyed the greatest improvement of all symptoms. faculty recognition of signs and symptoms of concussion is illustrated in figure 4. faculty knowledge on prevention, physical and cognitive sign and symptoms, treatment and management, rtl, and rtp increased in all categories. results of improvement for physical and cognitive signs and symptoms and rtl are illustrated in figure 5. more faculty were extremely knowledgeable and moderately knowledgeable in these areas than found in the baseline assessment. faculty knowledge about concussion and a better understanding of academic adjustments were the greatest improvement. when asked how often the care of concussed student-athletes were discussed between the faculty and the cmt 65% (n = 17/26) of faculty reported always, 23.08% (n = 6) almost always, and 26.92% (n = 7) often. this was a significant increase from 33% (n = 11/27) of faculty reporting in the same categories. communication improved between the faculty and the cmt. faculty indicated that they received information on injured or ill students more often in the post survey, 77% (n = 22/24), than reported at baseline 36% (n = 8/22) resulting in a 41% increase in communication. familiarity with academic adjustments also improved. initial baseline results indicate that 9% (n = 5/53) of faculty were not familiar, 43.40% (n = 23/53) minimally familiar, 35.85% (n = 19/53) were moderately familiar, and 11.32% were extremely familiar with academic adjustments. post-survey results found all faculty (n = 24) were either moderately familiar 58% (n = 14/24) or extremely familiar 42% (n = 10/24) with academic adjustments. there was a 10% increase of faculty who recognized the institution has an academic support team. faculty were also more likely to recommend academic adjustments to a student after the educational presentation. at baseline 33% (n = 17/53) of faculty responded they rarely to never recommended academic adjustments; however; in the post-survey, all faculty (n = 23) responded they always, almost always, often, or sometimes recommend academic adjustments. there continues to be a variety of responses in the post-survey when faculty (n = 16) were asked who is involved in the academic support team for concussion students. however, 100% of faculty surveyed recognized the cmt was part of the academic support team. some of the weakest areas of recognition were the nurse 44% (n = 7/16), team physician 25% (n = 4/16), teachers and disability services each at 44% (n = 7/16). faculty still do not fully know who the point person is to manage academic adjustments. percentages on the baseline and post-survey improved by 8%, only raising the score to 52%. this is an area that indicates further education and growth. optimizing return to learn following a sport-related concussion: a quality improvement project 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 act over the course of the fall semester there were 36 total src. with a large number of src in future pdsa cycles there needs to be more than one person in the cmt that facilitates concussion assessment following injury. initial, follow-up, and discharge paperwork to the faculty was time consuming and difficult to keep up with. allowing more individuals in the cmt to contribute to the assessment and documentation in the fall 2019 semester will allow some of burden to be lifted and more efficient communication may occur. continuing to educate the athletic trainers, coaches, and other healthcare providers on the institutions rtl policy will also improve awareness. in the fall semester student-athletes who suffered a src were still going to study hall, film, athletic practices, and weight lifting. continued education will improve faculty and staff awareness of student-athletes with increased symptoms during various activities and allow them to more confidently adjust activities that could hinder recovery. pdsa cycle 2 plan following the results of the post-survey the plan was to assess 8-10 faculty member’s comfort and satisfaction with: 1. the educational presentation, 2. the concussion awareness brochure, 3. the cmt, and 4. the eight stage rtl policy using a semi-structured face-to-face interview. the interview questions were a modification from the interview protocol used for the perceived outcomes of web-based modules designed to enhance athletic trainers knowledge of evidence based practice (table 2).13 written permission was given from the original author of the interview questions. the aim was to recruit 8-10 faculty members to achieve saturation. faculty members were selected for an interview if they had one or more student-athletes who sustained a src in a course fall 2018. do there were 18 src reported august october 2018 that impacted 28 individual faculty members at the institution. a total of 8 faculty members volunteered to be interviewed (males 3, females 5). all faculty members were given pseudonyms to maintain participant anonymity. demographics on the faculty interviewed are illustrated in table 3. the purpose of the in-person interview was to determine the effectiveness of an educational presentation and brochure on concussion management and academic adjustments following the rtl from a src. specifically, the aim was to assess faculty perceptions of whether the implementation of educational presentation promoted immediate changes in a classroom. study the results of the interviews revealed four underlining themes; 1. the knowledge gain and transfer from the presentation and brochure, 2. increased communication and positive impact for the students, 3. barriers in implementing academic adjustments, and 4. suggestions for future improvements. overall the faculty were pleased with the presentation and brochure. the majority thought that the education was eye opening when thinking about concussion and rtl. one faculty responded, “having the presentation in a handout so that individuals who are visual learners can follow along while the presentation is going can be helpful. additionally, having the brochure available both in a paper format and a digital format to refer back to, whether that’s an e-mail or on the website could be helpful for faculty for a quick reference.” optimizing return to learn following a sport-related concussion: a quality improvement project 8 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 4. baseline and post-survey faculty knowledge of concussion symptoms figure 5. knowledge of physical and cognitive signs and symptoms and return to learn at the initial survey and following the educational intervention. 0% 20% 40% 60% 80% 100% 120% pe rc en ta ge o f re sp on de nt s baseline faculty knowledge of concussion symptoms post survey faculty knowledge of concussion symptoms 0 10 20 30 40 50 60 70 80 90 100 pre physical signs/symptoms post physical signs/symptoms pre cognitive signs/symptoms post cognitive signs/symptoms pre rtl post rtl percentage of respondents extremely knowlegeable moderately knowledgeable minimally knowledgeable not knowledgeable optimizing return to learn following a sport-related concussion: a quality improvement project 9 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 table 2. interview protocol questions with probes 1. tell me a little about your background as a faculty member? 2. in what ways, if any, do you feel the presentation and brochure can be improved? 3. did the concussion presentation and brochure change your perception about concussion in any way? 4. do you feel that the concussion presentation and brochure had a positive or negative impact when a student returned to the classroom with a concussion? please explain. 5. what concepts, if any, did you take from the concussion presentation and brochure that you implemented in your classroom with students returning to school from a concussion? a. are there concepts you feel like you need more information on before you can implement? b. are there any barriers preventing you from implementing adjustments into your classroom? 6. do you feel that the communication has improved between various personnel when a student in you class has sustained a concussion? a. what about the return to learn process do you feel need to be improved? b. do you feel there are ways to further improve the communication between personnel and student? c. do you feel that you receive sufficient and timely information on the student who sustained a concussion as well as continued follow-up information throughout the process? d. do you feel confident in the students stage of rtl and the adjustments for the student each day? e. is there anything that you would improve or change in the rtl policy or communication? 7. are there any questions or topics i have not asked about that you would like to discuss? overall a majority of the faculty agreed they were more comfortable with making decisions in the classroom when one or more students returned following a src. the educational presentations made them more aware of the symptoms a student could experience in the classroom and the role of the faculty necessary for student with accommodations. faculty recognized that small adjustments to the classroom such as; turning the florescent lights down, providing paper copies of the notes, and closing the door to decrease outside noise increased the student’s attendance to class. one faculty states, “i think the biggest impact that i’ve benefited from is getting the update for each of my students so that if i have information that a student has to take short breaks, or if i need to dim the lights, or if a student has to wear sunglasses or a hat within the class to help them manage their symptoms.” communication among medical personnel, faculty, staff, students, and administration was recognized as a barrier when students are injured or ill. interview question 6 focused on faculty perception of communication across the institution. all agreed that communication among faculty, the cmt, and students has increased this year. faculty felt that students were being more proactive with their professors and notification of injury was being e-mailed with 24 hours of injury. faculty were more aware of student injury and recognized the need to provide academic adjustments. half the faculty agreed some sort of electronic information site would be helpful especially for faculty who only have 1 to 2 students return to their classroom following a src. one faculty agreed, “communication has increased tremendously. we were getting nothing before. i didn’t know who had a concussion. the new formula for getting those periodic reports is much improved.” most faculty agreed they were more aware of the student’s injury and received timely updates on the students throughout the process; however, they were not confident about academic adjustments with all courses they teach and would like to see more information related to rtl. all faculty members agreed the educational presentation and brochure had a positive effect on their ability to recognize the seriousness of concussion. one faculty responded “it helped more faculty members to realize that they needed to take concussion seriously. i think it helped to realize more of the symptoms that go with concussions, as well as some of the signs to look for. what i really appreciate is the increase in communication that’s come from the cmt because now i know more about those students that have optimizing return to learn following a sport-related concussion: a quality improvement project 10 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 table 3. participants demographics participant pseudonym sex experience as a faculty member at limestone primary teaching role method of instruction julian bailey male 1 year literacy library on-line classroom lora lane female 7 years computer science on-line/traditional vicky perkins female 16 years athletic training traditional day cheryl raines female 1 year english traditional day eva moore female 5 years english traditional day sara martin female 18 years biology/hs on-line/traditional alex lamb male 6 years strength & conditioning traditional day concussions as well as how they are progressing through the stages of rtl and rtp.” half the faculty interviewed found at least one barrier to implementing academic adjustments in a classroom this year when a student returned following a src. non-traditional courses that included science labs, discussion classes, activity classes, and on-line classes experienced that most difficulty with providing the student with academic adjustments necessary to attend classes. faculty agreed the educational presentation and brochure was a great first step to student success in the rtl following a src. however, the majority of faculty interviewed agreed it would be beneficial to have some sort of faculty resource page online they could refer to periodically. act the faculty interviews revealed that communication had improved however, faculty are still not comfortable with classroom adjustments. barriers to implementation included limited time and not knowing how to provide adjustments for course that are not taught as traditional day classes. improvements for future pdsa cycles will include education on additional resources available for faculty that teach nontraditional courses such as discussion class, on-line classes, and science labs. lessons and limitations during the 40 weeks of this qi project there were several changes occurring at the institution. the inauguration of a new president and a complete football staffing change both took place mid-year in january 2018. additionally, acrobatics and tumbling was added as a new ncaa sport for the fall 2018 and the athletic training staff were in the process of transitioning from paper files and sportswear to nextt software system. one lesson that was learned was that the timing of the survey is extremely important to have a good response rate from the faculty. unfortunately, the baseline survey was available to the faculty at a time when several other surveys were circulating through faculty e-mail. it also occurred at the end of the semester just before final exams. because faculty were not required to return to campus until the annual faculty staff meetings on august 16, 2018 the presentation was given after all fall sport student-athletes had already been practicing. however, the presentation was held before the first traditional day courses started. additionally, it was difficult to educate all faculty at one meeting because there are three methods of education at the institution; the traditional day program, on-line program, and off campus sites. most of the student-athletes take courses in both the traditional day and on-line program. there were only a few problems with academic adjustments for the traditional day program in discussion based classes and biology lab. however, it was difficult to provide academic adjustments for students that took on-line course that required the student to use their cell phone or computer to complete all homework, assignments, projects, and exams for the course. this is an issue that is still not resolved especially when a studentathlete had prolonged symptoms beyond the twoweek period. optimizing return to learn following a sport-related concussion: a quality improvement project 11 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 finally, faculty attendance at the concussion presentation and acceptance and implementation of the new rtl policy may be a limitation of this project. academic freedom in higher education protects the faculty in the classroom. faculty have the freedom to express their views through speech, written, or electronic communication without reprimand. academic freedom also protects faculty and students from punishment for disagreeing with administrative policies or proposals.14 faculty have the freedom to disagree with the new rtl policy for studentathletes returning to the classroom following a src. fortunately, concussion and mtbi fall under the americans with disabilities act which also protect the student.15 future education will provide faculty with additional long-term effects from src and the importance in providing students with academic adjustments as they recover. however, because of the high volume of stunt-athletes at the institution some faculty may become frustrated with the increased workload of accommodating a large number of concussed students. conclusions return to learn is still a relatively new addition to the concussion management plan with limited empirical evidence to support it. although it is unclear if concussion education has sustainable long-term effects on knowledge, attitude, and beliefs, there have been short-term preliminary results of knowledge gains. this qi project identified a lack of a standardized cmp that included rtl. this qi project identified a lack of a standardized cmp that included rtl. this problem has been identified in the literature at other ncaa institutions and has led to an increase awareness and recognition for the importance of cognitive rest following injury as well as quick notification of injury and academic adjustments for successful student outcomes upon return to class.3 at the college, this has hindered the development of a cmt, communication and notification to key stakeholders following injury, education about concussion to the staff, faculty, and administration, and proper academic accommodations necessary for student success. a university faculty knowledge, attitudes, and beliefs about academic adjustments for students with concussion survey was used initially to determine gaps with the faculty. following the survey results a new cmp was drafted including a rtl plan. these changes were implemented in fall 2018. in addition, an educational concussion presentation and brochure was provided to each faculty member. in october, 8 faculty members were interviewed to assess effectiveness of the educational concussion presentation and the user friendliness of the brochure and rtl plan in the classroom. finally, a post-survey was provided to determine improvements in the qi project. return-to-learn is a relatively new term in concussion management of student-athletes. this qi project provides insight related to faculty knowledge, attitude, and beliefs about src and suggests that a short-term education intervention can influence the level of communication across the campus. by providing an effective policy and line of communication and minimal changes to the environment we saw a culture shift among studentathlete’s faculty, and administration relationships related to classroom support. we are incorporating the new policy into daily practice and are sharing ideas and methods via e-mail, inperson, and during faculty meetings. during the 2018-2019 academic year there were a total of 58 src. these student-athletes will to be reassessed in the 2019-2020 academic year and monitored for any classroom support still needed. this qi project will continue to educate faculty on src and student-athletes classroom accommodated. further investigation could include evaluation of will look at improving student-athlete, athletic staff, and medical professional knowledge, attitude, and belief of src to improve the cmp with regards to the rtp and student success. references 1. mcavoy k, eagan-johnson b, halstead m. return to learn: transitioning to school and through ascending levels of academic support for students following a concussion. optimizing return to learn following a sport-related concussion: a quality improvement project 12 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 neurorehabilitation. 2018(preprint):1-6. https://doi.org/10.3233/nre-172381 2. heaps a. knowledge and experience of inservice, secondary and post-secondary teachers on mild traumatic brain injuries: return to learning in the classroom. 2018. 3. webbe fm. the handbook of sport neuropsychology. new york: springer publishing company; 2011. 4. moser rs, schatz p, jordan bd. prolonged effects of concussion in high school athletes. neurosurgery. 2005;57(2):300-306. https://doi.org/10.1227/01.neu.00001666 63.98616.e4 5. wasserman eb, bazarian jj, mapstone m, block r, van wijngaarden e. academic dysfunction after a concussion among us high school and college students. am j public health. 2016;106(7):1247-1253. https://doi.org/10.2105/ajph.2016.30315 4 6. ransom dm, vaughan cg, pratson l, sady md, mcgill ca, gioia ga. academic effects of concussion in children and adolescents. pediatrics. 2015;135(6):1043-1050. https://doi.org/10.1542/peds.2014-3434 7. swanson mw, weise kk, dreer le, et al. academic difficulty and vision symptoms in children with concussion. optom vis sci. 2017;94(1):60-67. https://doi.org/10.1097/opx.000000000 0000977 8. russell k, hutchison mg, selci e, leiter j, chateau d, ellis mj. academic outcomes in high-school students after a concussion: a retrospective population-based analysis. plos one. 2016;11(10):e0165116. https://doi.org/10.1371/journal.pone.0165 116 9. erin b w, zachary y k, scott l z, tracey c. epidemiology of sports-related concussions in national collegiate athletic association athletes from 2009-2010 to 2013-2014: symptom prevalence, symptom resolution time, and return-to-play time. am j sports med. 2016(1):226. https://doi.org/10.1177/0363546515610 537 10. mcleod tv, bay rc, lam kc, valier ars. the association between length of recovery following sport-related concussion and generic and specific health-related quality of life in adolescent athletes: a prospective, longitudinal study. j head trauma rehabil. 2019;34(1):e1-e9. https://doi.org/10.1097/htr.0000000000 000394 11. williamson cl, norte ge, broshek dk, hart jm, resch je. return to learn after sportrelated concussion: a survey of secondary school and collegiate athletic trainers. j athl train. 2018. https://doi.org/10.4085/1062-6050-23417 12. bacon cew, kay mc, mcleod tcv. athletic trainers' roles and responsibilities regarding academic adjustments as part of the concussion-management process in the secondary school setting. j athl train. 2017;52(10):937-945. https://doi.org/10.4085/1062-605052.7.02 13. welch ce, van lunen bl, hankemeier da, et al. perceived outcomes of web-based modules designed to enhance athletic trainers' knowledge of evidence-based practice. j athl train. 2014;49(2):220-233. https://doi.org/10.4085/1062-605049.2.14 14. poch rk. academic freedom in american higher education: rights, responsibilities and limitations. ashe-eric higher education report no. 4. 1993. 15. halstead me, mcavoy k, devore cd, carl r, lee m, logan k. returning to learning following a concussion. pediatrics. 2013;132(5):948-957. https://doi.org/10.1542/peds.2013-2867 https://doi.org/10.3233/nre-172381 https://doi.org/10.1227/01.neu.0000166663.98616.e4 https://doi.org/10.1227/01.neu.0000166663.98616.e4 https://doi.org/10.2105/ajph.2016.303154 https://doi.org/10.2105/ajph.2016.303154 https://doi.org/10.1542/peds.2014-3434 https://doi.org/10.1097/opx.0000000000000977 https://doi.org/10.1097/opx.0000000000000977 https://doi.org/10.1371/journal.pone.0165116 https://doi.org/10.1371/journal.pone.0165116 https://doi.org/10.1177/0363546515610537 https://doi.org/10.1177/0363546515610537 https://doi.org/10.1097/htr.0000000000000394 https://doi.org/10.1097/htr.0000000000000394 https://doi.org/10.4085/1062-6050-234-17 https://doi.org/10.4085/1062-6050-234-17 https://doi.org/10.4085/1062-6050-52.7.02 https://doi.org/10.4085/1062-6050-52.7.02 https://dx.doi.org/10.4085%2f1062-6050-49.2.14 https://dx.doi.org/10.4085%2f1062-6050-49.2.14 https://doi.org/10.1542/peds.2013-2867 optimizing return to learn following a sport-related concussion: a quality improvement project 13 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 3. current src flowchart optimizing return to learn following a sport-related concussion: a quality improvement project 14 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 3. current src flow chart (cont.) optimizing return to learn following a sport-related concussion: a quality improvement project 15 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 3. current src flow chart (cont.) abstract presentation 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 unique shoulder arthroscopies: snapping scapula syndrome and scapular nerve entrapment erica l. taylor, ms, lat, atc, otc; spero karas, md emory sports medicine, atlanta, ga full citation taylor e & karas s. unique shoulder arthroscopies: scapulothoracic bursectomy and spinoglenoid cyst excision. clin pract athl train. 2020;3(1):6-8. https://doi.org/10.31622/2020/0003.3. presented at the 3rd annual athletic trainers in the physician practice society meeting and conference, columbia south carolina. february 28-29, 2020 abstract anatomy review: the scapula provides the stable base for glenohumeral motion and provides origins and insertions for 17 muscles. the scapulothoracic (st) joint lacks synovial lining and cartilaginous interface. the anterior scapula glides over the thoracic wall between several bursal and soft tissue planes.1,2 the suprascapular nerve emerges from the superior trunk of the brachial plexus (c5, c6) and travels across the posterior triangle of the the neck of the scapula trough the suprascapular and spinoglenoid notches. the suprascapular nerve innervates half of the rotator cuff musculature, the infraspinatus and supraspinatus. snapping scapula syndrome (sss) occurs when the st articulation impinges on bony or soft tissue structures including a hooking or excessive angulation of the superomedial scapula or bursal inflammation.1,2,3,4 patients experience pain with overhead activities accompanied by palpable and/or audible crepitus. suprascapular nerve entrapment (sne) can occur at the suprascapular notch, affecting both supraspinatus and infraspinatus muscles or at the spinoglenoid notch affecting only the infraspinatus muscle.5,6,7 extravasation of glenohumeral synovial fluid, due to a torn posterior labrum, can cause a ganglion cyst to appear secondarily. a spinoglenoid cyst causes a patient to have atrophy of the infraspinatus, weakness with external rotation, and posterior shoulder pain or tenderness. patient a: the patient was a 30-year-old female. chief complaint of worsening left posteromedial scapular pain for 6 months with clicking, cracking, and popping of scapula. recent treatment included 4 months of physical therapy and st injection by outside md. injection provided significant relief and decreased crepitus. physical exam revealed audible and palpable posterior crepitus with active and passive rom, tenderness along posteromedial border of scapula. due to success of previous injection and current worsening symptoms, she consented for diagnostic scapulothoracic arthroscopy.1,2,3,4 positioned prone on wilson frame, max internal rotation/”chicken wing” positioning of arm, surgeon stands opposite surgical side.3,4 intra-operative findings included diffuse scapulothoracic bursitis and prominent superomedial scapular border that were addressed with a bursectomy and recession respectively. at 2 days post-op, she had no palpable/audible crepitus with 90° arom/prom and tenderness along scapula. physical therapy focused on rom and scapular stabilization. at 3 months post-op, she had no tenderness long medial scapular border and no recurrence of palpable or audible crepitus. discussion scapulothoracic arthroscopy/bursectomy: this procedure is indicated when there is pain at the superomedial border of the scapula with painful, audible and/or palpable crepitus that has responded well to injections but failed other conservative measures. advantages include easy visualization of st bursa and superomedial border of scapula https://doi.org/10.31622/2020/0003.3 unique shoulder arthroscopies: snapping scapula syndrome and scapular nerve entrapment 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 with minimal tissue disturbance.1,2,3,4 care should be taken to ensure superficial periosteal layer of superomedial scapula border remains intact. although long term results are limited, patients have improved outcome scores are 2 years postop with primary and revision procedures.2 injury to the chest well, thoracic cavity, and dorsal scapular nerve and/or artery is possible if portals are not made appropriately (<3m from medial border of scapula).3,4 patient b: the patient was a 39-year-old female. chief complaint of worsening right shoulder pain and weakness for 1 year with insidious onset and failed conservative measures including physical therapy, nsaids, and activity modifications. physical exam revealed marked weakness with external rotation, infraspinatus fossa atrophy and positive special tests including neers, hawkins, and external rotation lag. mri revealed posterior labral tear, spinolaminar labral cyst (2.7cm) extending into spinoglenoid notch, and edema within infraspinatus. study was otherwise normal. due to failed conservative treatment, the patient was consented for arthroscopic posterior bankart repair and spinoglenoid cyst decompression.5,6,7 cyst was decompressed with switching stick/shaver and posterior labral tear (10-6 o’clock) was repaired with ultra tape and 4 micro-raptor knotless anchors. given physician’s standard posterior bankart rehabilitation protocol which included 4 weeks in sling with abduction pillow. at 7 months post-operation, she has regained infraspinatus fossa bulk, significant strength on operative side yet continues to have decreased strength when comparted to uninvolved side. rom is equal bilaterally. discussion scapulothoracic arthroscopy/bursectomy: spinoglenoid notch cysts can be treated in several ways including physical therapy and/or nsaids, needle aspiration, labral repair, and cyst excision/decompression +/labral repair.5 when treated operatively, patients can be positioned in beach chair or lateral decubitus. the cyst can be viewed/decompressed in the subacromial or intra-articular spaces.5,6,7 in this case, the patient was in lateral decubitus and the cyst was decompressed intra-articularly. literature shows no recurrence of surgical decompressed cysts at 6 months post-op (n=21) versus 45% recurrence with needle aspiration (n=11).5,6 correspondence erica taylor, 10310 the grove blvd. baton rouge, la, 70810. email: etaylor225@gmail.com references 1. menge tj, horan mp, tahal ds, mitchell jj, katthagen jc, millett pj. arthroscopic treatment of snapping scapula syndrome: outcomes at minimum of 2 years. arthroscopy. 2017;33(4):726–732. https://doi.org/10.1016/j.arthro.2016.08.0 29. 2. tahal ds, katthagen c, marchetti dc. a cadaveric model evaluating the influence of bony anatomy and the effectiveness of partial scapulectomy on decompression of the scapulothoracic space in snapping scapula syndrome. am j sports med. 2017;45(6) 1276-1282. https://doi.org10.1177/03635465166877 55. 3. saper m, kaisk c, dietzel d. arthroscopic scapulothoracic decompression for snapping scapula syndrome. arthrosc tech. 2015;4(6):e631-636. https://doi.org/10.1016/j.eats.2015.07.00 2. 4. karas, spero. arthroscopic resection of the superior medial border of the scapula. vumedi.com. www.vumedi.com/video/arthroscopicresection-of-the-superior-medial-border-ofthe-scapula/. 5. piatt b, hawkins r, frit, r, ho c, wolf e, schickendantz m. clinical evaluation and mailto:etaylor225@gmail.com https://doi.org/10.1016/j.arthro.2016.08.029 https://doi.org/10.1016/j.arthro.2016.08.029 https://doi.org10.1177/0363546516687755 https://doi.org10.1177/0363546516687755 https://doi.org/10.1016/j.eats.2015.07.002 https://doi.org/10.1016/j.eats.2015.07.002 http://www.vumedi.com/video/arthroscopic-resection-of-the-superior-medial-border-of-the-scapula/ http://www.vumedi.com/video/arthroscopic-resection-of-the-superior-medial-border-of-the-scapula/ http://www.vumedi.com/video/arthroscopic-resection-of-the-superior-medial-border-of-the-scapula/ unique shoulder arthroscopies: snapping scapula syndrome and scapular nerve entrapment 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 treatment of spinoglenoid notch ganglion cysts. j shoulder elbow surg. 2002;11(6):600-604. https://doi.org/10.1067/mse.2002.127094 6. kim sj, choi yr, jung m, park jy, chun ym. outcomes of arthroscopic decompression of spinoglenoid cysts through a subacromial approach. arthroscopy. 2017;33(1):62-67. https://doi.org/10.1016/j.arthro.2016.05.0 34. 7. ghodadra n, nho s, verma, n, reiff s, piasecki d, provencher m, romeo a. arthroscopic decompression of the suprascapular nerve at the spinoglenoid notch and suprascapular notch through the subacromial space. arthroscopy. 2009;25(4):439-445. https://doi.org/10.1016/j.arthro.2008.10.0 24. https://doi.org/10.1067/mse.2002.127094 https://doi.org/10.1016/j.arthro.2016.05.034 https://doi.org/10.1016/j.arthro.2016.05.034 https://doi.org/10.1016/j.arthro.2008.10.024 https://doi.org/10.1016/j.arthro.2008.10.024 manuscript type abstract presentation 61 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 redeployment of athletic trainers during a pandemic james caiola, ms, lat, atc* *medstar health, washington, dc full citation caiola j. redeployment of athletic trainers during a pandemic. clin pract athl train. 2021;4(1):61. https://doi.org/10.31622/2021/0004.1.8. presented at the 4rd annual athletic trainers in the physician practice society meeting and conference, february 26-27, 2021. abstract before covid-19 was recognized as a global pandemic involving the united states of america in march of 2020, medstar health employed 40 athletic trainers (ats) in multiple settings. while ats worked in the traditional setting at 17 high schools, 2 universities, and with 2 professional teams in the baltimore, md and washington, dc area, they also have been used in nontraditional ways. they are used in the physician practice setting to manage clinic flow, evaluate patients and present to the physician, provide preand post-surgical patient education, and being an overall patient point of contact in a busy clinic. they have also been used in nontraditional ways with work as coordinators for research projects, helping to organize information and write grant proposals. community liaisons (cl), an additional at function in our system, are also a crucial and beneficial member of the medstar health sports medicine staff. there are 5 cl’s in the system ranging from working in locations such as the national headquarters of us lacrosse and the saint james sports complex, a commercial multipurpose sports training site, and on the frontline overseeing partnerships such as the maryland black bears and area boys and girls clubs. it has not been uncommon for employees within medical systems to be furloughed due to shifting clinic needs. no employees of medstar sports medicine have been laid off as a result of redeployment, they have been utilized in different areas. in these times, system ats have exemplified their versatility by being redeployed to call centers, facilitating patient contact with covid test results, working urgent cares shifts to do preop testing and help with patient flow in busy centers, and becoming contact tracers. this presentation will explore how medstar health sports medicine responded to covid-19. correspondence james caiola, 1120 20th st nw suite 115, washington, dc 20036 email: james.m.caiola@medstar.net https://doi.org/10.31622/2021/0004.1.8 mailto:james.m.caiola@medstar.net manuscript type disablement model case study 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 bi-lateral hand compartment syndrome secondary to autoimmune disorder in a former high school multi-sport athlete alyssa vaniman, ms, lat, atc *california state university, los angeles, los angeles, ca abstract patient is a 21-year-old female former multiple-sport athlete who has suffered from the development of multiple cases of compartment syndrome throughout their body. at the time the medical staff encountered the patient, they were diagnosed with bilateral hand compartment syndrome. an autoimmune disorder known as scleromyositis was diagnosed as the source of the multiple diagnosed cases of compartment syndrome. prior to surgical intervention, the patient was unable to complete everyday tasks as a student. as pressure within their hypothenar, thenar, and interosseous compartments grew, the patient was no longer able to complete everyday fine motor skill tasks. a post-surgical rehabilitation plan was developed and implemented to improve the patient’s dexterity, grip strength, and range of motion. the patient successfully regained strength and dexterity by 8-week post-surgical intervention. currently, the patient has not shown any recurrent signs and symptoms of compartment syndrome returning to any anatomical structure. however, it has been roughly four years since their diagnosis of scleromyositis, they are no longer on immune suppressants, and their primary care physician found no evidence of the autoimmune disorder. key phrases college and university patient population, diagnostic testing and physical examination: upper extremity correspondence alyssa vaniman, 11 s. barranca ave, west covina, ca 91791. e-mail: alyssa.vaniman@gmail.com. twitter: @thatladylyss full citation vaniman a. bi-lateral hand compartment syndrome secondary to autoimmune disorder in a former high school multi-sport athlete. clin pract athl train. 2021;4(1): 57-60. https://doi.org/10.31622/2021/0004.1.7. submitted: october 27, 2020 accepted: april 8, 2021. introduction according to the national institutes of health, approximately 24 million people in the united states suffer from an autoimmune disorder.1 in a healthy person, the immune system protects the body against disease and infection. however, in an individual who is diagnosed with an autoimmune disease, the immune system does not function properly, and wrongly starts attacking healthy cells. scleromyositis is a unique and very rare overlap autoimmune disorder. scleromyositis is classified as a cross-over disorder because the disease presents with both symptoms of scleroderma and myositis.2 scleroderma is characterized by excessive collagen production and storage within a person’s connective tissues.3 this excess collagen is coupled with inflammation of the muscles caused by symptoms of myositis. scleroderma can develop within different anatomical structures throughout the body.3 depending on where the increase in collagen production takes place, this can lead to the inability to compete in athletics or even complete tasks associated with daily life. due to the excessive amount of collagen production within the connective tissues paired with the significant amount of inflammation of muscle within the hand, the patient developed bilateral compartment syndrome of their hypothenar, thenar, and interosseous compartments. this inflammation and collagen production lead to the patient being unable to hold a pencil, drive, brush their hair, or compete in extramural athletics without severe pain. this particular patient had been managing developing compartment syndrome in multiple parts of their body without a proper diagnosis for years. the lack of answers from medical providers coupled with continued pain took a significant toll on the patient’s overall quality of life. patient informaiton patient is a 21-year old female college senior participating in extramural athletics. the patient was a former high school multi-sport athlete who participated in repetitive impact sports for mailto:alyssa.vaniman@gmail.com https://doi.org/10.31622/2021/0004.1.7 bi-lateral hand compartment syndrome secondary to autoimmune disorder in a former high school multi-sport athlete 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 multiple years (soccer, cross-country, basketball). the patient has a previous history of compartment syndrome in their anterior and superficial posterior compartment of the lower limbs as well as in the dorsal and superficial volar compartments of the forearms. treatment included 12 fasciotomies across the lower and upper extremities of their body in total over five years. the patient also has a previous history of endometriosis in addition to multiple cases of compartment syndrome. the medical team was introduced to the patient in the athletic training clinic after a formal diagnosis of scleromyositis was issued by the patient’s primary physician back home. following this diagnosis, the patient was referred to an immunologist and rheumatologist to rule out the differential diagnosis of carpal tunnel syndrome, median nerve compression at the elbow, ulnar or cubital tunnel syndrome, brachioplexus pathology, or spinal stenosis. the patient stated that proper diagnosis was achieved after a series of extensive blood work to diagnosis the autoimmune disorder and compartment pressure measurement to diagnosis the bilateral compartment syndrome of the thenar, hypothenar, and interosseous compartments. as an out-of-state resident, the patient was making numerous trips to their home state of wisconsin to get proper testing, followups, and formal visits with their primary physician and care team. the medical team was introduced to the patient after surgery to assist them with post-surgical rehabilitation. intervention to relieve the pain, diminished sensation, loss of grip strength, and dexterity, the patient underwent three simultaneous fasciotomies of the thenar, hypothenar, and interosseous compartments of both hands. when the patient first reported to the athletic training clinic, to the athletic training clinic, clinic staff (or whomever) conducted a preoperative evaluation. for the presurgical evaluation, the following assessment tools/diagnostic tools were used: sollerman hand function test 4, hand-grip dynamometer, manual muscle testing, goniometry, blood pressure, reflexes, myotomes, and dermatomes, pulse oximeter, heart rate, and hand and forearm girth measurements. because the patient would undergo anesthesia, medical staff chose to include vitals in pre and postoperative assessment to accurately monitor for adverse reactions following surgery. two weeks post-surgery, the patient returned to the athletic training clinic for re-evaluation. the patient underwent the same preoperative qualitative and quantitative testing, and soap (explained in parenthesis) notes were completed every two weeks to monitor the patient’s postoperative results. medical staff waited to implement the developed protocol until the patient was pain-free or 0/10 on a numeric pain scale, which was predicted to happen threeweeks post-surgery. due to pain limitations, the developed rehabilitation was not implemented until week four. bi-weekly assessments and nerve flossing exercises were recommended in the interim. at four weeks postoperative, the patient was pain-free and able to start a rehabilitation regimen. rehabilitation consisted of nerve flossing (ulnar, median, radial), passive and restive range of motion exercises of the wrist, 6-way wrist movements (flexion, extension, radial/ulnar deviation, supination, pronation), water cup pick up with various amounts of liquid, coloring in an adult coloring book with multiple writing implements, and the use of progressive resistive exercise putty. formal rehabilitation sessions took place once a week in the athletic training clinic where the majority of these exercises were performed. the patient was encouraged to color and complete nerve flossing multiple times a week. outcomes after surgical intervention, the patient’s nerve function fully returned after 5 weeks. the patient stated that their range of motion and strength bi-lateral hand compartment syndrome secondary to autoimmune disorder in a former high school multi-sport athlete 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 returned to functional levels 8-10 weeks postoperative. however, the patient stopped coming into the athletic training clinic for scheduled rehabilitation appointments after seven weeks due to patient graduating and moving out of state. the patient’s relocation also meant testing values and soap notes at four weeks and six-week postoperative were unable to be completed. however, medical staff maintained communication with the patient for postoperative follow-up. after the surgical intervention, the patient has not redeveloped any signs or symptoms of compartment syndrome in the hands. as of june 2020, patient’s previously diagnosed autoimmune disorder is asymptomatic without the use of immunosuppressant medication. the patient was closely monitored by their primary care physician upon returning home and continues to have no symptoms of compartment syndrome. discussion the diagnosis of the injury in this patient’s case was extremely complex. without a direct mechanism of injury and conflicting symptoms, the diagnosis remained unclear until the rheumatologist and immunologist confirmed with differential diagnostic testing. the patient and medical team also faced additional challenges during treatment: the patient’s status as an outof-state resident, lack of insurance coverage due to patient’s out-of-state status, and a lack of expertise in autoimmune disorders at the treatment facility. this patient’s case was unique with regard to epidemiology – the case presentation was individual and atypical. due to the complex nature of this case, medical professionals from various specialties were involved in the diagnosis, treatment, and rehabilitation of this patient. it is important to note that an accurate diagnosis would have been unlikely without proper referrals and the patient’s quality of life and functional capabilities would have continued to suffer. more importantly, without the proper referrals during the diagnosis, treatment, and rehabilitation phases the patient’s quality of life and functional capabilities would have continued to suffer. clinical bottom line when diagnosing a patient, referral for clinical lab testing, alternate diagnostic tools, and referral to the appropriate medical professional team could be the defining factors in proper diagnosis and treatment for your patient. athletic trainers are a valuable piece of the sports medicine team that work collaboratively with other medical professionals in diagnosis and treatment of illness and injury. this case serves as a great reminder that athletic trainers are a critical component of the healthcare team and often serve as facilitators for communication and collaboration among team members, ensuring the patient receives the highest possible level of care. references 1. the autoimmune diseases coordinating committee. u.s. department of health and human services; 2005. https://www.niaid.nih.gov/sites/default/ files/adccfinal.pdf. accessed july 7, 2020. 2. venables pj. polymyositis-associated overlap syndromes. br j rheumatol. 1996;35(4):305-306. https://doi.org/10.1093/rheumatology /35.4.305. 3. bhansing kj, lammens m, knaapen hk, van riel pl, van engelen bg, vonk mc. scleroderma-polymyositis overlap syndrome versus idiopathic polymyositis and systemic sclerosis: a descriptive study on clinical features and myopathology. arthritis res ther. 2014;16(3):r111. https://doi.org/10.1186/ar4562. https://doi.org/10.1093/rheumatology/35.4.305 https://doi.org/10.1093/rheumatology/35.4.305 https://doi.org/10.1186/ar4562 bi-lateral hand compartment syndrome secondary to autoimmune disorder in a former high school multi-sport athlete 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 4. sollerman c, ejeskär a. sollerman. hand function test: a standardised method and its use in tetraplegic patients. scand j plast reconstr surg hand surg. 2009;1995;29:167-176. https://doi.org/10.3109/0284431950 9034334. https://doi.org/10.3109/02844319509034334 https://doi.org/10.3109/02844319509034334 abstract disablement model case study 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 2 – october 2018 exercise dependence and shin pain in a division i cross-country runner: a case study allyssa k. memmini, ms, atc university of michigan, ann arbor, mi abstract the following case investigates insidious onset of shin pain in a division i female cross-country runner. though her initial evaluation revealed early onset medial tibial stress syndrome, the sequence of events that occurred immediately afterwards is what makes this case unique. as the studentathlete underwent lower extremity rehabilitation to increase her mileage, she reported that her pain had plateaued. the initial x-ray revealed a periosteal reaction of the posterior left tibia. after adhering to the treatment plan for four weeks, the student-athlete continued to report significant bouts of pain as demonstrated by the visual analog scale. a follow-up x-ray revealed a transverse fracture through the proximal tibia. it was discovered through teammates that she was exercising at the university’s recreation center for up to three extra hours per day, despite set limitations by the athletic trainers, team physician, and coaches. her roommate also confided in the coaching staff that there were instances of the student-athlete deliberately skipping meals, and even conducted bouts of binging and purging. the student-athlete was immediately removed from team activities and referred to the team physician, who reviewed her case and relevant medical history. further, she was referred to additional behavioral counseling for disordered eating, obsessive compulsive tendencies, and her idealization of weight and excessive exercise. although true exercise addiction is rare, the comorbidity rate in patients with disordered eating is clinically relevant. the exercise addiction inventory is a simple and reliable questionnaire for healthcare providers to utilize during pre-participation examinations as a way of identifying athletes who may have a related medical history, and greater risk of developing comorbidities. key phrases emotional wellness and mental health, comorbidities, college and university patient population correspondence allyssa k. memmini, university of michigan, 401 washtenaw ave. ann arbor, michigan 48109 e-mail: amemmini@umich.edu full citation memmini ak. exercise dependence and shin pain in a division i cross country runner: a case study. clin pract athl train.2018;1(2):4-8. https://doi.org/10.31622/2018/0002.2 submitted: august 6, 2018 accepted: october 4, 2018 introduction a division i female cross-country runner with a previous history of depression, anorexia, and bulimia nervosa presented with increasing left proximal shin pain at the beginning of winter training. initial evaluation revealed early-onset medial tibial stress syndrome, which was treated conservatively for two weeks with instrument assisted soft tissue mobilization, as well as intrinsic foot, gluteus medius and calf strengthening. despite defined parameters for cross-training, in addition to daily rehabilitation and treatment, her reporting of pain remained relatively high compared to her baseline levels at the onset of medical care. as cross-country is often defined as an aesthetic sport, this studentathlete experienced episodes of body dysmorphia, depression, disordered eating habits, and even unhealthy patterns of excessive exercise. at this time, the student-athlete was referred to our team physician, nutritionist, and behavioral psychology department for further evaluation. patient information patient: the student-athlete is a female crosscountry runner (age=20years; height: 1.91m; mass: 56.9kg). she had a previous history of bilateral tibial and metatarsal stress fractures that began as a freshman in high school and occurred intermittently until her senior year of college. she was consistently meeting with a psychiatrist through the institution for episodes of anorexia nervosa and bulimia, which initially began upon arrival to campus. the studentathlete’s parents were well-known ultramarathoners – sometimes running up to 80https://doi.org/10.31622/2018/0002.2 exercise dependence and shin pain in a division i cross-country runner: a case study 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 october 2018 100 miles a weekend which may have added additional pressure for her success. in terms of family dynamic, she would often report a distanced relationship between herself and her father, and a heightened desire to please her parents. although she has an extensive medical history specifically related to the female athlete triad, her parents would often minimize her injuries, such as blaming the reoccurrence of injuries on inconsistent wear of compression socks or inadequate turnover rate in her training shoes. differential diagnosis and evaluation the student-athlete presented with left shin pain of insidious onset. she denied night pain, including difficulty falling or staying asleep, and denied antalgic gait pain during the first few steps after awakening. when asked to point where the pain resides, she was able to locate the muscle belly of the tibialis anterior. she reported that it did not replicate the same pain that she experienced previously during her numerous stress injuries. in general, she reported the most discomfort while ascending and descending staircases when her ankle was positioned in full plantarflexion. she reported no difficulty completing activities of daily living, but reported that she could only run one mile before the symptoms became bothersome. the differential diagnoses list included: chronic exertional compartment syndrome, tibialis anterior contusion, tibial stress reaction or fracture, fibular stress reaction or fracture, and medial tibial stress syndrome. with continuation of rehabilitation and controlled training parameters, her reporting of pain remained moderately high. after an additional two weeks of rehabilitation, initial x-rays confirmed a left proximal periosteal tibial stress reaction, and she was again limited in weight-bearing training. approximately four weeks post-imaging, a follow-up x-ray revealed a complete transverse fracture through her left proximal tibia. body structure and function upon examination, she was tender to palpation along the muscle belly of the tibialis anterior and its insertion of the muscle onto the tibia, but did not present with edema surrounding the muscle belly, or effusion within the tibiofemoral joint. there were no other signs of trauma. a tuning fork was placed at her tibial tuberosity and along her distal tibial shaft to determine any areas of stress-related injury. she denied pain at all of the locations that the tuning fork was placed. the patient reported pain was a 4/10 measured with the visual analog scale. when compared bilaterally, she demonstrated full active and passive ankle and knee ranges of motion and were all within normal limits. manual muscle tests demonstrated weakness of the left tibialis anterior (4/5), gastrocnemius (4/5), medial hamstring (4/5) and gluteus medius (4/5). during functional testing, she was able to complete calf raises without discomfort, but noted localized pain with double leg hopping (forward/backward and side-side). activity and participation due to her medical history, the mileage assigned for this specific student-athlete was scaled back to 30-35 miles/week, in comparison to the rest of the team, which typically completed around 60 miles. as a high school runner, she was very successful at regional and state track and field championships. when she initially arrived at the university, she presented with a significantly smaller frame than when she was first recruited, thus leading the coaching staff to believe she was suffering from some form of disordered eating or possible overtraining. she was referred to mental health counseling the following week and continued to work with counselors until her junior year of college. environmental and personal factors she had a previous mental health history that included depression, anorexia nervosa, bulimia and most recently, suicidal ideation. the studentathlete’s parents were well-known for competing exercise dependence and shin pain in a division i cross-country runner: a case study 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 october 2018 in ultramarathons, and appeared unconcerned about the number of stress-related injuries that she had accumulated over time. interventions the physician and athletic trainers outlined a structured cross-training plan to maximally reduce the amount of force through her shins while maintaining her overall fitness. the studentathlete’s adherence to the treatment plan was demonstrated by completing rehabilitation at least three times during the week. despite consistent treatment sessions with the athletic trainers, her symptoms continued to worsen with specified training intervals. when the team physician asked her to clarify her symptom reporting, she reported lower pain thresholds compared to what she reported to her athletic trainers and coaching staff. she was to solely complete one workout per day for a maximum of 30 minutes on the bicycle, or 60 minutes in a pool setting. her training progression would begin with aqua jogging or supervised bike workouts, and then eventually to elliptical and anti-gravity treadmill training until she became asymptomatic for at least eight weeks. outcomes body structure and function: prior to her followup x-ray, she described having a “drop foot” sensation while walking to class. subsequent evaluation demonstrated knee joint effusion and edema at the proximolateral tibia. a neurological screen of the lower quarter was completed and proved to be negative. despite rehabilitation to strengthen her gastrocnemius and tibialis anterior, she still lacked full strength in comparison to the contralateral side (4/5 manual muscle testing). activity and participation based on her numerous referrals, and previous physical and mental health history, the athlete ultimately decided that it was in her best interest to dismiss herself from all team activities. she was immediately removed from activity and referred to our team physician, who then referred her to mental health counseling and nutrition staff. in order to ensure that she had full potential to return to a healthy lifestyle, she had access to the same medical treatment that was available to her while actively participating on the team. although she was no longer physically on the team, she remained active with the student-athlete community through an internship developed by the nutritional department. she volunteered her time by preparing post-practice meals, and setting up hydration stations throughout various facilities. she remained roommates with her previous teammates until her graduation the following spring. environmental and personal factors over the following weeks, the healthcare team was notified of the student-athlete completing numerous additional unsupervised cross-training sessions lasting between two to three hours at the university recreational center. furthermore, the student-athlete’s roommate confided in the coach that she observed her skipping multiple meals throughout the week, and was behaving similarly to previous episodes of binging and purging. even though there were several interventions between the student-athlete, coaches, and medical staff about the importance of compliance to the physician’s recommendations, she continued to complete additional workouts in secrecy. discussion: the literature reports an inconsistent prevalence of individuals suffering from exercise dependence (exd), ranging from 0.3% to 77%, yet the co-occurrence rate with persons diagnosed with anorexia nervosa is three times higher than other diagnoses of disordered eating.1-4 exd is often described as a manifestation of uncontrollable exercise, increased tolerance, and associated anxiety/ depression with withdrawal of activity.2-4 a exercise dependence and shin pain in a division i cross-country runner: a case study 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 october 2018 component of exd related to this patient specifically is continuance – the perpetuation of exercise despite comprehension of the potential to increase the physical deficits and interpersonal strains.4 populations commonly affected by exd include young women, high-performance athletes, and high achievers with associated body dysmorphia.4-6 although this patient presented with several red flags in relation to the female athlete triad, the effects of a possible underlying diagnosis of exd and additional biopsychosocial disorders on her initial shin pain make this case unique. a prominent strength in this case was the closeknit relationship between the athletic trainers, team physician, and coaching staff. by maintaining thorough communication, the entire staff was able to provide the student-athlete the help that she crucially needed. another strength was the willingness of her teammates to discuss her irregular eating and exercise patterns with the staff. since it was difficult to know when the patient was truthful in her responses, the advocacy of her teammates assisted in an efficient transition to referral. on the other hand, a significant limitation included minimal communication with the sports medicine staff and the mental health counseling center on campus. since the center is located outside of the athletic department, it was difficult for the athletic trainers to communicate their concerns and any crucial updates directly to the counselors. another limitation includes the inability to control the student-athlete’s activity outside of the athletic training room and track facilities. because she was able to walk, bike, and run anywhere on campus, she had greater capability to complete additional workouts, in contrast to someone who plays soccer or lacrosse and needs extensive equipment or teammates for activity. lastly, there were no patient-reported outcomes tracked throughout this patient case beyond subjective pain. however, the background and psychosocial factors that influenced this case are still evident, and can help other athletic trainers understand how family and social factors influence difficult patient cases. clinical bottom line: typical red flags in cases related to the female athlete triad include accelerated weight loss within a short period of time, dark and sunken orbitals, brittle nails, dissociation from team activities both on and off campus, and comorbidities such as depression, anxiety, and obsessive-compulsive disorder. although the diagnosis of exd is rare, there are a number of screening tools available for clinicians to utilize for the referral process should concerning histories present themselves. the exercise addiction inventory is a simple survey with significant reliability when paired with other disordered eating questionnaires.7 since the sports medicine staff did not utilize this scale with their current student-athletes, it is something to consider for future pre-participation screening, especially for student-athletes with relevant medical history. in general, athletic trainers should be well-educated about the long-term health risks of relative energy deficiency in sport, and employ supplemental resources when working with high-risk teams such as crosscountry, volleyball, and be aware of the effects related to aesthetic sports such as gymnastics, cheerleading, and swimming on athletes’ mental health and overall well-being. acknowledgements: the author would like to thank all the members of the care team for their contributions, guidance, and clinical recommendations in providing care for this student-athlete. references: 1. starcevic v, khazaal y. relationships between behavioural addictions and psychiatric disorders: what is known and what is yet to be learned? front psychiatry. 2017;8:53. https://doi.org/10.3389/fpsyt.2017.0005 https://doi.org/10.3389/fpsyt.2017.0005 exercise dependence and shin pain in a division i cross-country runner: a case study 8 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 1issue 2 october 2018 2. weinstein a, maayan g, weinstein y. a study on the relationship between compulsive exercise, depression and anxiety. j behavl addict. 2015;4(4):315-318. https://doi.org/10.1556/2006.4.2015.034 3. egorov ay, szabo a. the exercise paradox: an interactional model for a clearer conceptualization of exercise addiction. j behavl addict. 2013;2(4):199-208. https://doi.org/10.1556/jba.2.2013.4.2 4. freimuth m, moniz s, kim sr. clarifying exercise addiction: differential diagnosis, cooccurring disorders, and phases of addiction. int j environ res public health. 2011;8(10):4069-4081. https://doi.org/10.3390/ijerph8104069 5. scully d, kremer j, meade mm, graham r, dudgeon k. physical exercise and psychological well being: a critical review. br j sports med. 1998;32(2):111-120. 6. harris n, gee d, d’acquisto d, ogan d, pritchett k. eating disorder risk, exercise dependence, and body weight dissatisfaction among female nutrition and exercise science university majors. j behavl addict. 2015;4(3):206-209. https://doi.org/10.1556/2006.4.2015.029 7. griffiths m, szabo a, terry a. the exercise addiction inventory: a quick and easy screening tool for health practitioners. br j sports med. 2005;39(6):e30. https://doi.org/10.1136/bjsm.2004.01702 0 https://doi.org/10.1556/2006.4.2015.034 https://doi.org/10.1556/jba.2.2013.4.2 https://doi.org/10.3390/ijerph8104069 https://doi.org/10.1556/2006.4.2015.029 https://doi.org/10.1136/bjsm.2004.017020 https://doi.org/10.1136/bjsm.2004.017020 manuscript type evidence-to-practice review 67 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 clinical implications of telemedicine for surgical care: an evidenceto-practice review adam m. hollien, scat, atc; mary catherine avey, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract telemedicine is a newer concept in medicine that utilizes technological devices to provide care to patients. in a society already greatly advanced with technology, telemedicine is the new frontier in healthcare. implementing telemedicine into current practices will benefit both the patient and the provider. the technology utilized with telemedicine has demonstrated promise by decreasing patient travel time, decreasing lost time from work, increasing patient interactions, and increasing interprofessional collaboration. the cost of implementation is minimal compared to the cost savings that will be accrued from utilizing this technology. there are many specialty areas in healthcare where telemedicine can be implemented such as primary care, surgical, orthopedic, rehabilitation, and evidence-based research. an emerging setting for telemedicine is athletic training and sports medicine with potential to drastically change the profession for the better. many of the skills athletic trainers perform on a regular basis can be completed via telemedicine. regular use of telemedicine can provide benefits for the clinician, the patient, and the organization. using telemedicine expedites the speed at which care can be provided to aid in patient recovery by limiting restrictions of distance or time away from work, life, and sport. overall, telemedicine can advance the medical system by allowing a larger number of patients to have access to high quality health care similar to that of a face-to-face visit. key phrases patient education, healthcare information technology, preceptor training and development correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation hollien am, avey mc, winkelmann zk. clinical implications of telemedicine for surgical care: an evidence-to-practice review. clin pract athl train. 2022;5(1): 69-74. https://doi.org/10.31622/2022/0005.01.10. submitted: may 2, 2020 accepted: february 15, 2021. original reference asiri a, albishi s, madani w, el-metwally a, househ m. the use of telemedicine in surgical care: a systematic review. acta informatica medica. 2018;26:201. summary clinical problem and question the use of electronic information and communication technologies to provide and support health care started as simple audio-only consultations following the invention of the telephone in 1876.1 today, telemedicine has reflected the innovations of technology to provide health care utilizing a wide variety of virtual methods. access to care is an essential aspect of patient-based health care, and providers must have the ability to make contact with the patient, especially when a distance separates them.2,3 it was reported that transportation issues such as distance, and not owning a vehicle delayed medical care for 5.8 million americans in 2017.4 even when transportation is not an issue, the increasing costs of outpatient services inhibits access for about 1 in 10 adults.5 telemedicine allows many populations to benefit from health care interactions while maximizing time.6 for example, patients that have undergone surgery may experience functional impairments or may be prescribed opioids, both preventing them from operating motor vehicles which limits their ability to access providers.7 medical professionals can perform pre-operative assessment, postoperative care, and follow-up without the need for the patient to travel as they often include patient education, surgical wound checks, vital sign monitoring, or symptom assessments.7 utilizing mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.01.10 clinical implications of telemedicine for surgical care: an evidence-to-practice review 68 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 telemedicine for health care limits patient travel while saving time and money and broadening provider reach limited by physical location. 7 telemedicine can be used with, but is not limited to, video and tele-conferencing, mobile-phone images, text messaging, and electronic monitoring devices.7 many studies have investigated different aspects of telemedicine within specific subsets of surgical care, but none have looked at the use of this delivery method for surgical care from a larger perspective. therefore, the purpose of this evidence-based review is to explore the broad range of telemedicine for surgical care with a specific reflection on how the athletic training profession may have a role in the use and deployment of telemedicine in operative management. for athletic trainers, understanding the role and benefits of telemedicine is necessary for the potential future growth of the profession. specifically, telemedicine has the potential to impact the ease of communication with patients and the guidance of self-care initiatives for athletic trainers. summary of literature this guiding systematic review included 24 articles that assessed telemedicine use before, during, or following any type of surgery guided by the preferred reporting items for systematic reviews and meta-analyses.7 the articles included were mostly prospective observational studies, but also included retrospective studies, randomized control trials, and pilot studies. the studies reviewed the usage of various types of telemedicine technology including video and tele-conferencing, mobile phone, tablet applications such as skype, digital images, and text messages.7 within this guiding systematic review, three types of surgical protocols utilized telemedicine, including: pre-operative assessment, postoperative assessment, and conventional clinic replacement.7 articles in the review analyzed the comparisons between usual care and telemedicine. those that used some type of telemedicine pre-operatively utilized it for surgical referrals, diagnosis, review from other surgical teams, as well as at home consultation.7,8 comparisons between telemedicine and direct vision were analyzed for pre-operative means. post-operative telemedicine was utilized by providers to assess wounds and medical equipment from vascular surgeries, appendectomies, total joint arthroplasties, ambulatory surgeries, and orthopedic trauma.7 post-operative telemedicine also included use of at-home medical technology such as surgical drains, blood pressure monitors, and electronic medication trays.7 conventional clinic visits were replaced with telemedicine to address follow-up requirements for various surgeries, such as ileostomies, prostatectomies, and pediatric urology surgeries.7 analysis of how telemedicine compared to usual in-person visits were assessed for both post-operative and conventional clinic care. summary of outcomes the outcomes from the guiding systematic review identified significant benefits of using telemedicine for both the providers and patients.7 overall, the experience of using telemedicine in surgical care for the providers yielded benefits with the ease of transmission of information to other hospitals regarding pre-operative details from the original patient interaction.6,7 additionally, pre-operative surgical care performed using telemedicine for diagnostic procedures, specifically such as analyzing organ structure and function, had the same level of provider accuracy as assessments performed within a conventional on-site clinic.7 the experience for providers using both synchronous and store-and-forward telemedicine was positive. improved communications leading to reductions in unnecessary transfers and faster access to a specialist. finally, the providers also noted improvements with overall surgical care provided, clinical implications of telemedicine for surgical care: an evidence-to-practice review 69 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 based on fewer complications during surgery and a reduced mortality rate.7 the ability for the patient to conduct preand post-operative appointments from home saved them a trip to the healthcare facility, while also enhancing at-home care plan adherence and long-term outcomes.7 during the at-home care, patients utilized synchronous telemedicine through live video and mobile phone communication to monitor surgical wounds. moreover, patients used remote monitoring devices like an electronic blood pressure cuff and surgical drains for continuity of care with their providers.7 patients also noted a strong patient-provider connection using telemedicine that resulted in a faster adjustment medications as needed.7 findings and clinical implications according to the guiding systematic review, telemedicine was found to be useful in surgical care. the majority of studies assessed the use of telemedicine between providers and patients, while one explored the inter-hospital use of telemedicine.7 we believe the findings highlighted in the summary of outcomes section identifies that telemedicine has a place in the care of surgical patients by allowing patient education and continuity of providers from pre-operative care to discharge. the findings also suggest that the benefits of telemedicine are two-fold, with patients and providers both noting improvements in their work and in their health outcomes. based off the findings of this review, athletic trainers should continue to explore the implementation of telemedicine in various clinical settings. to get started with telemedicine in one’s clinical practice, technology and equipment must be obtained. previous research exploring interhospital use of telemedicine stated several limitations focused on the cost of telemedicine technology.7 in one study, the hospital systems believed implementing telemedicine would not save enough money to be significant for the overall cost of the system.7 however, the cost of technology to implement telemedicine has drastically decreased in the last decade, making it more affordable to health care providers and patients. for example, mobile phone applications and web browser platforms exists that are either no cost or low-cost alternatives to larger telemedicine systems, while telepresence robots are often seen in larger hospital systems. we recommend that athletic trainers attempting to introduce telemedicine explore these budgetfriendly options, such as doxy.me, for their daily use. it is important to note that as we explore costeffective options for telemedicine that we consider the privacy and security of the platforms. an aspect of care that differs from traditional faceto-face appointments is the privacy of the patient.7 previous research highlighted that athletic trainers, whether they were users or nonusers of telemedicine, were most concerned with the privacy of platforms when exploring telemedicine opportunities.9 additional precautions and policies should be implemented to reduce the threat of patient confidentiality being breached.7 encrypted servers and specific telemedicine rooms within the healthcare facility can be beneficial in providing private telemedicine patient encounters.7 many of the low-cost applications are compliant with the health insurance portability and accountability act (hipaa) rules, as well as the health information technology for economic and clinical health (hitech) act. platforms that are hipaa compliant such as doxy.me, thera-link, vsee, or zoom for healthcare should be used rather than non-compliant platforms like facetime, skype, and facebook live. after the initial cost for startup is considered, the guiding systematic review identified that longterm benefits may involve cost savings from other aspects of patient care. previous research analyzing costs of multidisciplinary healthcare clinical implications of telemedicine for surgical care: an evidence-to-practice review 70 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 team meetings between face-to-face and telemedicine methods identified that the actual cost per patient was more expensive with the use of face-to-face evaluations and telemedicine may serve as an alternative.10 while most, but not all, athletic trainers do not bill for their athletic training services, the cost-savings from using telemedicine meetings may come from a reduction in missed time from work or additional expenses such as driving. for example, outpatient services that were conducted using telemedicine in comparison to traditional in-person visits saved each patient an average of 31.2 miles and 39 minutes of travel time and $4.26 in travel costs.11 we suggest that athletic trainers consider the long-term cost benefit of adopting telemedicine from multiple facets of their patient care, as well as the expenses from the patient perspective when choosing to adopt telemedicine. the findings from the guiding systematic review highlighted improvements in the communication and collaboration of the healthcare team, as well as the patient’s involvement in the process. the use of telemedicine has the potential to expand the access to specialty physician care and healthcare options that may not be directly accessible to physical location barriers. the access to specialty physician care has a direct influence on the shared decision making that shapes the patient-centered care approach that athletic trainers hope to achieve. moreover, the connection of specialty care via telemedicine may allow the specialists to be more accessible. previous research identified that specialists only attended 15% of face-toface meetings compared to 100% attendance at telemedicine meetings.10 while it is surprising, the decreased rate of those specialist physicians attending face-to-face meetings was undoubtedly due to the burden of travel through direct and indirect costs. we believe that telemedicine has the potential to improve the efficiency of the specialist providers, like orthopedic physicians and neurologists for sports medicine, when consults are needed on difficult or timely patient cases. increasing the attendance of specialty care can improve the quality of the work-ups, as well as the overall patient satisfaction of the pre-operative education.10 methods similar to this can be transitioned to the athletic training facility as collaborating physicians are typically not readily accessible, especially in the secondary school setting. the access to an orthopedic physician via telemedicine can provide student-athlete patients with access to a diverse and multifaceted healthcare system. the integration of telemedicine at the secondary school, college/university, and professional sport settings allows for ease of scheduling and scheduling preferences for the patient and the stakeholders involved in the patient’s care plan. we believe that in-person collaborations between physicians and athletic trainers for patient care can often seem rushed, limited in number or pushed to a specific time (example: waiting till game day). time constraints for these physicians can be cut down by utilizing telemedicine visits to save travel time, as well as potentially increasing the number of appointments throughout the week.10,11 athletic trainers that experience difficulties with physician collaboration should explore telemedicine as a creative solution to enhance interactions. for the providers, standardization is needed to ensure that each patient telemedicine encounter is similar in experience. this requires training for the providers to learn how to use the system and provide care through a different medium other than face-to-face.7 the length of the telemedicine visits also varied compared to face-to-face visits.7 the initial telemedicine encounters were longer, but as the patient and clinician were more familiarized with the process, the appointment times decreased.7 state regulations should be reviewed prior to a telemedicine encounter to ensure the location of the meeting, and to ensure that procedures for informed consent and documentation are followed. providers should also prepare for and conduct the meeting with a professional approach, establishing a webside clinical implications of telemedicine for surgical care: an evidence-to-practice review 71 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 manner through empathy and eye contact with their camera. it is also essential that providers dedicate and organize a specific private area that is sufficient for telemedicine with adequate lighting and sound quality and a stable internet connection. we suggest that athletic trainers, regardless of athletic training facility size, dedicate a space such as their office to telemedicine encounters. clinical bottom line there are many options that make telemedicine possible for healthcare providers. in the current climate with an abundance of technology in our society, telemedicine is becoming a part of everyday practice. there are significant benefits of using technology to provide medical care including decreased travel time, decreased number of unnecessary visits, and ease of communication. telemedicine can be used in a variety of settings and for a variety of clinical reasons including wound care, surgical follow-up, and initial evaluation, all of which skills athletic trainers are qualified to do. specific to surgery, athletic trainers have a direct role in being there from time of injury to diagnosis and care planning, to pre-operative and post-operative care, and finally during return-to-activity and discharge of the patient. as athletic trainers are engaged in several practice settings, telemedicine for surgical care has the potential to improve the job duties and experiences for those in both traditional (secondary school and college/university) and non-traditional (physician practice and hospitals) settings. for example, follow-up appointments to monitor wounds post-surgery are common practice and can be provided via telemedicine.7 this method is respectful of the patient and provider’s time because these interactions are typically short.7 it is also important to note that most clinicians are already using telemedicine without even realizing it. when patients send pictures of rashes or postsurgical scars, the identification of the pathology and communication of next steps is technically telemedicine. athletic trainers can use telemedicine to communicate with patients who may not be able to show up to the athletic training facilities for multiple reasons such as being bedridden following surgery, taking prescribed opioids, and conflicting class schedules. telemedicine can also be utilized in many practical ways in the profession of athletic training, including wound checks and postoperative evaluations, but also with initial evaluations and therapeutic rehabilitation. additionally, the use of telemedicine allows for improved provider communication and collaboration with the patient or separately for general clinical advancement. telemedicine allows these meetings to happen despite time and location constraints. as athletic trainers, we are encouraged to improve our patient-centered approach to healthcare delivery. patientcentered care can be achieved with many platforms including telemedicine as it prioritizes patient comfort, needs, and improves the ease of communication. overall, the integration of telemedicine as a supplement to the practice of athletic training specifically for preand postsurgical care, as well as other routine daily practices, has the ability to enhance patient outcomes and improve the patient-centeredness of our interactions. references 1. challacombe b, dasgupta p. telemedicine the future of surgery. j surg. 2003;1(1):1517. https://doi.org/10.1016/s17439191(06)60004-6. 2. hong yr, samuels sk, huo jh, lee n, mansoor h, duncan rp. patient-centered care factors and access to care: a path analysis using the andersen behavior model. public health. 2019;171:41-49. https://doi.org/10.1016/j.puhe.2019.03.02 0. 3. douthit n, kiv s, dwolatzky t, biswas s. exposing some important barriers to health https://doi.org/10.1016/s1743-9191(06)60004-6 https://doi.org/10.1016/s1743-9191(06)60004-6 https://doi.org/10.1016/j.puhe.2019.03.020 https://doi.org/10.1016/j.puhe.2019.03.020 clinical implications of telemedicine for surgical care: an evidence-to-practice review 72 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 care access in the rural usa. public health. 2015;129(6):611-620. https://doi.org/10.1016/j.puhe.2015.04.00 1. 4. wolfe mk, mcdonald nc, holmes gm. transportation barriers to health care in the united states: findings from the national health interview survey, 1997-2017. am j public health. 2020;110(6):815-822. https://doi.org/10.2105/ajph.2020.30557 9. 5. claxton g sb, cox c. how does cost affect access to care? kaiser family foundation analysis of national health interview survey. 2019. https://www.kff.org/slideshow/costof-insurance-and-its-affect-on-access-tocare-slideshow/. 6. demartines n, otto u, mutter d, et al. an evaluation of telemedicine in surgery: telediagnosis compared with direct diagnosis. arch surg. 2000;135(7):849-853. https://doi.org/10.1001/archsurg.135.7.84 9. 7. asiri a, albishi s, madani w, el-metwally a, househ m. the use of telemedicine in surgical care: a systematic review. acta inform med. 2018;26:201. https://doi.org/10.5455/aim.2018.26.201206. 8. winkelmann z, eberman le. the confidence and abilities to assess a simulated patient using telemedicine. athl train ed j. 2020;15(2):132-147. https://doi.org/10.4085/1947-380x-6219. 9. connell sa, games ke, winkelmann zk. athletic trainers’ exposure to telemedicine influence perspectives and intention to use. athl train sports health care. 2020. https://doi.org/10.3928/1942586420200915-03. 10. stalfors j, björholt i, westin t. a cost analysis of participation via personal attendance versus telemedicine at a head and neck oncology multidisciplinary team meeting. j telemed and telecare. 2005;11(4):205-210. https://doi.org/10.1258/1357633054068 892. 11. paquette s, lin jc. outpatient telemedicine program in vascular surgery reduces patient travel time, cost, and environmental pollutant emissions. ann vasc surg. 2019;59:167-172. https://doi.org/10.1016/j.avsg.2019.01.02 1. https://doi.org/10.1016/j.puhe.2015.04.001 https://doi.org/10.1016/j.puhe.2015.04.001 https://doi.org/10.2105/ajph.2020.305579 https://doi.org/10.2105/ajph.2020.305579 https://www.kff.org/slideshow/cost-of-insurance-and-its-affect-on-access-to-care-slideshow/ https://www.kff.org/slideshow/cost-of-insurance-and-its-affect-on-access-to-care-slideshow/ https://www.kff.org/slideshow/cost-of-insurance-and-its-affect-on-access-to-care-slideshow/ https://doi.org/10.1001/archsurg.135.7.849 https://doi.org/10.1001/archsurg.135.7.849 https://doi.org/10.5455/aim.2018.26.201-206 https://doi.org/10.5455/aim.2018.26.201-206 https://doi.org/10.4085/1947-380x-62-19 https://doi.org/10.4085/1947-380x-62-19 https://doi.org/10.3928/19425864-20200915-03 https://doi.org/10.3928/19425864-20200915-03 https://doi.org/10.1258/1357633054068892 https://doi.org/10.1258/1357633054068892 https://doi.org/10.1016/j.avsg.2019.01.021 https://doi.org/10.1016/j.avsg.2019.01.021 abstract clinical outcomes research 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 range of motion changes in female elite swimmers throughout a competitive season mccall e christian, dat, lat, atc1 and lindsey e eberman, phd, lat, atc2 1missouri state university, springfield, mo; 2indiana state university, terre haute, in abstract upper extremity injuries are the most common injury in swimming athletes specifically in the collegiate setting. females in particular, are more likely to suffer these injuries when comparing to male collegiate swimmers. “swimmer shoulder”, a generic term for overuse shoulder injuries in the swimming population occurs with high rate and intensity of training. significant factors that have been found to contribute to this pathology are deficits in internal rotation, lack of stability, and increased demands on the shoulder. the aim for this clinical outcomes project was to evaluate changes in range of motion (rom) total arc of the shoulder, and patient-perceived function in female elite swimmers throughout a competitive season. shoulder total arc rom was measured passively with the student-athlete supine. a digital inclinometer was used to make it simpler for the clinician to assess rom on their own. the kerlan-jobe orthopedic clinic shoulder and elbow score (kjoc) was used to measure selfperceived upper extremity function in sport. it consisted of a set of demographic and participation questions followed by 10 visual analogue scale questions about upper extremity function during sport. upper extremity stability was also measured using the closed-kinetic chain upper extremity stability test (ckcue). results showed shoulder rom (total arc) restrictions occurred during times of increased training intensity and volume. when patients had smaller total arc measurements, the student-athletes reported lower kjoc scores for sport related function. there was an increase in rom at a time where intensity, and distance of training were decreased. overall upper extremity stability gradually improved over the course of a competitive season. key phrases clinician-rated outcome, college and university patient population, patient-reported outcomes correspondence dr. mccall christian, missouri state university, 901 s. national ave. prof 160b, springfield, mo 65897 816-835-3771. e-mail: mchristian@missouristate.edu twitter: @mchrist10 full citation christian me, eberman le. range of motion changes in female elite swimmers throughout a competitive season. clin pract athl train. 2019;2(1):11-18. https://doi.org/10.31622/2019/0001.3. submitted: august 31, 2018 accepted: february 18, 2019 introduction upper extremity injuries, specifically to the shoulder, neck, and back, are the most common injury in swimming athletes specifically in the collegiate setting.1,2 sallis et al.3 established that females sustained shoulder injuries three times more often and are five times more likely to sustain neck and back injuries than men. when these injuries occur, drop off in performance and participation can occur due to their debilitating nature. factors such as technique, yardage, training, and intensity are contributing factors to such injuries. physical factors like posture, technique, strength, and range of motion (rom) may also contribute to higher risk of injury.2 intrinsically, factors like integrity of the ligaments of the shoulder girdle, core and scapular muscle control, muscle imbalances in the shoulder and scapulothoracic region and extrinsically, factors like high-level, high-intensity training in and out of the pool, sports specialties, history of injury, and age all contribute to an increased risk of injury in swimming.2 the shoulder joint is complex, allowing for substantial mobility, while sacrificing stability. both the dynamic and static stability are reliant on the coordination of the rotator cuff muscle and complimentary ligaments.4 any movement, especially repetitive movement, requires coordination of these static and dynamic stabilizers to maintain proper joint position to avoid injuries derived from overuse. rom abnormalities have been associated with pain, decreases in performance, and the development of shoulder pathologies.5 “swimmer shoulder” is a pathology that occurs with high rate and https://doi.org/10.31622/2019/0001.3 range of motion changes in female elite swimmers throughout a competitive season 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february intensity of training,6 and is a generic term for shoulder overuse injuries in the swimming population.2,3,7 swimming athletes have unique mechanics and movement patterns and a better understanding of dysfunction and pain within this population is needed in order to develop prevention strategies to avoid overuse injuries. we aimed to understand rom changes and characteristics of disease through measures of rom, upper extremity stability, and changing perceptions of function over the course of a season. although there are many factors that could contribute, deficits in internal rotation, lack of stability, and increased demands on the shoulder have all been theorized to increase risk of injuries.8 also, previous research in collegiate overhead throwing athletes showed changes in rotational rom, over the course of a season.9 however, these changes and potential pathology that often come from excessive rom have not been explored in swimmers. the purpose of clinical outcomes research is to describe patientand clinician-reported outcomes measured in clinical practice. the measurements were part of clinical practice as a means of assessing various changes in student-athletes over the course of a season, to help the clinicians working with these studentathletes identify when they were at an increased risk for injury. patients twenty female swimmers (age = 19 ± 1 years, height = 85.78 ± 34.26 in., weight = 123.65 ± 41.40 lbs.) from a midwestern national collegiate athletic association division i institution were followed over the competition season. each student-athlete was cleared to participate in sport, per department guidelines that each student-athlete is required to be seen by various medical personnel as part of a mass preparticipation screening. all student-athletes continued to be active in their sport and training regimens throughout the season, including weight lifting, conditioning, whole body musculoskeletal injury prevention, and core-focused workouts. none of the student-athletes were excluded from measurement sessions due to injuries suffered before or during the competitive season. the main objective of the outcomes assessment was to observe changes over the duration of the season; one student-athlete was excluded from statistical analysis for absence from more than two measurement sessions. student-athletes who experienced injuries sought treatments and inventions on an individual basis with the athletic training staff. because outcomes research is a collection of outcomes in clinical practice, interventions were not controlled. outcomes measures measurement sessions occurred seven times over the course of the season by the same clinician. measures were collected monthly with the sessions lasting around one hour for the whole team. we collected measurements from the start to the end of the ncaa collegiate swimming season (lasting 7 months). the first collection (september) occurred before the first official meet and the last collection (march) was after post-season competition was complete. each collection was completed on a similar day and time each month in order to replicate the state of tissue. many factors could not be controlled such as activity outside of sport and voluntary additional practice. the day and time chosen each week month fell on a day that the team had only a single practice session. collection was done before the studentathletes participated in any team activities. on each measurement session day, one clinician completed glenohumeral total arc measurements and the closed-kinetic chain upper extremity stability test (ckcues) as well as asked the student-athlete to complete the kerlan-jobe orthopedic clinic shoulder and elbow score (kjoc) on a paper form. glenohumeral rom range of motion changes in female elite swimmers throughout a competitive season 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february glenohumeral rom can be measured in a variety of ways. the use of goniometry is the gold standard for measuring joint rom.10 due to the shoulder’s vast mobility and wide ranges of motion, finding the correct position to measure glenohumeral motion alone can cause some difficulties. collecting passive rom for the shoulder in external and internal rotation can sometimes cause difficulties for a single clinician. attempts to avoid inconsistency in student-athlete positioning can be tasking for clinicians while trying to move the shoulder through the rom with figure 1. digital goniometer measure of external rom the goniometer. a standard goniometer has two working arms that need to be positioned precisely with the body and the limb being measured in order to gather an accurate measurement. this becomes a process that can be challenging to recreate consistently. other options for measuring rom include digital inclinometer,11 bubble inclinometer, and video analysis.7 we used a digital inclinometer (saunders baseline digital inclinometer, the saunders group inc, chaska, mn) and a nylon fabric strap glued on to protective guards to attach the device to the forearm (figure 1). this aided the clinician to ensure proper positioning throughout the rom measurement. during measurement sessions, the clinician measured bilaterally for glenohumeral rom. we calculated total arc of motion by combining measures of external rom and internal rom while the patient was lying in the supine position. the student-athlete was positioned in 90° of glenohumeral abduction position as shown in figure 1. the practitioner passively moved the patient through the rom and end-range rom was decided based on the firm end-feel of the glenohumeral joint and the rise of the scapula off the table.10 closed-kinetic chain upper extremity stability test (ckcues) we measured upper extremity stability with the ckcues. the ckcues test is an easy-to-use clinical test that has been validated on a variety of populations. it requires very little equipment and a brief commitment to complete. the studentathlete was placed in a pushup position (figure 2) with their hands 36 inches apart (designated with tape on the floor), where they were asked to touch the supporting or weight-bearing hand with the unattached hand and alternate as many times as possible within 15 seconds. they completed this functional outcome measure three times for 15 seconds each.12,13 every touch was recorded as one toward the score for that trial. the patients completed a 45-second rest between trials. the average of the three trials are recorded as the final measure.13 although swimming is an open kinetic chain activity, this functional movement outcome measure mimics a number of other training activities such as dry land activities and strength programs. for healthy individuals, there is great intersession reliability.14 range of motion changes in female elite swimmers throughout a competitive season 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february figure 2. starting position for ckcues kerlan-jobe orthopedic clinic shoulder and elbow score (kjoc) the kjoc is a patient-rated outcome measure created for highly functioning individuals participating in sport. in comparison to other similar measures, the kjoc has less of a ceiling effect allowing for it to measure changes for higher functioning individuals.15 although it was originally created for throwing athletes, the wording of the questions do not address throwing directly, and is therefore applicable to all overhead athletes. the first part of the tool addresses history of injury and sport participation. the second part is a series of 10 visual analogue scale questions about current pain or dysfunction. the left side of the line represents high levels of pain or dysfunction while the right side indicates no pain or dysfunction. the tool is scored based on an average of the 10 visual analogue scale measure from 0 to 10 cm.15 research studies done on the kjoc in other high-level athletes demonstrate that this tool is more sensitive to athletes compared to other upper extremity patient-rated outcome tools.16 this same study found that there was a high predictability of lower scores if the patient missed practice or game(s) in the last year.16 the researchers also found that time of administration had no effect on the outcome.16 no minimal clinically important difference (mcid) has been established for this tool. this was also collected at each measurement session. results student-athlete demographic data was analyzed using means, standard deviations, frequencies, and percentages. means and standard deviations were calculated for the bilateral total arc rom, ckcues (average of three trials), and kjoc (total score) for each month (table 1). we analyzed the outcome measures using three separate repeated measures anovas and significance was set a priori at <0.05. we identified a significant main effect for time and total arc rom in the right arm (p<0.001), and specifically we identified that months one, two, and five deviated more than 5° below 180° associating restriction. months six and seven mean measures deviated 7° more than 180° suggesting possibly hypermobility. we also identified a significant main effect for time and total arc rom in the left arm (p<0.001). month one deviated 10° below 180° and month seven deviated 7° above 180° in the left arm. there was a gradual increase in ckcues touches through the duration of the outcomes assessment ranging from an average of 13.7 touches in the first month to 20 touches in the last month (p<0.001). the kjoc scores indicated high levels of function among the student-athletes over the course of the competitive season (mean = 88.16 ± 3.29 points [total score possible 100 points]). month two was significantly different compared to the other months with a mean score of 81.14 points (p<0.001). range of motion changes in female elite swimmers throughout a competitive season 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february 2019 discussion the primary purpose of this outcomes assessment was to evaluate changes in passive glenohumeral total arc, closed-kinetic chain upper extremity stability, and self-perceived function over the course of a competitive season in collegiate female swimmers. clinical outcomes research is meant to help clinician’s measure patientand clinician-rated outcome measures and to use those measures to improve their own clinical practice. sample size and techniques to control data collection are not necessary in clinical outcomes research and were therefore not utilized here. however, based on our data, we were able to monitor patients over the course of a season and future prevention programs may be developed. since the reliability of goniometry measurement is varied and often hard to complete with one clinician, we chose an alternative method using a digital inclinometer. methods of collection helped to free the hands of the clinician in order to assure proper passive rom and to make it more clinically applicable. the intra-rater reliability of the digital inclinometer is excellent (icc (3,k) =0.94-0.98).18 other ways to measure rom of the shoulder include bubble inclinometers and emerging used of cellphone application. advances in technology and future research on electronic goniometer could help in incorporate these measures into clinicians’ practice more frequently. changing methods are helping to ensure that measurements, especially in the shoulder, could be collected efficiently and independently. largely, we saw more variation on the right arm rom than the left. month one, two, and five had significant restrictions. restrictions in internal rotation rom has been connected to increased rate of internal impingement and posterior shoulder limitations.19 decrease of total arc greater than 25° increases the likelihood of a patient to experience an upper extremity injury by four times.5 another consideration when measuring total arc is humeral torsion. posterior fibers of the rotator cuff and posterior capsule have been hypothesized to change orientation with significant humeral torsion. this can affect rom measurements19 because the fiber changes effect placement of the humeral head on the glenoid over time, possibly causing injury. age also plays a factor in identifying these changes and addressing postural corrections can help aid in prevention. the ckcues is an easy and low-cost clinicianrated outcome measure used to assess upper extremity stability in a close-kinetic chain position. although closed-kinetic chain is not a characteristic of the swimming motion itself, dry land training and other conditioning activities are completed in the closed-kinetic chain postures.20 anecdotally, patients complained of more discomfort and table 1. monthly outcome measures month kjoc total arc (r) total arch (l) ckcues 1 88.4±16.1 172.7±14.6 169.7±11.4 13.8±2.5 2 81.1±19.9 169.1±13.0 177.1±9.4 15.6±2.9* 3 88.2±12.3 180.4±14.9 178.3±12.5 17.8±1.5* 4 88.9±13.7 180.2±18.4 178.6±11.8 19.2±3.2 5 88.8±14.8 175.3±16.5 170.3±15.4 19.4±2.7 6 90.9±13.2 188.7±12.0 187.0±16.9* 19.5±2.8 7 90.7±13.5 187.6±21.9 179.4±12.6 20.5±3.5 values are expressed in the mean ± standard deviation. *significantly different from previous month (p<.05). range of motion changes in female elite swimmers throughout a competitive season 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february strength deficits when completing closed-chain activities compared to swimming activities. in the previous study, active females, positioned in a kneeling stance, produced mean scores ranging from 27 to 31 touches. the men in the study, whose procedures matched ours, ranged from 24 to 27 touches on average.14 the mean touch counts for the student-athletes in this outcomes assessment was well below where other active females and males have scored despite positioning.14 a connection can be made that due to the physical adaptions in open-chain training, participating in closed-chain exercise is more difficult and therefore could possibly be a cause for injury risk or a reduction in performance. patients showing instability or dysfunction while completing this stability test should be considered for changes in dry-land training and an assessment of these deficits before returning to previous activity status. it is evident that there could be a learned effect when completing the test so frequently. the test-retest means found by tucci et al14, saw increases in all populations possibly justifying a similar improvement among the student-athletes in this study. in total, the ckcues may not be a great indicator of injury in open-chain activities but should be used to help guide closed-chain training. the kjoc was a tool developed for specific high functioning individuals participating in sport. it has sensitivity and reliability and is thought to demonstrate more subtle changes in high functioning individuals. the student-athletes we monitored scored 88 points for all seven months with a significant decrease in month two. measurements returned to the 88-point range after month two. kraeutler et al.21 reported normalized values in asymptomatic professional baseball players well above 90 points. out of 44 players, only seven reported scores below 90.17 our population was significantly below the 94.8 points reported previously.21 the differences could be attributed to the higher impact that swimming can have on upper extremity function, specifically where baseball involves the use of unilateral shoulder movement, the nature of swimming is bilateral. the sport level may also play a role in the kjoc scores. clinical application overall, we observed significant increases in total arc rom bilaterally, improved upper extremity stability, and consistent perceived function in collegiate female swimmers. future implementations of these measurements sessions should look to correlate mileage and training intensity to determine the relationships between these changes and workload. it is very likely that the student-athletes developed a learned effect to the upper extremity stability testing and those findings may not inform clinical practice; however, student-athletes did report pain doing this test, indicating that further exploration of swimmers and this test may be necessary. identifying risks of injury and making decisions on prevention strategies should incorporate many different factors such as rom, stability, and self-perceived function. similar clinician-rated outcomes research has examined rotational rom outcomes in the baseball and softball patients9 and patient-rated outcomes research with the kjoc scores in elite level baseball players.9 we found similar changes in rotation rom described, but found the student-athletes in this population scored substantially lower than elite overhead throwing athletes. although both populations are considered overhead athletes, swimming includes bilateral use of the upper extremity while throwing utilizes unilateral workloads and the difference in mechanics may require specific considerations when developing prevention strategies. prevention strategies for the shoulder and upper extremity in the literature are inconsistent. practice patterns for prevention among team-based care secondary or tertiary in nature. by conducting similar clinical outcome measures can provide information specific to the population and help to range of motion changes in female elite swimmers throughout a competitive season 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february guide changes in injury prevention on a primary level. although these are preliminary measures to understand changes over the course of a competitive swimming season, it has described the benefits and limitations of various patient and clinician-rated outcome measures. once more appropriate measures are identified for this population, future clinical outcomes research could be used to test prevention strategies. references 1. wanivenhaus f, fox aj, chaudhury s, rodeo sa. epidemiology of injuries and prevention strategies in competitive swimmers. sports health. may 2012;4(3):246-251. https://dx.doi.org/10.1177%2f19417381 12442132. 2. wolf br, ebinger ae, lawler mp, britton cl. injury patterns in division i collegiate swimming. am j sports med. oct 2009;37(10):2037-2042. https://doi.org/10.1177/0363546509339 364. 3. sallis re, jones k, sunshine s, smith g, simon l. comparing sports injuries in men and women. int j sports med. aug 2001;22(6):420-423. https://doi.org/10.1055/s-2001-16246. 4. weldon ej, 3rd, richardson ab. upper extremity overuse injuries in swimming. a discussion of swimmer's shoulder. clin sports med. jul 2001;20(3):423-438. https://doi.org/10.1016/s02785919(05)70260-x. 5. shanley e, rauh mj, michener la, ellenbecker ts, garrison jc, thigpen ca. shoulder range of motion measures as risk factors for shoulder and elbow injuries in high school softball and baseball players. am j sports med. sep 2011;39(9):19972006. https://doi.org/10.1177/0363546511408 876. 6. rupp s, berninger k, hopf t. shoulder problems in high level swimmers-impingement, anterior instability, muscular imbalance? int j sports med. nov 1995;16(8):557-562. https://doi.org/10.1055/s-2007-973054. 7. kevern ma, beecher m, rao s. reliability of measurement of glenohumeral internal rotation, external rotation, and total arc of motion in 3 test positions. j athl train. sepoct 2014;49(5):640-646. https://doi.org/10.4085/1062-605049.3.31. 8. beach ml, whitney sl, dickoff-hoffman s. relationship of shoulder flexibility, strength, and endurance to shoulder pain in competitive swimmers. j orthop sports phys ther. 1992;16(6):262-268. https://doi.org/10.2519/jospt.1992.16.6.2 62. 9. dwelly pm, tripp bl, tripp pa, eberman le, gorin s. glenohumeral rotational range of motion in collegiate overhead-throwing athletes during an athletic season. j athl train. nov-dec 2009;44(6):611-616. https://doi.org/10.4085/1062-605044.6.611. 10. awan r, smith j, boon aj. measuring shoulder internal rotation range of motion: a comparison of 3 techniques. arch phys med rehabil. sep 2002;83(9):1229-1234. https://doi.org/10.1053/apmr.2002.34815 . 11. mullaney mj, mchugh mp, johnson cp, tyler tf. reliability of shoulder range of motion comparing a goniometer to a digital level. physiother theory pract. jul 2010;26(5):327333. https://doi.org/10.3109/0959398090309 4230. 12. roush jr, kitamura j, waits mc. reference values for the closed kinetic chain upper extremity stability test (ckcuest) for collegiate baseball players. n am j sports phys ther. aug 2007;2(3):159-163. 13. goldbeck tg, davies gj. test-retest reliability of the closed kinetic chain upper https://dx.doi.org/10.1177%2f1941738112442132 https://dx.doi.org/10.1177%2f1941738112442132 https://doi.org/10.1177/0363546509339364 https://doi.org/10.1177/0363546509339364 https://doi.org/10.1055/s-2001-16246 https://doi.org/10.1016/s0278-5919(05)70260-x https://doi.org/10.1016/s0278-5919(05)70260-x https://doi.org/10.1177/0363546511408876 https://doi.org/10.1177/0363546511408876 https://doi.org/10.4085/1062-6050-49.3.31 https://doi.org/10.4085/1062-6050-49.3.31 https://doi.org/10.2519/jospt.1992.16.6.262 https://doi.org/10.2519/jospt.1992.16.6.262 https://doi.org/10.4085/1062-6050-44.6.611 https://doi.org/10.4085/1062-6050-44.6.611 https://doi.org/10.1053/apmr.2002.34815 https://doi.org/10.1053/apmr.2002.34815 https://doi.org/10.3109/09593980903094230 https://doi.org/10.3109/09593980903094230 range of motion changes in female elite swimmers throughout a competitive season 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 1 – february extremity stability test: a clinical field test. j sport rehabil. 2000;9(1):35-45. 14. tucci ht, martins j, sposito gde c, camarini pm, de oliveira as. closed kinetic chain upper extremity stability test (ckcues test): a reliability study in persons with and without shoulder impingement syndrome. bmc musculoskelet disord. jan 03 2014;15:1. https://doi.org/10.1186/1471-2474-15-1. 15. alberta fg, elattrache ns, bissell s, et al. the development and validation of a functional assessment tool for the upper extremity in the overhead athlete. am j sports med. may 2010;38(5):903-911. https://doi.org/10.1177/0363546509355 642. 16. franz jo, mcculloch pc, kneip cj, noble pc, lintner dm. the utility of the kjoc score in professional baseball in the united states. am j sports med. sep 2013;41(9):21672173. https://doi.org/10.1177/0363546513495 177. 17. lim jy, kim th, lee js. reliability of measuring the passive range of shoulder horizontal adduction using a smartphone in the supine versus the side-lying position. j phys ther sci. oct 2015;27(10):3119-3122. https://dx.doi.org/10.1589%2fjpts.27.311 9. 18. kolber mj, hanney wj. the reliability and concurrent validity of shoulder mobility measurements using a digital inclinometer and goniometer: a technical report. int j sports phys ther. jun 2012;7(3):306-313. 19. myers jb, laudner kg, pasquale mr, bradley jp, lephart sm. glenohumeral range of motion deficits and posterior shoulder tightness in throwers with pathologic internal impingement. am j sports med. mar 2006;34(3):385-391. https://doi.org/10.1177/0363546505281 804. 20. butler r, arms j, reiman m, et al. sex differences in dynamic closed kinetic chain upper quarter function in collegiate swimmers. j athl train. jul-aug 2014;49(4):442-446. https://doi.org/10.4085/1062-605049.3.17. 21. kraeutler mj, ciccotti mg, dodson cc, frederick rw, cammarota b, cohen sb. kerlan-jobe orthopaedic clinic overhead athlete scores in asymptomatic professional baseball pitchers. j shoulder elbow surg. mar 2013;22(3):329-332. https://doi.org/10.1016/j.jse.2012.02.010. https://doi.org/10.1186/1471-2474-15-1 https://doi.org/10.1177/0363546509355642 https://doi.org/10.1177/0363546509355642 https://doi.org/10.1177/0363546513495177 https://doi.org/10.1177/0363546513495177 https://dx.doi.org/10.1589%2fjpts.27.3119 https://dx.doi.org/10.1589%2fjpts.27.3119 https://doi.org/10.1177/0363546505281804 https://doi.org/10.1177/0363546505281804 https://doi.org/10.4085/1062-6050-49.3.17 https://doi.org/10.4085/1062-6050-49.3.17 https://doi.org/10.1016/j.jse.2012.02.010 disablement model case study 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study lucas d. dargo, dat, lat, atc*; kendra borton, lat, atc; rachel roths, lat, atc; and zachary dougal, dat, lat, atc† *manchester university, north manchester, in †ball state university, muncie, in abstract deep vein thrombosis (dvt) occurs when a blood clot forms in deep veins in the body, usually in the lower extremity. dvt is commonly seen in older or hospitalized patients. this case is unique because the patient is a 20-year-old female division iii collegiate volleyball athlete, which is not the typical age or population affected by dvt or clotting disorders. the patient presented with swelling, pain, and decreased knee flexion (3/5) and plantarflexion (4/5) strength in her left lower extremity. these impairments reduced her ability to walk or run. the patient’s athletic trainer (at) initially diagnosed her with a left gastrocnemius muscle strain, resulting in contraindicated treatments. the at referred the patient to the team physician, who referred her to the emergency department (ed) where she received a real-time grayscale and doppler ultrasound of the left lower extremity deep venous structures, leading to the dvt diagnosis. the patient received a dose of lovenox, an intravenous anticoagulant, by the ed physician. the following day, she began 15 mg of xarelto, twice per day for 21 days, to dissolve the blood clots. she could not participate in volleyball for approximately two weeks, which reduced her ability to socialize with teammates and coaches. the wells’ scoring system is a clinical prediction tool to identify patients with low risk of being diagnosed with dvt. the at had a low suspicion of dvt and therefore did not use the wells’ scoring system, likely leading to a delay in the diagnosis and treatment. although the patient reported that she had a positive outcome, ats should be familiar with the wells clinical prediction rule. blood clots in veins can dislodge and travel through the bloodstream. the loose clot can block blood flow in the lungs, forming a pulmonary embolism. early diagnosis can prevent this life-threatening condition. key phrases diagnostic testing, lower extremity, general medical conditions correspondence dr. lucas dargo, manchester university, 604 e. college avenue north manchester, in 46962. e-mail: lddargo@manchester.edu twitter: @lucasdargo full citation dargo l, borton k, roths r, dougal z. deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study. clin pract athl train. 2020;3(2):55-62. https://doi.org/10.31622/2020/0002.8. submitted: april 7, 2019 accepted: march 15, 2020 introduction venous thrombosis is a condition that includes deep vein thrombosis (dvt) and pulmonary embolism (pe). an annual incidence rate of about 1 per 1000 adults,1 which rapidly increases after the age of 45.2 incidence rates are slightly higher in men than women, and approximately two-thirds of episodes manifest as dvt, while one-third as a pe with or without dvt.3 dvt occurs when a blood clot forms in one or more of the deep veins in the body, usually forming in the lower extremity. however, it can also occur in the upper extremities.4 this disease typically occurs after surgical procedures and trauma in the presence of malignancy or inherited coagulation disorders, but can present without any apparent etiologic event.5 approximately half of all dvt cases occur in hospitalized patients or nursing home residents.6 symptoms of dvt include tachycardia, pyrexia, leg pain and tenderness, swelling, and dilation of the superficial veins. the well’s clinical prediction rule, commonly known as the well’s scoring system, is a valid, nine-item, clinical prediction rule for dvt. this clinical prediction rule previously demonstrated excellent interobserver reliability (kappa = 0.85),8 developed as a safe and feasible pretest with probability for dvt.9 it is critical for ats to be familiar with these 9 questions so they may consider using this tool if a patient presents with signs and symptoms consistent with dvt, particularly when the patient presents with three or more signs and symptoms. the number and location of the clots, patient's age, and absence of trauma created a unique case of dvt. in this https://doi.org/10.31622/2020/0002.8 deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 case study, the patient first received a misdiagnosis due to the lack of suspicion. patient information this case follows a 20-year-old female division iii collegiate volleyball player. a timeline of this case is provided (figure 1). on august 14, 2017, the patient reported to the athletic training facility (atf) with a swollen lower left leg and discomfort with walking. the team’s at performed the initial evaluation. during this evaluation, the patient reported to the athletic trainer (at) that she had no previous history of dvt. the patient revealed to the clinician that she took propafenone-ethinyl estradiol (yaz) 3-0.02 mg, a daily oral contraceptive medication. the patient reported that she had previously diagnosed with pes planus a few months earlier in the summer preceding camp, and received a walking boot for two weeks. furthermore, she stated that a week before reporting to the atf, her uninvolved leg had swelled, but reduced within a couple of days. differential diagnosis and evaluation after four days of treatment, the patient did not progress as the at had expected for a gastrocnemius muscle strain. during this time, the patient returned-to-play without restrictions. the team physician later referred her for additional diagnostic testing due to her calf swelling and difficulty with walking. during his evaluation, the team physician referred her to the hospital for a doppler ultrasound to rule out dvt. the patient drove to the ed via her mother’s personal vehicle. after being admitted to the ed, the patient’s mother reported to the ed physician that the patient had a factor v leiden deficiency, an inherited blood-clotting disorder due to a mutation of the blood’s factor v protein. furthermore, the patient received a doppler ultrasound, positive for dvt. the patient had three blood clots, one in each of her left femoral vein, popliteal vein, and the profundal vein. the wells’ scoring system (table 1) would have revealed a score of 3 at the initial evaluation; one point given due to her recent immobilization of the walking boot, one point given for her entire left leg swelling, and localized tenderness along the distribution of the deep venous system of her left lower extremity. due to the low suspicion for dvt, there were no measurements of calf girth or the use of the homan’s sign to rule in or rule out dvt. due to the location of pain, obvious swelling, use of contraceptive, suspicion for dvt should have been raised and the use of the wells’ score would have suggested a high probability for a dvt diagnosis. initial visit to at: august 18, 2017 referred to team physician: august 23, 2017 seen by team physician & sent to ed: august 24, 2017 • removed from sport patiet underwent doppler ultrasound • diagnosed with dvt • given a dose of lovenox patient started 21 day 15 mg xarelto (2x daily) cleared by team physician to rtp: september 15, 2017 figure 1. timeline of care; at, athletic trainer; ed, emergency department; rtp, return-to-play deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 body structure and function manual muscle testing determined the severity within the left lower extremity: 3/5 knee flexion, 5/5 knee extension, 5/5 dorsiflexion, and 4/5 plantarflexion. the patient reported with knee flexion and plantarflexion limitations. once the patient received the correct diagnosis of dvt, the focus of her treatment changed from the musculoskeletal system to the circulatory system. the ed physician referred the patient to a hematologist for additional care. the patient reported that she still had pain throughout the range of motion of the left knee. activity and participation during the initial evaluation, the patient could not walk without pain and had an observable limp. functional tests were determined to be unnecessary to perform during this time. the at withheld the patient from practice following the initial evaluation and established the goal to help control the patient’s pain and swelling. two days later, the patient returned to the at without the need for crutches. although the patient’s calf still had some swelling, she returned to full practice participation for two days before she had to discontinue activity due to pain. during this time, the patient received treatment: 20-minutes of compression cryotherapy, seven minutes of a milk massage, instrument-assisted soft tissue mobilization, bike or treadmill warm up, and abdominal core workouts. following the dvt diagnosis, the patient received a single dose of lovenox to dissolve her blood clots. the ed physician discharged her the same day as arrival. she returned to her dorm room, where she elevated the affected area above the level of her heart when sitting. she wore a compression stocking and applied a warm compress or heating pad to the affected area as directed by the ed physician. the physician encouraged the patient to avoid prolonged standing or bed rest, avoid smoking, to discontinue taking meloxicam, and her oral contraception. after this time, the ed physician allowed her to return to activities of daily (adl). the physician did not provide a specific progression for adls. once the patient discontinued the 15 mg of xarelto, taken twice a day for 21 days the physician determined the patient no longer had a risk for developing a pe. after that time, the patient returned to volleyball without restriction. table 1. wells criteria for the prediction of deep vein thrombosis (dvt)10,11 clinical characteristic score active cancer (patient either receiving treatment for cancer within the previous 6 months or currently receiving palliative treatment) 1 paralysis, paresis, or recent cast immobilization of the lower extremities 1 recently bedridden for ≥ 3 days, or major surgery within the previous 12 weeks requiring general or regional anesthesia 1 localized tenderness along the distribution of the deep venous system 1 entire leg swelling 1 calf swelling at least 3 cm larger than that on the asymptomatic side (measured 10 cm below tibial tuberosity) 1 pitting edema confined to the symptomatic leg 1 collateral superficial veins (non-varicose) 1 previously documented dvt 1 alternative diagnosis at least as likely as dvt -2 wells scoring system for dvt: -2 to 0: low probability, 1 to 2 points: moderate probability, 3 to 8 points: high probability deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 currently, there is not an established return-toplay protocol for individuals recovering from a venous thromboembolism. however, it is critical that providers develop a structured program of gradually increased activity as tolerated by the patient.12 roberts and christie report a case of a female triathlete with acute lower extremity dvt that suggested a structured, gradual return-totraining protocol (table 2).13 in the first three weeks, the gradual introduction of adls is suggested, while patients complete their anticoagulation medication.13 once endothelialization and adhesion are achieved, the potential for clot migration and embolism is reduced.12 between the fourth to sixth weeks of this protocol, roberts and christie suggest a gradual return-to-training regimen that starts with non-weight-bearing exercises, next cycling, and finally, running.13 if the patient reports any previous signs or symptoms returning, the protocol should be discontinued. moreover, it is important the at and patient note any bruising.12 in this case, the patient completed the first three weeks of this protocol prior to fully return to play (rtp). additional sport-specific activities should have been gradually integrated prior to full rtp. table 2. post-anticoagulation return-totraining recommendations. weeks 1-3 gradual return to adls week 4 begin non-weight-bearing exercises (e.g., swimming) week 5 begin nonimpact-loading exercises (e.g., cycling) weeks 6 + begin impact-loading exercises (e.g., begin running progression) environmental and personal factors the patient hesitated to schedule the initial evaluation because she worried about losing her spot on the team. also, she reported that the right calf presented similarly, earlier in the summer but resolved within a couple of days. after several days of pain and inflammation in her left calf causing difficulties with walking, she decided to seek help. the patient’s pain affected her ability to perform adls such as walking, running, and going upstairs. the patient discontinued her oral contraception due to the increased increase risk of dvt. intervention the patient’s at initially provided treatment for a soft tissue injury, a left gastrocnemius muscle strain. the primary goals of the interventions were to reduce the patient’s pain and swelling. treatments included 20-minutes of compression cryotherapy, seven minutes of a milk massage, instrument-assisted soft tissue mobilization, bike or treadmill warm up, and abdominal core workouts. the at performed these treatments for three consecutive days. once the patient received the dvt diagnosis, this course of treatment was discontinued. the massage and soft tissue treatments are contraindicated for a dvt diagnosis because of the potential risk factors for developing a pe by dislodging a blood clot.11 after the ed physician diagnosed the patient with dvt they did not suspect an active pe. the ed physician discharged the patient the same day as arrival and instructed her to begin ambulation within 24 hours, elevating her left calf above her heart when seated. the day following discharge, the patient began a 21-day series of twice-daily 15 mg of xarelto. after the 21-day series, the patient could perform all adls. the team physician cleared the patient for full rtp. to reduce the potential of bleeding, the hematologist ordered the patient to reduce her dosage of xarelto to one daily dose of 20mg. the patient was instructed by the team physician to discontinue taking propafenone-ethinyl estradiol (yaz) 3-0.02 mg because of its known side-effect of increasing the risk for clot formation.14 additionally, the team physician told her to discontinue taking meloxicam, an acne medication, due to its possible interactions with the xarelto. the ed physician prescribed the patient 15mg of xarelto, administered orally twice daily, deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 to treat the pre-existing blood clots and prevent new clots from forming. following her visit to the hematologist, further testing confirmed that the patient was positive for factor v leiden mutation. this is an inherited blood-clotting disorder due to a mutation of the blood’s factor v protein.15 as of january 2019, the patient continued to see both her hematologist and primary care physician several times throughout the year for a physical exam and a comprehensive metabolic panel to monitor the status of the blood clots. outcomes body structure and function the xarelto is expected to continue to shrink the blood clots. this allows the body to naturally dissolve them. the left leg continues to remain swollen. the hematologist deemed this as normal; this condition is referred to as post-thrombotic syndrome.15 after 22 months following her diagnosis, the patient is now able to complete full range of motion without pain. muscle strength returned to pre-injury performance. strength was accessed by the patient’s ability to perform both adls and sport participation without any restrictions. activity and participation the team’s at monitored the patient for signs and symptoms as she rtp. the team physician followed roberts and christie’s suggested rtp protocol for the first three weeks,13 keeping the patient out of sport participation. neither the team physician nor the at initiated a gradual rtp progression after this time. the patient successfully competed in the rest of the volleyball season without her symptoms returning or sustaining any additional injuries. environmental and personal factors the patient reported that she was pleased with how she performed following her rtp. since her left leg was more swollen than the right, people often asked her if it was safe for her to rtp. this caused her to be irritated. the oral contraception medication the patient was taking may have predisposed her the blood clots. discussion deep vein thrombosis is a rare and emergent medical condition, especially in young active individuals.14 it is critical that ats are educated properly on the appropriate recognition and management for dvt. the wells’ scoring system is a helpful 9-item clinical diagnostic prediction tool for dvt;6 based on yes or no questions. each question is given a numeric value (table 1). a score of zero or lower suggests dvt is unlikely (5%), 1-2 moderate risk (17%), 3 and above dvt is likely (17-53%).9,10 an at should consider using the wells’ scoring criteria if they suspect a patient presents with any combination of signs or symptoms of dvt, such as sudden shortness of breath, chest pain or discomfort that worsens when they take a deep breath or cough, feeling lightheaded or dizzy, have a pulse > 100 beats per minute, coughing up blood, or having posterior leg pain. it is critical to ask patients about their current and past use of oral contraceptive medications because some brands and dosages can cause patients to be prone to blood clotting. moreover, it is critical to determine if patients have a known medical history that includes genetic disorders. vandenbroucke et al. found that there is an increased risk of dvt in oral contraceptive users who are carriers of factor v leiden mutation.16 additionally, the at in this case likely overlooked dvt as a differential diagnosis, due to lack of suspicion because of the patient’s young age and active status. the use of a patient-rated outcome measure, such as the sf-36, should be used throughout a patient’s treatment to measure their healthrelated quality of life. the sf-36 would have complemented the use the wells’ scoring system, as it can be used to track the overall quality of life of patients with dvt.17 the sf-36 can be used deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 to determine when a patient is ready to progress to the next step in the return-to-play dvt progression.13 additionally, patients who develop post-thrombotic syndrome pts after dvt report poorer health related quality of life using both generic and disease-specific questionnaires.18 for example, if the sf-36 was used in this case by the at, they may have identified that the patient was having difficulty with adls as well as their emotional health. although the patient’s care was delayed, this patient was able to return to full participation and alds. although the patient was able to fully return-to-play, as of 22 months post diagnosis the patient continued her treatment of 20 mg of xarelto, taken once daily. we recommend that ats consider implementing the wells’ scoring system when patient’s present with signs and symptoms consistent with dvt. although evidence supports anticoagulation and early mobilization, guidelines for return-to-play require additional research.12 we propose ats use roberts and christie’s suggested return-to-play protocol (table 2) and patient-rated outcome measures to determine when dvt patients’ activity levels should progress. clinical bottom line when evaluating a patient who presents with calf pain, ats should determine if other signs, symptoms, and risk factors associated with venous thrombosis are present (figure 2). if warranted, ats should consider implementing the wells’ scoring criteria. this will aid the clinician in determining if the patient is a low, moderate, or high probability of dvt. if further consultation is needed, ats should consult with their supervising physician or activate their emergency action plan. early diagnosis can help prevent the progression of a dvt to a pe. compression ultrasonography is considered the gold standard to diagnose dvt.19 additional research is needed to determine specific clinical practice guidelines. if the patient is diagnosed with dvt, patient-rated outcome measures should be used in combination with clinician-rated outcome measures to confirm the patient’s progress. patients should be instructed to discontinue sport participation if signs or symptoms return. particular attention should be given to bruising or loss of blood. figure 2. evaluation process for patient with potential dvt patient perspective the patient agreed to do an interview about her experience. the interview was conducted approximately a year after she returned-to-play. the patient thought the care she received was adequate. she reported that the athletic training staff provided care to the best of their abilities and used the knowledge that was best at the time. the patient was asked what the athletic training staff could do differently about her treatment. she answered, “no milk massage or scraping because it made my leg hurt more.” when asked how she felt about her return-to-play, the patient answered, “i wasn’t worried. they warned me that my leg would remain swollen. i was more worried about getting other injuries.” when asked how the injury affected this year’s season, the patient replied, “it didn’t really affect this year. my leg still swells. i still have the blood clots, but they are shrinking. i am still on the medication. it’ll take time for the clots to go away. the only thing that is different is that i take the medication at night now.” patient presents with calf pain determine if other signs, symptoms or risk factors for dvt are present implement the wells' scoring system9,10 if the patient has a score ≥2, refer the patient for additional medical consulation deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 61 copyright © by indiana 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https://doi.org/10.1016/s01406736(95)92535-x. 9. wells ps, anderson dr, bormanis j, guy f, mitchell m, gary l, et al. value of assessment of pretest probability of deepvein thrombosis in clinical management. lancet. 1997;350(9094):1795-8. https://doi.org/10.1016/s01406736(97)08140-3. 10. wells ps, anderson dr, rodger m, forgie m, kearon c, dreyer j, et al. evaluation of ddimer and the diagnosis of suspected deep vein thrombosis. n engl j med. 2003:12271235. https://doi.org/10.1056/nejmoa023153. 11. lim dc, jayanthi hk, money-kyrle a, ramrakha p. massaging the outcome: an unusual presentation of pulmonary embolism. bmj case rep. 2009; 1505. https://doi.org/10.1136/bcr.01.2009.1505 12. depenbrock pj. thromboembolic disorders: guidance for return-to-play. curr sports med rep. 2011;10(2):78-83. https://doi.org/10.1249/jsr.0b013e3182 14d828. 13. roberts wo, christie dm. return to training and competition after deep venous calf thrombosis. med sci sports exerc. 1992;24(11:2-5). 14. atmaca h, köprülü d, kiriş t, zeren g, şahin i. simultaneous total occlusion of two coronary arteries associated with use of drospirenone-ethinyl estradiol (oral contraceptive). turk kardiyol dern ars. 2018;46(1): 69-72. https://doi.org/10.5543/tkda.2017.57606. 15. schleimer k, barbati me, gombert a, wienert, v, grommes j, jalaie h. the treatment of post-thrombotic syndrome. dtsch arztebl int. 2016;113(50):863-870. https://doi.org/10.3238arztebl.2016.0863. 16. vandenbroucke jp, koster t, rosendaal fr, briet e, reitsma ph, bertina rm. increased risk of venous thrombosis in oralcontraceptive users who are carriers of favor v leiden mutation. the lancet. 1994;344(8935):1453-1457. https://doi.org/10.1161/01.cir.0000078468.11849.66 https://doi.org/10.1161/01.cir.0000078468.11849.66 https://doi.org/10.1001/archinte.162.10.1182 https://doi.org/10.1001/archinte.162.10.1182 https://doi.org/10.1016/j.amjmed.2004.01.018 https://doi.org/10.1016/j.amjmed.2004.01.018 https://dx.doi.org/10.3238%2farztebl.2017.0244 https://dx.doi.org/10.3238%2farztebl.2017.0244 https://doi.org/10.1001/archinte.158.6.585 https://doi.org/10.1001/archinte.158.6.585 https://dx.doi.org/10.1038%2fsrep11834 https://doi.org/10.1016/s0140-6736(95)92535-x https://doi.org/10.1016/s0140-6736(95)92535-x https://doi.org/10.1016/s0140-6736(97)08140-3 https://doi.org/10.1016/s0140-6736(97)08140-3 https://doi.org/10.1056/nejmoa023153 https://doi.org/10.1136/bcr.01.2009.1505 https://doi.org/10.1249/jsr.0b013e318214d828 https://doi.org/10.1249/jsr.0b013e318214d828 https://doi.org/10.5543/tkda.2017.57606 https://doi.org/10.3238arztebl.2016.0863 deep vein thrombosis in lower extremity of a female collegiate volleyball athlete: a case study 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 https://doi.org/10.1016/s01406736(94)90286-0. 17. kahn sr, hirsch a, shrier i. effect of postthrombotic syndrome on health-related quality of life after deep venous thrombosis. arch intern med. 2002;162(10):1144-8. https://doi.org/10.1001/archinte.162.10.1 144. 18. ghanima w, wik hs, tavoly m, enden t, jelsness-jørgensen lp. late consequences of venous thromboembolism: measuring quality of life after deep vein thrombosis and pulmonary embolism. thromb res. 2018;164:170-176. https://doi.org/10.1016/j.thromres.2017.0 7.025. 19. scarvelis d, wells ps. diagnosis and treatment of deep-vein thrombosis. cmaj. 2006;175(9):1087-1092. https://doi.org/10.1503/cmaj.060366. https://doi.org/10.1016/s0140-6736(94)90286-0 https://doi.org/10.1016/s0140-6736(94)90286-0 https://doi.org/10.1001/archinte.162.10.1144 https://doi.org/10.1001/archinte.162.10.1144 https://doi.org/10.1016/j.thromres.2017.07.025 https://doi.org/10.1016/j.thromres.2017.07.025 https://doi.org/10.1503/cmaj.060366 manuscript type evidence-to-ractice review 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization matthew g. moore, scat, atc; aneika r daley, scat, atc; and zachary winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract instrument assisted soft tissue mobilization (iastm) is the use of specially designed instruments that provide a mobilizing effect to soft tissue to help with decreasing pain and improving range of motion. over the years, there has been an increase in the use of iastm as well as an increase in research for its effects on soft-tissue injuries, range of motion (rom), and pain management; however, the results have not been supported as a whole. evidence for the positive outcomes from the use of iastm, in conjunction with therapeutic exercise or other interventions, has been lacking in many studies. as a result, clinicians question its effectiveness. the purpose of this evidence-to-practice review was to summarize the results of the systematic review and apply it to clinical practice. the authors of the guiding systematic review aimed to investigate the current state of available literature on the topic of iastm, specifically using studies that compared iastm pre & post-treatment and compared the iastm group to other intervention or control groups. seven total studies were included in the final review, and of those, five focused on iastm treatment for musculoskeletal pain and two focused on iastm treatment for joint rom. each study varied in methodology, interventions, treatment times, and outcome measures. therefore, the systematic review was unable to make a direct comparison between all studies and results were deemed inconclusive. in conclusion, using iastm as a stand-alone treatment is not recommended in any case. however, in the event the treatment is not contraindicated and the clinician is inclined to use the treatment for physiological improvement, then implementation and use of iastm is not unreasonable and could potentially benefit the patient when used in conjunction with therapeutic exercise or other form of treatment. key phrases therapeutic devices, rehabilitation, clinician-rated outcomes correspondence dr. zachary winkelmann, university of south carolina 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation moore mg, daley ar, winkelmann zk. an evidence-topractice review on the efficacy of instrument assisted soft tissue mobilization. clin pract athl train. 2020;3(3):4-11. https://doi.org/10.31622/2020.0003.3.2. submitted: april 20, 2020 accepted: september 1, 2020 original reference and summary cheatham sw, lee m, cain m, baker r. the efficacy of instrument assisted soft tissue mobilization: a systematic review. journal of the canadian chiropractic association. 2016;60(3):200-211. summary clinical problem and question soft tissue injuries are common among the general and athletic populations and these injuries can lead to acute and chronic loss of function, adhesions, and pain.2-4 instrument assisted soft tissue mobilization (iastm) is the use of specially designed instruments that provide a mobilizing effect to soft tissue to help with decreasing pain and improving range of motion (rom).2-4 over the years, iastm has become a popular treatment for soft tissue injuries involving myofascial restrictions and in increasing pain thresholds.5 this therapy has been utilized over a variety of different treatment areas, almost all of which involving a musculoskeletal injury or pathology.2-4 during the healing process of an injury or pathology, the human body will respond with an initial inflammatory response, followed by a proliferation phase, and then finally maturation of the new tissue. during these last two phases, iastm is traditionally utilized as an intervention/modality in order to aid the realignment of tissue, collagen elasticity, and increase perfusion of tissues to promote healing.2 studies have been conducted to investigate the effect of iastm on patient rom and pain.2,4,5 results of these studies lack mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2020.0003.3.2 an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 definitive findings in almost all cases, and in turn, many clinicians have been using iastm without truly understanding the outcomes of the technique. therefore, the purpose of this review was to assess the clinical effectiveness and efficacy of iastm as a treatment protocol. summary of literature the authors conducted a systematic search for studies/clinical trials using iastm through the databases of pubmed, pedro, science direct, the ebscohost collection, and hand searching known journals. studies that were included in the review had to meet the following criteria: 1) peer reviewed, english language publications, 2) controlled clinical trials that compared preand post-test measurements for an intervention data extraction and synthesis program using iastm, 3) investigations that compared an intervention program using iastm, and 4) investigations that compared two intervention programs using iastm. the search identified 261 articles, plus two others identified through other sources, for initial review. after duplicates were removed and records were screened, 47 full-text articles were reviewed for inclusion. after review, seven articles were included in the qualitative synthesis. summary of interventions of the articles synthesized (table 1), six articles examined the graston technique® and one examined the fascial abrasion technique®. five studies investigated the effects of iastm on the patients’ pain from a musculoskeletal pathology, while two studies examined the effect of iastm on the rom in healthy individuals. for the five studies that focused on iastm treatment for patients with pathology, the interventions in each study differed so it was difficult to determine which resulted in a better outcome. two studies focused on comparing iastm with a control group, one to treat patients classified with lateral epicondylitis6 and the other to treat the upper back.7 one study compared iastm with soft-tissue massage to treat patients with carpal tunnel syndrome8 and one study compared two different intervention programs that included iastm, strengthening exercises, stretching, and chiropractic manipulative therapy to treat patients with patellofemoral pain syndrome.9 the final study compared three intervention programs including iastm, dynamic strengthening, or proprioception exercises to treat patients with chronic ankle instability.10 all studies that used graston technique® had a timeframe for interventions ranging from 2-6 weeks. only one study followed the recommended graston technique® protocol with other studies modifying it or not including all components of intervention in their reported methods. the two studies that focused on iastm treatment for joint rom measured the effects of the treatment on rom of the shoulder and knee in healthy subjects. the study focusing on the shoulder measured the difference in glenohumeral rom after a single session of graston technique® treatment with an experimental and nonintervention control group.11 the other study compared the effects of one session of iastm following the fascial abrasion technique® and one session of foam rolling.11 the graston technique® protocol was not followed in the first study and no specific iastm protocol was used in second study. from these two studies we can see that iastm was able to increase rom over control group, so iastm could possibly be a tool used for increasing rom, however, further research is needed to validate this. summary of outcomes the five studies that focused on iastm as treatment for musculoskeletal pathologies included a combination of patient-reported and clinical-rated outcome measures (table 1). the most common patient-reported outcome used was the visual analog scale for pain. all studies an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 measured outcomes pre-intervention and immediately post-intervention. three studies reported a second follow-up, which ranged between 2-3 months post-treatment. the two studies using iastm as treatment for joint rom both used joint rom, measured with a digital inclinometer, as the primary outcome measure. there were no patient-reported outcome measures used in those studies, but they both measured pre-intervention and immediately postintervention outcomes. the study that followed the fascial abrasion technique® was the only method to conduct a 24-hr post-intervention follow-up assessment. findings and clinical implications each study varied in methodology, interventions, treatment times, and outcome measures (table 1) and therefore, the systematic review was unable to make a direct comparison between all studies and results were deemed inconclusive. out of the 7 articles included in the systematic review, graston technique® was the most common form of iastm used, only one study did not use graston technique®. however, the recommended treatment protocol was only followed by one of the six studies, while others had their own variation, which may have been a contributing factor to the inconsistent results across the studies. the studies examined in the review, along with their methods and outcomes, can be seen in table 1. the differences in the protocols followed by each study also deemed the results insignificant in determining the effectiveness of graston technique® because the specified graston technique® protocol was not followed. due to the variability in the study protocols (which includes methodology, interventions, and outcome measures), it was difficult to determine the best treatment protocol. clinicians conducting future research should consider what technique they are utilizing and differentiate if the technique chosen followed the manufactures’ specific treatment protocols, or if just the tools or general treatment method was used. from this systematic review, evidence does not support the efficacy of iastm for treating certain musculoskeletal pathologies and is weak in supporting effectiveness of iastm for increasing lower extremity joint rom as a standalone treatment. though iastm is a form of myofascial therapy, there is a lack of evidence to support its use or validation. as a result of this, there still lies a gap between the current research and clinical practice. however, iastm may have a degree of clinical utility due to each study individually identified improvements for their outcome measures. clinicians should be tentative in the use of iastm since it has not been validated; however it may still be used clinically paired with another treatment to help improve patient-reported outcomes, barring any contraindications. future research should focus on testing specific iastm protocols, with uniformity in methodology, interventions, and outcome measures, to validate its use. clinical bottom line the guiding systematic review suggests that iastm lacks the efficacy to positively support its use in myofascial treatment. while iastm was found to not have good efficacy, depending on the patient, it may help improve outcomes of acute joint rom (table 1).11 in order to implement iastm clinically to have the best possible results, it is recommended that the clinician follow the specific iastm treatment protocols provided by the manufacturer and to ensure the patient does not have any contraindications for the treatment. if a clinician were to implement iastm into a treatment, it is always important to consider the patient population that is undergoing the treatment as well as the patient presentation. in the case of working with patients that are minors, parent/guardian education and consent should an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 always be considered, especially if the treatment results in adverse effects such as visible bruising, ecchymosis, petechiae, or inflammation. when treating the geriatric patient population, it is important to consider their current health status and the ability of their bodies to withstand and recover from this type of treatment. in order to maintain consistent quality and standard of iastm treatment, it is recommended that clinicians utilizing iastm receives training in the application and administration of the treatment, and specialized training should be at the discretion of the clinician or the clinician’s employer. to conclude, iastm has not been shown to have adequate efficacy, and using iastm as a standalone treatment is not recommended. based upon the results of current literature, iastm was not an effective intervention for certain musculoskeletal pathologies and further research is necessary to better understand the clinical effect of this intervention. references 1. cheatham sw, lee m, cain m, baker r. the efficacy of instrument assisted soft tissue mobilization: a systematic review. j can chiropr assoc. 2016; 60(3):200-211. 2. kim j, sung dj, lee j. therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. j exerc rehabil. 2017; 13(1):12-22. https://doi.org/10.12965/jer.1732824.41 2. 3. stow r. instrument-assisted soft tissue mobilization. int j athl ther train. 2011; 16(3):5-8. https://doi.org/10.1123/ijatt.16.3.5. 4. ikeda n, otsuka s, kawanishi y, kawakami y. effects of instrument-assisted soft tissue mobilization on musculoskeletal properties. med sci sports exerc. 2019; 51(10):21662172. https://doi.org/10.1249/mss.0000000000 002035. 5. gulick dt. instrument-assisted soft tissue mobilization increases myofascial trigger point pain threshold. j body mov ther. 2018; 22(2):341-345. https://doi.org/10.1016/j.jbmt.2017.10.01 2. 6. blanchette ma, normand mc. augmented soft tissue mobilization vs natural history in the treatment of lateral epicondylitis: a pilot study. j manipulative physiol ther. 2011; 34(2):123-130. https://doi.org/10.1016/j.jmpt.2010.12.00 1. 7. gulick dt. influence of instrument assisted soft tissue treatment techniques on myofascial trigger points. j bodyw mov ther. 2014; 18(4):602-607. https://doi.org/10.1016/j.jbmt.2014.02.00 4. 8. burke j, buchberger dj, carey-loghmani mt, dougherty pe, greco ds, dishman jd. a pilot study comparing two manual therapy interventions for carpal tunnel syndrome. j manipulative physiol ther. 2007; 30(1):50-61. https://doi.org/10.1016/j.jmpt.2006.11.01 4. 9. brantingham jw, globe ga, jensen ml, et al. a feasibility study comparing two chiropractic protocols in the treatment of patellofemoral pain syndrome. j manipulative physiol ther. 2009; 32(7):536-548. https://doi.org/10.1016/j.jmpt.2009.08.00 5. 10. schaefer jl, sandrey ma. effects of a 4week dynamic-balance-training program supplemented with graston instrumentassisted soft-tissue mobilization for chronic ankle instability. j sport rehabil. 2012; 21(4):313-326. https://doi.org/10.1123/jsr.21.4.313. 11. laudner k, compton bd, mcloda ta, walters cm. acute effects of instrument assisted soft tissue mobilization for improving posterior https://doi.org/10.12965/jer.1732824.412 https://doi.org/10.12965/jer.1732824.412 https://doi.org/10.1123/ijatt.16.3.5 https://doi.org/10.1249/mss.0000000000002035 https://doi.org/10.1249/mss.0000000000002035 https://doi.org/10.1016/j.jbmt.2017.10.012 https://doi.org/10.1016/j.jbmt.2017.10.012 https://doi.org/10.1016/j.jmpt.2010.12.001 https://doi.org/10.1016/j.jmpt.2010.12.001 https://doi.org/10.1016/j.jbmt.2014.02.004 https://doi.org/10.1016/j.jbmt.2014.02.004 https://doi.org/10.1016/j.jmpt.2006.11.014 https://doi.org/10.1016/j.jmpt.2006.11.014 https://doi.org/10.1016/j.jmpt.2009.08.005 https://doi.org/10.1016/j.jmpt.2009.08.005 https://doi.org/10.1123/jsr.21.4.313 an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 shoulder range of motion in collegiate baseball players. int j sports phys ther. 2014; 9(1):1-7. 12. markovic g. acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. j bodyw mov ther. 2015; 19(4):690-696. https://doi.org/10.1016/j.jbmt.2015.04.01 0. https://doi.org/10.1016/j.jbmt.2015.04.010 https://doi.org/10.1016/j.jbmt.2015.04.010 evidence-to-ractice review 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 table 1. summary of studies1 study pathology intervention outcome measures graston technique® used graston technique® protocol followed results blanchette and normand6 lateral epicondylitis • iastm: twice a week for 5 weeks • control: education, computer ergonomics, stretching exercise, ice, and anti-inflammatory medication • vas • pain rated evaluation • grip strength yes no • post intervention and 3month follow-up: both groups showed improvement in all outcome measures burke et al8 carpal tunnel syndrome • iastm:2x/week for 4 weeks, 1x/week for 2 weeks • control: soft tissue mobilization, 2x/week for 4 weeks, 1x/week for 2weeks • vas yes yes • post intervention and 3month follow-up: both groups showed improvements in all outcome measures gulick7 myofascial trigger points in upper back • 2 phases of iastm: 5 min, 6 treatments (2x/week for 3 weeks) • control: no treatment • pressure sensitivity with algometer yes no • post intervention: both groups showed improvements in outcome measures • no secondary follow-up reported an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 laudner et al11 posterior shoulder muscle • iastm: 1 treatment, treatment time of 40 seconds • control: no treatment • glenohumeral horizontal adduction, and internal rotation of motion yes no • post intervention: iastm group showed greater acute improvements in rom compared to the control group • no secondary follow-up reported markovic12 quadriceps and hamstrings • iastm: one treatment, 2 minutes each region • control: foam rolling, one session 2x/i minute • passive straight leg raise test • supine passive knee flexion test no (fascial abrasion technique® used) n/a • post intervention: both groups showed improvement in joint rom • 24-hour follow-up: iastm group -> the most joint rom schaefer and sandrey10 chronic ankle instability • iastm: 2x/week, max of 8 min • control: 4-week balance program (single-limb hops to stabilization, hop to stabilization and reach, unanticipated hop to stabilization, single-limb stance activities) • vas • foot and ankle ability measure • 4-way ankle rom • star excursion balance test yes no • post-intervention: all groups showed improvement in all outcome measures • no long-term follow-up reported an evidence-to-practice review on the efficacy of instrument assisted soft tissue mobilization 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 brantingham et al9 patellofemoral pain syndrome • chiropractic manipulative therapy, exercise • group 1: iastm to knee joints only • group 2: iastm to lumbosacral, hip, knee, ankle, and foot • both groups received treatment 1-3x/week for 2-6 weeks, total of 6 treatments • vas • anterior knee pain scale • patient satisfaction scale yes no • post-intervention and 2month follow-up: both groups showed improvement in all outcome measures vas = visual analog scale; iastm = instrument assisted soft tissue mobilization manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 2 – june 2019 celebrating our first year lindsey e. eberman indiana state university, terre haute, in key phrases practice-based research, practice-led research, quality improvement correspondence dr. lindsey eberman, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: lindsey.eberman@indstate.edu twitter: @isuathltraining full citation eberman le. developing the athletic training clinical scholar. clin pract athl train. 2019;2(2):1-3. https://doi.org/10.31622/2019/0002.1. editorial as we enter into our second year of publication for clinical practice in athletic training, and as the journal continues to grow and expand, i wanted to take the time and notify the readership about a leadership change within the editorial board. as of this june, i will be assuming the role of editorin-chief. we are immensely grateful for the leadership, dedication, and commitment that dr. cameron powden has demonstrated in taking our shared vision and solidifying a place for clinicians to share their practice-based research. his guidance and oversight in laying the ground work were instrumental to our first year’s success. dr. cameron powden will be moving into the section editor role for our evidence-to-practice review manuscript type. however, as with any transition in life, this period offers a unique opportunity to reflect on all the growth and momentum that we have gained. in our inaugural year of publication we have 18 published articles across the 3 issues. these articles have been viewed or downloaded over 4,200 times in the span of our first year. we have had the pleasure and opportunity to publish unique practice-based and translational research in each of the manuscript categories that we offer, helping to give clinicians and patients a voice in translating evidence to practice. our video podcast series #atanswers has over 350 views. lastly, our social media presence continues to grow as we have over 1000 followers across our social media outlets (twitter: @clinatjourn; instagram: @clinatjournal). as we reflect on our first year of publication for clinical practice in athletic training, it is evident that we would not have experienced this growth without the help and contribution of all the individuals that serve the journal. we, as the editorial board, are extremely grateful for all the hard work from all our section editors in the service that they have provided to establish author guidelines and facilitate submissions. thank you for your continued support, contributions, and dedication to clinical practice research. additionally, we would like to thank dr. zachary winkelmann for the devotion and enthusiasm for the term he served as managing editor (january to august of 2018). throughout his time as managing editor, dr. winkelmann was able to secure and foster vital relationships that fueled much of the early growth the journal experienced. further, dr. winkelmann oversaw the securing of our issn and indexing as the journal was launched. we would like to thank our copy editor, susan frey, ms, mls, gc for her unique skill set and commitment to ensuring the highest quality writing and style guide for the journal. her attention to detail and work ethic are significant to the continued quality assurance of the articles we are publishing. finally, we would like to thank our graphic designer, denny wongosari, ms, lat, atc, lmt, for his contribution in creating our logo, social media graphics, and marketing materials. below we recognize our section editors and reviewers who have contributed to the journal over the past year: https://doi.org/10.31622/2019/0002.1 celebrating our first year 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 section editors: disablement model case studies and reports alison o’connor sutherland, ms, lat, otc, aemt dartmouth university validation case studies and reports esther nolton, med, lat, atc, cscs george mason university point-of-care research zachary winkelmann, phd, lat, atc university of south carolina clinical outcomes research jj wetherington, ms, lat, atc st. luke’s sports medicine quality improvement (pdsa cycle) reports brian vesci, dat, atc northwestern university preceptor case studies zachary dougal, dat, lat, atc, cktp ball state university evidence-to-practice reviews cameron powden, phd, lat, atc university of indianapolis clinical expertise commentary hollie walusz, ma, atc, pes boston university patient-centered care commentary mark laursen, ms, atc boston university reviewers: thomas abdenour dhsc, atc, ces – retired samantha jane atkelski, ms, lat, atc, ces – university of wisconsin milwaukee adam babiarz, dat, lat, atc – indiana state university savannah bailey, lat, atc – united states marine corps joseph beckett, edd, atc – marshall university kelly brock, dat, lat, atc – carson-newman university connor burton, dat, lat, atc – indiana state university nicholas dephillipo, ms, atc, otc, cscs – the steadman clinic r. ross dexter, ms, mkin, at, lat, cscs – grtiman medical center drew duckett, ms, atc – boston university jessica elder, phd, lat, atc – grand view university emily ford, ms, atc – boston university emily gabriel, phd, atc – mercer university christen gessel, ms, at – marietta college vicky graham, dat, atc – xavier university kelcey granger, ms, lat, atc indiana state university wade green, med, lat, atc – tria orthopedic center maria hutsick, ms, latc, cscs – medfield high school celebrating our first year 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 2issue 2 – june 2019 rachel koldenhoven, med, atc – university of virginia ryan kryzanowicz, dat, at – university of buffalo skye livermore-brasher, dat, mpa, at – columbus state university jamie mansell, phd, lat, atc – temple university rodrigo martinez, dat, lat, atc – florida international university jessica martinez, phd, atc – old dominion university allyssa katrina memmini, ms, atc – university of michigan nicolas c. merritt, dat, scat, atc, ns – furman university elizabeth r. neil, phd, lat, atc – xavier university jamie nikander, dat, lat, atc – west olympia sports medicine rich o. patterson dat, atc – temple university miguel quintero, dat, atc – viewpoint school amy richmond, dat, atc, cscs, ces – high point university sean m. rogers, dat, atc – california state university, northridge shannon l. rowe, dat, atc – university of california davis maura shea, dat, lat, atc – indiana state university janet simon, phd, at – ohio university justin tatman, ms, lat, atc – tria orthopedic center brady l. tripp, phd, atc – university of florida daniel walen, dat, lat, atc – western michigan university alli zeigel, dat, atc – colorado mesa university manuscript type abstract presentation 66 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 the role and value of the athletic trainer in the chiropractic medicine setting nicholas spangler, dat, lat, atc* *community care network, schererville, in full citation spangler n. the role and value of the athletic trainer in the chiropractic medicine setting. clin pract athl train. 2021;4(1):66. https://doi.org/10.31622/2021/0004.1.11. presented at the 4rd annual athletic trainers in the physician practice society meeting and conference, february 26-27, 2021. abstract in the united states, back pain is the most common cause of activity limitation in people younger than 45 years, the second most frequent reason for visits to the physician, the third most common cause of surgical procedure, and the most frequently reported subcategory of musculoskeletal impairment in the united states of people aged up to 65 years (51.7%).1 chiropractors are healthcare professionals who are trained in the evaluation and treatment of this patient population and utilize a variety of skills like spinal manipulation, soft tissue mobilization, modalities, and therapeutic exercise. athletic trainers are healthcare professionals whose educational and clinical background in musculoskeletal evaluation make them specifically suited to work alongside chiropractors as both providers utilize many of the clinical skills listed above. as the employment of athletic trainers in the physician practice setting continues to grow, the setting of chiropractic medicine offers athletic trainers unique opportunities that are both similar and different from that of the traditional orthopedic physician practice. comparable to the orthopedic physician setting, athletic trainers can provide indirect value in the chiropractic setting through rooming patients, taking vitals, and charting during evaluations. however, the chiropractic setting also offers athletic trainers the unique opportunity to perform therapeutic exercise and manual therapy in the physician practice setting. by doing so, the athletic trainer can provide direct value to this setting by performing billable services that would otherwise not be offered without either the training of another provider or at the expense of the chiropractor’s time. specifically, using data from our practice, we see that an athletic trainer alone performs approximately 30% of the services billed for by the provider. when projecting the value of these services over a calendar year, an athletic trainer alone can provide up to $40,000 worth of services in a practice operating at near full patient load. as athletic training continues to grow in the physician practice, the profession should continue to be aware of the variety of settings in which athletic trainers can provide value and practice near the top of their scope of practice. this presentation will overview the direct and indirect value an athletic trainer can provide in the chiropractic setting. correspondence dr. nicholas spangler, 1345 us 30, schererville in 46375 email: spanglern1020@gmail.com twitter: @spanglernat references 1. andersson gb. epidemiological features of chronic low-back pain. lancet. 1999;354(9178):581-585. https://doi.org/10.1016/s01406736(99)01312-4. https://doi.org/10.31622/2021/0004.1.11 mailto:spanglern1020@gmail.com https://doi.org/10.1016/s0140-6736(99)01312-4 https://doi.org/10.1016/s0140-6736(99)01312-4 manuscript type clinical outcomes research 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals scott w. cheatham, phd, dpt, pt, ocs, at, cscs*; rodrigo e. martinez, dat, lat, atc†; alicia montalvo, phd, lat, atc, cscs†; michelle odai, phd, lat, atc†; stephanie echeverry, ms, atc†; brianna robinson, ms†; elizabeth bailum, bs†; kevin viecco, ms†; kasey keller, bs, atc†; sofia nunez-riveria, ms, atc†; adriana pena, ms, atc† *california staet university dominguez hills, carson, ca; †florida international university, miami, fl abstract myofascial compression interventions have become popular in rehabilitation and fitness. to date, no studies have directly compared foam rolling, instrument assisted soft-tissue mobilization, and floss band among unexperienced individuals. the primary purpose of this investigation was to compare the immediate post intervention effects of foam rolling, instrument assisted soft-tissue mobilization, and floss band on passive knee joint range of motion (rom) among inexperienced individuals using a standard treatment time. the secondary purpose was to determine the interchangeability of the interventions and to provide preliminary research for long-term comparison studies. this pretest-posttest randomized controlled trial was conducted in a university laboratory. thirty participants (m=15, w=15) were randomly assigned to three groups: (1) foam rolling, (2) instrument assisted soft-tissue mobilization, and (3) floss band. the intervention time for each group was 2-minutes. the outcome was passive knee joint rom. between group analysis revealed a statistically significant post-intervention difference between the three interventions for passive knee flexion rom (p <.001). within group comparison for rom revealed a 2 degree (p<.001) post-intervention increase for foam rolling, a 3.5-degree (p<.001) increase for the instrument assisted soft-tissue mobilization, and a 4-degree (p<.001) increase for the floss band. the three interventions produced similar immediate post intervention effects on passive knee joint rom among inexperienced individuals. clinically, these interventions may be interchangeable by producing similar effects on knee rom. clinicians may want to consider these finding prior to administering these interventions with their patients. key phrases massage, muscle soreness, pain, release correspondence dr. scott cheatham, california state university dominguez hills, 1000 e. victoria street, carson, ca 90747 e-mail: scheatham@csudh.edu full citation cheatham sw, martinez re, montalvo a, odai m, echeverry s, robinson b, bailum e, viecco k, keller k, nunez-riveria s, pena, a. myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals. clin pract athl train. 2020;3(3):24-36. https://doi.org/10.31622/2020/0003.3.5. submitted: february 13, 2020 accepted: august 3, 2020 introduction myofascial compression is a popular intervention used by allied health professionals.1 there are several types of myofascial compression interventions such as foam rolling (fr), instrument assisted soft-tissue massage (iastm), and floss band (fb). these interventions can be found in various clinical and fitness settings. the research on these types of interventions has increased over the past decade. the research on fr has documented positive outcomes with reduced post exercise decrements in muscle performance,2-6 increased post treatment pressure pain thresholds (ppt),4,7-9 and decreased post exercise muscle soreness in healthy individuals.2,3,10-12 several recent studies have also documented positive post intervention effects of fr for different sports,11,13-15 occupations,16 and chronic pain conditions.17 the iastm research suggests that the intervention is an effective treatment for tendoinopathies,18,19 arthrofibrosis,20,21 cerebral palsy,22,23 musculoskeletal pathologies,18,24-26 post mailto:scheatham@csudh.edu https://doi.org/10.31622/2020/0003.3.5 myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 mastectomy,27 post total joint arthroplasty,28,29 and athletic performance measures.18,24-26 the fb research is still emerging and the available studies have documented post intervention improvements in jump and sprint performance,30,31 reduced effects of edema in post-surgical patients,32 and improved pain and function in individuals suffering from achilles tendinopathy.33 one of the most common outcome measures professionals use for all three interventions is joint range of motion (rom).34 researchers have found that fr may improve joint rom at the shoulder,35,36 lumbopelvis,37,38 hip joint,39-45 knee joint, 9,45-47 and ankle.48,49 iastm has also been shown to improve joint rom at the shoulder,27,28,50,51,52 hip and knee joint,51,53,54,55 ankle,56 and spine.57 the fb research has documented improved post intervention ankle joint rom in healthy individuals.30,31 to date, no studies have directly compared the effects of all three interventions on joint rom among individuals with no prior experience. only one study has compared the effects of fr and iastm on passive hip and knee joint rom in collegiate soccer players.51 the study author did not document if the athletes had prior experience with myofascial compression interventions. the primary purpose of this investigation was to directly compare the immediate post intervention effects of foam rolling, instrument assisted soft-tissue mobilization, and floss band on passive knee joint rom among inexperienced individuals using a standard treatment time. the secondary purpose was to determine the interchangeability of the interventions and to provide preliminary research for long-term comparison studies. the researchers hypothesize that all three interventions will produce similar post treatment effects on passive knee joint rom after a standard treatment time. methods participants thirty healthy, active adults (m=15, w=15) were recruited via convenience sampling and enrolled in the study. participants were randomly assigned into one of three groups: foam roller (fr) (n=10), instrument assisted soft-tissue mobilization (iastm) (n=10), and flossing bands (fb) (n=10) (figure 1). a random number generator was used to allocate participants to each group. participants reported no prior experience using any of the myofascial interventions in this study. participant exclusion criteria included the following: musculoskeletal, systemic, neurosensory, or metabolic conditions that would affect joint rom of the lower extremity or the inability to avoid medications that may affect testing.18,58,59 participant demographic information is described in table 2. this pre-test, post-test clinical study was approved by the institutional review board at florida international university. outcome measure and instrument the outcome measure used for this investigation was passive knee joint rom. the clinometer smartphone application™ (plaincode, stephanskirchen deutschland) was used to measure each participant. the clinometer app has been shown to be valid and reliable for measuring lower extremity rom.60-64 for testing, the participant was placed in the prone lying position on a table. the investigator grasped the left ankle and passively moved the left knee. the knee was flexed to the point where the joint could no longer be passively moved without providing overpressure or to the point of initial discomfort. this position was held and a measurement was taken. the investigator monitored for any compensatory movement throughout the lumbopelvis and lower extremities. the investigator took the average of 3 measurements for each participant. left passive knee joint rom measurements have been used in prior myofascial compression studies.65-67 myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 interventions the fr group used a commercial foam roll and related instructional video were used in this investigation (triggerpoint, a division of implus, llc, 2001 tw alexander drive durham, nc 27709, usa). the video demonstrated the use of the foam roll on the left quadriceps muscle group. the grid® surface foam roll used in this investigation was commercially manufactured with a hard-hollow core (14 cm diameter) with a moderately firm outer ethylene-vinyl acetate (eva) foam (figure 2). participants were issued the foam roll and followed the video with no feedback from the observing investigator. the figure 1: data collection diagram excluded (n= 0) analysed (n= 10) excluded from analysis (n= 0) lost to follow-up (n= 0) discontinued intervention (n= 0) allocated to foam roll group (n= 10) • received allocated intervention (n= 10) lost to follow-up (n= 0) discontinued intervention (n= 0) allocated to flossing band group (n= 10) • received allocated intervention (n= 10) analysed (n= 10) excluded from analysis (n= 0) allocation analysis follow-up assigned (n= 30) enrollment allocated to iastm group (n= 10) • received allocated intervention (n= 10) lost to follow-up (n= 0) discontinued intervention (n= 0) analysed (n= 10) excluded from analysis (n= 0) assessed for eligibility (n= 30) myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 instructor in the video provided a brief introduction and then discussed the foam rolling technique. the instructor divided the left quadriceps into zone one: top of patella to middle of the quadriceps and zone two: middle quadriceps to anterior inferior iliac spine. the model in the video was instructed to get in the plank position, position the roller above the left patella and roll back and forth in zone one 4x at a cadence of 1inch per second. the model was then instructed to stop at the top of zone one followed by 4 active knee bends to 90 degrees. this sequence was repeated for zone two. the intervention portion lasted a total of 2 minutes. this video has been used in prior foam roll research.68 for the iastm group, the investigator administered an instrument intervention using the smart tools® crossbar tool (423 grams) (smart tools, 20636 castlemaine circle, oh 4419, usa) (figure 2) to the left quadriceps muscle. the investigator was a trained researcher certified in several iastm paradigms. participants lied supine on a table with hip and knee straight. a waterbased gel was used to decrease friction between the skin and instrument. the investigator delivered a superior and inferior longitudinal stroke with the crossbar perpendicular to the soft tissues while maintaining a 45° instrument edge angle. the investigator first began by placing the edge of the instrument just above the patella. the investigator then delivered a superior stroke up towards the anterior inferior iliac spine (aiis). just before reaching the aiis, the investigator reversed the cross bar and delivered an inferior stroke back to the starting position while maintaining the edge angle. the investigator used a 2 second cadence to complete the sequence using only the weight of the tool. the total intervention lasted 2 minutes. for the fb group, a 5.08 cm (2-inch) rockfloss® floss band (rocktape®, a division of implus, llc, 2001 tw alexander drive durham, nc 27709, usa) was used along with a related instructional video. the video demonstrated the use of the floss band to the left quadriceps muscle. participants were issued the floss band and followed the video with no feedback from the observing investigator. the video narrator provided a brief introduction and then demonstrated the technique using a model. the model wrapped the floss band around the left quadriceps muscle (distal to proximal) using a 50% overlapping pattern with an elongation stretch of 50% band length (figure 2).69 the wrap covered the quadriceps muscles above the patella to below aiis. the model then demonstrated an active movement sequence consisting of standing hip flexion (30 seconds), seated knee extension and flexion (30 seconds), and bodyweight squats (1minute). the intervention portion lasted a total of 2 minutes. participants followed the video and wrapped their own leg. figure 2: different myofascial compression devices: grid foam roller, iastm tool, and floss band myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 pilot study pilot training was conducted over two-sessions to practice the testing procedures and establish intrarater and interrater reliability among three investigators for passive knee joint rom. fifteen participants were independently recruited and enrolled for this portion of the investigation. the intraclass correlation coefficient was used to calculate intrarater (icc model 3, k) and interrater reliability (icc model 2, k).63,70 the results revealed good intrarater (icc= 0.99; 95% ci 0.88-1.0) and interrater (icc= 0.94; 95% ci 0.67-0.99) reliability among all investigators. these coefficients are in accordance with the minimum threshold of ≥ .90 for icc values postulated to be acceptable for clinical decision making.71 procedures prior to testing, eligible participants reviewed and completed study related materials including the written irb consent form and demographic questionnaire. all participants underwent one session of testing that included pre intervention measures, followed by the intervention, and then immediate post intervention measures. all participants were tested between the hours of 10 a.m. and 2 p.m. and were instructed to not participate in any strenuous activity 5 hours prior to testing. participants were also instructed to refrain from taking any medications (e.g. opioids, muscle relaxants) that would interfere with testing. all participants were blinded to the testing results and other individuals in the study. for each group, one investigator was assigned to take three pre intervention and three immediate post intervention measures and was blinded from the intervention. a second investigator was present to explain the intervention procedures (fr and fb) to each participant and answer any questions. for the iastm group, the second investigator administered the intervention. these testing methods have been used in prior myofascial research.72 statistical analysis the statistical analysis was performed by the program spss version 25.0 (ibm spss, armonk, ny, usa). the descriptive statistics for participants were calculated for age, height, body mass, and body mass index (bmi). the anova statistic was used for continuous descriptive data and the kruskal wallis statistic for ordinal descriptive data. the ancova statistic was used to measure between group differences. the independent variable was the group, dependent variable was post test scores, and pretest scores was the covariate.73 post hoc within group differences were measured with the paired t-test. the average of three joint rom measurements was used for all pre-test and post-test calculations. the effect size was also measured (d = m1 m2 / σpooled). the effect size values were interpreted as: >0.70 was considered strong, 0.41 to 0.70 was moderate, and < 0.40 was weak.74 all statistical assumptions were met for the anova, ancova and paired t-test statistics. statistical significance was considered p< .05 using a two-tailed test. results thirty participants were enrolled and completed the study (mean age= 25.43 ± 2.46 years; height= 170.00 ± 9.17 cm; body mass= 73.82 ± 9.65 kg; body mass index (bmi)= 26.65 ± 3.83 kg/m2) (table 1). descriptive analysis revealed no statistically significant difference between groups for age (p=0.10), height (p=0.70), body mass (p=0.55), or bmi (p=0.14). all enrolled participants completed the study with no adverse events or attrition. the between group analysis for passive knee joint rom revealed a statistically significant post intervention difference between the three groups [f (1,39) =612.32, p=<0.001, partial η2=0.944]. the post hoc within group analysis myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 revealed an approximate post intervention knee flexion increase of 2 degrees (p <.001, es=.26) for fr, 3.5 degrees (p=.004, es= .26) for iastm, and 4 degree (p<.001, es=.47) for fb (table 2). discussion the primary purpose of this investigation was to directly compare the immediate post intervention effects of fr, iastm, and fb on passive knee joint rom among inexperienced individuals. to date, no studies have compared these interventions among this population. the results suggest that these interventions produced a statistical significant post intervention effect. however, there was less than a 2◦ post treatment difference between interventions which may not be clinically meaningful in some settings. it is important to note that the passive joint rom in this study was taken with a digital device which may be more accurate than standard goniometry.60 these findings are similar to prior research documenting increased post intervention knee rom values that ranged from 2-7◦ for the these interventions.45-47,51,55 the secondary purpose was to determine the interchangeability of the three interventions using a standard treatment time of 2-minutes which has been a common intervention time used in prior myofascial research.68,69 there was a rom difference of 1-2◦ between all three interventions which suggests they may produce similar post treatment responses when using the same treatment time and body region (quadriceps muscle). these findings support their interchangeability. for example, a professional may administers a skilled 2-minute iastm technique to the quadriceps then prescribe a 2minute self fr or fb intervention as a home exercise to maintain the effects of the iastm table 1. participant demographics (n=30) characteristics age (years) height (cm) mass (kg) bmi (kg/m2) foam roll group (n=10) 26.13 ± 2.56 (range 23-30) 169.50 ± 8.72 (range 155-183) 72.73 ± 9.35 (range 59-89) 24.67 ± 2.84 (range 21-28) iastm group (n=10) 24.80 ± 2.04 (range 23-28) 168.15 ± 9.49 (range 150-180) 77.59 ± 9.49 (range 57-99) 27.34 ± 4.45 (range 21-36) floss band group (n=10) 24.40 ± 2.13 (range 22-31) 172.39 ± 10.37 (range 158-188) 72.26 ± 10.57 (range 57-108) 27.90 ± 4.83 (range 21-38) data reported as mean± sd; range (min-max); m=meters; bmi= body mass index; kg/m2= kilograms-meter squared table 2. pre and post-intervention results (n=30) pretest posttest change p-value effect size foam roll group knee flexion rom (degrees) 115.60 ± 8.66 117.93 ± 9.06 2.33 ± 0.40 <.001 .26 iastm group knee flexion rom (degrees) 121.97 ± 13.81 125.48 ± 13.00 3.51 ± 0.81 .004 .26 floss band group knee flexion rom (degrees) 110.73 ± 8.48 114.73 ± 8.43 4.00 ± 0.03 <.001 .47 data reported as mean ± sd, kpa= kilopascals; statistical significance considered p<.05; effect size: d = m1 m2 / σpooled myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 treatment. the results of this study are consistent with findings from the markovic study which compared the efficacy of a 2-minute fr and iastm intervention on soccer players.51 the authors documented improved post intervention passive knee and hip joint rom from both interventions (p < 0.05). thus, these myofascial compression interventions produced similar post treatment effects. there are two main scientific theories being postulated by researchers regarding the post treatment effects of these myofascial compression interventions. these interventions may provide a greater deformation of the local myofascial tissues which creates a mechanical and neurophysiological effect. for the mechanical effect, the pressure of the device or wrap may change the viscoelastic properties of the myofascia by mechanisms such as thixotropy (reduced viscosity), reducing myofascial restriction, fluid changes, and cellular responses.48,75 clinically, these changes may be observed as a greater lengthening or “stretch tolerance” of the muscle and surrounding tissues as measured by changes in joint rom. for the neurophysiological effect, the mechanical pressure from the device or wrap may have produced a local and global neurophysiological effect that influences tissue relaxation in the target and surrounding tissues through central nervous system afferent input from the golgi tendon reflex and mechanoreceptors (e.g. golgi tendon organ).7,48,75-78 perhaps, the active joint movements in the fr and fb interventions enhance the effects of the devices as well as the assisted iastm intervention. prior research suggests that active myofascial interventions may enhance the neurophysiological effect producing greater benefits.68,79 future studies are needed to validate these theories. limitations there are four limitations with this study. first, this study tested healthy non-experienced participants with no pathology. this limits the generalizability to this population. second, the three different myofascial compression interventions studied were from specific manufacturers. other similar interventions from different manufacturers may have produced different results. third, the immediate post intervention effects were investigated. the long-term effects of the intervention cannot be determined. fourth, the interventions in this study used a specific technique (e.g. left quadriceps) for a predetermined 2 minute intervention time which has been used in prior myofascial research.68,69 other treatment techniques and intervention times may have produced different results. conclusion this was the first study to directly measure the immediate post treatment effects of three different myofascial compression interventions on passive knee joint rom among individuals with no prior experience using a standard treatment time. the results suggest that all three interventions may produce similar immediate post treatment effects which supports their interchangeability. future studies are needed to further validate these results over a long post intervention time period. the goal of this study was to be exploratory and establish the methodology for long-term investigations. clinicians may want to consider these results when choosing and administering myofascial compression interventions with their patients. acknowledgements: we would like to thank implus, llc for providing permission to use the triggerpoint instructional video and associated foam roller and rocktape® floss band. we would also like to thank jasmin grimes, kay scales, aline valiengo, and matthew hershgordon for helping with this research project. myofascial compression interventions: comparison of roller massage, instrument assisted soft-tissue mobilization, and floss band on passive knee motion among inexperienced individuals 31 copyright © by 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2577-8188 volume 3 – issue 3 – november 2020 https://doi.org/10.1113/jphysiol.2011. 211326. 79. cheatham sw, stull kr, batts wn, ambler-wright t. roller massage: comparing the immediate post-treatment effects between an instructional video and a self-preferred program using two different density-type roller balls. j hum kinet. 2020; 71:119-129. https://doi.org/10.2478/hukin-20190077. https://doi.org/10.1113/jphysiol.2011.211326 https://doi.org/10.1113/jphysiol.2011.211326 https://doi.org/10.2478/hukin-2019-0077 https://doi.org/10.2478/hukin-2019-0077 allocation analysis follow-up enrollment manuscript type validation case report 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study matthew j. rivera, dat, lat, atc; cameron j. powden, phd, lat, atc; kenneth e. games, phd, lat, atc indiana state university, terre haute, in abstract the purpose of this case validation study was to examine the effects of a previously established proprioception training program on the number of lateral ankle sprains in secondary school basketball players. the patient population consisted of 22 patients (5 females, 17 males, age = 16±1 years old, height = 181.8±8.9 cm, weight = 74.8±12.8 kg) from a small rural high school in illinois. the team completed the proprioceptive training program as part of a warm-up supervised by the athletic trainer and took approximately five minutes to complete. the program was completed every day for five weeks with one additional week of maintenance exercises. the main outcomes assessed were the number of lateral ankle sprains, anterior reach distance from the ybalance test, and foot and ankle ability measure (faam) sport scale scores. data collection occurred at baseline (prior to starting the program), week 6, week 12, and follow-up. there were a total of 9 lateral ankle sprains and 3 re-injury throughout the course of the previous season without using the proprioceptive training program. there were 6 lateral ankle sprains and only 1 re-injury during this competition season. anterior reach distances on the ybalance test improved from follow-up to week 6; but decreased from week 6 to week 12 and follow-up. faam sport scale scores remained consistent throughout the duration of the season. the proprioceptive training program was effective in reducing the number of lateral ankle sprains in the adolescent population and helped improve anterior reach distance while patients were completing the exercise program. athletic trainers should incorporate more proprioceptive training programs with their patient population as primary prevention measures. key phrases injury risk reduction, clinician-rated outcomes, secondary school patient population correspondence dr. matthew rivera, indiana state university, 567 n. 5th street, terre haute, in 47809. e-mail: mrivera11@sycamores.indstate.edu twitter: @matt_riveraat full citation rivera mj, powden cj, games ke. ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study. clin pract athl train. 2018;1(1):3-10. https://doi.org/10.31622/2018/0001.2 submitted: may 14, 2018 accepted: may 23, 2018 article citation and summary schiftan gs, ross la, hahne aj. the effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: a systematic review and metaanalysis. j sci med sport. 2015;18:238-244 we selected a guiding systematic review1 that examined the evidence regarding the use of ankle proprioceptive training programs and its influence on ankle sprain rates. the authors completed a comprehensive literature search of medline, cinahl, sportdiscus, and pedro through october 2013. studies were evaluated using the following criteria: (1) study design was a moderate-to-high level randomized controlled trial (4/10 on the pedro scale), (2) participants were physically active (regardless of previous ankle injury), (3) intervention group received proprioceptive training only compared to a control group (no proprioceptive training), and (4) the rate of ankle sprains was reported as a main outcome. the authors examined the number of participants, interventions, and injury rates. seven of the initial 345 studies were included in the review totaling 3,726 patients. a comprehensive meta-analysis of all patients from the 7 included studies, regardless of history of injury, revealed a significant reduction in ankle sprain rates for the proprioceptive training group compared to the control group (relative risk = 0.65, 95% ci = 0.51-0.81). proprioceptive training was statistically significant exclusively as a primary preventative measure (relative risk = 0.57, 95% ci = 0.34-0.97). the review concluded that proprioceptive training programs are effective at reducing the incidence rates of lateral ankle sprains, including those with a history of ankle sprains. https://doi.org/10.31622/2018/0001.2 ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 objective the purpose of our validation case study was to examine whether the use of a previously established ankle proprioceptive training program would effectively reduce the number of lateral ankle sprains in secondary school (grades 9-12) patients, which student-athletes were competing in basketball. additionally, we investigated the use of the proprioceptive training program on dynamic balance (y-balance test) and perceived function of the ankle (foot and ankle ability measure sport). patient population the clinical practice setting was a secondary school in rural illinois. both female and male basketball programs from one secondary school were utilized for the project. twenty-two patients (5 females, 17 males, age = 16±1 years old, height = 181.8±8.9 cm, weight = 74.8±12.8 kg) completed the proprioceptive training program throughout the basketball season. patients were included regardless of ankle sprain history and were free of injury at the onset of the proprioceptive training program. there were 8 males and 3 females with a history of previous ankle sprains. intervention the proprioceptive training program (table 1) was developed based on recommendations provided by a study in the guiding review.2 each participant completed the proprioceptive training program as a part of a structured, active, group warm-up supervised by the athletic trainer. the program was initiated at the beginning of the competitive season and consisted of 5-week long phases of increasing difficulty based on individual participant performance and concluded at the end of week four with a maintenance week (week 5). the first 4 phases (weeks 1 through 4 ) required patients to complete 5 training sessions per week for approximately 15 to 20 minutes total per week. the final phase (week 5) consisted of maintenance exercises 3 times for approximately 10 minutes total per week. during each session, 3 to 4 tasks were completed. the patients did not complete the program on game days. the program (table 1) consisted of single leg stance on flat surface, dribbling a basketball on a single leg, double leg stance on a balance board, single leg stance on a balance board, and dribbling a basketball in a single leg stance on the balance board (figure 1).2 each task was part of a progression and not every task was completed each day. each exercise was performed for 30 seconds on each leg with a 30second rest period between each exercise. each task was completed with eyes open initially and progressed to eyes closed in the subsequent phases. the balance boards were constructed using a round, precut 16-inch board. a piece of round plastic tubing approximately 5 inches wide was adhered to the middle of the board. figure 1. balance boards created for the proprioceptive training program. if a participant missed 5 consecutive days or was unable to perform the outcome assessments, the patient’s data were not used in the analysis. patients were excluded from the outcome assessment if they had an injury that prevented ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 them from bearing weight on a single leg to perform the anterior reach distance at the time of data collection. outcomes were assessed before starting the proprioceptive training program (baseline), at the conclusion of the training program (week 6), 6 weeks after conclusion (week 12), and at the end of the season (follow-up). outcomes data were collected before patients participated in practice. the 3 main outcomes that were assessed throughout the data collection period were number of lateral ankle sprains, anterior reach distances on the star excursion balance test, and the foot and ankle ability measure (faam) sport scale. table 1. proprioceptive training program. week surface eyes exercises week 1 floor open open open open single leg stance single leg stance with leg swing single leg squat (30°45°) single leg stance while dribbling ball week 2 floor closed closed closed single leg stance single leg stance with leg swing raised single leg squat (30°45°) week 3 board open open open open single leg stance single leg stance with leg swing raised single leg squat (30°45°) double leg stance while rotating the board week 4 board closed open open open single leg stance single leg stance with leg swing raised single leg squat (30°45°) single leg stance while rotating the board week 5-6 board closed open open open single leg stance single leg squat (30°45°) single leg stance while rotating the board single leg stance while dribbling the ball table 2. means (± standard deviations) for all main outcome measures. baseline week 6 week 12 follow-up y-balance test (%) anterior dominant limb 84.23 ± 7.48 86.82 ± 6.60a 83.79 ± 6.44b 83.23 ± 6.63b non-dominant limb 84.58 ± 7.82 87.89 ± 8.43a 84.09 ± 7.64b 83.05 ± 6.19b faam sport scale score 31.32 ± 1.76 30.55 ± 3.99 31.09 ± 3.07 31.36 ± 2.26 perceived function (%) 96.91 ± 5.38 99.14 ± 3.23a 99.32 ± 2.34 99.09 ± 2.94b a=significantly different from pre-intervention at p<0.05, b=significantly different from week 6 (termination of intervention) at p>0.05. ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 ankle sprains were evaluated by the athletic trainer and defined as an injury localized to the lateral ankle (indicated by positive anterior drawer test and inversion stress test), required at least 48 hours of activity modification, and documented in the electronic medical record system (emr). the number of ankle sprains were compared to the number of ankle sprains in the same population in the previous season that also fit the definition of injury and treatment outlined above. the anterior reach distance on the y-balance test was utilized to assess any changes in dynamic postural control throughout the duration of the proprioceptive training program.3,4 the ybalance test has been shown to have good reliability and validity in assessing dynamic postural control as an indicator of le injury in the adolescent population.4 the same evaluator collected anterior reach distances using a standard tape measure secured to the floor. patients were instructed to place their big toe at the 0 indicator on the tape measure and to reach the opposite foot as far as they could straight ahead while maintaining single leg balance.4 the distance was recorded at the most distal aspect of the reach foot. each patient completed three practice trials followed by three testing trials. reach distances were normalized to patient height and classified as dominant limb or non-dominant limb. a trial was void if they could not maintain the single leg stance, stance foot was lifted off the ground, or of the non-stance limb touched the ground.4 perceived ankle function was measured using the faam sport scale. the faam has been demonstrated to detect self-reported functional deficits in those with chronic ankle instability and a range of other musculoskeletal conditions in the foot and ankle.5,6 patients were given an electronic version of the faam sport scale and instructed to complete the form based on their current symptom score. each item on the faam sport scale is an 8-item measure scored on a 5point likert scale of 0-4.5,7 zero indicating the patient could not complete the task and “4” indicating the patient had no difficulty completing the task.5,7 a 4x2 repeated measures anova was used to assess differences in anterior reach scores over time (baseline, week 6, week 12, follow-up) and between limbs (dominant, non-dominant). a oneway anova was used to examine faam sport scale differences over time. post hoc analysis was completed using fishers lsd test. significance was set a-priori at p<0.05. all statistical analyses were completed using spss version 24 (ibm corp. released 2016. ibm spss statistics for windows, version 24.0. armonk, ny: ibm corp.). the number of ankle sprains was extracted from an emr and compared to data from the year prior to the implementation of the proprioceptive training program. main findings nine first time lateral ankle sprains were sustained in the competition year prior to the proprioceptive training program. during the proprioceptive training program year, 6 first time lateral ankle sprains were sustained. in the previous year, 3 patients sustained a second lateral ankle sprain to the same ankle in the same competition year. while using the proprioceptive training program, only 1 patient sustained a re-injury in the same competition year. there were no major changes in competition level, number of patients, training schedules, competition schedules, etc. a significant time main effects was found for anterior reach distance (p<0.001). post hoc analysis indicated that anterior reach distances were significantly greater at six 6 weeks compared to baseline (p<0.001), week 12 (p =0.003), and follow-up (p<0.001). no other significant differences were found between each time point (p>0.17). there was no limb main effect for the anterior reach distances (p=0.58). there was no time by limb interaction detected (p ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 =0.51). after patients, ceased participation in the proprioception training program anterior reach distances decreased in both dominant and nondominant limbs. there was no time main effect for faam sport scale scores throughout data collection (p =0.56). there was no time main effect in the perceived level of function (0-100% scale) on the faam sport scale (p=0.56) (table 2). discussion no statistical tests were used to compare the rates of ankle sprains due to the small patient population; rather, the number of ankle sprain were reported. our findings are consistent with other literature investigating the use of proprioceptive training programs to prevent lateral ankle sprains.1,2,8-10 specifically, from investigations within the guiding review, both the number of initial injury and re-injury rates decreased for patient populations utilizing the proprioceptive training programs.1 however, perhaps a greater achievement in the reduction of ankle sprains is time saved treating these injuries. athletic trainers spend an increased amount of time treating patients with time-loss injuries compared to non-time-loss injuries.11 athletic trainers primarily use therapeutic exercise and neuromuscular reeducation as treatments for patients with ankle sprains.11 this current study suggests that athletic trainers can reduce the amount of ankle sprains they are treating and further reduce the amount of time spent treating ankle sprains by using a primary prevention program targeting proprioception. the results from the current study suggest that proprioceptive training programs can improve dynamic balance as we identified increases in anterior reach distances from baseline to week 6. further evidence of the improvements are indicated by the decreases in anterior reach distances at week 12 and follow-up once compliance rates dropped. this reduction in scores highlights the need to assure compliance with proprioceptive training programs to ensure optimal outcomes. a similar investigation looking at balance improvements with the use of neuromuscular training also found comparable improvements in the sebt.12 similar to the current investigation the authors found improvements in the reach distances after a 6 week program targeted at neuromuscular control.12 however, the previous study utilized a program that also incorporated strength and plyometric exercise with longer training sessions.12 furthermore, other investigations examining dynamic balance found an 8-week balance and strength program to increase the anterior reach distances in collegiate female soccer players.13 the program focused primarily on strength and conditioning for more elite athletes compared to the current investigation. however, the findings of improved dynamic balance with a targeted program are similar. overall, the use of the proprioceptive training program can help patients improve dynamic balance and thus could reduce the risk of suffering an ankle sprain. there was no time main effect for faam sport scale scores suggesting that the proprioceptive training program did not change perceived foot and ankle function. there was also no time main effect for perceived level of function ranked from 0-100% function. other investigations implementing rehabilitative protocols or proprioceptive training programs have found improvements in faam scores.14,15 however, these previous investigations used participants that had chronic ankle instability whereas the current investigation used healthy subjects from baseline. the patients in this study were athletes functioning at a high level with no disability to start. previous research has shown that participants that are healthy have higher faam scores and therefore could have had a ceiling effect on faam scores in the current project.5 future investigations should focus on the use of a proprioceptive training program and severity of ankle sprains that ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 patients sustain. additionally, future studies should investigate the influences of a prophylactic proprioception training program and the amount of time patients take to return to baseline outcome scores. in order to be more proactive in injury reduction, athletic trainers should attempt to incorporate more preventative measures in their clinical practice. by becoming more proactive, athletic trainers can reduce the amount of time spent treating initial injury and re-injuries for ankle sprains.11 neuromuscular reeducation is the second most common intervention used when treating ankle sprains in the secondary school setting.11 treating from a reactionary standpoint after a patient is injured may costs athletic trainers more time and limits their focus on other aspects of their duties. by becoming more proactive in using neuromuscular training as a prevention method, athletic trainers can reverse this cycle. furthermore, by decreasing the amount of injuries sustained athletic trainers can help combat inflating healthcare costs and long-term consequences of injury such as chronic ankle instability and osteoarthritis. the implementation of a prevention program can be a difficult task to accomplish, especially in settings where no previous effort in injury prevention has been made. there are a variety of variables that should be considered and accounted for to successfully implement a prevention program. first, the time required for patients, coaches, and practitioners to complete the prevention program is considered a limitation of injury prevention.16 in an investigation looking at a comprehensive prevention program in youth football, investigators found coaches were 87% less likely to not implement a prevention program if they felt the time required was too long.16 however, through this case validation the investigators implemented a program with a realistic length to track changes in positive outcomes. the overall time required was less than 5 minutes per player, per day, totaling only 2530 minutes for the entire week. additionally, the proprioceptive training program was implemented as a component of a team warm up before practice each day to ensure daily compliance for each player. as previously established, compliance rates with injury prevention measures can greatly improve the outcomes seen for participants.17 additionally, it has been shown that supervised programs (either by athletic trainer or coaches) are likely to have higher adherence rates than unsupervised programs.17,18 athletic trainers need to evaluate their clinical practice, the common injuries they treat, and the time required to implement a prevention program for such injuries to leverage compliance from coaches, patients, and stakeholders. data collection, management, and analysis was simple and effective for this clinical practice site. the emr in the project, which was already in place at the clinical practice site, was utilized to store and protect data. the use of electronic fillable pdfs made data collection for the faam sport score easy. data collection periods were quick and efficient with 1 athletic training student facilitating the faam sport scale administration and 1 athletic trainer measuring the anterior reach distances. data were downloaded from the emr and exported onto a microsoft excel 2016 (microsoft corp, richmond wa) sheet for analysis. athletic trainers should explore the data management capabilities of their record systems in place; additionally, athletic trainers should investigate which clinician and patient reported outcomes would be most appropriate to track based on their patient population, needs, time, and prevention methods being implemented. resources such as money, equipment, and training are required for the implementation of prevention practices. however, for this project, the only associated costs were those required for the building of the balance boards, which was minimal. the budget for a program used in this project was small and the time required to ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 complete the exercises was minimal. athletic trainers should leverage resources and positive relationships with coaches to explore options for prevention program implementation. clinical bottom line the findings from this case validation study concur with the guiding systematic review and metaanalysis that the use of proprioceptive training programs are effective in the reduction of lateral ankle sprains. additionally, the use of the proprioceptive training program also improved dynamic stability and postural control of patients as the anterior reach distances of the y-balance test increased. athletic trainers should begin to examine their own clinical practice to determine the feasibility of implementing a proprioceptive training program with their patient population to reduce the incidence of ankle sprains. references 1. schiftan gs, ross la, hahne aj. the effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: a systematic review and metaanalysis. j sci med sport. 2015;18(3):238244. https://doi.org/10.1016/j.jsams.2014.04.0 05 2. mcguine ta, keene js. the effect of a balance training program on the risk of ankle sprains in high school athletes. am j sports med. 2006;34(7):1103-1111. https://doi.org/10.1177/0363546505284 191 3. gribble pa, hertel j, plisky p. using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. j athl train. 2012;47(3):339-357. https://doi.org/10.4085/1062-605047.3.08 4. plisky pj, rauh mj, kaminski tw, underwood fb. star excursion balance test as a predictor of lower extremity injury in high school basketball players. j orthop sports phys ther. 2006;36(12):911-919. https://doi.org/10.2519/jospt.2006.2244 5. carcia cr, martin rl, drouin jm. validity of the foot and ankle ability measure in athletes with chronic ankle instability. j athl train. 2008;43(2):179-183. https://doi.org/10.4085/1062-605043.2.179 6. martin rl, irrgang jj, burdett rg, conti sf, van swearingen jm. evidence of validity for the foot and ankle ability measure (faam). foot ankle int. 2005;26(11):968-983. https://doi.org/10.4085/10.1177/107110 070502601113 7. cosby nl, hertel j. clinical assessment of ankle injury outcomes: case scenario using the foot and ankle ability measure. j sport rehabil. 2011;20(1):89-99. https://doi.org/10.1123/jsr.20.1.89 8. emery ca, rose ms, mcallister jr, meeuwisse wh. a prevention strategy to reduce the incidence of injury in high school basketball: a cluster randomized controlled trial. clin j sport med. 2007;17(1):17-24. https://doi.org/10.1097/jsm.0b013e3180 2e9c05 9. mohammadi f. comparison of 3 preventive methods to reduce the recurrence of ankle inversion sprains in male soccer players. am j sports med. 2007;35(6):922-926. https://doi.org/10.1177/0363546507299 259 10. verhagen e, van der beek a, twisk j, bouter l, bahr r, van mechelen w. the effect of a proprioceptive balance board training program for the prevention of ankle sprains: a prospective controlled trial. am j sports med. 2004;32(6):1385-1393. https://doi.org/10.1177/0363546503262 177 11. simon je, wikstrom ea, grooms dr, docherty cl, dompier tp, kerr zy. athletic training service characteristics for patients with ankle sprains sustained during high school athletics. j athl train. forthcoming 2018. https://doi.org/10.4085/1062-6050-44916 12. mcleod tc, armstrong t, miller m, sauers jl. balance improvements in female high school basketball players after a 6-week neuromuscular-training program. j sport https://doi.org/10.1016/j.jsams.2014.04.005 https://doi.org/10.1016/j.jsams.2014.04.005 https://doi.org/10.1177/0363546505284191 https://doi.org/10.1177/0363546505284191 https://doi.org/10.4085/1062-6050-47.3.08 https://doi.org/10.4085/1062-6050-47.3.08 https://doi.org/10.2519/jospt.2006.2244 https://doi.org/10.4085/1062-6050-43.2.179 https://doi.org/10.4085/1062-6050-43.2.179 https://doi.org/10.4085/10.1177/107110070502601113 https://doi.org/10.4085/10.1177/107110070502601113 https://doi.org/10.1123/jsr.20.1.89 https://doi.org/10.1097/jsm.0b013e31802e9c05 https://doi.org/10.1097/jsm.0b013e31802e9c05 https://doi.org/10.1177/0363546507299259 https://doi.org/10.1177/0363546507299259 https://doi.org/10.1177/0363546503262177 https://doi.org/10.1177/0363546503262177 https://doi.org/10.4085/1062-6050-449-16 https://doi.org/10.4085/1062-6050-449-16 ankle proprioception training program for preventing lateral ankle sprains in adolescent basketball players: a case validation study 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 1 – issue 1 – june 2018 rehabil. 2009;18(4):465-481. https://doi.org/10.1123/jsr.18.4.465 13. ness bm, comstock ba, schweinle we. changes in dynamic balance and hip strength after an eight-week condiitoning program in ncaa division 1 female soccer (football) athletes. int j sports phys ther. 2016;11(7):1054-1064. 14. wright cj, linens sw, cain ms. a randomized controlled trial comparing rehabilitation efficacy in chronic ankle instability. j sport rehabil. 2017;26(4):238249. https://doi.org/10.1123/jsr.20150189 15. schaefer jl, sandrey ma. effects of a 4-week dynamic-balance-training program supplemented with graston instrumentassisted soft-tissue mobilization for chronic ankle instability. j sport rehabil. 2012;21(4):313-326. https://doi.org/10.1123/jsr.21.4.313 16. soligard t, nilstad a, steffen k, et al. compliance with a comprehensive warm-up programme to prevent injuries in youth football. br j sports med. 2010;44(11):787793. https://doi.org/10.1136/bjsm.2009.07067 2 17. van reijen m, vriend i, van mechelen w, finch cf, verhagen ea. compliance with sport injury prevention interventions in randomised controlled rials: a systematic review. sports med. 2016;46(8):1125-1139. https://doi.org/10.1007/s40279-0160470-8 18. steffen k, meeuwisse wh, romiti m, et al. evaluation of how different implementation strategies of an injury prevention programme (fifa 11+) impact team adherence and injury risk in canadian female youth football players: a cluster-randomised trial. br j sports med. 2013;47(8):480-487. https://doi.org/10.1136/bjsports-2012091887 https://doi.org/10.1123/jsr.18.4.465 https://doi.org/10.1123/jsr.2015-0189 https://doi.org/10.1123/jsr.2015-0189 https://doi.org/10.1123/jsr.21.4.313 https://doi.org/10.1136/bjsm.2009.070672 https://doi.org/10.1136/bjsm.2009.070672 https://doi.org/10.1007/s40279-016-0470-8 https://doi.org/10.1007/s40279-016-0470-8 https://doi.org/10.1136/bjsports-2012-091887 https://doi.org/10.1136/bjsports-2012-091887 abstract presentation 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 patient satisfaction with athletic trainers working in a physician practice setting nathaniel p. acree, ma, lat, atc*; forrest q. pecha, ms, lat, atc*; joshua b. lavigne, ms, lat, atc†; esther c. nolton, med, lat, atc, cscs‡ *st. luke’s sports medicine, boise, id; †mid-columbia medical center, the dalles, or; ‡ george mason university, fairfax virginia full citation acree np, pecha fq, lavinge jb, nolton ec. patient satisfaction with athletic trainers working in a physician practice setting. clin pract athl train. 2020;3(1):9-10. https://doi.org/10.31622/2020/0003.4. presented at the 3rd annual athletic trainers in the physician practice society meeting and conference, columbia south carolina. february 28-29, 2020 abstract background: recent changes in healthcare administration via the introduction of the triple aim by the institute of healthcare improvement have challenged healthcare institutions to improve the efficiency and effectiveness with which services are provided, while also enhancing patient experience. these changes have facilitated the hiring of clinical support staff from varying backgrounds with the aim of ensuring the goals of the triple aim are met within the clinical environment. recently orthopedic practices have begun to include certified athletic trainers in the healthcare delivery team due to their advanced base of musculoskeletal knowledge. previous literature has observed increased efficiency and revenue in physician practices where certified athletic trainers (ats) are included in the healthcare team. however patient satisfaction with certified athletic trainers as healthcare providers in a physician practice is yet to be measured. methods: design: cross-sectional, descriptive. setting: physician clinic. participants: new patients (np) and guardians of minors who are np presenting for evaluation in a primary care sports medicine practice. intervention: a 10-item survey consisting of six-point likert-scale items was developed in order to assess patient satisfaction with ats in the domains of interpersonal care, technical care and global satisfaction within a physician practice setting. the survey was offered during a 23-month period to new patients in a physician clinic when ats were involved with healthcare delivery during the initial encounter. responses were collected via an electronic platform. descriptive statistics were calculated, and mean scores were calculated for each likert scale item and domain. results: a total of 186 completed surveys were analyzed. mean score and standard deviation were: m = 5.76 for interpersonal care, m = 5.78 for technical care, and m = 5.81 for global satisfaction. conclusion: in this study among new patients presenting for musculoskeletal care in an orthopedic physician clinic, participants reported high satisfaction with the technical, interpersonal, and overall care provided by athletic trainers. ats may be an asset to the orthopedic physician practice with regard to patient satisfaction within the model utilized at study sites. correspondence forest pecha, st. luke’s plaza-central plaza, 720 park blvd. suite 115, boise, id 83789 email: fpecha@slhs.org references 1. molinari c. does the accountable care act aim to promote quality, health, and control costs or has it missed the mark? comment on “health system reform in the united states.” int j of health policy manag. 2014;2(2):97https://doi.org/10.31622/2020/0003.4 mailto:fpecha@slhs.org patient satisfaction with athletic trainers working in a physician practice setting 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 99. https://doi.org/10.15171/ijhpm.2014.23. 2. berwick d, nolan t, whittington j. the triple aim: care, health, and cost. health aff. 2008;3:759-769. https://doi.org/10.1377/hlthaff.27.3.759. 3. berg g, crowe r, nyberg s, burdsal c. trauma patient satisfaction with physician assistants : testing a structural equation model. jaapa. 2012;25(5):42-51. https://doi.org/10.1097/01720610201205000-00008. 4. day cs, boden sd, knott pt, o'rourke nc, yang bw. musculoskeletal workforce needs: are physician assistants and nurse practitioners the solution? aoa critical issues. j bone joint surg am. 2016;98(11):e46. https://doi.org/10.2106/jbjs.15.00950. 5. pecha fq, nicolello ts, xerogeanes jw, karas s, labib sa. patient perceptions of athletic trainers and orthopaedic medical residents as primary clinical support staff in sports medicine practice: a randomized, double-blinded prospective survey. j allied health. 2015;44(4):225-228. https://doi.org/10.15171/ijhpm.2014.23 https://doi.org/10.1377/hlthaff.27.3.759 https://doi.org/10.1097/01720610-201205000-00008 https://doi.org/10.1097/01720610-201205000-00008 https://doi.org/10.2106/jbjs.15.00950 manuscript type evidence-to-practice review 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review hayley o’connell, scat, atc; brittany decamp, scat, atc; and zachary winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract when comparing imaging techniques for rotator cuff pathologies, clinicians tend to consider musculoskeletal ultrasonography (msk us), magnetic renaissance imaging (mri), and magnetic renaissance imaging with arthrogram (mra) as diagnostic imaging techniques. since the most recent systematic review on imaging conducted in 2003, imaging technology has improved, indicating the need for a metaanalysis to evaluate the accuracy of new diagnostic techniques (msk us) for evaluating rotator cuff pathologies. the accuracy of msk us readings between radiologists and non-radiologists was also analyzed. data were extracted from three different databases and included articles exploring diagnostic imaging and the accuracy of technique at the shoulder joint. all research findings were then rated for any risk of bias using the revised version of the quality assessment of diagnostic accuracy studies (quadas-2). statistically, the authors used hierarchical summary receiveroperating characteristics to compare accuracy of diagnostic imaging techniques across the literature. the results from the guiding manuscript indicated that msk us, mri, and mra were considered highly sensitive diagnostic imaging techniques for full-thickness rotator cuff tears (sn: us: 0.860.94, mri: 0.85-0.95, mra: 0.83-0.95). for partial-thickness rotator cuff tears, likelihood ratios indicated an increased accuracy in mra diagnostic ability (sn: mra: 0.83), though msk us and mri were still considered highly sensitive for diagnosing partial-thickness rotator cuff tears (sn: msk us: 0.68, mri: 0.67). when comparing radiologists and nonradiologists use of msk us, there was no significant difference in diagnostic accuracy based on the reading provider. as the diagnosis based on imaging determines the need for surgical intervention, the guiding review indicated that all three diagnostic tools (msk us, mri and mra) were considered highly sensitive for rotator cuff pathologies (average sn of all diagnostic tools: 0.90-0.91). determining which imaging technique to use should be based on patientcentered factors, such as possibility of the presence of other shoulder pathology, invasiveness of the procedure, and financial implications. diagnostic msk us optimizes these factors, in addition to being highly sensitive. key phrases diagnostic testing and physical examination: upper extremity; college and university patient population, clinic and hospital patient population correspondence dr. zachary winkelmann, university of south carolina 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation o’connell h, decamp b, winkelmann zk. diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review. clin pract athl train. 2020;3(3):12-17. https://doi.org/10.31622/2020/000.3.3. submitted: april 20, 2020 accepted: august 17, 2020 original reference roy js, braen c, leblond j, et al. diagnostic accuracy of ultrasonography, mri, and mr arthrography in the characterization of rotator cuff disorders: a systematic review and meta-analysis. br j sports med. 2015;49(20):1316-1328 summary clinical problem and question shoulder pathologies affect much of the general population and most commonly are a result of injury to the rotator cuff tendons.1 the rotator cuff is the group of muscles (supraspinatus, infraspinatus, teres minor and subscapularis) that are primarily responsible for external and internal rotation of the shoulder along with assisting in stabilizing the glenohumeral joint during a majority of all other shoulder movements. and in stabilizing the glenohumeral joint. conditions of the rotator cuff often constitute rotator cuff tendinopathies, partial thickness rotator cuff tears, and full thickness rotator cuff tears.2 without treatment, such as therapeutic rehabilitation or surgical intervention, patients mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2020/000.3.3 diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 suffering from a rotator cuff pathology may experience lifelong pain and significant functional limitations.2 surgical intervention is often indicated and time-sensitive for individuals with full thickness rotator cuff tears, so an accurate diagnosis is critical.3 the three diagnostic imaging techniques tools to determine the degree of injury and guide treatment are musculoskeletal ultrasonography (msk us), magnetic resonance imaging (mri) and magnetic resonance arthrography (mra). musculoskeletal ultrasound (often referred to as diagnostic ultrasound) is the use of a sound wave through a transducer to visualize the structures below. the mri and mra are both operated by using a high-powered magnet within the machine to formulate an image to be interpreted by a radiologist. the sole difference between mri and mra is the joint being evaluated is injected with medical dye before an mra scan to help define the structures of concern.1 since each diagnostic imaging technique’s last systematic review (20102015) of diagnostic accuracy, new research and advanced technology have emerged including a more widespread use (+347% between 20032015) of musculoskeletal ultrasonography nonradiologists (radiology us decreased by 28% from 2003-2015).4,5 in sports medicine cases, a re-evaluation of the diagnostic imaging techniques is warranted. a new statistical measure, the hierarchical summary receiveroperating characteristic (hsroc), has been validated for diagnostic accuracy and guides the study recommendations for utilization of msk us, mri and mral. hsroc allows researchers to take into account within and between study variability and better differentiates different thresholds of study results.6-8 the purpose of the guiding systematic review study was to evaluate the diagnostic accuracy of msk us, mri, and mra for rotator cuff pathologies. the secondary aim was to determine the accuracy of improved technology in diagnosing rotator cuff tears and to assess the use of msk us when utilized by radiologists as compared to non-radiologists. understanding the diagnostic accuracy of msk us, mri and mra is important to better guide intervention strategies, especially in regard to making surgical recommendations, in addition to the benefits regarding patient-centered care (i.e. less cost, time, and a less invasive of the procedure). summary of literature the guiding systematic review and meta-analysis authors used medline, embase and cinahl in their search for articles published before 2014. articles were included if they 1) included adults participants with shoulder pain, 2) utilized msk us, mri, and/or mra as a diagnostic tool and surgery as a reference standard, and 3) reported on the diagnostic accuracy of the imaging techniques in diagnosing a rotator cuff pathology.4 the search of the databases revealed 264 studies that met criteria for a full review. studies were excluded due to incomplete data, small population size, and the use of a different index/diagnostic test. after study exclusion based on two evaluator analyses, 82 studies were included in the meta-analysis. of these, 47 articles included msk us studies, 29 articles were included for mri, and 21 articles were included for mra. these articles were then analyzed for bias using the quality assessment tool for diagnostic accuracy studies (quadas-2) assessing four main components of bias including patient selection bias, the diagnostic test utilized, the reference standard (surgery), and flow and timing in regard to patient retention and speed of intervention.9 of the studies included, most had a high risk of bias in 3 of the 4 quadas-2 categories.9 as the reference standard is an invasive procedure (surgery), researchers noted that some bias could not be avoided, particularly in participant selection. summary of outcomes data was extracted based on participant characteristics, index test, diagnostic accuracy (sensitivity and specificity) and based on the reference standard. the researchers of the diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 guiding systematic review utilized the hsroc to evaluate the diagnostic accuracy of the three different diagnostic imaging techniques with a specific focus on test settings and technology. the hsroc is a statistical measure used to determine the overall sensitivity and specificity of diagnostic testing.6 this statistical measure was utilized as it considers between-study and within-study variability and ultimately provides a receiver operating curve, graphing specificity over sensitivity to indicate the tool’s accuracy.9 in addition to analyzing diagnostic accuracy, this measure was also used to compare mri magnet strength and msk us transducer frequency levels to guide the best practice use of these tools. accuracy of radiologist and non-radiologist use of the msk us was also calculated. results were deemed clinically important only if variation was beyond the error associated with the accuracy scores. this, along with the analysis of bias through the quadas-2 were combined and used to formulate diagnostic tool recommendations. findings and clinical implications the guiding systematic review and meta-analysis suggests that there are no significant differences between the accuracy of the three diagnostic imaging techniques based on their specificity and sensitivity found using the hsroc statistics.8 diagnostic imaging techniques were assessed for accuracy diagnosing rotator cuff tendinopathy (figure 1), rotator cuff partial-thickness tears (figure 2), and full-thickness rotator cuff tears (figure 3). the hsroc indicated that msk us had an overall sensitivity of 0.79 (95% confidence interval [ci] = 0.63 0.91) and specificity of 0.94 (95% ci = 0.86 0.99). for partial-thickness tears, the literature indicated a sensitivity of 0.68 (95% ci = 0.54 0.83) and specificity of 0.94 (95% ci = 0.90 0.97) while full-thickness rotator cuff tears, sensitivity was 0.91 (95% ci = 0.86 0.94) and specificity was 0.93 (95% ci 0.91 0.96). for most of these findings, the sensitivity and specificity for msk us were considered high enough to rule in and/or out suspected rotator cuff pathologies. in addition to assessing the accuracy of the diagnostic test, information was extracted that indicated the qualifications of radiologists or non-radiologist healthcare personnel in reading the msk us, and their ability to accurately diagnose a rotator cuff pathology using this diagnostic tool. with the reference standard being surgical diagnosis of pathology for all conditions, they found no significant difference (radiologist sn: 0.89, sp: 0.85; sonographers & orthopaedists – sn: 0.88, sp: 0.89) in accuracy of the reading provider. while this finding supports the use of msk us without preference of the individual reading the images, the authors noted that all non-radiologists were specifically trained in the use of diagnostic ultrasound, which could explain the consistencies in imaging interpretations, even when considering alterations in msk us transducer frequency. transducer frequency in diagnostic msk us on average ranges from 5mhz to 20mhz, with the most widely accepted use being set for 7.5mhz. the guiding manuscript indicated that there are no improvements in image quality at transducer frequencies above or below the generally accepted 7.5 mhz.8 the findings also indicated that mri is a highly specific tool. for partial-thickness rotator cuff tears, mri has a sensitivity of 0.67 (95% ci = 0.50 0.82) and a specificity of 0.94 (95% ci 0.88 0.99). for full-thickness tears in the rotator cuff, mri was found to have an overall sensitivity of 0.90 (95% ci = 0.85 0.95) and specificity of 0.93 (95% ci = 0.89 0.97). there was minimal variation in the sensitivity and specificity numbers between mri and msk us. for mri, diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 rc – rotator cuff diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 though not statistically significant, data did reveal an advantage in image quality when using a 3.0t mri when compared to a 1.5t machine. finally, the sensitivity and specificity did not significantly vary between the results for full-thickness tears and partial-thickness rotator cuff tears for mra. the literature did indicate that likelihood ratios supported the use of mra in diagnosing partialthickness tears when compared to msk us and mri.8 the limitation in this analysis was that the accuracy of msk us as a diagnostic tool may be inflated. when the quadas-2 assessment was used, researchers believed there was bias that led to an increased likelihood of rotator cuff pathologies. this further resulted in an increased likelihood of findings through imaging. this review is also limited by the incomplete patient profiles reported resulting in incomplete data reporting. when exploring hsroc curves assessing diagnostic imaging techniques tools for their accuracy, it is evident that there is no significant difference between msk us, mri, and mra. each graph’s curve was similar and had statistically significant numbers to help substantiate the accuracy of each tool. the only reason that mri or mra would be indicated over msk us would be if there is an additional structure injured that may be contributing to the signs and symptoms the patient is presenting with. additionally, insurance and instrument availability of diagnostic imagery may play a role in diagnostic image used though not considered by this review. clinical bottom line patients who participate in sport and physical activity experience various pathologies including rotator cuff injuries. the sports medicine team is tasked with accurately advising their patients in the proper management of these shoulder injuries. for rotator cuff pathologies, it is imperative that full-thickness rotator cuff tears are diagnosed quickly and accurately as research indicates surgical intervention yields the best outcome for patients and athlete to return to play.3 msk us, mri and mra are the most commonly used diagnostic imaging tools for diagnosing rotator cuff pathology. the guiding manuscript indicates that there is no statistical difference between the ability of msk us, mri and mra to diagnose rotator cuff pathology in individuals presenting with a possible rotator cuff pathology when performed and read by trained individuals.8 there is some evidence indicating that mra has a slightly increased ability to detect partialthickness rotator cuff tears, though this finding is not considered to be statistically significant.8 mri and mra are not cost or time effective due to their need for additional insurance authorization and appointments since imaging machines need to be reserved ahead of time. msk us is recommended as an immediate screening tool, prior to ordering further imaging. in the athletic population, there is an abundance of overuse shoulder pathology, especially in overhead sports such as baseball, softball, tennis and throwing events in track and field.10 rotator cuff pathology can be managed through intensive therapeutic rehabilitation and modification of activities, though concern for worse injury is often present. musculoskeletal ultrasound provides a cost effective, timely and reliable means of preliminarily evaluating a patient to assess the degree of injury and determine if surgery is warranted. currently, msk us can be performed by physician’s trained in its uses and in the identification of musculoskeletal pathology or by an athletic trainer who has been trained and has the approval from their supervising physician. further research is warranted to examine the cost benefit of an msk us machine when portability and integration with various technological interfaces are considered. as the athletic training profession advances, all athletic trainers should be encouraged to take advantage of msk training options. the use of msk us in the athletic training facility can decrease the need for referral to an diagnostic accuracy of imaging techniques for rotator cuff pathology: an evidence-to-practice review 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 orthopedic physician as identification of a tendinopathy vs. a tear in the shoulder and other joint pathologies would be possible, ultimately decreasing cost and time for the patient. for the athletic trainer, msk us machines are on average msk us is recommended when rotator cuff pathology is suspected, but considerations should be made specific to the individual. orthopedic evaluation should precede the use of msk us as other pathologies may be present and not found upon evaluation with this diagnostic imaging technique. references 1. balich sm, sheley rc, brown tr, sauser dd, quinn sf. mr imaging of the rotator cuff tendon: interobserver agreement and analysis of interpretive errors. radiology. 1997; 204(1):191-194. https://doi.org/10.1148/radiology.204.1.9 205245. 2. van der windt da, koes bw, boeke aj, deville w, de jong ba, bouter lm. shoulder disorders in general practice: prognostic indicators of outcome. br j gen pract. 1996; 46(410):519-523. 3. lambers heerspink fo, dorrestijn o, van raay jj, diercks rl. specific patient-related prognostic factors for rotator cuff repair: a systematic review. j shoulder elbow surg. 2014; 23(7):1073-1080. https://doi.org/10.1016/j.jse.2014.01.001. 4. dinnes j, loveman e, mcintyre l, waugh n. the effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. health technol assess. 2003; 7(29):iii, 1-166. https://doi.org/10.3310/hta7290. 5. kanesa-thasan rm, nazarian ln, parker l, rao vm, levin dc. comparative trends in utilization of mri and ultrasound to evaluate nonspine joint disease 2003 to 2015. j am coll radiol. 2018; 15(3 pt a):402-407. https://doi.org/10.1016/j.jacr.2017.10.01 5. 6. leeflang mm. systematic reviews and metaanalyses of diagnostic test accuracy. clin microbiol infect. 2014; 20(2):105-113. https://doi.org/10.1111/14690691.12474. 7. harbord rm, deeks jj, egger m, whiting p, sterne ja. a unification of models for metaanalysis of diagnostic accuracy studies. biostatistics. 2007; 8(2):239-251. https://doi.org/10.1093/biostatistics/kxl00 4. 8. roy js, braen c, leblond j, et al. diagnostic accuracy of ultrasonography, mri and mr arthrography in the characterisation of rotator cuff disorders: a systematic review and meta-analysis. br j sports med. 2015; 49(20):1316-1328. https://doi.org/10.1136/bjsports-2014094148. 9. whiting pf, rutjes aw, westwood me, et al. quadas-2: a revised tool for the quality assessment of diagnostic accuracy studies. ann intern med. 2011; 155(8):529-536. https://doi.org/10.7326/0003-4819-1558-201110180-00009. 10. zaremski jl, wasser jg, vincent hk. mechanisms and treatments for shoulder injuries in overhead throwing athletes. curr sports med rep. 2017; 16(3):179-188. https://doi.org/10.1249/jsr.0000000000 000361. https://doi.org/10.1148/radiology.204.1.9205245 https://doi.org/10.1148/radiology.204.1.9205245 https://doi.org/10.1016/j.jse.2014.01.001 https://doi.org/10.3310/hta7290 https://doi.org/10.1016/j.jacr.2017.10.015 https://doi.org/10.1016/j.jacr.2017.10.015 https://doi.org/10.1111/1469-0691.12474 https://doi.org/10.1111/1469-0691.12474 https://doi.org/10.1093/biostatistics/kxl004 https://doi.org/10.1093/biostatistics/kxl004 https://doi.org/10.1136/bjsports-2014-094148 https://doi.org/10.1136/bjsports-2014-094148 https://doi.org/10.7326/0003-4819-155-8-201110180-00009 https://doi.org/10.7326/0003-4819-155-8-201110180-00009 https://doi.org/10.1249/jsr.0000000000000361 https://doi.org/10.1249/jsr.0000000000000361 clinical outcomes research 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 graston technique® as a treatment for patients with chronic plantar heel pain troy r. garrett, edd, lat, atc, emt1 & peter j. neibert, phd, lat, atc2 1university of northern iowa, cedar falls, ia; 2dixie state university, st. george, ut abstract use of instrument-assisted soft tissue massage has increased in popularity, and the plantar fascia is a superficial tissue that may benefit from this treatment. the objective of this study was to determine the effectiveness of graston technique® (gt) for decreasing pain and increasing function in participants with chronic plantar heel pain over a six-week period. a single blind, pretest-posttest control/comparison group design, with a sample of 22 adults (5 males, 17 females) was utilized. participants were assigned to three groups: gt/stretching, effleurage/stretching, and stretching only. after completion, effleurage/stretching and stretching only groups were later offered gt with posttest scores recorded. participants were pretested/posttested using the foot health status questionnaire (foot pain, foot function, and general foot health), mcgill pain questionnaire, and visual analog scale. a posttest kruskal-wallis analysis between the three groups demonstrated a significant difference of the visual analog scale between the gt/stretching and effleurage/stretching groups. from pre to posttest, wilcoxon test resulted in gt/stretching group significantly improving in 4 out of 5 variables, with effleurage/stretching significant in 1 out of 5, and stretching only demonstrating significance in 3 out of 5. friedman’s test for effleurage and stretching only groups resulted in significant differences in all the variables when gt was later administered. the mean differences between pre and posttest for the groups demonstrated a minimal important difference of 4 out of 4 variables for gt/stretching, 2 out of 4 variables for effleurage/stretch, 2 out of 4 variables for the stretching only group. participants improved in variables measured over a six week treatment of gt. this was both shown to be not only statistically significant, but clinically significant utilizing minimal important difference. key phrases instrument assisted soft tissue massage, chronic plantar heel pain, manual techniques correspondence dr. troy garrett, university of northern iowa, 2351 hudson road – hpc 008a, cedar falls, ia 50614-0244 twitter: @tgarrettatc full citation garrett tr & neibert pj. graston technique® as a treatment for patients with chronic plantar heel pain. clin pract athl train. 2019;2(3):22-34. https://doi.org/10.31622/2019/0003.4. submitted: august 8, 2019 accepted: october 18, 2019 introduction chronic plantar heel pain (cphp), previously referred to as “plantar fasciitis”, is one of the most common causes of heel pain, accounting for approximately 11-15% of all foot disorders.1 cphp typically results from repetitive micro trauma or excessive overload to the fascia.1 individuals most prone to this condition are middle-age women,2 and those with high body mass index.2 cphp has been shown to have a negative impact on foot health and overall quality of life resulting in functional disabilities.3 historically, cphp has been described as a painful heel with inflammation of the plantar fascia at its origin.1 in recent years, research has suggested that plantar heel pain is rather a noninflammatory degenerative fasciosis.4 snider et. al, 5 conducted histological examinations of surgical biopsy specimens and found degenerative tissue markers such as collagen necrosis, angiofibroplastic hyperplasia, chondroid metaplasia, and matrix calcification. others observed similar findings on histological examination such as, “marked thickening and fibrosis,”6 and “fiber fragmentation in association with myxoid degeneration.”4 however, no markers for inflammation were found in these studies. numerous interventions have been utilized for treatment of cphp, which include, heat,7 cryotherapy,7 non-steroidal anti-inflammatory drugs,7 heel pads/cups,8 night splints,9 low-dye arch taping,10 plantar fascia specific stretching,11 calf stretching,12 steroid injection,13 extracorporeal shock wave therapy,14 platelet-rich plasma injection,13 and myofascial trigger point therapy.15 unfortunately, not all patients https://doi.org/10.31622/2019/0003.4 graston technie® as a treatment for patients with chronic plantar heel pain 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 experience a resolution of symptoms following these treatment interventions. in recent years instrument assisted soft tissue massage (iastm) has grown in popularity and usage among clinicians working with active populations.16-21 it has been hypothesized, for degenerative tissue conditions such as tendinosis and fasciosis, that iastm reinitiates the inflammatory response by creating controlled microtrauma in the affected tissues.16,22 it has been further hypothesized that this controlled microtrauma to degenerated tissue ultimately results in tissue maturation and remodeling.16,17,2326 while numerous case studies have been published regarding the gt (indianapolis, in) with chronic degenerative disorders, 16,18-21 there is only one case series study of plantar heel pain on multiple participants.23 the effectiveness of iastm on cphp has not, to our knowledge, been studied in a randomized group design. therefore, the purpose of our study was to determine the effectiveness of instrument-assisted soft tissue mobilization, specifically the gt (gt), for the treatment of patients suffering from cphp. we hypothesized that gt would be more effective at decreasing foot pain and increasing foot function with patients suffering from chronic plantar heel pain when compared to a placebo and stretch only protocol. participants following institutional review board approval, volunteers were recruited for a period of 10 months. of the 44 patients screened, 28 met the inclusion criteria and agreed to participate (figure 1). overall, 7 men and 21 women with cphp symptoms (age = 46.45 ± 12.5 years, body mass index = 30.45 ± 6.13) were enrolled. four participants discontinued intervention, due to scheduling conflicts (n=2) and due to not tolerating the gt (n=2). also, two participants (n=2) were later excluded from the analysis because they were later diagnosed with a pathological bone spur of the calcaneus, therefore, they were deemed ineligible for inclusion in the study. of the remaining 22 participants, 7 were assigned to the gt/stretching group (2 males and 5 females, 48.5 ± 13.8 years), 7 were assigned to the effleurage/stretching group (2 males and 5 females, 44.6 ± 13.3), and 8 were assigned to the stretching only group (1 male and 7 females, 46.1 ± 10.4 years). individuals were included in the study if they had a physician (m.d., d.o., or d.p.m.) clinical diagnosis of cphp that resulted in pain and discomfort for at least 3 months; with no corticosteroid injections within 30 days of participation. individuals were excluded from participation if they reported having a history of diabetes; pathological bone spurs of calcaneus; any past plantar fascia release surgery; or any acute plantar fascia injuries. cancer, burn scars, rheumatoid arthritis, polyneuropathies, chronic regional pain syndrome, or other conditions known to be contraindications to gt also resulted in exclusion from the study.22 interventions carey et al22 states that the basic components of the gt are: (1) 3-5 minutes of active warm-up, (2) 8-10 minute gt treatment, and (3) specifically targeted tissue stretches. for the warm up, the participants were placed on a stationary bike, then asked to cycle for 5 minutes, at a comfortable pace appropriate to their level of fitness prior to the treatment intervention. participants then removed the shoe and sock of the involved foot and assumed a prone position on the treatment table. a drapery was attached to wires hanging from the ceiling between the levels of the waist to mid-thigh to ensure visual blinding to the treatment (figure 2a). graston technique® as a treatment for patients with chronic plantar heel pain 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 figure 2: (a): blinding of the participant during interventions. (b) gt instrument #4. (c) gt instrument #2. (d) gt instrument #3. (e) plantar fascia sp ecific stretching as defined by digiovanni et. al.1 graston technie® as a treatment for patients with chronic plantar heel pain 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 the knee of the involved foot was flexed to 90°, while the investigator supported the ankle proximal to the malleoli, maintaining the ankle in a neutral position. gt emollient (indianapolis, in) was applied to the plantar surface of the foot for all participants. for the gt/stretching group, one of three certified athletic trainers (atc) level m1 certified graston technique® providers (years of gt experience = 4.17 ± 2.02) performed a predetermined protocol of: 4 minutes of gt instrument #4 (figure 2b), the large convex instrument; 3 minutes of gt instrument #2 (figure 2c), the medium concave instrument; and 3 minutes of gt instrument #3 (figure 2d), the small convex instrument, for a total of 10 minutes. all certified providers were instructed to provide pressure to the participants comfort level, while performing sweeping strokes from anterior to posterior and posterior to anterior22 from the calcaneus to the metatarsal heads of the plantar surface. participants were monitored and encouraged to report if the treatment was too painful or caused a high level of discomfort. treatment was focused on areas where adhesions were discovered through the gt instruments. when using gt instruments, if adhesions are detected, a vibratory sensation is felt by the clinician.22 the effleurage/stretching group participants were placed in the same prone position following the warm-up. however, after the emollient was applied, the investigator provided light touch effleurage with the fingertips, from the calcaneus to the metatarsal heads, for 8 minutes. investigators were instructed that the effleurage was to be very light for sensory effects and not deep enough to cause mechanical effects to the tissue. for the stretching only group, participants were placed in the same position. emollient was lightly applied for 10 seconds, the ankle was held in the same neutral position for 8 minutes without any additional contact to the plantar surface. a towel was used to remove the emollient at the end of the timed treatment for each group. each session, for all participants regardless of treatment group, was concluded with plantar flexion specific stretching as described by digiovanni et al.11 the participant assumed a seated position, crossed the involved foot over the uninvolved leg, stabilized the calcaneus with the contra-lateral hand, and stretched the plantar fascia by forcibly extending the toes at the metatarsal heads with the ipsilateral hand (figure 1e). the investigator confirmed successful stretching by verifying tautness of the medial plantar fascia. participants performed 10 stretches holding each for 10 seconds.11 participants were scheduled for 11 more sessions (2 per week, not on consecutive days). all the participants were instructed not to perform any additional plantar fascia specific stretching outside of their scheduled treatment sessions. this information was repeated after each treatment session. in addition, patients were told there were no restrictions in physical activity or activities of daily living. at the end of the 12th session all participants completed posttest survey instruments of the foot health status questionnaire, mcgill pain questionnaire, and visual analog scale. participants of the effleurage/stretching and stretching only groups were offered the investigative gt treatment for another 12 sessions as the gt/stretching group, with 12 out of 15 eligible participants electing to receive the treatment. of the three that declined, two had no interest in receiving gt, one later voluntarily discontinued. this group of (n=12) received a second round of posttest survey outcome measurement after the 12th gt session. procedures/outcome measures this study was a single blind, randomized pretest-posttest control/comparison group graston technie® as a treatment for patients with chronic plantar heel pain 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 design, in which individuals with cphp were randomly assigned to one of three interventions: (1) gt of plantar fascia plus plantar fascia specific stretching (graston/stretching); (2) effleurage of the plantar surface of the foot plus plantar fascia specific stretching (effleurage/stretching); (3) and the only stretching group (received no treatment) plus plantar fascia specific stretching (stretching only). participants underwent 2 treatment sessions a week (not on consecutive days) for 6 weeks, totaling 12 sessions. the foot health status questionnaire, mcgill pain questionnaire, and visual analog scale were administered before and after the 6 week intervention for all 3 groups. after the posttest, the effleurage/stretching and stretching only groups were offered the investigative treatment in the same manner as the graston/stretching group for an additional 6 weeks. the independent variable was treatment type, with gender being controlled by randomization. the dependent variables were foot function, foot pain, and general foot health (from the foot health status questionnaire) and also foot pain of two other instruments (mcgill pain questionnaire and visual analog scale). participants were recruited from local podiatry clinics and by a university-wide online advertisement. four local podiatry clinics with 8 doctors of podiatry provided letters of support for this study. patients with a clinical diagnosis of cphp were given an envelope with an enclosed recruitment flyer including the contact information of the investigators. potential participants were instructed to contact the investigators if they were interested in participation. upon making contact, a telephone interview was conducted to determine if inclusion and exclusion criterion were met. following the telephone interview, participants were scheduled to meet an investigator at the athletic training research laboratory, where the: consent form, list of contraindications, and a medical release form (to verify cphp diagnosis) were signed. specific information such as treatment interventions, full design of the study, and to which group assigned was withheld from the participants during the screening process and throughout the treatment intervention phase of the study. initial pretesting survey outcome instruments consisting of the foot health status questionnaire, mcgill pain questionnaire, and visual analog scale were completed. foot pain, foot function, and general foot health were utilized. foot health status questionnaire scores were calculated using the foot health status questionnaire data analysis software© (version 1.03). numerous sources have shown strong content validity and reliability, with cronbach α ranging from .85 to .8828 with appropriate factorial structure and high internal consistency and test-retest reliability, iccs ranging from .74 to .92,28,29 with specific sensitivity to patients with cphp. the mcgill pain questionnaire long form consists of 20 groups of words describing pain, with the participant circling the word in each subsection that best applies and then an ordinal ranking score is tabulated.30 the range of the total mcgill pain questionnaire score is 0 for “no pain” and 76 being the maximal score for the “worst pain”. test-retest reliability of multiple studies report a correlation of r > .70.31 the visual analog scale is a 10 cm line that states “no pain” on the left, and “worst pain imaginable” on the right. participants are instructed to make a vertical mark on the scale best describing their pain within the last 24 hours. the score is measured from the distance from the left border to the vertical mark in millimeters. visual analog scale scores were tabulated by an individual independent of the study measuring the distance from the left (no pain) to the vertical mark made by the subject in graston technie® as a treatment for patients with chronic plantar heel pain 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 millimeters. test-retest reliability has been reported as high as r=.94, with correlations ranging from .61 .92 when compared to pain scales using words for validity.32 landorf and radford33 examined the minimal important difference (mid) which is defined as the amount of improvement needed that was deemed important to the patient, for the foot health status questionnaire and visual analog scale, specifically for patients with ‘plantar fasciitis.’ for the foot health status questionnaire, the minimal important differences were reported as: 14 for foot pain, 7 for foot function, and 9 for general foot health. for the visual analog scale, 9 millimeters of improvement was reported as the minimal important difference.33 mid data for the mcgill pain questionnaire has not been reported in the literature. statistical analysis non-parametric tests were utilized to analyze the data. a kruskal-wallis test was conducted to determine differences between the three treatment groups at pretest, and later at posttest. any significant differences was analyzed with a mann-whitney u test. within group differences between pretest and posttest for each of the five variables was calculated utilizing wilcoxon signed ranks test. effleurage/stretching and stretching only group was computed together from pretest to posttest to post gt with friedman’s test. alpha was set at p<0.05 for all tests, with post hoc for friedman’s test having bonferroni correction set at 0.0167.34 all data were analyzed on ibm spss statistics 24 (chicago, il). results to test for homogeneity between the groups, a kruskal-wallis test was conducted to analyze the pre test scores. there were no significant differences between the groups on all the dependent variables: foot pain h(2) = 2.73, p = 0.25, r = .58, foot function h(2) = 1.16, p = 0.55, r = .24, general foot health h(2) = 0.95, p = 0.62, r = .20, mcgill pain questionnaire h(2) = 1.47, p = 0.47, r = .31, and visual analog scale h(2) = 1.90, p = 0.36, r = .40. a posttest analysis between the three groups resulted in a significant difference with visual analog scale h(2) = 8.78, p = 0.012, r = 1.87. post hoc mann-whitney test demonstrated a significant difference for visual analog scale between the gt/stretching and effleurage/stretching groups (p=0.011). within groups significance was measured utilizing the wilcoxon signed ranks test and are displayed in table 1. four of the five variables of the gt/stretching group were found to be significant. one out of 5 variables were significant for the effleurage/stretching group. the stretching only group was significant on 3 out of 5 variables. mean differences within groups from baseline to posttest along with 95% ci and mid data are reported in table 2. the effleurage/stretching and stretching only groups were offered gt after the initial posttest, and 12 out of 15 participants received the treatment. data for the two groups were combined, and friedman’s test was conducted between pretest (baseline), post effleurage or stretching only, and following the administration of gt. data for friedman’s test is displayed in table 3, as the combined effleurage/stretching and stretching only groups demonstrated significant differences after gt, utilizing the bonferroni correction level of significance. discussion the purpose of this study was to determine the effectiveness of instrument-assisted soft tissue mobilization, specifically the gt, for the treatment of patients suffering from cphp. the results showed significant kruskal-wallis posttest graston technique® as a treatment for patients with chronic plantar heel pain 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 table 1: within groups baseline to post test wilcoxon signed ranks results. graston/stretching effleurage/stretching stretch only baseline post sig effect baseline post sig effect baseline post sig effect variable mean±sd mean±sd size mean±sd mean±sd size mean±sd mean±sd size foot pain 41.0±14.1 75.2±13.6 *0.028 0.58 27.5±16.3 40.3±32.0 0.173 0.36 47.4±27.7 59.2±27.0 0.26 0.28 foot function 58.9±23.6 91.9±8.6 *0.018 0.63 41.1±37.4 50.8±34.0 *0.042 0.54 53.9±21.6 72.6±27.1 *0.011 0.63 general foot health 40.0±28.2 65.4±26.4 0.058 0.5 26.8±39.2 31.1±39.4 0.414 0.21 38.1±33.1 29.1±29.5 0.144 -0.36 mpq 29.6±10.3 13.4±9.7 *0.043 0.54 22.8±11.7 24.0±12.0 0.866 -0.04 28.8±18.1 15.5±11.5 *0.012 0.63 vas 47.8±20.0 13.9±10.2 *0.018 0.63 63.1±18.7 63.7±31.6 0.865 -0.04 51.4±25.8 24.1±16.2 *0.017 0.59 * = p<0.05 foot pain, foot function, and general foot health are categories of the foot health status questionnaire, where 100 equals optimal foot health. mpq=mcgill pain questionnaire is scored with 0 being no foot pain and 76 as maximal foot pain. vas=visual analog scale is scored with 0 being no foot pain and 100 as maximal foot pain. table 2mean differences and 95% confidence intervals between baseline and post-test. foot pain foot function general foot health mpq vas graston technique® mean 42.5 32.8 25 14.8 35 (95%ci) (11.9,58.1) (12.5,56.25) (-12.5,75.0) (-2,29) (13,54) effleurage mean 11.9 12.5 10.6 -0.75 -3.5 (95%ci) (-6.3,33.1) (-17.0,12.5) (-29,37) stretch only mean 10.6 18.8 -16.3 13.3 27.3 (95%ci) (-12.5,39.1) (12.5,28.1) (4.5,23.0) (7.5,46.5) mid33 14 7 9 na 9 mpq=mcgill pain questionnaire; vas=visual analog scale; mid=minimal important difference. = calculation not possible due to small amount of differences between baseline and posttest (n<=5). graston technique® as a treatment for patients with chronic plantar heel pain 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 table 3. friedman mean ranks for effleurage/stretching and stretching only groups with additional graston/stretching treatment (n=12). pre test 1 post test 2 post test 3 post hoc post hoc post hoc freidman 1v2 2v3 1v3 sig foot pain 1.46 (0.068) 1.71(0.004)* 2.83 (0.003)* 0.001 foot function 1.08 (0.001)* 2.08 (0.008)* 2.83 (0.003)* 0.000 general foot health 1.71 (0.496) 1.50 (0.005)* 2.79 (0.008)* 0.001 mpq 2.75 (0.061) 2.17 (0.004)* 1.08 (0.002)* 0.000 vas 2.58 (0.069) 2.33 (0.003)* 1.08 (0.002)* 0.000 *= bonferroni correction to 0.0167 level of significance. mpq=mcgill pain questionnaire; vas=visual analog scale differences between the gt/stretching and effleurage/stretching groups with the visual analog scale. within group prepost-test comparison revealed significant differences with the gt/stretching group in 4 out of 5 variables. the effleurage/stretching group showed significant differences in 1 out of 5 variables, and stretching only was significant with 3 out of 5 variables. additionally, we found a bimodal response utilizing the minimal important difference (mid) as reported by landorf and radford33, who report the mid of the scores for foot health status questionnaire and visual analog scale for cphp (14 points for foot pain, 7 points for foot function, 9 points for general foot health, and 9 points with the visual analog scale). the gt/stretching group exceeded the mid in all 4 variables that report mid data. effleurage/stretching group exceeded the mid with 2 out of 4 variables, and the stretch only group also exceeded on 2 out of 4 variables. the unexpected positive effects for the effleurage/stretching and stretching only groups may be a result of the plantar fascia specific stretching which was performed for all three groups. the gt manual22 recommends that a therapy session ends with a period of stretching the treated tissue. digiovanni11 has reported benefits with plantar fascia specific stretching compared to achilles stretching during an eight week program, which therefore may explain the improvements among all three groups. however, the effleurage/stretching and stretch only groups improved significantly with all measured variables utilizing friedman’s analysis (table 3) after completing the gt regimen. therefore, there appears to be a trend of improved outcomes when utilizing gt combined with plantar specific stretching for the treatment of cphp. to date, only one study23 utilizing gt for cphp with multiple participants, has been published. their findings are similar to this current study, where they found significant improvement for pain and function from baseline to follow-up. however, due to the case series design and the lack of a control group, a cause-and-effect relationship could not be established. in addition, different outcome instruments, treatment durations, and stretches were used in the design of this study. therefore, caution should be used when comparing looney et.al.23 with our results due to methodology differences, and comparing a case series to randomized comparison group design. while there is limited published research using gt as a treatment intervention for cphp, there are positive benefits16,18-21 for the treatment of other chronic disorders. sevier et al19 reported improvements in function and pain when comparing a treatment intervention consisting of graston technie® as a treatment for patients with chronic plantar heel pain 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 transverse friction massage, phonophoresis, stretching, and cryotherapy with a gt intervention for the treatment of lateral epicondylitis. in a case report of a 40 year old patient presenting with chronic achilles tendinopathy, miners and bougie21 reported improvements in self-reported pain and function following an 8 week intervention of gt, active release techniques, eccentric exercise and static gastrocnemius/soleus stretching. one noticeable limitation of each of these case reports is the combination of several treatment modalities in the treatment of the patients. therefore, it is difficult to determine if the gt was responsible for the improvements in pain relief and function. in a systematic review conducted by cheatham et al35 looking at the efficacy of iastm as an intervention to treat various pathologies, they similarly concluded that a lack of treatment protocol homogeneity makes it difficult to determine the effects of iastm in general. cheatham et al35 also report that no iastm study has ever reported a significant difference between control or comparison groups and iastm groups. in contrast, we found a post-test significant differences with the visual analog scale between our gt/stretching and effleurage/stretching groups. schaefer and sandrey,18 examined the effects of gt in conjunction with a dynamic balancing treatment (dbt) program on outcomes associated with chronic ankle instability; they found no significant difference between the groups. the gt/dbt group demonstrated an increase in functional outcomes as did the other groups in the study. thus, it appears that gt offers some benefit in the treatment of other chronic conditions in addition to this study with patients suffering from cphp. this study was limited by the small sample size (n=22). in addition, it was also limited by a lack of a repeated-measures design, therefore only an immediate follow-up after the intervention. therefore, no long term results are known for our study population, including the rates of recurrence or a need for any additional intervention. the sample population represented the group that is most susceptible to chronic plantar heel pain, consisting of people of middle age with elevated body mass index, so our results may not represent young healthy athletes, and not patients with acute plantar fascia injury. the participants represented a population with an average age in the mid 40’s with a body mass index averaging 28-30, which is above the obese range of greater than 25. it has been previously reported that a population of higher body mass index and over age 40 are more susceptible to suffering from cphp.2 the participants were not monitored for activity levels during the duration of the intervention. this study was also limited by the inequality of males (n=5) to females (n=17) as participants. the methods of this study limited the gt treatment to the use of 3 instruments with basic sweeping strokes. future research needs to be completed regarding different gt strokes, different foot and ankle positions, and the use of more advanced gt techniques. future research should also incorporate more objective instruments, such as plantar fascia thickness via diagnostic ultrasound to supplement the subjective scales. clinical application to our knowledge, this study is the first randomized pretest-posttest control/comparison group design investigating the use of gt plus plantar-fascia specific stretching as an intervention for cphp. consequently, our findings shed light on the use of gt as a potential treatment of cphp. it is our recommendation that clinicians take a multifaceted approach to treating patients with cphp which includes gt along with plantar fascia specific stretching11 and other traditional treatment methods.36 future research should focus on multicenter randomized graston technie® as a treatment for patients with chronic plantar heel pain 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 controlled trials incorporating iastm specifically regarding cphp. the authors declare that no financial conflict of interest exists with the research comprised within this article. there is no commercial or proprietary interest with any materials used for this study. acknowledgements the authors wish to thank dawn jacobson, ma, atc, pes for her assistance with data collection, also courtney sheets, atc for her assistance with data analysis. the authors as well would like to thank mark jacobson of the uni statistical consulting center and dr. robin lund, phd for their assistance with statistical analysis. references 1. thomas jl, christensen jc, kravitz sr, et al. the diagnosis and treatment of heel pain: a clinical practice guidelines-revision 2010. j foot ankle surg. 2010;49:s1-s19. https://doi.org/10.1053/j.jfas.2010.01.001 2. irving db, cook jl, menz hb. factors associated with chronic plantar heel pain: a systematic review. j sci med sport. 2006;9(12):11-22. https://doi.org/10.1016/j.jsams.2006.02.0 04 3. irving db, 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https://doi.org/10.1016/03043959(75)90044-5 32. hawker ga, mian s, kendzerska t, french m. measures of adult pain: visual analog scale for pain, numeric rating scale for pain, mcgill pain questionnaire. short-form mcgill pain questionnaire, chronic pain grade scale, short form-36 bodily pain scale, and measures of intermittent and constant osteoarthritis pain. arthritis care res. 2011;63(s11):s240-s252. https://doi.org/10.1002/acr.20543 33. landorf kb, radford ja. minimal important difference: values for the foot health status questionnaire, foot function index and visual analog scale. the foot. 2008; 18:15-19. https://doi.org/10.1016/j.foot.2007.06.00 6 34. field a. discovering statistics using spss. thousand oaks, ca: sage publications ltd; 2011. 35. cheatham sw, lee m, cain m, baker r. the efficacy of instrument assisted soft tissue mobilization: a systematic review. journal of the canadian chiropractic association. 2016;60(3):200-211. https://www.ncbi.nlm.nih.gov/pmc/articles/p mc5039777/ 36. martin rl, davenport te, reischel sf, et al. heel pain-plantar fasciitis revision 2014. clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopaedic section of the american physical therapy association. j orthop spors phys ther. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.692&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.692&rep=rep1&type=pdf http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.469.692&rep=rep1&type=pdf http://doi.org/10.1249/01.mss.0000323218.58317.e8 http://doi.org/10.1249/01.mss.0000323218.58317.e8 https://doi.org/10.1097/00005768-199904000-00006 https://doi.org/10.1097/00005768-199904000-00006 https://www.natajournals.org/doi/full/10.4085/1062-6050-43.2.215 https://www.natajournals.org/doi/full/10.4085/1062-6050-43.2.215 https://doi.org/10.7547/87507315-88-9-419 https://doi.org/10.7547/87507315-88-9-419 https://doi.org/10.1177%2f107110070202300611 https://doi.org/10.1177%2f107110070202300611 https://doi.org/10.1016/0304-3959(75)90044-5 https://doi.org/10.1016/0304-3959(75)90044-5 https://doi.org/10.1002/acr.20543 https://doi.org/10.1016/j.foot.2007.06.006 https://doi.org/10.1016/j.foot.2007.06.006 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5039777/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5039777/ graston technie® as a treatment for patients with chronic plantar heel pain 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 2 – issue 3 – november 2019 2014;44(11):a1-a23. https://doi.org/10.2519/jospt.2014.0303 https://doi.org/10.2519/jospt.2014.0303 editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 athletic trainers’ value in physician practice forrest q pecha, ms, lat, atc st. luke’s sports medicine, boise, id moderator: lindsey e eberman, phd, lat, atc key phrases physician practice setting, athletic training residencies, quality improvement correspondence forest pecha, st. luke’s plaza-central plaza, 720 park blvd. suite 115, boise, id 83789 email: fpecha@slhs.org full citation pecha fq. athletic trainers’ value in the physician practice. clin pract athl train. 2020;3(1): 1-3. https://doi.org/10.31622/2020/0003.1. editorial we are excited to announce a new partnership with the athletic trainers in the physician practice society (atpps). the clinical practice in athletic training journal will partner in a double-blind peer review process of submitted abstracts and serve as the official host of atpps conference proceedings. the mission of atpps is to serve as the leading advocate for athletic trainers in physician practice, providing education and resources to improve patient care and experience. as you know, the vision of clinical practice in athletic training is to provide an outlet for the practicing athletic trainer to share their story, successes and failures, in terms of patient services and practice advancement. this partnership will allow athletic trainers in the physician practice to share their story through our journal. in this issue, we will show case the 2020 atpps conference abstracts and an editorial from the atpps president, forrest pecha. we asked forrest to help our readers understand athletic trainers in physician practice through a few questions developed by the senior editorial staff. eberman: what is the range of responsibilities you see an athletic trainer in physician practice doing in their day-to-day work? pecha: this is a great question. athletic trainers are working at every level within the physician practice setting (pps) and hospitals, from entrylevel patient access/triage to c-suite decisionmaking. athletic trainers’ knowledge and background in musculoskeletal disorders and general medicine provide the foundation to be successful as clinicians in the pps and beyond. athletic trainers are found in many specialty areas within healthcare: orthopedic and sports medicine, pediatrics, trauma, emergency departments, primary care and family medicine, neurology, concussion clinics to name a few. some states may have restrictions on athletic trainer practice and not just in pps. but typically you might find an athletic trainer in a physician practice engaged in any number of roles with varied responsibilities, including, but not limited to patient triage (limiting unnecessary patient visits), rooming patients, taking patient vitals, taking patient histories, completing physical exams, ordering appropriate radiographs based upon exam, interpretation of radiographs, chart reviews of past medical history, intake of the patient presentation, order entry, scribing, patient education, instructing and providing home exercise programs, discharging patients, charting/documenting (per institution and cms guidelines), along with any clinical administrative responsibilities. athletic trainers are also found assisting in surgical cases and clinical procedures, support or giving injections, and diagnostic ultrasound. many of these skills typically fall mailto:fpecha@slhs.org https://doi.org/10.31622/2020/0003.1 athletic trainers’ value in physician practice 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 within the parameters of an athletic trainer’s educational preparation and within state practice acts, with a few exceptions. eberman: what are essential skills and experiences a hiring manager might be looking for from an athletic trainer in physician practice? how does someone acquire and improve upon these skills if they are unable to complete a residency? pecha: as i mentioned, athletic trainers have the foundational knowledge in musculoskeletal pathologies and general medical conditions. when reviewing and interviewing candidates, hiring managers will often look for professional traits such as experience in the setting and roles and responsibilities performed during those times. equally important is the candidate’s personal traits such as willingness to learn and grow within the position, quest for knowledge, commitment to patient care and provider care model, drive and ambition. i have said many times during presentations, “athletic trainers are highly qualified healthcare professionals in nonemergent settings. athletic trainers are prepared to handle the most challenging situations if they occur. in the pps athletic trainers also need to think forward and anticipate how the day will flow and address the challenges before they happen; to be proactive rather than reactive.” athletic training residencies are defined by the program specialty area. some of the residencies within the specialty area of orthopedics are housed within the pps, which allows for understanding the roles and responsibilities through socialization to the setting. for an athletic trainer who has not completed one of the residencies housed within the pps, there are opportunities to learn from those who are working and successful currently working in the setting. a lot of how an athletic trainer will be able to practice, will be determined by the hospital/institution or provider they are working with. learning about potential work site in preparation for interviewing or through the interview process can help to understand what the role of an athletic trainer is within the facility. it can also keep an athletic trainer from being surprised by what they can and cannot do in their position upon hiring. the national athletic trainers’ association committee on practice advancement (copa) provides resources for the emerging settings including physician practice (website: https://www.nata.org/professionalinterests/emerging-settings/physician-practice) and similarly the atpps (website: https://atpps.org/) also provides resources for those interested in pps. in addition, social media groups may help to socialize to physician practice through communication and community with other providers within the setting. athletic trainers considering working in this setting should be cautious when looking for training opportunities and assure that that the training is coming from credible content driven by athletic trainers or physicians. we recommend you review our position on the orthopedic physician extender certification (ope-c), as this is an example of an educational opportunity that may be redundant to an athletic trainer’s professional preparation (website: https://atpps.org/atppsstatement-opec/). eberman: what are some common metrics in physician practice that help demonstrate value to the organization? pecha: athletic trainers have been shown to demonstrate their value within the pps across many metrics and across the varying healthcare delivery models seen in this setting. much of the work being done focuses on metrics highlighted within the triple and quadruple aims for healthcare reform. from the current literature in the pps, common metrics include: patient access or throughput (the ability to see more patients with in the same amount of time), documentation strategies to reduce physician burnout, physician https://www.nata.org/professional-interests/emerging-settings/physician-practice https://www.nata.org/professional-interests/emerging-settings/physician-practice https://atpps.org/ https://atpps.org/atpps-statement-opec/ https://atpps.org/atpps-statement-opec/ athletic trainers’ value in physician practice 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 1 – april 2020 satisfaction with hiring athletic trainers, patient satisfaction when athletic trainers are part of the patient care team, and the reduction of unnecessary referrals, visits, and ancillary testing. more information and published articles can be found at https://atpps.org/publicationsresearch-and-documents/. eberman: how does an athletic in physician practice increase revenue and return on investment? in your opinion, what is the value of an athletic trainer in physician practice? pecha: another great question… and hard question to answer definitively. return on investment and the value of athletic trainer is highly dependent on what the goals of the provider or institution are. athletic trainers have been able to demonstrate their value in numerous ways (as indicated from the publications described above). these may not always translate specifically to what the institution’s needs are. i suggest always starting with asking the question, “what are the needs of the institution/provider?” this will help the organization identify how the athletic trainer will be able to demonstrate value. this will change depending on the health care delivery model. if the institution/provider is working in a fee-forservice model, improving patient throughput is a great and easy was to demonstrate value and return on investment. the financial impact of an athletic trainer working as a physician extender in the orthopedic practice was a landmark article describing the impact of athletic trainers in pps (website: https://secureservercdn.net/198.71.233.64/wzr .9ab.myftpupload.com/wpcontent/uploads/2018/07/the-financialimpact-of-an-athletic-trainer-working-as-aphysician-extender-in-orthopedic-practice.pdf). in value-based care or accountable care delivery models, access, patient and physician satisfaction are important indicators. eberman: a majority of attendees at the 2020 atpps conference were young professionals. what advice do you have for those young professionals interested in physician practice? pecha: i would suggest: 1. reach out to those who have paved this professional path for advice and suggestions on how they achieved success. don’t try to reinvent the wheel. 2. identify the best training opportunities you can, to prepare yourself for the position. this may be through the form of residency training and/or continuing education opportunities. again, be aware of the quality of the educational opportunity and know where the education is coming from. 3. continue to have open conversations, with the physician/team you are working with on how to improve your skills and support in providing patient care. and 4. continue to challenge yourself and the ability to work to the top of your scope of practice. eberman: what are career advancement opportunities within a physician practice setting? pecha: there are many opportunities to advance within the pps or hospital setting. we are seeing more and more athletic trainers advancing into clinical leadership, managerial, director positions, up to c-suite roles (ceo, coo, cfo). the atpps has members serving in all these roles and for athletic trainers who have aspirations to rise to these positions, we will do our best to provide connections. members of the atpps can connect with other members and make requests through this contact form (website: https://atpps.org/contact/). https://secureservercdn.net/198.71.233.64/wzr.9ab.myftpupload.com/wp-content/uploads/2018/07/the-financial-impact-of-an-athletic-trainer-working-as-a-physician-extender-in-orthopedic-practice.pdf https://secureservercdn.net/198.71.233.64/wzr.9ab.myftpupload.com/wp-content/uploads/2018/07/the-financial-impact-of-an-athletic-trainer-working-as-a-physician-extender-in-orthopedic-practice.pdf https://secureservercdn.net/198.71.233.64/wzr.9ab.myftpupload.com/wp-content/uploads/2018/07/the-financial-impact-of-an-athletic-trainer-working-as-a-physician-extender-in-orthopedic-practice.pdf https://secureservercdn.net/198.71.233.64/wzr.9ab.myftpupload.com/wp-content/uploads/2018/07/the-financial-impact-of-an-athletic-trainer-working-as-a-physician-extender-in-orthopedic-practice.pdf https://secureservercdn.net/198.71.233.64/wzr.9ab.myftpupload.com/wp-content/uploads/2018/07/the-financial-impact-of-an-athletic-trainer-working-as-a-physician-extender-in-orthopedic-practice.pdf https://atpps.org/contact/ manuscript type clincal outcomes research 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy monica matocha, dat, lat, atc*; patti syvertson, dat, atc†; janet mcmurray, dat, lat, atc‡; emily r. dietz, dat, lat, atc, ceis**, russell t. baker, phd, dat, at, cmp, prt-c© §; alan nasypany, edd, lat, atc§; don reordan, pt, ms, ocs, mcta, cidn€; darcy downey edd, lat, atc¥ *texas lutheran university, seguin, tx; †crystal springs upland schools, uplands, ca; ‡ mcmurry university, abilene, tx; **elizabethtown college, elizabethtown, pa; § university of idaho, moscow, id; €jacksonville physical therapy, jacksonville, fl; ¥texas state universtiy, san marcos, tx abstract the general and athletic populations commonly experience patellar tendon pain, which is frequently treated with a gold standard 12-week eccentric exercise protocol. the present research study was designed to determine the effects of a treatment based classification (tbc) algorithm utilizing indirect treatment techniques in patellar tendinopathy participants. ten participants (seven females, three males, mean age = 19.6 ± 1.07, mean symptom duration = 2.14 years with a range of one week to six years) with patellar tendinopathy were evaluated and included in this study. each participant underwent a thorough evaluation process to aid in determining inclusion: participant medical history, range of motion measurements, orthopedic tests, a scan for soft tissue tender points, neurodynamic tests, and a local mulligan concept technique to determine diagnosis, study inclusion, and treatment classification. the following outcome measures were collected to establish baseline scores and assess participant improvement: the disablement in the physically active scale (dpa scale), numerical rating scale (nrs), victorian institute of sports assessment for the patellar tendon (visa-p), global rating of change (grc), nirschl phase rating scale, and blazina knee scale. paired t-tests with 95% confidence intervals, were analyzed on nrs, dpa scale, and visa-p to determine the effectiveness of all treatment from initial exam to discharge. cohen’s d was also computed to determine the effect size of each of the aforementioned outcome measures. descriptive statistics were computed for the grc at discharge. the mean change for the nrs (m = 4.7, 95% ci[3.57 to 5.82], p < .001), dpa scale (m = 21.8, 95% ci[12.43 to 31.16], p = .001), and visa-p (m = 22.70, 95% ci[33.71 to 11.68], p < .001) were statistically significant. the mean for the grc (m = 5.3) was clinically meaningful. all of the participants (100%) met discharge criteria. the results of this case series demonstrated an increase in function and decrease in pain for participants with patellar tendinopathy within three office visits when utilizing a tbc algorithm. key phrases patellar tendinopathy, manual therapies, treatmentbased classification, patient-reported outcomes correspondence dr. monica matocha, texas lutheran university, 1000 w court st, seguin, tx 78155 e-mail: mamatocha@tlu.edu. full citation matocha m, syvertson p, mcmurray j, dietz er, baker rt, nasypany a, reordan d, downey d. an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy. clin pract athl train. 2021;4(2): 6-20. https://doi.org/10.31622/2021/0004.2.2. submitted: april 3, 2019, 2020 accepted: february 1, 2021. introduction tendon related pathologies comprise 30 to 45% of sport related injuries,1 and frequently cause impairment in the general population.2 patellar tendinopathy accounts for 7 to 40% of tendon related pathologies in sport3 and is characterized clinically by tendon pain, tendon dysfunction,4,5 decreased performance in association with tendon swelling, morning stiffness,4,6,7 palpable crepitus,3,6,7 and localized swelling.4 pain over a tendon is the key clinical diagnostic criteria used by clinicians to diagnose tendinopathy.8 the use of advanced diagnostic imaging/testing (e.g., diagnostic ultrasound) is not common clinically, but is necessary to determine the exact physical state of the tendon.5 though the clinical exam is the accepted standard for tendinopathy diagnosis, varying patient presentations and injury states make it difficult to identify the origin of tendon pain.9 previously, tendon pain was thought to be a mechanical overuse injury, which caused inflammation in the tendon, and was classified as a tendinitis.10 due to a lack of inflammatory markers being present mailto:mamatocha@tlu.edu https://doi.org/10.31622/2021/0004.2.2 an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 during histological tests, the term tendinopathy has generally become the preferred diagnostic term for tendon pain,2,11 while tendinosis is utilized for a degenerative tendon diagnosed using diagnostic imaging.2 as tendon pathology research has elucidated other causative factors for the presentation of tendon pain (e.g., mechanical, neural, vascular),10 other researchers have proposed the use of the terms reactive tendinopathy and tendinalgia when classifying a patient with tendon pain. 12, 13 the use of the term tendinalgia would allow clinicians to acknowledge the patient complaint of pain at the site of a tendon without predetermining a state of tissue pathology.13 the risk of using terminology focused on a specific causative factor is that it may lead to treatments that are not optimal for a specific patient or situation.9 due to the previous acceptance of an inflammatory condition being present when diagnosed as tendinitis, most interventions have been aimed at treating the inflammatory process. most of these strategies do not produce effective long-term results (i.e., improvement past six weeks).14-16 commonly used conservative treatments for patellar tendinalgia include: rest, nonsteroidal anti-inflammatory drugs (nsaids), stretching, eccentric exercises, and corticosteroid injections.2,7,17 the current treatment gold standard is the use of eccentric exercises. the alfredson et al. protocol has become the foundation of most eccentric exercise protocols with participants performing the exercises two times a day, seven days a week, for 12 weeks. 1824 for many patients, however, compliance is difficult due to the length of the treatment, muscle soreness, and/or the pain experienced with treatment.18,23,25 other concerns with the protocol, such as tendon rupture rates, are not well understood as researchers do not always report treatment complications. upon return to activity, participants who complete the protocol also report a high recurrence rate.15,26 another treatment option is to utilize manual therapies theorized to address the different causative factors of tendon pain; however, few research studies have been conducted to assess the effectiveness of manual therapy for the treatment of patellar tendinalgia. while there are a variety of manual therapy options that have been proposed to treat this disorder, clinicians could theoretically address the causative factors by applying the mulligan concept (mc), positional release therapy (prt), and/or neurodynamics in these cases. the mc techniques for knee dysfunction are based on applying a pain free glide (mobilization) to the joint while the patient actively moves into a position that was painful prior to the glide being applied.27 positional release therapy (prt) is theorized to restore the muscle or tendon to normal function by increasing oxygen and decreasing inflammatory metabolites.28 to determine if a peripheral neural sliding or tension dysfunction is present, neurodynamics is performed. neurodynamics is the movement of the nervous system on other body structures.29 the use of these techniques in isolation, or combination, might better target the individual differences in patient presentation. the use of manual therapies and tendon classification have been proposed as a means to improve the treatment of tendon pain12,13 due to the high rate of tendon pathology recurrence15,26 and patient non-compliance.23,25 researchers have proposed that many patients classified with tendinalgia may not actually have a true tissue pathology that must be addressed with tissue remodeling13 and that classifying patients based on their response to sub-therapeutic doses of intervention techniques may improve patient outcomes.9,13 thus, it is important for clinicians to consider alternative examination and treatment strategies to better identify and treat these patients. the purpose of this study was to determine if a novel treatment based classification (tbc) algorithm could be used to classify tendon pain, participants, and what the effects of using the algorithm would be in participants diagnosed with patellar tendinalgia. participants an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 case description a convenience sample of participants diagnosed by athletic trainers with patellar tendinalgia at four clinical sites across the united states of america participated in the study. the texas lutheran university institutional review board approved the research project. all participants signed an informed consent form; if the participant was under the age of 18 years old, the legal guardian signed the informed consent and assent was provided by the minor. during the evaluation period, a total of 10 participants (seven females, three males, mean age = 19.6 ± 1.07, mean symptom duration = 2.14 years with a range of one week to six years) presented for possible inclusion in the study. all of the potential participants were diagnosed with patellar tendinalgia according to the inclusion criteria (table 1), agreed to participate in the study, and completed the study through discharge. all participants reported with patellar tendon pain, increased pain and stiffness in the morning and after sitting for long periods of time with a decrease in symptoms after warm up for physical activity.35 examination each participant was examined using a predetermined clinical evaluation to ensure consistency in patellar tendinalgia diagnosis and classification with the tbc algorithm. inclusion criteria included: tendon pain before, during, or after patella loading activities; point tenderness over the patellar tendon upon palpation; pain near patella origin; impaired function; and tendon focal or generalized swelling. exclusion criteria included: cortisone injection (<six weeks), fluoroquinolones ciprofloxacin use (<12 months), post-operative participants unable to perform the treatment (<eight weeks), wore orthotics, currently healing or suspected fractures, or receiving physical therapy for the tendon of concern. participants who met the inclusion criteria then completed a thorough history, range of motion (rom), and special test examination. special tests performed included: clark’s sign, patellar grind, patellar compression, prone knee bend, slump, a quarter screen for tender points (tp),28 and the application of the mc technique for the knee (an internal rotation glide followed by an external rotation glide if pain was not resolved during application). 27 clark’s sign, patellar grind, and patellar compression tests were performed to rule out patellar dysfunction as the source of pain. the prone knee bend and slump tests were performed to rule in neurological tension and sliding dysfunctions. 29 the quarter screen was performed to determine the presence of tps; while the mc technique was performed last to determine classification into the mc treatment. treatment-based classification algorithm the tbc algorithm consisted of a mc technique, prt, neurodynamics, and eccentric exercise. if the participant reported a resolution of his or her symptoms when the mc technique was applied during the exam, then the participant was classified as being a responder to the mc treatment. if the application of the mc did not resolve symptoms during the exam and the participant presented with tps in the lower extremity, which could be reduced by moving the participant into a position of comfort (poc), then the participant was classified as being a responder to the prt treatment. if the application of the mc did not resolve symptoms and a poc could not be identified with prt, the participant would be classified into the neurodynamic treatment if a positive neurodynamic test was found during the initial exam. in the case where the participant could not be classified into the mc, prt, or neurodynamic group, the participant was classified into the eccentric exercise treatment protocol (figure 1). once the clinician determined the appropriate treatment classification, the participant underwent three bouts of treatment within 10 days. the participant was re-assessed to determine if discharge criteria had been met at the conclusion of the third visit. discharge criteria included: phase clincal outcomes research 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 table 1. participant presentation and treatment participant # symptoms symptom duration positive special tests participant 1 pain mid-patellar tendon; unable to sit for more than 30 minutes without pain; pain interferes with competition; intermittent pain at rest; increase pain with stairs and squats; worst pain in the morning 1 week tp: patellar tendon, tibialis anterior mwm: lateral rotation – lunge participant 2 pain mid-patellar tendon; pain interferes with competition; intermittent pain at rest; increase pain with stairs, cutting, and squats; worst pain in the morning 2 weeks tp: flexor digitorum longus mwm: medial rotation – squat participant 3 pain slightly inferior to patella; increase pain when sitting with knees bent, squatting, lunging, going up stairs; pain at start of activity; worst pain in the morning 2 months tp: patella and acl mwm: lateral rotation – lunge participant 4 pain slightly inferior to patella; increased pain when sitting with knees bent longer than 30 minutes, squatting, lunging, and going upstairs; pain at start of activity; worst pain in the morning 2 months tp: patellar tendon mwm: lateral rotation – lunge participant 5 pain mid-patellar tendon; pain during adls, lunging, stairs, single leg hops; pain at onset of activity but able to perform; difficulty maintaining same position for extended period of time; pain at start of activity; worst pain in the morning 6 months tp: acl and patellar tendon mwm: lateral rotation – squat participant 6 pain mid-patellar tendon; pain during adls, lunging, stairs, single leg hops; pain at onset of activity but able to perform; difficulty maintaining same position for extended period of time; worst pain in the morning 6 months tp: patellar tendon mwm: lateral rotation – single leg squat participant 7 pain inferior to patella; unable to sit longer than 10 minutes without pain; unable to perform squats due to pain; difficulty with running and jumping; pain with adls and competition; worst pain in the morning 4 years nd: prone knee bend tp: medial hamstring mwm: medial rotation – squat participant 8 pain slightly superior to tibial tuberosity; unable to sit longer than 10 minutes without pain; unable to perform squats due to pain; difficulty with running and jumping; pain with adls and competition; worst pain in the morning 4 years nd: prone knee bend tp: patellar tendon mwm: medial rotation – squat participant 9 pain mid-patellar tendon; unable to perform single leg hops due to pain; difficulty with running and jumping; unable to compete due to pain; worst pain in the morning 6 years tp: patella, patellar tendon, acl, and medial hamstring participant 10 pain slightly superior to tibial tuberosity; intermittent pain at rest; unable to compete due to pain; worst pain in the morning 6 years tp: patella and patellar tendon mwm: lateral rotation squat nd: neurodynamics, tp: tender point, positive mwm: achieved pill effect; adls: activities of daily living clincal outcomes research 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 1 on the nirschl phase rating scale, phase 1 on the blazina knee scale, and met minimal clinical important difference (mcid) for global rating of change (grc), and acute mcid for the disablement of the physically active scale (dpa scale). additionally, participants had to report a worst pain score equal to or less than two out of ten on the numerical rating scale (nrs) during the discharge evaluation. if the participant was not discharged, a re-evaluation using the tbc algorithm was conducted to determine the participant’s treatment classification for the next three visits. the participant was only able to be re-classified into the initial treatment classification if the participant demonstrated enough improvement to meet 50% of each discharge outcome criteria; if not, the participant was classified into the eccentric exercise treatment. following discharge, each participant was sent a one-month follow up survey to collect follow-up scores on the nrs post-discharge. outcome measures disablement and global participant outcome measures were utilized in this study to determine participant perceptions of their condition and recovery. the six outcome measures utilized in this study were the: nrs, grc, dpa scale, visa-p, nirschl phase rating scale, and the blazina knee scale. the nrs is a rating scale a clinician can utilize to determine a participant’s perception of his or her pain from zero, no pain, to ten, worst pain imaginable.30 each participant of this case series was asked to rate his or her pain at best, worst, and rest before and after each treatment. the recorded nrs scores represent the participant’s reported worst pain. the participant was also asked to rate his or her pain while the clinician performed a quarter screen for tps. the grc was utilized to determine participant’s perception of his or her improvement or deterioration over time.31 the grc was reported at every third visit for each participant. the (mcid) has been established at two points for both the nrs32 and grc.31 the dpa scale was developed to determine the participant’s perception of how his or her injury has effected disablement.33 a participant reported his or her perception on a scale of one, no problem, to five, severe, on 16 questions across multiple domains: pain, motion, muscular function, stability, changing directions, daily actions, maintaining positions, skill performance, overall fitness, participation in activities, and well-being. the rating for each item on the scale is summed and 16 points are subtracted to produce a final score that ranges from zero to 64 points. the dpa scale was administered upon the first visit, third visit, and every third visit after until discharged. the mcid has been established for the dpa scale as nine points for acute injuries and six points for chronic injuries.33 the range of scores for healthy patients on the dpa scale has been reported to be between zero and 34 points.33 the visa-p was created to determine functional impairment in a participant with patellar tendon pain.34 the participant recorded responses to questions regarding his or her function on a numerical scale from zero, unable to perform, to ten, fully functional. all responses were then summed and recorded on a scale from zero, no function, to 100, fully functional. each participant recorded visa-p score upon the first visit, third visit, and discharge visit. currently, a mcid has not been established for visa-p. the nirschl phase rating scale and blazina knee scale were both developed to help classify participant symptoms. the nirschl phase rating scale was created for all tendon pain participants,2,35 whereas the blazina knee scale was created to determine dysfunction specifically for participants with patellar tendon pain.36 all participants reported his or her symptoms in accordance with both scales upon the first visit, third visit, and discharge visit. currently, the nirschl phase rating scale, and blazina knee clincal outcomes research 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 figure 1. treatment based classification algorithm for patellar tendinopathy does internal/external rotation mwm resolve symptoms? yes perform mwm no are tps & pocs present? no positive knee bend test? yes perform neurodynmaics for treatment yes no perform prt eccentric exercise protocol meets discharge criteria yes discharge and send follow-up survey at 1 month no re-evaluate the patient clincal outcomes research 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 scale do not have an established method for evaluating patient improvement on the scales. intervention if the participant was classified into the mc treatment subgroup, the participant was treated with the mobilization with movement (mwm) (internal or external rotation glide) to resolve the participant’s pain complaint.27 the internal or external rotation glide was applied by having the participant perform a movement that exacerbated the chief complaint. once the painful movement was established, the clinician gently placed her hands just below the tibiofemoral joint line, around the tibia and fibula and applied the appropriate glide to the tibia in association to the femur (figure 2). simultaneously, the participant performed the previously established painful movement. the mwm was performed through three sets of 10 repetitions of pain-free movement.27 if the participant was classified into the prt treatment subgroup, the dominant tp was monitored while the participant was passively moved into a poc.28 the clinician would begin with the participant in a supine position on a plinth with a bolster under their ankle to allow full knee extension. the clinician would then apply tibial rotation with the hand not palpating the tp. the poc was defined as a position resulting in the resolution of pain (zero out of 10 on the nrs) during palpation of the tp. if a poc was achieved, the participant received prt for the dominant tp only. the dominant tp was treated while the clinician maintained the poc (figure 3). the poc was held for a minimum of 30 seconds, and a maximum of 90 seconds.28 the participant was then returned to the normal anatomical position while the clinician continued monitoring the tp. the tp was reassessed by determining pain to palpation (using the nrs) in the normal anatomical position. if the participant still reported tenderness to palpation of the tp after one set of treatment, the clinician repeated the treatment; if the patient reported resolution of pain to palpation, the treatment was concluded for that session. a patient could receive a maximum of three treatment sets per visit. if the participant was classified into the neurodynamic treatment subgroup, the participant was instructed on the proper technique to perform a general neural slider in the prone knee bend position (figure 4).29 as the participant released tension at the head (head moved from cervical extension to neutral), tension was increased at the knee (knee moved from extension to flexion).29 each participant completed three sets of 10 repetitions, through a slow and controlled movement. if the participant was classified into eccentric exercise (ee) treatment subgroup, the participant completed a monitored ee protocol two times a day, seven days a week for 12 weeks.37 participants completed one set of 15 repetitions of a single leg squat on a 25-degree decline board for each session.37 the participant was instructed to keep the trunk in the upright position, slowly flexing the knee to 90 degrees and returning to the starting position with the uninjured leg.37 the participant was then instructed to squat into pain without exceeding seven out of ten on the nrs during the eccentric portion (knee flexion). if the participant’s pain decreased to less than or equal to two out of ten on the nrs while performing ee, an external load by use of a dumbbell was added to increase the difficulty of the exercise. an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 figure 2. example of the mobilization with movement statistical analysis all data was analyzed using spss version 23.0 (spss inc., chicago, il, usa). paired t-tests were performed on the nrs, dpa scale, and visa-p to determine the effects of classifying and treating participants with this novel tbc algorithm for patellar tendinalgia. mean differences from the initial visit scores and 95% confidence intervals (cis) were calculated for the nrs, dpa scale, and visa-p for discharge. cohen’s d was also computed to determine the effect size, or maximum likelihood, of each of the aforementioned outcome measures. for cohen's d an effect size of 0.2 to 0.3 was considered a "small" effect, around 0.5 a "medium" effect and 0.8 to infinity, a "large" effect.38 descriptive statistics were performed on the grc scores reported at discharge. figure 3. example of positional release therapy position of comfort figure 4. example of neurodynamic slider technique results during the initial examination, all participants were classified into a manual therapy treatment sub-group (mc = 9, prt = 1). all participants were successfully treated through discharge with the initial treatment classification and no participants met the criteria for classification into the ee subgroup at any point of time during treatment. the number of treatments each participant received was three over a mean of 4.8 ±1.4 days to discharge. numerical rating scale the use of the tbc algorithm resulted in a significant mean change in pain from initial visit to discharge, m = 4.7 ± 1.64 (95% ci [3.57 to 5.82], p < .001) with a large effect size (cohen’s d = 2.41) (table 2). the mean difference in pain an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 scores from initial visit to discharge, as well as the lower boundary ci, exceeded the mcid of “much better” for the nrs.26 the mean change was accomplished in just three visits that took place within 4.8 ± 1.4 days. at discharge, 60% of participants (6/10) reported a complete resolution of their pain. the remaining 40% of participants (4/10) reported their “worst” pain as a one (20%, 2/10) or two (20%, 2/10) on the nrs. one-month post discharge data demonstrated that all participants who completed the follow-up survey (n = 2) continued to experience a resolution of pain with full return to activity. disablement in the physically active scale statistically significant changes on the dpa scale from initial evaluation to discharge were recorded m = 21.8 ± 12.3130, (95% ci [12.43 to 31.16], p = .001), with a large effect size (cohen’s d = 1.98) when using the tbc algorithm (table 2). the mean change from initial visit to discharge, as well as the lower boundary of the ci, exceeded the mcid for acute conditions, a reduction of nine points or greater, which is greater than the mcid for chronic conditions (six points).33 all of the participants (100%) met mcid for both acute and chronic conditions prior to discharge, as well as being discharged within the healthy range (zero to 34 points).33 published data for dpa scale scores for return to activity for chronic conditions does not exist; however, the reported mean for participants who returned from acute injury is m = 8.82 ± 6.71 (r = 0 – 23 points). all of the participants (100%) in this case series were discharged below the reported mean score for returning to activity after an acute injury (m = 8.5 ± 9.11; r = 0 22). consequently, participants in this case series perceived less disablement than has been reported in the previous literature on the dpa scale.33 victorian institute sport assessment patella the use of the tbc algorithm resulted in a significant increase in scores on the victorian institute of sport assessment-patella outcome measure from initial exam to discharge (m = 22.70 ± 16.07, 95% ci [33.71 to 11.68], p < .001), with a large effect size (cohen’s d = 1.37) (table 2). of greater clinical importance, 80% (8/10) of the participants reported a visa-p score for “completely recovered” within three days of initiating treatment. global rating of change a clinically meaningful increase on grc scores from initial visit to discharge was reported (m= 5.7 ± 2.11) (table 2). the grc scale ranges from -7 (a very great deal worse) to +7 (a very great deal better).31 all (100%) of the participants exceeded a mcid for the grc scale (≥ 2) upon discharge.31 more clinically relevant, 50% (5/10) of participants reported a +7 (a very great deal better), 10% (1/10) reported a +6 (a great deal better), and 40% (4/10) reported a +4 (moderately better) at discharge.31 nirschl phase rating scale during initial evaluations, 30% (3/10) of participants reported a phase three on the nirschl phase rating scale meaning “pain that is present during activity without causing activity modification”,35 40% (4/10) reported a phase five “pain that is present during all activities and occurs with activities of daily living”,35 and 30% (3/10) reported a phase six “intermittent rest pain that does not disturb sleep”.35 all participants (100%, 10/10) reported a phase one (“mild stiffness or soreness after activity with resolution of symptoms within 24 hours”) on the nirschl phase rating scale prior to discharge. more clinically relevant, 60% (6/10) of the participants did not feel a phase one rating on the nirschl phase rating scale was applicable due to their experience of full resolution of symptoms. clincal outcomes research 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 table 2. outcome results outcome measure intake score discharge score mean change 95% cis p-value effect size (cohen’s d) nprs 5.30±1.94 0.60±0.84 4.78±1.64 3.52, 6.04 0.000 2.41 dpa scale 30.3±11.02 8.50±9.12 19.89±12.31 10.42, 29.35 0.001 1.98 visa-p 53.60±16.58 76.30±18.36 -23.56±16.71 -35.91, 11.20 0.002 1.37 nprs: numeric pain rating scale; dpa scale: disablement of the physically active scale; visa-p: victorian institute of sport assessment for patellar tendon; cis: confidence intervals blazina knee scale during the initial evaluation, 50% (5/10) of participants reported a phase two on the blazina knee scale “pain/discomfort during and after activity with the subject still able to perform at a satisfactory level (does not interfere with participation)”;36 while the other 50% (5/10) of participants reported a phase three “pain during and after activity with more prolonged, with subject having progressively increasing difficulty in performing at a satisfactory level (interferes with competition)”.36 all of the participants (100%) reported a phase one on the blazina knee scale prior to discharge (“pain after activity only”).36 more clinically relevant, 60% (6/10) of participants did not feel a phase one rating on the blazina knee scale was applicable due to their experience of full resolution of symptoms. discussion currently, eccentric exercise is the gold standard treatment for patellar tendinalgia. several researchers have demonstrated positive results with the use of a 12-week protocol.18-21,23-25,38,39 jonsson and alfredson40 compared an eccentric exercise group to a concentric exercise group for the treatment of “jumper’s knee” and reported nine out of 10 participants who completed the study were “satisfied” and discharged with a mean visual analogue scale (vas) of 23 out of 100 and a visa-p score of 83 points with the use of a 12-week eccentric exercise protocol. similarly, purdam, et al.24 reported a mean vas score of 28.5 points at discharge for participants who performed eccentric exercises on a decline board, compared to a mean vas score of 72 points at discharge for participants who performed traditional squat eccentric exercises for 12 weeks. in these studies, however, not all participants reported being “satisfied” at discharge (10%,40 25%24). the participants, who did report being “satisfied” did not, on average, experience a full resolution of pain at discharge after 12 weeks of therapy.24,40 although nrs and vas are measured on different scales, the values of the numbers are similar. the clinicians of the present study were able to discharge participants with mean nrs scores of .05 out of 10 (0/10=6, 1/10=2, 2/10=2), which is lower than the aforementioned studies. although the mean vas of the present study was lower, the mean visa-p (m = 78.11) of this study is also lower than the aforementioned study, which is potentially indicative of participant perception of more function from the ee protocol. although ee has been found to produce beneficial results when the protocol is completed, there are still concerns over the effectiveness of the protocols for all patients and a lack of a clear understanding of the mechanism of action. thus, there is a need to determine if tendinalgia participants should be screened prior to using an ee protocol in a one-size fits all model.8,9 the lack of a screening process for identifying patients likely to respond to ee and the extended time required for patients to become symptom free has created a need for improved assessment methods.8,9 one potential solution to improve tendinalgia outcomes is the use of a tbc system or more novel manual therapy techniques. lewis9 has suggested a series of four mechanical techniques, an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 or a combination of interventions, to be used as a tbc system to produce improved patient classification and treatment outcomes for patients with rotator cuff tendinalgia. the manual therapies used in the tbc algorithm in this study also have evidence of effectiveness on tendinalgia patients in other research studies.13,4244 researchers have found promising results with the use of the mc when treating lateral epicondylalgia.41-43 bisset, et al.43 observed favorable outcomes for the use of mc mobilizations in combination with exercises over corticosteroids and a “wait and see” method. although corticosteroid injections were more statistically significant while the preliminary results of this case series are important, the limitations of this study must also be noted. although many attempts were made to decrease the risk of bias, there could have been a bias created because the clinician and participants were not blinded to the treatment or collection of outcome measures. additionally, a control or placebo group was not used in the study. the lack of control group and long term follow-up made it difficult to definitively determine if the outcomes were the result of treatment or the natural course of healing; however, a number of participants presented with chronic symptoms (mean symptom duration = 2.14 years with a range of one week to six years) unlikely to have spontaneously healed over the treatment period. the lack of comparison group made it difficult to determine if one treatment intervention was superior to another within the tbc algorithm, but the purpose of the study was not to identify the “best” intervention. instead, the focus was on determining the effectiveness of classifying patients using sub-therapeutic doses on indirect manual therapies. additionally, it could be argued the treatments provided as part of the tbc algorithm were provided at sub-therapeutic doses (e.g., not treating multiple tps with prt, etc.) and the interventions could be more effective if treatment dose was maximized. furthermore, the specific techniques utilized (e.g., internal rotation and external rotation mwm, etc.) for this tbc algorithm were limited to increase usability of the algorithm; however, other techniques within the different intervention paradigms have the potential to maximize the effectiveness of each paradigm (e.g., mc taping technique, other glides, etc.). the full examination of the original tbc was not fully assessed due to the lack of diverse treatment subgroups. there were nine participants classified in the mc subgroup, one in the prt subgroup, and zero in the nd and ee subgroups. the final limitation is that the participants may not have fully represented patellar tendinalgia patients and those who volunteered may have been motivated to improve. as this study is an initial examination of a tbc algorithm for patellar tendon pain, it is possible that altering the order or adding other treatment paradigms may be appropriate to maximize the effectiveness of the tbc algorithm. the results of this study do provide support for the utilization of a tbc algorithm for patellar tendinalgia patients because all 10 participants experienced statistically and clinically significant improvements in pain and function in three visits. future research should compare this tbc algorithm with a control or placebo group and utilize long-term follow-up with the participants. forthcoming research should also include diagnostic imaging or histological exams, which would benefit the understanding of the physiological changes in the tendon following treatment utilizing the tbc algorithm. clinical application the tbc algorithm used in this study was designed because the clinicians could observe participant response to potential interventions while in a painful state and to utilize manual therapy techniques that could potentially produce rapid changes. patient response enabled the clinician to classify the participant to an intervention that was designed to be matched to their dysfunction. in theory, matching tendinalgia patients to therapies an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 through classification could improve outcomes. in this study, all of the participants were classified as being a responder to either the mc or prt and were able to meet the pre-established discharge criteria without a single participant needing to be classified into the ee protocol sub-group at any time. thus, a tbc algorithm may be more effective at matching participants to appropriate treatments that do not require extended therapy or a painful experience to produce effective outcomes. additionally, the use of a tbc algorithm may allow clinicians to identify which participants actually need to participate in an ee protocol or when to add this protocol as an adjunct therapy to provide complete resolution of participant complaints. references 1. murtaugh, b., ihm j. eccentric training for the treatment of tendinopathies. curr sports med rep. 2013;12(3):175–182. https://doi.org/10.1249/jsr.0b013e31829 33761. 2. kaux j-f, forthomme b, goff c le, crielaard j-m, croisier j-l. current opinions on tendinopathy. j sports sci med. 2011;10(2):238–253. 3. fredberg u, stengaard-pedersen k. chronic tendinopathy tissue pathology, pain mechanisms, and etiology with a special focus on inflammation. scand j med sci sports. 2008;18(1):3–15. 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sports med. 2003;22(4):813–836. https://doi.org/10.1016/s02785919(03)00051-6. 36. blazina me, kerlan rk, jobe fw, carter vs, carlson gj. jumpers knee. orthop clin north am. 1973;4(3):665–678. 37. young m, cook j, purdam c, alfredson h. eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players.br j sports med.2005;39:102-105. https://doi.org/10.1136/bjsm.2003.01058 7. 38. ohberg l, alfredson h. effects on neovascularisation behind the good results with eccentric training in chronic mid-portion achilles tendinosis? knee surg sports traumatol arthrosc. 2004;12(5):465–70. https://doi.org/10.1007/s00167-0040494-8. 39. cannell lj, taunton je, clement db, smith c, khan km. a randomised clinical trial of the efficacy of drop squats or leg extension / leg curl exercises to treat clinically diagnosed jumper ’ s knee in athletes : pilot study. br j sports med. 2001;35:60–64. https://doi.org/10.1136/bjsm.35.1.60. 40. jonsson p, alfredson h. superior results with eccentric compared to concentric quadriceps training in patients with jumper's knee: a prospective randomised study. br j sports med. 2005;39:847-850. https://doi.org/10.1136/bjsm.2005.01863 0. 41. vicenzino, b., & wright, a. effects of a novel manipulative physiotherapy technique on tennis elbow: a single case study. man ther. 1995;1:30-35. https://doi.org/10.1054/math.1995.0247. 42. amro, a., diener, i., bdair, w., hameda, i., shalabi, a., & ilyyan, d. the effects of mulligan mobilization with movement and taping technique on pain, grip strength, and function in patients with lateral epicondylitis. hong kong physiotherapy journal. 2010; 28: 19-23. https://doi.org/10.1016/j.hkpj.2010.11.00 4. 43. bisset l., beller e., jull, g., brooks, p., darnell, r., & vicenzino, b. mobilisation with movement and exercise, corticosteroid injection, or wait https://doi.org/10.1136/bmj.38961.584653.ae https://doi.org/10.1136/bmj.38961.584653.ae https://doi.org/10.1016/s0004-9514(09)70015-7 https://doi.org/10.1016/s0004-9514(09)70015-7 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.1016/s0278-5919(03)00051-6 https://doi.org/10.1016/s0278-5919(03)00051-6 https://doi.org/10.1136/bjsm.2003.010587 https://doi.org/10.1136/bjsm.2003.010587 https://doi.org/10.1007/s00167-004-0494-8 https://doi.org/10.1007/s00167-004-0494-8 https://doi.org/10.1136/bjsm.35.1.60 https://doi.org/10.1136/bjsm.2005.018630 https://doi.org/10.1136/bjsm.2005.018630 https://doi.org/10.1054/math.1995.0247 https://doi.org/10.1016/j.hkpj.2010.11.004 https://doi.org/10.1016/j.hkpj.2010.11.004 an exploratory analysis of a treatment based classification algorithm to treat patellar tendinopathy 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 and see for tennis elbow: randomised trial. bjm. 2006;333: 939–941. https://doi.org/10.1136/bmj.38961.58465 3.ae. 44. matocha ma, baker rt, nasypany am, seegmiller jg. effects of neuromobilization on tendinopathy: part ii. int j athl ther train. 2015;20(2):41–47. https://doi.org/10.1123/jsr.2016-0033. https://doi.org/10.1136/bmj.38961.584653.ae https://doi.org/10.1136/bmj.38961.584653.ae https://doi.org/10.1123/jsr.2016-0033 abstract manuscript type clincal outcomes research 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 use of response shift to improve agreement between patientreported and performance-based outcomes in knee patients shelby baez, phd, atc*; johanna m. hoch, phd, atc†; carl mattacola, phd, atc, fnata‡; philip gribble, phd, atc, fnata†, jennifer s. howard, phd, atc** *michigan state university, east lansing, mi; †university of kentucky, lexington, ky; ‡ university of north carolina at greensboro, greensboro, nc; **appalachian state university, boone, nc abstract the purpose of this study was to determine whether the implementation of performance-based tasks (pbts) prior to completion of patient-reported outcome measures (pros) would create a change, or a response shift, in pros in patients with knee injuries. a randomized controlled trial was implemented to examine the effectiveness of a response-shift based interventions to enhance the correlation between pbts and pros. participants (n=20) were knee-injured patients who were removed from activity for a minimum of 1-week. participants were randomly assigned to complete pbts (intervention) or to watch videos detailing an injury prevention program (control). the international knee documentation committee subjective form (ikdc) and the knee injury and osteoarthritis outcome score recreational and sports subscale (koossports) were completed both preand post-testing. the independent variable was group. dependent variables included raw change scores and absolute change scores on the ikdc and koossports. mann-whitney u tests were used to examine between group differences. changes in pro scores were not considered statistically significant or clinically meaningful (ikdc raw p = 0.14, absolute p = 0.74; koossports raw p = 0.85 absolute p = 0.32). implementation of pbts prior to pros did not induce a response shift. pros may better evaluate symptoms and/or confidence in a patient, while pbts evaluate physical function. key phrases patient-reported outcomes, clinician-rated outcomes, functional testing correspondence dr. shelby baez, michigan state university, 308 w circle drive 27p, east lansing, mi 48824. e-mail: baezshel@msu.edu full citation baez s, hoch jm, mattacola c, gribble p, howard js. use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients. clin pract athl train. 2021;4(1): 24-35. https://doi.org/10.31622/2021/0004.1.4. submitted: july 30, 2020 accepted: february 22, 2021. introduction after an injury, patients often seek medical treatment to resolve their injury. whether that treatment is therapeutic rehabilitation, surgical interventions, or even just the application of ice, it is important to evaluate the effectiveness of the method of treatment. the assessment of health outcomes is a fundamental component of a clinician’s duties, as it provides a basis to determine which treatments are more effective.1 assessment of health outcomes also provides a foundation to determine whether a patient can return to their pre-injury levels of activity.1 in athletics, most often the goal is to return patients to their pre-injury status and back to full participation as quickly and safely as possible. different evaluation techniques have been employed to assess a patient’s health status and to determine whether a patient is able to return to sport. these different techniques often include disease-oriented, performance-based, and patient-oriented measures.2-4 disease-oriented measures assess outcomes associated with impairments at the body function and structure level.2 these measures typically include testing or evaluating the involved tissue, such as the lachman’s maneuver or the kt-1000 device, to test the integrity of the acl.2 performance-based measures are typically closed-kinetic tasks that examine the patient’s ability to perform functional tasks that will likely stress the involved structure.3-5 frequently used lower extremity performance-based measures include the single-leg hop for distance, crossover mailto:baezshel@msu.edu https://doi.org/10.31622/2021/0004.1.4 use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 hop, 6-metered timed hop, shuttle run, and star excursion balance test.2,6-8 lastly, patient-oriented outcomes are used to determine the perceived limitations and restrictions, most often through the use of patient reported outcome measures (pros).9 while many reliable and valid measures exist for each type of outcome, the observed correlation between various types of outcome measures is often poor to moderate, at best.10,11 specifically, performance-based measures and pros have frequently been observed to be only low to moderately correlated among knee-injured patients.10,11 it has been theorized that failure to provide a frame of reference for patients to answer questions on pros has led to the disagreement between pros and performance-based measures.10 patients may be asked to answer questions related to tasks that they have not performed since sustaining injury.12 asking patients to complete questionnaires prior to completing functional testing may result in patients having an insufficient sample of experiences from which to self-evaluate their current function. as proposed by logerstedt et al.,13 if patients can be provided with a relevant sample of experiences to be used to evaluate their current function, then their perceived function may be more in line with their true physical performance. anecdotally, it has been observed that patients tended to either underestimate or overestimate on pros if completed prior to performance-based testing.14 fitzgerald et al.14 hypothesized that completing performance-based tasks prior to the completion of pros allowed the participant an opportunity to self-evaluate the status of their knee, which provided more accurate ratings of knee function on the self-report surveys. inconsistencies between pros and performancebased measures may be due to the varying frame of reference patients use to complete pros. as a result, pros may be influenced by a response shift phenomenon. although primarily studied in ill and chronic disease patients, response shift can also be detected in individuals suffering from an orthopaedic injury.15,16 response shift is defined as a change in an individual’s internal standards, values, or conceptualization of a construct when evaluating their health related quality of life.17 a response shift results in a change in one’s selfevaluation either through recalibration, reconceptualization, or reprioritization.18 recalibration refers to a person’s change in their internal standards of measurement; reconceptualization refers to a change in definition of the target construct; and reprioritization refers to a change in an individual’s internal values.18 if individuals are susceptible to these changes, then it may be possible to recalibrate and/or reconceptualize an individual’s self-perceived function through the implementation of a performance-based assessment intervention. while the response shift phenomenon has been reported in orthopaedic cases15,16, use of this theory to optimize pros has not been previously evaluated. therefore, the purpose of this study was to examine the effect of testing order on pro scores to determine if completing a performance-based assessment with the intent to provide a frame of reference for the individual prior to the administration of pros would alter pro scores in knee patients. we hypothesized that completion of performancebased assessments prior to pros would lead to a greater change on pro scores between pre-test and post-test when compared to a control group. patients participants were between the ages of 14-40 and had been restricted due to a knee pathology from full participation in physical activity for at least 1week prior to testing and had recently been cleared to return to full activity. participants could have no other injuries besides their current knee injury affecting their sports participation status, and they must have reported having a pre-injury activity level of 5 or greater on the tegner use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 physical activity assessment.20 additionally, participants were excluded based on the following criteria: known balance disorders, not cleared to return to activity, not cleared to perform functional testing, scored below a 46 on the ikdc, failure to pass the pre-participation functional assessment screening, or cleared for activity > two weeks at time of recruitment. as a precaution, participants who scored below a 46 on their pre-intervention ikdc were not permitted to continue in the study. a cut-off of 46 was chosen because this value represented the mean preoperative value for surgical knee patients in the university of kentucky patient registry at the time of study development which suggested that the patient may not be able to safely complete the functional tasks required of the study. intervention design a randomized controlled trial was used for this study, with participants randomized into either a performance-based assessment intervention group or an educational control group (figure 1). a block randomized design with random block sizes ranging from 2-6 participants was used to complete randomization. an independent third party generated the randomization scheme using a publicly available randomization generator (http://randomization.com/) and created blinded envelopes for subject allocation. individuals in the performance-based assessment group completed a battery of functional tests, while those selected for the educational control group participated in a placebo intervention consisting of watching exercises from the fifa 11+ program.19 the intervention session lasted approximately 40 minutes for both groups. both groups completed the international knee documentation committee subjective knee form (ikdc) and the knee injury and osteoarthritis outcome score sports and recreation subscale (koossports) preand postintervention. all participants reviewed and signed an informed consent approved by the university of kentucky irb prior to study participation. figure 1. study design and participant allocation procedures participants completed a single testing session in a clinical laboratory lasting approximately 40 minutes. after informed consent and prior to randomization, all participants completed the ikdc and koossports as pre-test assessments. upon completion of pre-test pros, the participant randomization envelope was opened, revealing group allocation. educational control group participants randomized into the educational control group were shown the fifa11+19 exercise videos. the fifa11+ is a sports and injury performance program that has been used extensively in the soccer community and beyond and, when implemented with high compliance, has been shown to reduce injury risk among soccer players.19,24-27 it was chosen as an educational control for this study, as the information provided in the video may be of some benefit to study participants, but was not anticipated to alter pro use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 scores. we chose to include a patient education component for the control group to reduce participant bias and provide some benefit to all participants. at the conclusion of the study, participants in both groups received a handout with links to the fifa 11+19 website as additional information to take with them. following conclusion of the videos, the participants were again asked to complete the ikdc and koossports. performance-based assessment screening as a precaution, prior to the completion of the performance-based tests, participants randomized to the performance-based assessment group completed a screening to verify the patient’s eligibility/readiness to complete the performance-based tasks included in the study protocol. this screening consisted of a series of single-leg squats, side-to side-hops, and vertical hops. all participants were required to complete these tasks without pain, or any other symptoms. instrumentation those participants randomized into the performance-based assessment intervention group completed a 5-minute jogging warm-up followed by a battery of performance-based assessments. to ensure there was minimal fatigue and muscle soreness throughout the study, the order of tests was standardized for all participants and a three-minute rest period was provided between each test. for all assessments, participants were given ample time to practice each task, and for unilateral assessments the uninvolved limb was tested first. star excursion balance test (sebt) – anterior reach28 the sebt was used to assess dynamic balance. participants maintained a single-leg stance on the involved limb while reaching for maximum distance in the anterior direction with the opposite limb. the participant’s first toe was placed at the 0 point on the tape measure. participants then reached as far anteriorly as possible and touched the tape measure while maintaining a single-leg stance. participants were required to keep their hands on their hips and stance heel in contact with the ground. all participants were given the opportunity to complete 4 practice trials, followed by 3 test trials in the anterior direction only. the test was performed bilaterally with the uninvolved limb first. reach distances were measured in centimeters and normalized by leg length. leg length was measured from the anterior superior iliac spine to the base of the medial malleolus of the tibia. mean reach distances were used to calculate limb symmetry index (lsi = (mean distance involved limb/mean distance uninvolved limb) x 100). single-leg hop tests29 the single-leg hop for distance test is commonly used to measure power and confidence. the patient began standing on one leg and then jumped as far forward as possible landing on the same leg. the total distance hopped forward was recorded (cm). the crossover hop for distance also measures power and confidence in the tested leg. the patient began standing on one leg and then hopped as far as possible forward 3 times while alternating crossing over a 6-centimeters wide strip on the floor. the total distance hopped forward was recorded (cm). both hop tests were performed three times, with a 10 second recovery between trials. a successful trial included landing stable on the test leg and maintaining balance for three seconds. the trial was repeated if the participant landed with early touchdown of the contralateral leg, lost balance, touched the surrounding area, or included additional hops after landing. mean hop distances were used to calculate limb symmetry index (lsi = [mean distance involved limb/mean distance uninvolved limb] x 100). the single-leg hop for distance and the crossover hop for distance have previously been reported to be reliable and valid measures use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 of functional performance,30 and are routinely used clinically to evaluate recovery and readiness to return to sporting activity. 30 second step-down test31 participants were asked to perform a step-down motion from a platform 8-inches high. participants were instructed that contact with the floor should only be a brush and not be used to accelerate back onto the step, hands must remain on the hips, and to complete as many repetitions as possible within a single 30-second trial. participants completed one 30-second test trial on each limb, with a 3-minute recovery time between test legs.31 limb symmetry index was calculated using the following equation: (lsi = [mean distance involved limb/mean distance uninvolved limb] x 100). compact agility test (cat) participants completed an assessment of agility, quickness, and body control by completing a sprinting and shuffling task on a 4-meter path. the path was marked by tape and the individual performed the following tasks with their best effort. the testing procedure followed the pattern presented in figure 2. this resulted in a total distance traversed of 20 meters. participants completed a walk-through of the task to gain familiarity and then were asked to complete a submaximal effort of the task to ensure fluidity of the task. additional submaximal trials were permitted if necessary, for the participants to feel comfortable with the test. the participants were then asked to complete two test trials at the highest speed with which they were comfortable. a two-minute rest period was given between test trials. verbal cuing occurred from the investigator throughout the entire testing session of the cat. the faster of the two trials was used as the cat result for analysis. this test was designed to be completed in a small space, such as a doctor’s office, and to provide patients with a sampling of experiences that involved sprinting, cutting/planting, and lateral movements. outcome measures following completion of the performance-based assessment battery, participants completed the postikdc and koossports assessments. to avoid biasing pro scores, participants did not receive scores on performance-based measures until post-test pros were completed. both the ikdc and koos are valid and reliable pros used for individuals suffering from knee pathology.21,22 the ikdc is a 20-item outcome measure used to determine patient perceived function. the koossports is a 5-question subscale of the koos used to evaluate patient perceived function for activities such as running, cutting, and jumping. all pros were collected and managed using research electronic data capture (redcap) tools hosted at the xxx. redcap is a secure, webbased application designed to support data capture for research studies.23 statistical analysis descriptive statistics were generated for all performance-based measures and pros. to ensure that the randomization resulted in comparable groups, independent t-tests or mannwhitney u tests were used to compare height, weight, age, and time between clearance to rts and the data collection session between groups. to determine if participation in performancebased assessments resulted in a change in pro figure 2. compact agility test (cat). completed on 4metered pathway. use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 scores, mann-whitney u tests were used to compare the raw change (post-test – pre-test) and absolute change (|post-test – pre-test|) between groups for both the ikdc and koossports scores.15 minimal detectable change (mdc) values were interpreted to identify clinically meaningful changes in the ikdc and koos sports scores. results a total of 20 participants were enrolled into the study (performance-based assessment n=10, educational control n=10). participants’ demographic information are presented in table 1. eleven out of 20 of the participants were cleared to return to activity following aclreconstruction. two other patients were postsurgical (medial meniscal allograft transplantation and meniscectomy). the remaining nine participants suffered from it band friction syndrome (n=1), morel-lavalle lesion (n=1), lateral collateral ligament sprain (n=2), articular cartilage damage (n=2), meniscal tear (n=2), or patellofemoral pain syndrome (n=1). participants were tested a median of 1.5 days from physician and/or other healthcare professional’s clearance to return to sport. there were no differences in demographics between the two groups. average pre-test, post-test, and change scores for the performance-based assessment group and educational control group are presented in table 2. descriptive statistics for performance-based measures are presented in table 3. no significant differences were observed between groups when comparing raw change scores and absolute change scores for the ikdc and koossports (ikdc raw change p = 0.14, absolute value p = 0.74; koossports raw change p = 0.85 absolute value p = 0.32) (table 2). discussion to our knowledge, this is the first study to use a response shift theory-based intervention to enhance the agreement between performancebased measures and pros. the aim of this study was to determine whether testing order would improve the agreement between performancebased measures and scores on the ikdc and koossports. however, our results did not support our hypothesis as we observed that providing a specific frame of reference from which patients could evaluate themselves did not result in systematic changes in pro scores. these results suggest that pros can be implemented before or after performance-based testing during the rehabilitation of knee patients and support the use of both pros and performance-based testing in clinical practice. while no between group differences were identified, some participants included in this study did increase or decrease their score at the posttest despite their ability to successfully complete performance-based tasks with high lsis (table 3). in accordance with howard et al.,20 the present study also observed evidence that a response shift may occur on a patient-by-patient basis after knee injury. fifty percent of the participants randomized into the performance-based assessment group reported lower scores on the ikdc at the post-test (table 4). this suggests that participants overestimated their function prior to completion of functional testing. concerns for overestimation on pros in patients after acl reconstruction has been previously postulated.14 while evaluating decision-making criteria for return to sport after acl reconstruction, fitzgerald et al.14 altered their methods of administering pros to their patients to accommodate anecdotal observations involving testing order.14 investigators reported observing that patients tended to overestimate or underestimate on selfreport scores if hop tests were performed after the completion of pros. while not statistically or clinically meaningful between groups, the results from the present study further support this observation that individual patients may shift their responses on pros due to their experience while engaging in the performance-based assessments. clincal outcomes research 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 table 1. participant demographics measure performance group (n=10) educational control (n=10) total (n=20) p-value mean (sd) height (cm) 177.24 (9.43) 173.00 (11.27) 175.12 (10.32) 0.37* weight (kg) 80.40 (18.70) 82.20 (17.22) 81.30 (17.52) 0.83* tegner score (current level) 8.00 (1.70) 8.00 (1.42) 8.00 (1.52) 1.00* median (iqr) age (years) 20.00 (3.00) 20.50 (4.00) 20.00 (3.00) 0.63# time from clearance (days) 6.50 (7.00) 1.00 (3.00) 1.50 (7.00) 0.09# tegner score (before injury) 9.00 (3.00) 9.00 (3.00) 9.00 (2.00) 0.39# *pba = performance-based assessment group, ec = educational control group *independent t-test, #mann whitney-u test table 2. patient-reported outcome measures pre-test, post-test, and change scores performancebased assessment median (iqr) educational control median (iqr) total median (iqr) mannwhitney u test p-value measure ikdc pre-test 87.94 (11.78) 88.51 (22.13) 87.94 (13.21) 0.57 ikdc post-test 87.36 (15.80) 89.66 (23.56) 87.94 (15.23) 0.35 koossports pre-test 90.00 (26.00) 92.50 (41.00) 90.00 (29.00) 1.00 koossports post-test 90.00 (26.00) 92.50 (41.00) 90.00 (29.00) 0.91 δ ikdc raw change -0.57 (3.16) 0.01 (2.59) 0.00 (3.16) 0.14 δ ikdc absolute value 1.16 (2.87) 1.72 (2.30) 1.16 (2.30) 0.74 δ koossports raw change 0.00 (6.00) 0.00 (0.00) 0.00 (0.00) 0.85 δ koossports absolute value 2.50 (5.00) 0.00 (1.00) 0.00 (5.00) 0.32 *ikdc = international knee documentation committee, koossports = knee injury and osteoarthritis outcome score sports and recreational subscale, pba = performance-based assessment group, ec = educational control group use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 table 3. outcomes of pros change scores and performance-based testing demonstrating mean values and standard deviation (sd), and p-value performance-based assessment mean (sd) sebt anterior reach 99.22 (4.90) sl hop for distance lsi 100.29 (11.12) crossover hop for distance lsi 95.91 (13.66) 30 second step down task lsi 96.50 (11.71) compact agility test avg 10.13 (1.57) *lsi = limb symmetry index, sebt = start excursion balance test, sl = single leg table 4. individual changes in pro scores between groups ikdc – pre ikdc post koossports pre koossports post pba 91.95 91.96 100 100 pba 89.66 89.66 90 90 pba 51.72 41.38* 25 35# pba 80.46 79.32* 85 80* pba 87.36 86.21* 75 70* pba 79.31 77.02* 90 90 pba 78.16 73.57* 70 75# pba 90.8 93.11# 100 95* pba 90.8 91.96# 100 100 pba 88.51 88.51 100 100 control 57.47 55.18* 55 55 control 87.36 87.36 90 80* control 83.91 82.76* 90 90 control 97.7 97.7 95 95 control 78.16 80.46# 60 60 control 94.25 97.71# 100 100 control 40.23 42.53# 35 40# control 94.25 94.26 100 100 control 100 100 100 100 control 89.66 91.96# 100 100 pba = performance-based assessment, ikdc = international knee documentation committee, koossports = knee injury and osteoarthritis outcome score sports and recreational subscale * = decreased from pre to post test, # = increased from pre to post test use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 these results also highlight the importance of integration of a holistic approach to health outcome evaluation. performance-based measures completed in this study provided information about the patient’s strength, power, and agility. however, those tasks may only provide limited information about the patient’s pain or confidence levels, particularly when performed in a controlled laboratory environment. evaluation of a patient’s confidence levels, and perception of function are just as important as evaluating the patient’s strength, power, and agility. providing a frame of reference did not alter median pro scores, which suggests that these outcomes are measuring different aspects of health. this study adds to the growing body of literature supporting a multifaceted approach to outcome measurement to provide the most effective evaluation of patient care and progress. interestingly, 4 out of 10 participants in the educational control group exhibited increased scores on the ikdc at the post-test (table 4). we hypothesize that these results may have occurred because of the influence of modeling on confidence.32 it has been demonstrated that vicarious experiences, or knowledge gained through observing the experiences of others, can enhance confidence.32 participants in the educational control group may have increased their confidence to complete functional tasks through observation of individuals completing functional tasks in the fifa 11+19 videos. it is plausible that deficits in confidence were present in this sample at the time of testing as previous literature has demonstrated that lack of confidence is often reported as a barrier for return to sport after a sports-related knee injury.33 these results further support the integration of pros into clinical practice. use of the ikdc and koossports may also provide insight into a patient’s confidence levels prior to return to sport. limitations this study is not without limitations. due to the nature of subject recruitment, researchers were unable to test most participants on the day of clearance. participants, particularly those randomized into the performance-based assessment group, could have already been exposed to different stimuli that would represent a sample of experiences from which to answer pro questions. another limitation of this study is the small sample size (n = 20). however, despite the small sample size, given that only 1 participant demonstrated a change value exceeding minimal detectable change values for either pro (ikdc = 6.7-20.5, koos sports = 12.2-7), it is very clear that neither statistical nor clinical significance were likely to be reached for pros even if more subjects had been enrolled. clinical application evaluating health outcomes following rehabilitation is a fundamental component of a clinician’s duties. this study demonstrated that providing a frame of reference for a highly trained athletic population did not significantly alter median pro scores. therefore, among knee patients it is acceptable to complete pros either before or after completing performance-based measures. furthermore, these outcome measures should not be used in substitute and both should be incorporated into clinical practice to provide a holistic approach to rehabilitation after knee injury. patient reported outcome measures may be better suited at the evaluation of symptoms and/or confidence in a patient, while performance-based measures evaluate physical function in a controlled setting. thus, it is important to utilize all forms of health outcome evaluation techniques to provide the best healthcare for our patients. acknowledgements this publication was supported by the national athletic trainers’ association research and education foundation grant number 15mgp002. use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 its contents are the authors’ sole responsibility and do not necessarily represent official national athletic trainers’ association research and education foundation views. the project described was supported by the national center for research resources and the national center for advancing translational sciences, national institutes of health, through grant 8ul1tr000117-02. the content is solely the responsibility of the authors and does not necessarily represent the official views of the nih. references 1. kaplan s. outcome measurement & management. philadelphia, pa: f.a. davis company; 2007. 2. neeb tb, aufdemkampe g, wagener jhd, mastenbroek l. assessing anterior cruciate ligament injuries: the association and differential value of questionnaires, clinical tests, and functional tests. j orthop sports phys ther. 1997;26(6):324-331. https://www.jospt.org/doi/10.2519/jospt.1 997.26.6.324. 3. aalund pk, larsen k, hansen tb, bandholm t. normalized knee-extension strength or legpress power after fast-track total knee arthroplasty: which measure is most closely associated with performance-based and self-reported function? arch phys med rehabil. 2013;94(2):384-390. https://doi.org/10.1016/j.apmr.2012.09.0 31. 4. sernert n, kartus j, koehler k, et al. analysis of subjective, objective, and functional examination tests after anterior cruciate ligament reconstruction: a follow-up of 527 patients. knee surg sports traumatol arthrosc. 1999;7(3):160-165. https://doi.org/10.1007/s001670050141. 5. risberg ma, ekeland a. assessment of functional tests after anterior cruciate ligament surgery. j orthop sports phys ther. 1994;19(4):212-217. https://doi.org/10.2519/jospt.1994.19.4.2 12. 6. reiman m, manske r. functional testing in human performance. human kinetics; 2009. 7. stratford pw, kennedy dm. performance measures were necessary to obtain a complete picture of osteoarthritic patients. j clin epidemiol. 2006;59(2):160-167. https://doi.org/10.1016/j.jclinepi.2005.07. 012. 8. logerstedt d, grindem h, lynch a, et al. single-legged hop tests as predictors of selfreported knee function after anterior cruciate ligament reconstruction: the delaware-oslo acl cohort study. am j sports med. 2012;40(10):2348-2356. https://doi.org/10.1177/0363546512457 551. 9. meadows ka. patient-reported outcome measures: an overview. br j community nurs. 2011;16(3):146-151. https://doi.org/10.12968/bjcn.2011.16.3.1 46. 10. maly mr, costigan pa, olney sj. determinants of self-report outcome measures in people with knee osteoarthritis. arch phys med rehabil. 2006;87(1):96-104. https://doi.org/10.1016/j.apmr.2005.08.1 10. 11. mizner rl, petterson sc, clements ke, zeni ja, jr., irrgang jj, snyder-mackler l. measuring functional improvement after total knee arthroplasty requires both performance-based and patient-report assessments: a longitudinal analysis of outcomes. j arthroplasty. 2011;26(5):728737. https://dx.doi.org/10.1016%2fj.arth.2010. 06.004. 12. noyes fr, barber sd, mooar la. a rationale for assessing sports activity levels and limitations in knee disorders. clini orthop relat res. 1989(246):238-249. https://www.jospt.org/doi/10.2519/jospt.1997.26.6.324 https://www.jospt.org/doi/10.2519/jospt.1997.26.6.324 https://doi.org/10.1016/j.apmr.2012.09.031 https://doi.org/10.1016/j.apmr.2012.09.031 https://doi.org/10.1007/s001670050141 https://doi.org/10.2519/jospt.1994.19.4.212 https://doi.org/10.2519/jospt.1994.19.4.212 https://doi.org/10.1016/j.jclinepi.2005.07.012 https://doi.org/10.1016/j.jclinepi.2005.07.012 https://doi.org/10.1177/0363546512457551 https://doi.org/10.1177/0363546512457551 https://doi.org/10.12968/bjcn.2011.16.3.146 https://doi.org/10.12968/bjcn.2011.16.3.146 https://doi.org/10.1016/j.apmr.2005.08.110 https://doi.org/10.1016/j.apmr.2005.08.110 https://dx.doi.org/10.1016%2fj.arth.2010.06.004 https://dx.doi.org/10.1016%2fj.arth.2010.06.004 use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 13. logerstedt d, di stasi s, grindem h, et al. self-reported knee function can identify athletes who fail return-to-activity criteria up to 1 year after anterior cruciate ligament reconstruction: a delaware-oslo acl cohort study. j orthop sports phys ther. 2014;44(12):914-923. https://doi.org/10.2519/jospt.2014.4852. 14. fitzgerald gk, axe mj, snyder-mackler l. a decision-making scheme for returning patients to high-level activity with nonoperative treatment after anterior cruciate ligament rupture. knee surg sports traumatol arthrosc. 2000;8(2):76-82. https://doi.org/10.1007/s001670050190. 15. howard js, mattacola cg, mullineaux dr, english ra, lattermann c. influence of response shift on early patient-reported outcomes following autologous chondrocyte implantation. knee surg sports traumatol arthrosc. 2014;22(9):2163-2171. https://doi.org/10.1007/s00167-0132654-1. 16. balain b, ennis o, kanes g, et al. response shift in self-reported functional scores after knee microfracture for full thickness cartilage lesions. osteoarthritis cartilage. 2009;17(8):1009-1013. https://doi.org/10.1016/j.joca.2009.02.00 7. 17. schwartz ce, sprangers ma. methodological approaches for assessing response shift in longitudinal health-related quality-of-life research. social sci med. (1982). 1999;48(11):1531-1548. https://doi.org/10.1016/s02779536(99)00047-7. 18. sprangers ma, schwartz ce. integrating response shift into health-related quality of life research: a theoretical model. social sci med. (1982). 1999;48(11):1507-1515. https://doi.org/10.1016/s02779536(99)00045-3. 19. soligard t, myklebust g, steffen k, et al. comprehensive warm-up programme to prevent injuries in young female footballers: cluster randomised controlled trial. bmj. 2008;337:a2469. https://doi.org/10.1136/bmj.a2469. 20. tegner y, lysholm j. rating systems in the evaluation of knee ligament injuries. clin orthop relat res. 1985;198:43-49. 21. irrgang jj, anderson af, boland al, et al. development and validation of the international knee documentation committee subjective knee form. am j sports med. 2001;29(5):600-613. https://doi.org/10.1177/0363546501029 0051301. 22. roos em, roos hp, lohmander ls, ekdahl c, beynnon bd. knee injury and osteoarthritis outcome score (koos)-development of a self-administered outcome measure. j orthop sports phys ther. 1998;28(2):88-96. https://doi.org/10.2519/jospt.1998.28.2.8 8. 23. harris pa, taylor r, thielke r, payne j, gonzalez n, conde jg. research electronic data capture (redcap)—a metadata-driven methodology and workflow process for providing translational research informatics support. j biomed inform. 2009;42(2):377381. https://doi.org/10.1016/j.jbi.2008.08.010. 24. owoeye oba, akinbo sra, tella ba, olawale oa. efficacy of the fifa 11+ warm-up programme in male youth football: a cluster randomised controlled trial. j sports sci med. 2014;13(2):321-328. 25. longo ug, loppini m, berton a, marinozzi a, maffulli n, denaro v. the fifa 11+ program is effective in preventing injuries in elite male basketball players: a cluster randomized controlled trial. am j sports med. 2012;40(5):996-1005. https://doi.org/10.1177/0363546512438 761. 26. steffen k, emery ca, romiti m, et al. high adherence to a neuromuscular injury prevention programme (fifa 11+) improves https://doi.org/10.2519/jospt.2014.4852 https://doi.org/10.1007/s001670050190 https://doi.org/10.1007/s00167-013-2654-1 https://doi.org/10.1007/s00167-013-2654-1 https://doi.org/10.1016/j.joca.2009.02.007 https://doi.org/10.1016/j.joca.2009.02.007 https://doi.org/10.1016/s0277-9536(99)00047-7 https://doi.org/10.1016/s0277-9536(99)00047-7 https://doi.org/10.1016/s0277-9536(99)00045-3 https://doi.org/10.1016/s0277-9536(99)00045-3 https://doi.org/10.1136/bmj.a2469 https://doi.org/10.1177/03635465010290051301 https://doi.org/10.1177/03635465010290051301 https://doi.org/10.2519/jospt.1998.28.2.88 https://doi.org/10.2519/jospt.1998.28.2.88 https://doi.org/10.1016/j.jbi.2008.08.010 https://doi.org/10.1177/0363546512438761 https://doi.org/10.1177/0363546512438761 use of response shift to improve agreement between patient-reported and performance-based outcomes in knee patients 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 functional balance and reduces injury risk in canadian youth female football players: a cluster randomised trial. br j sports med. 2013;47(12):794-802. https://doi.org/10.1136/bjsports-2012091886. 27. grooms dr, palmer t, onate ja, myer gd, grindstaff t. soccer-specific warm-up and lower extremity injury rates in collegiate male soccer players. j athl train. 2013;48(6):782-789. https://doi.org/10.4085/1062-605048.4.08. 28. gribble pa, hertel j, plisky p. using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. j athl train. 2012;47(3):339-357. https://doi.org/10.4085/1062-605047.3.08. 29. noyes fr, barber sd, mangine re. abnormal lower limb symmetry determined by function hop tests after anterior cruciate ligament rupture. am j sports med. 1991;19(5):513518. https://doi.org/10.1177/0363546591019 00518. 30. munro ag, herrington lc. between-session reliability of four hop tests and the agility ttest. j strength cond res. 2011;25(5):14701477. https://doi.org/10.1519/jsc.0b013e3181d 83335. 31. loudon jk, wiesner d, goist-foley hl, asjes c, loudon kl. intrarater reliability of functional performance tests for subjects with patellofemoral pain syndrome. j athl train. 2002;37(3):256-261. 32. bandura a. self-efficacy: toward a unifying theory of behavioral change. psychol rev. 1977;84(2):191. https://psycnet.apa.org/doi/10.1037/003 3-295x.84.2.191. 33. burland jp, toonstra j, werner jl, mattacola cg, howell dm, howard js. decision to return to sport after anterior cruciate ligament reconstruction, part i: a qualitative investigation of psychosocial factors. j athl train. 2018;53(5):452-463. https://doi.org/10.4085/1062-6050-31316. https://doi.org/10.1136/bjsports-2012-091886 https://doi.org/10.1136/bjsports-2012-091886 https://doi.org/10.4085/1062-6050-48.4.08 https://doi.org/10.4085/1062-6050-48.4.08 https://doi.org/10.4085/1062-6050-47.3.08 https://doi.org/10.4085/1062-6050-47.3.08 https://doi.org/10.1177/036354659101900518 https://doi.org/10.1177/036354659101900518 https://doi.org/10.1519/jsc.0b013e3181d83335 https://doi.org/10.1519/jsc.0b013e3181d83335 https://psycnet.apa.org/doi/10.1037/0033-295x.84.2.191 https://psycnet.apa.org/doi/10.1037/0033-295x.84.2.191 https://doi.org/10.4085/1062-6050-313-16 https://doi.org/10.4085/1062-6050-313-16 abstract table 2. patient-reported outcome measures pre-test, post-test, and change scores table 3. outcomes of pros change scores and performance-based testing demonstrating mean values and standard deviation (sd), and p-value manuscript type disablement model case study 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 graston technique® combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study raul anaya jr. lat, atc*; kim bacalla, dat, mba, lat, atc†; annette d. monk, dat, lat, atc‡ *lake forest college, lake forest, il, †baptist health south florida, coral gables, fl ‡trinity international university, deerfield, il abstract nonoperative measures have been shown to have positive effects on thumb ulnar collateral ligament (ucl) sprains considered less than complete. this case presents evidence supporting graston technique® (gt) plus therapeutic exercise in order to decrease pain and stiffness in a collegiate football athlete who sustained a grade iii ucl sprain. the results showed that there was a reduction in pain level above the minimal clinically importance difference, and rom improved throughout the three-week intervention. the findings of this case study provide minimal support for an alternative treatment to reduce pain and stiffness in a grade iii ucl sprain, with further research needed. key phrases college and university patient population, patient-reported outcomes, therapeutic exercise correspondence dr. annette monk, 2065 half day road, trinity international university, department of health sciences deerfield, il, 60015 e-mail: admonk@tiu.edu full citation anaya r, bacalla k, monk ad. graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study. clin pract athl train. 2022;5(1): 36-45. https://doi.org/10.31622/2022/0005.01.6. submitted: may 4, 2020 accepted: may 4, 2021. introduction the term skier’s thumb refers to the acute mechanism of injury associated with the ulnar collateral ligament (ucl) of the first metacarpophalangeal (mcp) joint.1,2 the term gamekeeper’s thumb, similar in nature, is characterized by chronic repetitive stresses placed on the same joint.1,2 for this case study, skier’s thumb is a more accurate representation of the injury in question. injury to the thumb mcp joint is considered common in athletics.3 according to a study conducted by werner et al, 63% of isolated ucl sprains examined on a single nfl team required surgical intervention. 3 surgery is a common treatment method for grade iii thumb ucl sprains while non-operative treatment is vastly accepted for grades i and ii.4 yet, a systematic review indicated that there is no consensus regarding surgical indications for thumb ucl injuries.5 a previous investigation of nonoperative intervention for ucl injuries has shown favorable results, including patient satisfaction and grip strength.6 additionally, treatment of canine grade iii ligamentous injury has suggested that conservative treatment with early mobilization has improved tensile strength compared to surgical treatment with immobilization.7 non-surgical conservative treatment of a ucl injury includes a recommended early immobilization of the injured mcp joint followed by therapeutic intervention.8 early immobilization aims to protect the injured joint by restricting motion.9 the duration of immobilization is a fine balance between too long, which may lead to joint stiffness, and too short, which may not allow sufficient healing time.8 although joint protection through immobilization is necessary, motion loss and/or muscle atrophy can occur at its expense.9 suggested immobilization time ranges from 3 to 12 weeks, but the outcomes associated with such extended immobilization are unknown.8,10 the treatment principles which allow motion while concurrently avoiding additional injury are sought after because of its evidenced support in decreasing pain and inflammation throughout the healing process.9 instrument assisted soft tissue mobilization (iastm) has been found to cause physiological changes mailto:admonk@tiu.edu https://doi.org/10.31622/2022/0005.01.6 graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 and acts as an enhancement to the healing process of ligaments via significant increase in proportion of blood vessels and fibroblastic activity.11-13 it has also been shown to improve collagen formation in injured ligaments of rodent models.13 the current case study specifically addresses the proliferative phase of healing, where collagen formation occurs. at approximately 3 days following an injury, injured soft tissue begins to repair and regenerate and continues over the next 3 to 6 weeks.14 over several weeks, angiogenesis, fibroplasia, generation of new epithelial tissue and wound contraction occur, as the damaged cells at the site of injury are replaced with scar tissue.14 as the new collagen tissue matrix is forming, the new blood supply is supporting the tissue with nutrients, resulting in the formation of a vascularized bulk of immature connective tissue.14 the developing tissue includes type i and type iii collagen; type iii being especially significant because of its power to form cross-links that provide stabilization to the healing tissue.14 instrument assisted soft tissue mobilization can be considered controlled local microtrauma, causing local inflammation in the tissue in an effort to support the healing process. multiple treatments of iastm have been shown to increase tissue perfusion when initiated one week following injury of a ligament.12 additionally, iastm combined with rehabilitation exercises has been suggested as an alternative to surgical intervention.12,13 the graston technique ® (gt) is a form of iastm and is widely used across medical rehabilitation professions such as athletic training, physical therapy, and occupational therapy. the graston technique® uses stainless steel instruments specifically designed to apply controlled forces to muscles, tendons, and ligaments of the body.12,13 the aim of completing gt and therapeutic exercise in the current case study was to improve the limitations reported in a grade iii thumb ucl sprain. patient information the patient was an 18-year-old male naia collegiate football athlete who presented to the athletic training facility with pain and swelling in his right thumb. mechanism of injury (moi): the patient reached across his body to deflect an incoming pass, the football hit his open palm and hyper-abducted his first mcp joint of the right hand. otherwise, the patient was considered healthy and free from injury. the uniqueness of this case has two parts. the first aspect of uniqueness is that the injury sustained was diagnosed as a grade iii sprain, and surgery was not recommended by the referred hand specialist. conservative rehabilitation for the injury immediately began and continued during the three weeks prior to seeing the hand specialist. upon evaluation, the specialist recommended that all treatment be ceased, and the patient be placed in a thumb spica splint throughout the day and allowed to return to sport. a removable hard cast was provided for practice and game competition. the second portion of uniqueness concerns the treatment provided in this case study, as the use of gt combined conservative rehabilitation for treatment of a grade iii thumb ucl sprain is the first report to our knowledge. differential diagnosis and evaluation the patient was initially evaluated the same day of injury by the athletic training staff, which included the head athletic trainer and athletic training student. upon inspection of the hand there was moderate swelling and mild bruising along the thenar eminence and point tenderness in the first mcp joint. there were no symptoms of numbness or tingling and no obvious deformities noted. the patient had no previous history of hand injuries. the patient reported that his thumb felt “stiff and as if it was throbbing.” a decrease in flexion, extension, and abduction due to pain was graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 observed of the patient’s active range of motion (arom). the assessment of passive range of motion (prom) showed a decrease in flexion and abduction. the strength deficits that were observed in grip, flexion, extension, abduction and adduction were observed and confirmed through subjective bilateral comparison. manual muscle tests (mmts) were attempted but unable to be completed due to pain. joint laxity was discovered through a valgus stress test of the first metacarpophalangeal joint. special tests exhibited negative results in tap/percussion test, tuning fork, and varus stress test. the patient was believed to have sustained a moderate to severe sprain of the ucl in the first mcp joint. the patient was placed in a wrist and thumb soft splint for immobilization for approximately 5 days until he was able to see the team physician. no rehabilitation took place during this time, other than the application of cold modalities via ice tub or ice bag. the recommendation to the patient was that the splint was only removed when necessary (i.e., showers and therapeutic treatment) but otherwise worn day and night. the patient was referred to the team physician who confirmed the findings of the athletic trainer and athletic training student. the team physician recommended that the patient continue with splinting and provided a referral to a hand specialist. the patient continued to wear the soft thumb splint until his appointment with the hand specialist. sport participation had ceased since the time of initial evaluation by the athletic trainer. non-steroidal anti-inflammatory drugs (ibuprofen) was suggested on an asneeded basis for pain. during this time, there were no restrictions noted by the team physician for controlled rehabilitation of the hand. body structure and function the patient identified as right hand dominant and reported limitation in activities of daily living (adls), social leisure, and sport participation. the patient reported severe difficulty turning doorknobs, opening jars, writing, gripping a toothbrush, lifting weights, gripping a video game controller, shaking someone’s hand, and catching a football. the impact of the injury on the patient is illustrated using the international classification of functioning, disability and health (icf) disablement model15 in figure 1. activity and participation the athletic training staff, team physician, and patient agreed that the patient would not engage in football practice until evaluated and cleared by the orthopedic hand specialist. additionally, the patient was not participating in any other physical activity involving the use of his right hand. however, the patient was able to continue cardiovascular exercise in the athletic training facility and allowed to participate in conditioning with his team. at school, he reported and inability to write legibly and effectively type notes on his computer without restriction or pain. the patient explained on multiple occasions that he did not feel as if he could function properly in everyday life because anything involving his right hand was limited. socially, there were moments where the patient felt excluded from leisure activities because he could not participate with his friends. during rehabilitation, the athletic training staff would ask about the patient’s life outside of football. he admitted there were moments he felt dispirited while hanging with friends because it often revolved around playing videogames. given the injury to his thumb, holding a console controller was difficult. the athletic training staff saw the importance of treating the whole person and assisted the patient with psychosocial coping strategies of conversation and positive affirmation. the athletic training staff and patient began to use daily tasks/results as an opportunity to help discover and appreciate the small victories of rehabilitation (i.e., decrease in pain, stiffness). graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 figure 1: disablement model: impact of injury health condition: right thumb grade iii ucl sprain body function & structure: throbbing pain, swelling, stiffness weakness uncomfortable during sleep grip weakness decreased arom & prom participation: limited in videogaming limited sport participation activities: limiting adls difficulty writing, grabbing, lifting pushing doors, turning door knobs, opening tight jars, brushing teeth, holding groceries, preparing food, etc. environmental & personal factors environmental: school duties pressure from coaches/teammates feeling of abandonment from coaches and teammates personal: lack of motivation age (maturity) positive attitude turn around obliging to social norms (i.e. opening doors for others) graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 environmental and personal factors regarding psychosocial considerations of the injury, the patient had reported that he felt indirect pressure and feelings of abandonment from his coaches and teammates because he could no longer actively participate in practices or games. there was a lack of motivation because he felt his worth was dependent on football. since the patient was without football and was limited in daily activities, he was hesitant to begin rehabilitation. after completing one full week of treatment, the patient’s perceived pain improved. these results gave the patient hope, as he reported that he felt more motivated to continue the process and work hard in rehabilitation. this psychosocial finding was similar to a systematic review which noted that patient compliance may improve with decreased pain achieved through iastm.16 the patient began to slowly participate in everyday activities and noted feeling less extrinsic pressures. intervention the treatment for the first week included immobilization and cryotherapy to manage pain and swelling until he was seen by the team physician. once evaluated by the team physician, the patient was allowed to begin conservative hand therapy until he was seen by the hand specialist, approximately three weeks later. duri ng this time, the patient reported to the athletic training facility five days per week. the intervention included gt and therapeutic interventions to address rom and strength deficits. the graston technique® was selected as an intervention based on previous work which demonstrated improved range of motion of the thumb after eight sessions of combined gt and active release therapy during immobilization.17 in the current case, gt was administered by two providers certified in gt (head athletic trainer and athletic training student) two times per week with at least 48 hours in between application, and therapeutic exercise was performed at every appointment. this method of combining daily exercise with gt twice per week is consistent with a previous reported case of subacute lumbar injury.18 the graston technique® requires the treatment area be heated with either a modality or with a warm-up of the soft tissue before application of the technique, followed by treatment with therapeutic exercises after treatment.19 for this treatment, the patient performed 10 minutes of heating (paraffin bath: in an extended position, his hand was dipped 7 times with a 3 second hold in wax before the next dip) prior to gt. the intervention was administered for 10 minutes, using the gt2 and gt6 instruments. the treatment time selected is consistent with previous work where gt was applied to an acute ankle injury for 10 minutes.20 there are several strokes that require distinctive techniques; in the present case, brushing and scooping were the two strokes that were used. brushing requires a brush stroke motion up and down, similar to the stroke of painting. scooping requires a motion in a ushaped pattern, similar to scooping ice cream. following gt, therapeutic exercises were instructed and performed. the patient began with soft putty for 10 minutes (hand motions included pinching, squeezing, pulling, rolling, and smashing) in order to restore abductor pollicis longus, abductor pollicis brevis, and flexor pollicis brevis strength, followed by an additional 15 minutes of wrist and hand strengthening exercises (grip, finger flexion, finger extension, wrist flexion, wrist extension, ulnar deviation, and radial deviation). the same exercises were completed on days when gt was not performed in order to continue strengthening the wrist and hand. graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 approximately three weeks after seeing the team physician and completing the intervention of gt and therapeutic exercise, the patient was evaluated by the hand specialist who determined that the soft thumb splint was not rigid enough for immobilization during adl’s. the recommended plan of care was that the patient continuously wears a rigid splint for immobilization and rehabilitation should cease. the specialist created a different rigid removable cast for football activities, and the patient was allowed to participate in football activities contingent upon wearing the removeable cast during practice and game competition. outcomes throughout the treatment process, the chief complaints were pain and stiffness of the right thumb. the patient’s pain was monitored using the numeric pain rating scale (nprs).21,22 the tool has been found valid (r = 0.94, 95% ci = 0.93-0.95) in assessing acute pain.23 the rating of stiffness, although subjective in nature, was attempted to be captured through rom testing. given the patient’s concerns with his ability to function, the outcome measure of quick disabilities of arm, shoulder, and hand (quickdash) was completed by the patient. the quickdash is an assessment tool used to measure functional ability and symptoms in individuals with any musculoskeletal disorder of the upper extremity.24 no other patient-reported outcome measures were used by the athletic training staff. nprs: pain was measured weekly using the nprs. the patient was asked to rate his current, best, and worse state of pain within a 24-hour period on a scale from 0 (no pain) to 10 (worst pain imaginable). the three numbers were added together, and an average was calculated (sum of pain rating divided by number of ratings).21,22 for example, in the initial evaluation the patient reported a current pain rating of 6, best pain rating of 0, and a worse pain rating of 8 within a 24-hour period; 6 + 0 + 8 divided by 3 = 4.67 average. the nprs categorizes pain as either mild (score of 1-4), moderate (5-6), or severe (710).25 previous work has demonstrated that the minimal clinically importance difference (mcid) is a reduction of one point.26 during the first week of intervention the patient’s nprs score was 4.67, and week two’s average was 2.67. during the third week of the intervention the nprs score was 1.33, which remained unchanged the following week when the therapeutic intervention was discontinued per the hand specialist’s recommendation. rom: range of motion measurements during the 3-week gt and therapeutic intervention period are displayed in table 1. flexion measurements were taken using three landmarks: distal arm was positioned dorsal midline of proximal phalanx, center point was positioned dorsal aspect of mcp, and proximal arm was positioned dorsal midline of metacarpal. abduction measurements were taken using 3 landmarks: distal arm was positioned lateral midline of first metacarpal, center point was positioned lateral aspect of radial styloid, and proximal arm was positioned lateral midline of second metacarpal. thumb opposition was assessed through visual observation by the athletic training staff. the tip of the thumb was observed attempting to touch the mcp joint on the palmar side of the involved hand. during the initial week of treatment, the patient was unable to complete thumb opposition to his 4th and 5th mcp joints. at table 1: weekly rom measurements of patient’s right thumb rom week 1 week 2 week 3 flexion 35° 40° 46° abduction 50° 55° 58° *opposition (visual) able 2-3 able 2-4 able 2-5 *ability to successfully complete opposition to mcp joint of digits 2-5. graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 the conclusion of week three, the patient could successfully complete opposition by touching his thumb to mcp joint. measurements were not completed following the cessation of gt and therapeutic exercise. although, it is important to note that the patient reported an increase in stiffness within the weeks following cessation of therapeutic intervention. quick dash: this assessment was used to assess the patient’s ability to perform adls and sport specific activities. the quickdash consists of 11 items of adl and 4 items in each of the optional work or sports/performing arts modules. each item is rated on a scale from 1 (no difficulty) to 5 (unable), and the overall scoring ranges from 0 (no disability) to 100 (most severe disability).24 the patient first completed the quickdash with sport module upon initial evaluation with the athletic training staff. the work module portion of the quick dash was not included because the patient was not employed. the outcome measure was completed every 1 to 2 weeks. prior to the intervention of gt and therapeutic exercise the patient scored 50/100 in adls and 75/100 in the sport module. overall scores decreased throughout the intervention and continued to decrease after the intervention was halted. by the end of week 7, the patient scored 0/100 in both adl and the sport module. discussion medical providers share a desire to help improve the quality of life of individuals in need. the option of conservative intervention is increasing as patients consider the factors which play a role in deciding surgical versus nonsurgical interventions. there are various reasons one might choose conservative treatment over surgery. these reasons include, but are not limited to, financial stability, health insurance coverage, mental fears/adaptations, physical risks, and loss of time of work/sport. additionally, similar outcomes have been reported when examining conservative versus surgical treatment of both partial and full thickness ligamentous tears.12 the current case study provides an example of a potential beneficial nonoperative treatment option that warrants further exploration. specifically, the results of the treatment option of gt combined with therapeutic exercise suggest an effectiveness in decreasing the patient’s perceived pain and stiffness following a grade iii thumb ucl sprain. historically, chief complaints of a grade iii thumb ucl sprain are pain, decreased rom, and instability.27 it should be noted that instability was not a symptom reported by the patient in the current case. the graston technique® combined with therapeutic exercise was chosen as the treatment of choice in this case study to address both pain and stiffness. the results of this case study suggest an improvement of two of the three common chief complaints, both pain and rom. our findings showed that there was a reduction in pain level each week above the minimal clinically importance difference. additionally, rom improved each week, and opposition was restored to normal after the threeweek intervention. it should be noted that in addition to the gt and therapeutic exercise, the patient was instructed to wear a soft splint continuously, which may have been a factor in the outcomes. it is speculated splinting would decrease pain by protecting the joint from further disruption. interestingly, the primary reason for immobilizing acute soft-tissue injuries was for pain relief, while loss of motion was cited as the main reason to not immobilize, according to more than two-thirds of physicians polled.9 it is speculated that since gt and supervised therapeutic exercise was being completed once a day, rom was able to be improved despite immobilization. our findings are consistent with a previous literature review which reported that iastm decreases pain as well as improves range of motion in acute injuries.28 it is theorized that the ability of iastm to assist in healing of ligamentous injury is graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 due to its effects on collagen, including maturation and remodeling, through localized blood flow.12,13,29 scar tissue is thought to impede mobility and therefore oxygen supply to the injured area.28 through the controlled repetitive microtrauma elicited by gt, a reinitiating of the inflammatory process may have led to enhanced tissue perfusion,12 which in turn allowed for fibroblastic proliferation.28 tissue perfusion followed directly with therapeutic exercise may have played a role in the ability of the joint to reach improved rom. this may be a reason why it is recommended that stretching and strengthening exercises are recommended to immediately follow the application of gt.19 the results established from the quickdash presented noteworthy information. the patient reported an initial 50-75% disability to 0% in the adl and sport module, respectively, over a period of six weeks. we suggest two main reasons why there was such a dramatic change in scores. one theory is that the treatment decreased pain, which allowed him to participate in more activities, aiding in an improved level of physical function. it was evident that pain was diminishing throughout the intervention; however, when treatment was terminated the level of disability continued to drop. it is possible that the patient felt less disabled due to the allowance of sport participation by the hand specialist, which would explain the continued improvement in scores after the intervention was terminated. although there were promising scores in disability index, rom, and pain ratings in favor of gt and therapeutic exercise, there are limitations that need to be addressed. first, it would have been helpful to continue measuring rom once the intervention ceased to determine if the initial improvements were temporary. the authors acknowledge that the termination of the intervention may have played a role in the overall healing process, and the hand specialist’s judgement to cease treatment is unknown to have helped or hindered the outcome measures. the goniometric assessment could have also been measured by a second clinician to assist in accuracy – intra-rater reliability may have played a role in this case. additionally, a second measurement tool besides rom could have been used to assess the patient report of stiffness. lastly, the addition of a psychosocial patientrated outcome measure may have been helpful in indicating a reason for the decrease in disability score. it is believed that multiple extrinsic and intrinsic factors may have played a key role in the improvements seen, and future investigations should consider adding a psychosocial outcome measure when the quickdash is used. clinical bottom line the findings suggested in this case study demonstrate that gt combined with therapeutic exercise and soft splinting may be beneficial to patient-reported limitations of a grade iii thumb ucl sprain. this case study found that there were improvements in pain and rom of the affected joint during a three-week intervention. future research should investigate the effectiveness of initiating gt and therapeutic exercise at various time points of immobilization of thumb ucl sprains. acknowledgments i would like to acknowledge and thank the sports medicine team at trinity international university. thank you, dr. julia bruene, for your contribution and professional insights. i am immensely grateful for the astounding guidance and mentorship from ms. kim bacalla. thank you, ms. annette monk and dr. ryan wilkinson, for your endless support and outstanding guidance in writing this case study. references 1. campbell a, awan hm. thumb ulnar collateral ligament injuries (gamekeeper’s graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 and skier’s thumb). orthop surg clerkship. 2017:173-174. https://doi.org/10.1007/978-3-31952567-9_39. 2. ritting aw, baldwin pc, rodner cm. ulnar collateral ligament injury of the thumb metacarpophalangeal joint. clin j sports med. 2010;20(2):106-112. https://doi.org/10.1097/jsm.0b013e3181d 23710. 3. lane lb. acute grade iii ulnar collateral ligament ruptures: a new surgical and rehabilitation protocol. am j sports med. 1991;19(3):234-238. https://doi.org/10.1177/0363546591019 00305. 4. avery dm, 3rd, inkellis er, carlson mg. thumb collateral ligament injuries in the athlete. curr rev musculoskelet med. 2017;10(1):28-37. https://doi.org/10.1007/s12178-0179381-z. 5. samora jb, harris jd, griesser mj, ruff me, awan hm. outcomes after injury to the thumb ulnar collateral ligament—a systematic review. clin j sports med. 2013;23(4):247-254. https://doi.org/10.1097/jsm.0b013e31828 9c6ff. 6. kuz je, husband jb, tokar n, mcpherson sa. outcome of avulsion fractures of the ulnar base of the proximal phalanx of the thumb treated nonsurgically. j hand surg am. 1999;24(2):275-282. https://doi.org/10.1053/jhsu.1999.0275. 7. inoue m, woo sl, gomez m, amiel d, ohland k, kitabayashi l. effects of surgical treatment and immobilization on the healing of the medial collateral ligament: a longterm multidisciplinary study. connect tissue res. 1990;25(1):13-26. https://doi.org/10.3109/0300820900900 9809. 8. patel s, potty a, taylor ej, sorene ed. collateral ligament injuries of the metacarpophalangeal joint of the thumb: a treatment algorithm. strategies trauma limb reconstr. 2010;5(1):1-10. https://dx.doi.org/10.1007%2fs11751010-0079-7. 9. sommerfeldt m, bouliane m, otto d, rowe bh, beaupre l. the use of early immobilization in the management of acute soft-tissue injuries of the knee: results of a survey of emergency physicians, sports medicine physicians and orthopedic surgeons. can j surg. 2015;58(1):48. https://doi.org/10.1503/cjs.004014. 10. landsman jc, seitz wh, froimson ai, leb rb, bacher ej. splint immobilization of gamekeeper's thumb. orthopedics. 1995;18(12):1161-1165. https://doi.org/10.3928/0147-744719951201-06 11. kim j, sung dj, lee j. therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. j exerc rehabil. 2017;13(1):12. https://dx.doi.org/10.12965%2fjer.17328 24.412. 12. loghmani mt. the effects of instrumentassisted cross fiber massage on ligament healing [doctoral dissertation]. indiana university purdue university of indiana. 2010. http://dx.doi.org/10.7912/c2/2091. 13. loghmani mt, warden sj. instrumentassisted cross-fiber massage accelerates knee ligament healing. j orthop sports phys ther. 2009;39(7):506-514. https://doi.org/10.2519/jospt.2009.2997. 14. anderson m. foundations of athletic training: prevention, assessment, and management. vol 6th. philadelphia: wolters kluwer; 2017. 15. sitzler b. icf model: a framework for athletic training practice. national athletic trainer's association. https://www.nata.org/blog/beth-sitzler/icfmodel-framework-athletic-training-practice. published 2016. accessed december 28, 2020. 16. seffrin cb, cattano nm, reed ma, gardiner-shires am. instrument-assisted soft tissue mobilization: a systematic review and effect-size analysis. j athl train. 2019;54(7):808-821. https://doi.org/10.4085/1062-6050-48117. 17. howitt s, wong j, zabukovec s. the conservative treatment of trigger thumb using graston techniques and active release techniques®. j can chiropr assoc. 2006;50(4):249. https://doi.org/10.1007/978-3-319-52567-9_39 https://doi.org/10.1007/978-3-319-52567-9_39 https://doi.org/10.1097/jsm.0b013e3181d23710 https://doi.org/10.1097/jsm.0b013e3181d23710 https://doi.org/10.1177/036354659101900305 https://doi.org/10.1177/036354659101900305 https://doi.org/10.1007/s12178-017-9381-z https://doi.org/10.1007/s12178-017-9381-z https://doi.org/10.1097/jsm.0b013e318289c6ff https://doi.org/10.1097/jsm.0b013e318289c6ff https://doi.org/10.1053/jhsu.1999.0275 https://doi.org/10.3109/03008209009009809 https://doi.org/10.3109/03008209009009809 https://dx.doi.org/10.1007%2fs11751-010-0079-7 https://dx.doi.org/10.1007%2fs11751-010-0079-7 https://doi.org/10.1503/cjs.004014 https://doi.org/10.3928/0147-7447-19951201-06 https://doi.org/10.3928/0147-7447-19951201-06 https://dx.doi.org/10.12965%2fjer.1732824.412 https://dx.doi.org/10.12965%2fjer.1732824.412 http://dx.doi.org/10.7912/c2/2091 https://doi.org/10.2519/jospt.2009.2997 https://www.nata.org/blog/beth-sitzler/icf-model-framework-athletic-training-practice https://www.nata.org/blog/beth-sitzler/icf-model-framework-athletic-training-practice https://doi.org/10.4085/1062-6050-481-17 https://doi.org/10.4085/1062-6050-481-17 graston technique combined with therapeutic intervention as an alternative treatment for a grade iii ucl thumb sprain: a disablement model case study 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 18. hammer wi, pfefer mt. treatment of a case of subacute lumbar compartment syndrome using the graston technique. j manipulative physiol ther. 2005;28(3):199-204. https://doi.org/10.1016/j.jmpt.2005.02.01 0. 19. stow r. instrument-assisted soft tissue mobilization. int j sports phys ther. 2011;16(3):5-8. 20. thaman n. effect of graston technique on edema following a sprain to the lateral ankle ligaments [master’s thesis]. department of kinesiology indiana university; 2016. https://hdl.handle.net/2022/20916. 21. the numeric pain rating scale instructions. https://www.sralab.org/sites/default/files/ 201707/numeric%20pain%20rating%20scale% 20instructions.pdf. accessed march 3, 2020. 22. mccaffery m, beebe a. the numeric pain rating scale instructions. in: pain: clinic manual for nursing practice. mosby, st. louis; 1989. 23. bijur pe, latimer ct, gallagher ej. validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. acad emerg med. 2003;10(4):390-392. https://doi.org/10.1111/j.15532712.2003.tb01355.x. 24. beaton de, wright jg, katz jn. development of the quickdash: comparison of three item-reduction approaches. j bone joint surg am. 2005;87(5):1038-1046. https://doi.org/10.2106/jbjs.d.02060. 25. jensen mp. hypnosis for chronic pain management: therapist guide. oxford university press; 2011. 26. salaffi f, stancati a, silvestri ca, ciapetti a, grassi w. minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. eur j pain. 2004;8(4):283-291. https://doi.org/10.1016/j.ejpain.2003.09.0 04. 27. werner bc, belkin ns, kennelly s, et al. injuries to the collateral ligaments of the metacarpophalangeal joint of the thumb, including simultaneous combined thumb ulnar and radial collateral ligament injuries, in national football league athletes. am j sports med. 2017;45(1):195-200. https://doi.org/10.1177/0363546516660 979. 28. bitra m, sudhan s. instrument assisted soft tissue mobilisation in the management of musculoskeletal pain: a literature review with implications for clinical practice guidelines. j clin diagn res. 2019;13(12). http://dx.doi.org/10.7860/jcdr/2019/42 687.13356. 29. garrett tr, neibert pj. graston technique® as a treatment for patients with chronic plantar heel pain. clin prac athl train. 2019;2(3):35-47. https://doi.org/10.31622/2019/0003.4. https://doi.org/10.1016/j.jmpt.2005.02.010 https://doi.org/10.1016/j.jmpt.2005.02.010 https://hdl.handle.net/2022/20916 https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://doi.org/10.1111/j.1553-2712.2003.tb01355.x https://doi.org/10.1111/j.1553-2712.2003.tb01355.x https://doi.org/10.2106/jbjs.d.02060 https://doi.org/10.1016/j.ejpain.2003.09.004 https://doi.org/10.1016/j.ejpain.2003.09.004 https://doi.org/10.1177/0363546516660979 https://doi.org/10.1177/0363546516660979 http://dx.doi.org/10.7860/jcdr/2019/42687.13356 http://dx.doi.org/10.7860/jcdr/2019/42687.13356 https://doi.org/10.31622/2019/0003.4 abstract manuscript type editorial 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 rethinking quality improvement in athletic health care matthew j. rivera, dat, lat, atc & kenneth e. games, phd, lat, atc indiana state university, terre haute, in key phrases continuous improvement, systems-level, individual process improvement correspondence dr. matthew rivera, indiana state university, 567 n. 5th street, terre haute, in 47809. email: matthew.rivera@indstate.edu twitter: @matt_riveradat full citation rivera mj & games ke. rethinking quality improvement in athletic health care. clin pract athl train. 2020;3(2): 3-5. https://doi.org/10.31622/2020/0002.2. editorial the concept of continuous quality improvement (cqi) has gained more recognition within the profession of athletic training in recent years. with the new transition into the professional-level master’s degree and the commission on accreditation of athletic training education standards related to quality assurance in health care, it is no surprise that we are starting to talk about cqi more seriously. the purpose of this editorial is to speak frankly to our audience about how potentially unattainable large-scale, systems-level cqi is for an individual athletic trainer. from a behavioral change perspective, we are asking athletic trainers to equivocally overtake a mountain with no training. our goal is to make cqi achievable for each athletic trainer in their own system, on their own terms. some may question this philosophy, but because we are relative infants in this world of quality improvement, we propose an alternative. forms of cqi can vary, which may cause confusion, especially since formal training has been omitted in athletic training education to this point. currently, a majority of the literature that exists in athletic training that focuses on cqi involves broad-level, large systems process improvement. here, practicing athletic trainers serve to enter data into large databases such as the athletic training practice-based research network (atpbrn); high school reporting information online (high school rio), national athletic treatment, injury, and outcomes network (nation); or ncaa injury surveillance program. this evidence and information is meaningful and informs clinical practice in a way that can help us align our practice with best evidence. but, this asks athletic trainers not to reflect on their own practice or system, but to enter data to inform the larger profession. meaningful, but not the fuel necessary to create change within their own practice. there is a need for athletic trainers to share their experiences and data that they gather both in individual and systems level cqi processes. by sharing these experiences through dissemination, other athletic trainers can become aware of these individual cqi processes and improve their own practice. this identification and initial process improvement at the individual level is what will aid in athletic trainers becoming involved in process improvement within their organization at a system-level (figure 1). imagine an athletic trainer at a secondary school performs a small scale improvement project with a specific patient panel that they provide care for. they implement incremental change and track outcomes to make data driven decisions on the improvement project. this athletic trainer can then share their findings with another athletic trainer at the secondary school or at a similar school within the same system (e.g. healthcare system). they collaborate to expand the project. this shared project can then continue to grow between schools and eventually become a mailto:matthew.rivera@indstate.edu https://doi.org/10.31622/2020/0002.2 rethinking quality improvement in athletic health care 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 project that is implemented within the whole system. this is the eventual goal of cqi on the system-level. however, these progressive steps remain grounded in individual action. systems-based evaluation of clinical outcomes is the pinnacle of cqi, but there are many different frameworks, theories, or approaches to cqi in health care, most of which require action down to an individual level. regardless of the patient care or process that is the target for improvement, individual actions will lead to overall, sustainable change within the system. it is these individual actions that can build upon one another, spread across multiple providers that can lead to larger process improvement and larger change. this initiation of cqi at an individual level can fuel the momentum into larger systems-level change. there are many different cqi practices that athletic trainers can begin to implement on either an individual or systems-level. we have summarized a small portion of these in table 1 to help begin to expose athletic trainers to these methods. of particular interest within athletic training is the practice of checklist or standard work. by creating tools such as checklists for the processes within an athletic training clinic individual athletic trainers can help mitigate errors or make requirements explicit can help ensure quality of care. further, by standardizing the processes or the work in individual clinics athletic trainers can ensure that work is done in a consistent way, leading to improvements in care. with the addition of quality assurance in the caate standards as well as the push for cqi in health care it is important we continue to disseminate the findings of athletic trainers from various settings using various cqi methodologies. therefore we are excited to announce the expansion of our quality improvement section to include more methods than the model of improvement (plan, do, study, and act (pdsa) cycle) to include various cqi methodologies examining improvements in practice. readers can find the new expanded section at our manuscript guidelines. we encourage authors to consider submitting their work in cqi for consideration for publication to continue to disseminate their experiences and help other athletic trainers learn and engage with improvement measures. figure 1. translation of individual pda cycles to systems-level approach http://clinat.indstate.edu/index.php/clinat/qi http://clinat.indstate.edu/index.php/clinat/qi rethinking quality improvement in athletic health care 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 2 – june 2020 table 1. continuous quality improvement practices tool brief description and when to use affinity diagram1 affinity diagrams are the organized output of brainstorming with a group of individuals. affinity diagrams can be used when: • a problem must be solved at all costs • an easy solution is not found • time is needed to analyze the problem • participation of individuals promotes mutual understanding waste reduction2 waste reduction is a strategy to improve the function of a system by eliminating waste. common examples of where waste can be found include overproduction (e.g. unnecessary referrals), waiting, unnecessary processing, staff movement, defects, transportation, and inventory. checklist3 the idea of a checklist is a simple tool. critical quality control steps are sometimes overlooked without checklists. many healthcare functions benefit from the use of checklists which makes explicit the requirements for quality. a good checklist assures that the work has been done correctly and completely. standard work4 good quality requires that work be done in a consistent way. interventions to develop a better way will only have an impact on practice if the new practice results in change that is consistent and reliably implemented. standard work is a written description which is communicated and followed by all staff involved in a specific process. references 1. lepley, cj. problem-solving tools for analyzing system problems: the affinity map and relationship diagram. j nurs admin. 28(12). 1998. 44-50. https://doi.org/10.1097/00005110199812000-00014. 2. berwick, dm & hackbarth, ad. elimiting waste in us health care. jama. 2012;307(25):1513-1516. https://doi.org/10.1001/jama.2012.362 . 3. thomassen et al. implementation of checklists in health care; learning from high-reliability organisations. scand j trauma resusc, emerg med. 2011;53(19). https://doi.org/10.1186/1757-7241-1953. 4. ng, d et al. applying the lean principles of the toyota production system to reduce wait times in the emergency department. cjem. 2010;12(1):50-57. https://doi.org/10.1017/s14818035000 12021. https://doi.org/10.1097/00005110-199812000-00014 https://doi.org/10.1097/00005110-199812000-00014 https://doi.org/10.1001/jama.2012.362 https://doi.org/10.1001/jama.2012.362 https://doi.org/10.1186/1757-7241-19-53 https://doi.org/10.1186/1757-7241-19-53 https://doi.org/10.1017/s1481803500012021 https://doi.org/10.1017/s1481803500012021 manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 translating evidence to practice in athletic training cameron j. powden, phd, lat, atc university of indianapolis, indianapolis, in key phrases evidence-based, literature review, knowledge-translation resources correspondence dr. cameron powden, university of indianapolis, health pavilion, #331, 1643 e hanna ave, indianapolis, in 46227. e-mail: powdenc@uindy.edu twitter: @campowden full citation powden cj. translating evidence to practice in athletic training. clin pract athl train. 2020;3(3): 1-3. https://doi.org/10.31622/2020/0003.3.1. submitted: october 21, 2020 accepted: november 27, 2020 editorial evidence and evidence-based practice (ebp) are buzzwords within the field of athletic training and healthcare. these words may create mixed feelings, as polarizing as politics, for athletic trainers. however, the unifying of these words into the fabric of athletic training has been symbolized with the integration of ebp as a core competency in the 2020 standards for accreditation of professional athletic training programs.1 the framework for ebp is here to stay and it will be a driving force in the growth and recognition of the athletic training profession.2 the incorporation of ebp provides clinicians with the tools needed to search the literature, assess the quality, and integrate their clinical expertise in combination with patient values to interpret the appropriate clinical course of action.3,4 furthermore, ebp can provide the base for quality improvement initiatives within athletic training to formalize the clinical expertise portion of ebp. examples of the benefits of ebp are all around us, signaling the need for all athletic trainers to embrace the practice. the translation of ebp into clinical practice is not an easy one, however. athletic trainers perceive that they lack the knowledge on how to implement ebp into clinical practice.5 even when knowledge of ebp is increased, confidence in implementation methods decrease over time and resulted in the failed adoption of ebp concepts in clinical practice.5 to enhance the integration of the available literature into the clinical decisionmaking process there is a need to understand, breakdown, and overcome the barriers to ebp’s implementation. barriers related to time and the availability of ebp resources have been prevalent within the literature.6 these two barriers are most likely connected as busy clinicians’ feelings that they may not have the physical time to commit to the reading, understanding, and interpretation of complex research articles would only be exacerbated by a lack of access to ebp resources that would reduce the investment needed to complete this process.6 overall, this may signal the need for more processed and refined literature to reduce the perceived barrier of time and act as an approachable gateway into ebp habits.7 systematic reviews and meta-analyses stand as the pinnacle of evidence and attempt to provide a refined view of the knowledge on a given topic. they do this well by completing many steps of the ebp process for a practicing clinician: search of literature, organization of multiple investigations, critical appraisal, and summary of evidence.3,4 as such, systematic reviews have the potential to reduce the time needed to engage with the literature in order to develop the knowledge needed to inform clinical decisions. however, systematic reviews and meta-analyses often present barriers to the clinician as they may feel unapproachable due to complex contextualization of findings, statistical approaches, and a lack of actionable policy recommendations.8 you may be among the many clinicians that have identified a promising review https://doi.org/10.31622/2020/0003.3.1 translating evidence to practice in athletic training 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3 – november 2020 only to realize that there was a lack of clinically relevant and actionable information beyond the conclusion statements. this situation leaves clinicians to press on into a review of other literature for the answers they seek. in turn, the ebp process is lengthened and may leave clinicians frustrated as they fall back on their clinical expertise with the failure of the ebp process. to enhance the uptake of systematic reviews and meta-analyses, there is a need to reduce the barriers and enhance the clinical applicability of findings by enhancing knowledge-translation resources available to clinicians. simplistically, these resources can take on the form of summaries that layout the systematic reviews take-home messages in layman’s terms while adding value by evaluating the quality of the review, assessing the findings’ applicability, and providing recommendations for adoption and translation.9 the evidence-to-practice review (etpr) manuscript type for clinical practice in athletic training provides an innovative format for knowledge-translation. etprs are short and digestible reviews of timely and relevant systematic reviews and meta-analyses with the focus on clinical applicability. the reviews provide a non-threatening, focused, and concise entryway into the evidence for the practicing clinician. additionally, etprs focus on clinical translation of information as they are is designed to give actionable steps and organized resources for continued exploration, ultimately leading to enhancing knowledge and application into clinical practice. the goal of research is to provide information that can directly impact clinical practice and inform practices such as quality improvement and practice-based research. individual research investigations are often nuanced in ways that limit generalizability without the combination of multiple investigations. meanwhile, systematic reviews often lack the detail needed to allow for easy translation and application of summary findings into clinical practice. knowledgetranslation resources, like the etrp, provide a bridge between individual investigations and systematic reviews. etrp can provide summaries of the evidence in combination with specific protocol recommendations and details needed to inform practice-based research and quality improvement initiatives. initiatives that are imperative as the profession of athletic training aims prove that we have fulfilled our social contract with the public of providing safe, effective, and timely health care for our patients.2 i encourage all to engage with knowledgetranslation resources, such as the etpr, and to allow these innovative resources to facilitate the ebp process within their clinical practice. references: 1. commission on accreditation of athletic training education. 2020 standards for accreditation of professional athletic training programs. https://caate.net/wpcontent/uploads/2018/09/2020standards-for-professional-programscopyedited-clean.pdf. accessed october 26, 2020. 2. mckeon po, mckeon jmm, geisler pr. redefining professional knowledge in athletic training: whose knowledge is it anyway? athl train ed j. 2017;12(2):95105. https://doi.org/10.4085/120295. 3. sackett dl, rosenberg wm, gray jm, haynes rb, richardson ws. evidence based medicine: what it is and what it isn't. in: british medical journal publishing group; 1996. 4. steves r, hootman jm. evidence-based medicine: what is it and how does it apply to athletic training? j athl train. 2004;39(1):83. 5. manspeaker sa, hankemeier da. retained knowledge and use of evidence-based practice concepts. athl train ed j. 2018;13(3):239-247. https://doi.org/10.4085/1303239. https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://doi.org/10.4085/120295 https://doi.org/10.4085/1303239 translating evidence to practice in athletic training 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3 – november 2020 6. mccarty cw, hankemeier da, walter jm, newton ej, van lunen bl. use of evidencebased practice among athletic training educators, clinicians, and students, part 2: attitudes, beliefs, accessibility, and barriers. j athl train. 2013;48(3):405-415. https://dx.doi.org/10.4085%2f10626050-48.2.19. 7. welch ce, hankemeier da, wyant al, hays dg, pitney wa, van lunen bl. future directions of evidence-based practice in athletic training: perceived strategies to enhance the use of evidence-based practice. j athl train. 2014;49(2):234-244. https://doi.org/10.4085/1062-605048.2.19. 8. chambers d, wilson pm, thompson ca, hanbury a, farley k, light k. maximizing the impact of systematic reviews in health care decision making: a systematic scoping review of knowledge‐translation resources. the milbank quarterly. 2011;89(1):131-156. https://doi.org/10.1111/j.14680009.2011.00622.x. 9. lavis jn. how can we support the use of systematic reviews in policymaking? plos med. 2009;6(11):e1000141. https://doi.org/10.1371/journal.pmed.100 0141. https://dx.doi.org/10.4085%2f1062-6050-48.2.19 https://dx.doi.org/10.4085%2f1062-6050-48.2.19 https://doi.org/10.4085/1062-6050-48.2.19 https://doi.org/10.4085/1062-6050-48.2.19 https://doi.org/10.1111/j.1468-0009.2011.00622.x https://doi.org/10.1111/j.1468-0009.2011.00622.x https://doi.org/10.1371/journal.pmed.1000141 https://doi.org/10.1371/journal.pmed.1000141 patient-centered care commentary 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 treating the medicare population in a clinic setting alexandria jauregui-dusseau, dhsc, lat, atc; mccall christian, dat, lat, atc missouri state university key phrases clinic and hospital patient population, organization and personal outcomes, comorbidities, geriatric, rehabilitation correspondence dr. alexandria jauregui-dusseau, missouri state university 901 s. national avenue, springfield, mo 65897 email: dus10@missouristate.edu full citation jauregui-dusseau j, christian m. treating the medicare population in a clinic setting. clin pract athl train. 2021;4(3): 28-33. https://doi.org/10.31622/2021/0004.3.5. submitted: october 6, 2020 accepted: september 20, 2021. commentary athletic training started as a profession specific to sports and caring for the health and well-being of athletes within a specific institution. today, athletic trainers serve across the healthcare network in areas such as physician offices, industrial warehouses, tactical settings and performing arts. the profession has continued to expand its scope of training from a role in first aid and emergency care to incorporate comprehensive rehabilitation and prevention, ergonomic evaluations, and assistive roles within an orthopedic surgical setting. the required education needed to obtain certification in the profession has transformed from a secondarylevel teaching credential with preparations in athletic training to now a professional-master’s level education curriculum and many postprofessional doctorate and residency programs across the country.1 the practice and education of athletic training has progressed leading to the transformation in the population the profession treats. as a result, state practice acts are changing to accommodate the expanding patient populations. with a focus in pediatric and active populations, geriatric sectors often are not seen by athletic trainers due to being primarily treated by other rehabilitation specialties. a contributing factor is the lack of reimbursement and recognition in the medicare services sector. as a part of a funded research grant, the research team began collecting both patient-rated and clinician-rated outcome measures on the medicare-eligible population treated by an athletic trainer to understand the effect of athletic training rehabilitative services. patients were categorized based off their chief concern (lower extremity, knee, spine, upper extremity), which dictated the outcome measures that were collected. complete characteristics of the research participants are reported in table 1. the outcome measures were gathered based on developer suggestions for frequency. the intent for this project was to provide data that could facilitate recognition from medicare services. patients who volunteered for this study had no difference in their intended treatment plan, but rather, more intentional outcomes were collected to understand the perspective of their recovery. taking a patient-centered approach at caring for this population was a high priority. the structure of this research has led to a new perspective of what it takes to treat a novel population in the field of athletic training. preparation for the study understanding the needs of the population the medicare-eligible population is a unique population to work with as an athletic trainer in the orthopedic rehabilitation clinic setting. typically, the patient population ranges from seven to sixty years old, and their co-morbidity list is fairly short. the needs are unique, and it has required more preparation and research to mailto:dus10@missouristate.edu https://doi.org/10.31622/2021/0004.3.5 treating the medicare population in a clinic setting 29 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 refresh the understanding of co-morbidities specific to the medicare-eligible population. additionally, these patients have had more experiences in the healthcare system. some of those experiences could have negatively influenced their perception of healthcare providers. for instance, this population is subject to ageism and are treated differently by providers intentionally or unintentionally because of their age. ageism within healthcare is described by ugurlu et al2 as having preconceived notions and prejudices against the elderly population. studies have been conducted in a variety of healthcare disciplines to understand the intention and influences behind an ageist perspective.2,3,4 a study by ben-harush et al.3 found commonalities among a few healthcare professions and the prevalence of ageism.3 healthcare providers do not necessarily intend to treat older patients differently or inadequately, but the presence of implicit bias toward a patient’s age and ineffective communication strategies impact the care provided to this population.2 with this understanding, it was made a priority to treat these patients with the respect that would be given to any other patient, but also to be cognizant of unconscious ageism. it was important to keep the expectations of these patients high and did not let their age affect the goals we set, or they set for themselves. considering common preexisting conditions a significant adjustment to working with the medicare-eligible population was understanding medical diagnoses not familiar to the clinician and how those diagnoses would affect their recovery. co-morbidities prevalent among the aging population were foreign to the treating clinician and are not extensively discussed in athletic training curriculums. patients with progressing parkinson’s disease, hearing loss, osteoarthritis, auto-immune disorders, degenerative joint disease, and malignant cancer diagnoses were now being evaluated and treated by an athletic trainer. another consideration for the clinician was that they were working against decades of learned habits and postures. this required creative thinking and learning how to tailor the treatment approach to meet that patient where they were in terms of mobility and functional ability. most of the patients had some degree of joint degeneration and corresponding range of motion restriction. the immobility and range of motion loss could be attributed to previous history of injuries and surgeries as well as a lack of use of full, end range motion. a priority for many of these patients has been to restore their functional mobility, strength, and overall movement. it was imperative to maintain high expectations for every patient regardless of their functional capacity. there were many situations where patients were reluctant to try an activity, especially getting down and up from the floor or picking items off the ground. although they were active, many were not in the habit of performing these seemingly trivial tasks and were not confident in performing it independently. this was expressed through reporting lower health-related quality of life perceptions and disappointment in their ability to freely move. integrating transitional movements into treatment sessions, such as frequently moving from supine to a standing position, became a goal included in the patient’s treatment plan. another aspect considered when working with this population is how immobility and a lack of independence affected their overall healthrelated quality of life. for example, if a patient is unable to exercise due to pain, functional limitation, or a mechanical restriction, existing comorbidities could be exacerbated or developed from that lack of movement and sedentary lifestyle. several study participants expressed their concern of worsening blood pressure, weight gain, and general mental well-being due to an inability to perform their exercise routine. patient-centered care commentary 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 increasing the patient’s freedom of movement is essential to maintaining overall health and wellbeing throughout the remainder of their lifespan. prior to the clinician’s involvement in this research project, her knowledge of parkinson’s disease was limited. that changed drastically after working with three patients who have been battling this disease for several years. parkinson’s disease presents differently in each patient, and they all managed it in their own way. although they were referred for a musculoskeletal injury, the disease profoundly affected the treatment approach. for instance, the first patient with parkinson’s disease that participated in the study had a significant tremor in the upper extremity and had made the personal decision to not take any medication that would lessen the intensity of the tremor. she became accustomed to working with the tremor and adjusting manual therapy techniques and therapeutic activities. however, even when working with a different patient that was on medication to reduce the severity of their tremors, the daily treatment plan would be affected by when the medication was taken or if was not taken that day. hearing loss is common issue that affects the medicare-eligible population. the therapy area is a large, open workspace with ten clinicians treating patients. this environment can make it difficult to hear when conversing with patients. it is important to pay special attention to communicating effectively and respectfully with patients that suffered from hearing loss. to enhance communication between clinician and the patient, the implementation of strategies such as maintaining eye contact, using concise descriptions, and expanding teaching styles by providing visual and tactile cues and examples. communicating in a respectful way that does not make the patient feel uncomfortable or embarrassed is key to building a strong rapport with the patient and earning their trust. another consideration in treating the geriatric population is exposure to extensive medical histories and chart entries that were unfamiliar. the healthcare provider list is more extensive, and the patient might be undergoing active treatments for co-morbidities. in many cases, the treating clinician had to refresh their knowledge of lesser seen diagnostic and lab outputs. additionally, medication lists for this population are also more intensive and it is important to consider how they affect treatment. for instance, the tissue of a patient that is on blood thinners will react differently to instrument-assisted manual therapy and the provider must pay attention to these skin reactions. interprofessional collaboration was essential when working with these patients, not only to stay updated about evolving issues, but also to provide those providers with information about a patient’s progress and how it ties into their overall health profile. building relationships with referring physicians and other members of the patient’s health care team is a practical table 1. patient demographics variable n % m age 69.6 gender female 49 50 male 49 50 chief concern lower extremitya 37 37.76 knee 22 22.45 upper extremity 34 34.69 back 5 5.10 length of stay (weeks) 13.9 a lower extremity encompassed hip, lower leg, ankle, and foot injuries. treating the medicare population in a clinic setting 31 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 strategy to familiarize oneself with a specific patient and to better understand the extensive health histories of geriatric patients. common challenges working with a population that is vastly different from which is commonly associated to athletic training was a unique and challenging experience. these patients present with a variety of pre-existing conditions, complex medical histories, and may have had negative experiences within healthcare. unfortunately, geriatric patients are subject to lower expectations due to societal norms and ageism. stereotypes against medicare-eligible patients can significantly affect their care and how they are treated by healthcare providers.2,3 for example, a clinician exhibits an ageist attitude if they decide to “take it easy” on an elderly patient and lower their standards of what constitutes full function. on more than one occasion in working with these patients, they have made comments about how they were treated by other providers and how they felt about the expectations set for them because of their age. these patients are very aware of how their treatment plan is dictated by their age and many of them aspire beyond the conservative plans of a clinician. another sentiment expressed by our patients is how some providers expressed that their issue was “just due to their age” and could not be remedied. prior experiences like this shaped their perception of healthcare providers and healthcare in general. it presented the challenge to earn their trust and change their mind about health care providers and increase their knowledge of athletic trainers. benefits to the clinician and the population exposure to this population has created the opportunity to expand knowledge and to provide quality care to a deserving population. in every patient encounter, the clinician strived to instill confidence in their abilities and facilitate a sense of ownership over their healthcare journey. promoting elevated expectations among this population can improve their perspective of longterm care, functionality, and success in rehabilitation. conversations with the patients have indicated that there are gaps in rehabilitation care and there is limited focus on returning to functional and recreational activities. patients expressed that past therapy experiences mostly focused on returning to activities of daily living and did not address more dynamic activities. at the conclusion of participation, each individual was asked to complete a patient satisfaction survey. over fifty participants used the open comment box to express written strength and weaknesses. table 2 shows a compilation of these comments. agreeing on patient goals and the treatment plan must be a collaborative process and should not be determined solely on a patient’s medicare status or age. conclusion athletic trainers are not known for treating geriatric patients but are more than capable of providing quality care to this population. considerations must be made to complex medical histories and co-morbidities, but the expectations of what a geriatric patient can achieve should not be underestimated. gaining access to this population would be a multi-faceted process and would require cooperation from various entities and stakeholders. this research study has indicated what this patient population values in their therapy experience and has yielded outcomes that demonstrate the effectiveness of athletic trainer provided services to this population through patient satisfaction scores and patient-reported outcomes. this patient population needs comprehensive therapy that strives to improve their entire movement profile, address the whole-person, and improve overall capacity to engage in physical activity across their lifespan. it is a worthwhile endeavor to ensure that treating the medicare population in a clinic setting 32 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 these patients receive quality care and continue to perform functional activities without limitation. references 1. national athletic trainers’ association. history. 2020. available at: https://www.nata.org/history#:~:text=t he%20national%20athletic%20trainers '%20association,the%20future%20of%2 0their%20profession. 2. ugurlu z, kav s, karahan a, akgun citak e. correlates of ageism among health care professionals working with older adults. j transcult nurs. 2019;30(3):303312. http://doi.org/10.1177/10436596188 10128. 3. ben-harush a, shiovitz-ezra s, doron i, et al. ageism among physicians, nurses, and social workers: findings from a qualitative study. eur j ageing. 2017;14(1):39-48. http://doi.org/10.1007/s10433-0160389-9. table 2. themes in patient satisfaction responses with quotes personal attention: • took a personal interest in me and remembered things from one visit to the next. very professional but made me feel like i was her only client. • personalized attention. • has been a very professional, personable experience. • very professional but also very personable. • the care taken to address my unique needs at each session – it was definitely “patient driven” as opposed to “program driven.” • my issue was addressed on an individual basis. no one else helped my hip problem and i finally go answers. • personal touch was good. showed me lots of new stretches. felt cared for! • the athletic trainer is very personable and professional. focus on whole-person: • physical/intellectual/emotional blend of support. excellent. • the attention of my aches, regardless of its location, whether it is part of original problem or not. allowing me to be me during entire process (humoring me when i ask sideways questions (“what the muscle called?”)) it is easy to feel ‘old’ when surrounded by youth—i never felt old. • excellent listening, care, suggestions, knowledge… friendliness. • interested in my total welfare. very friendly. established relationship/ compassion: • the athletic trainer was patient and caring! • compassion for the client/patient. • empathy. • loved the care and rapport with the athletic trainer. • rapport, concern with meeting my needs. • kindness and empathy. http://doi.org/10.1177/1043659618810128. http://doi.org/10.1177/1043659618810128. http://doi.org/10.1007/s10433-016-0389-9. http://doi.org/10.1007/s10433-016-0389-9. treating the medicare population in a clinic setting 33 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 4. blackwood j, sweet c. the influence of ageism, experience, and relationships with older adults on physical therapy students' perception of geriatrics. gerontol geriatr educ. 2017;38(2):219231. http://doi.org/10.1080/02701960.20 15.1079709. http://doi.org/10.1080/02701960.2015.1079709. http://doi.org/10.1080/02701960.2015.1079709. manuscript type evidence-to-practice review 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review michael j. palm, ms, scat, atc; amanda n. flanscha, ms, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract the number of opioid overdoses (ods) has risen in recent years and has become more complex due to the coinvolvement of both prescription and illicit opioid drug use. provisional programs for take-home naloxone (a medication designed to rapidly reverse opiate od symptoms) kits have been distributed to combat this potentially fatal epidemic. although there is strong evidence to support the efficacy of naloxone in the reversal of opiate od, there is limited evidence to support the efficacy of take-home naloxone (thn) kits. the purpose of this evidence-to-practice review was to summarize a systematic review on the efficacy of thn programs. the authors aimed to include studies of thn programs that both trained opioid users in od prevention and reported on od outcomes. the bradford hill criteria (strength of association, temporality, consistency, specificity, dose-response relationship, biological plausibility, coherence, experimental evidence, and analogy) and five additional criteria (measure cost-effectiveness, absence of negative consequences, feasibility of implementation/expansion/ coverage, unanticipated benefits, and special populations) was used as dependent variables to determine the impact of public health intervention where randomized control trials (rcts) are not ethically feasible or operationally practical. all 22 studies included provided empirical support using the bradford hill criteria for community based thn programs. despite being unable to deduce whether death would have occurred without the administration of thn, the studies combined accounted for an estimated 2316 successful opioid od reversals. thus, there is a strong association between thn administration and overdose survival. additionally, there was a low rate of adverse events: withdrawal symptoms (2.8%), vomiting (2.2%), agitation (2.1%), seizures (0.1%). consequently, we recommend that athletic trainers include opioid crisis management equipment and procedures in a site-specific policies manual. clinical relevance is highly dependent on patient population and geographic location, considering 90% of reversed ods were heroin induced. application to individuals in organized sport is minimal, but nonetheless, individuals who are prescribed opioids for pain management should be candidates for thn programs. athletic trainers and guardians of minors prescribed opioid medications should be educated on dispensing medication, best practices for opioid crisis management, and distribution of naloxone/thn. key phrases public health, patient education, triage and emergency care correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation palm mj, flanscha an, winkelmann zk. effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review. clin pract athl train. 2021;4(2): 26-32. https://doi.org/10.31622/2021/0004.2.4. submitted: april 17, 2020 accepted: january 22, 2021. original reference mcdonald r, strang j. are take-home naloxone programs effective? systematic review utilizing application of the bradford hill criteria. addiction. 2016;111(7):1177-1187. doi:10.1111/add.13326. summary clinical problem and question from 1999-2017, 56.8% of the 702,568 drug overdose (od) deaths in the united states involved opioids.1 the number of opioid ods has risen in recent years, and combating the epidemic has become more complex due to the coinvolvement of both prescription opioid and illicit opioid (e.g. heroin, illicit fentanyl) drug use.2 opioid ods can be reversed and lives saved with the timely administration of naloxone.3,4 naloxone is a mu-opiate antagonist that rapidly reverses opiate-induced respiratory depression.3 a provisional program for take-home naloxone (thn) kits was first introduced in 1996.5 these thn programs typically involve training drug users and/or family members and peers on risk mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.2.4 effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 awareness, emergency management, and naloxone administration. both the world health organization (who)3 and the u.s. surgeon general6 have released statements emphasizing the importance of ‘[opioid users], health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid od, knowing how to use naloxone and keeping it within reach.’6 as such, athletic trainers are healthcare providers and should be trained on the identification and management of opioid crises. adolescents who participated in sports were found to have approximately 17% increased odds of non-medical opioid use as compared to peers who did not participate in sports.7 when looking across sport-specific use, adolescents who participated in football or wrestling had a 50% increased risk of nonmedical opioid use as compared to peers who did not participate in sports.7 among elite athletes, opioids are one of the most used substances.8 athletic trainers are recommended to educate and train those at risk of opioid od on use of thns. if resources are not available in the athletic training facility, it is recommended that patients be educated on options available to obtain thns and other counseling services. the purpose of this guiding systematic review was to answer the clinical question: are take home naloxone programs effective? the primary purpose of this evidenceto-practice review was to examine the applicability of thns in athletic training clinical practice. summary of literature a systematic review was conducted to find the effectiveness of thn programs. the electronic databases searched included medline, psychinfo (both via ovid), and pubmed. the following boolean search query was used: (opioid or opiate) and overdose and prevention. original quantitative (or mixed method) studies of randomized or observational trials articles from january 1946 to june 2015 were identified, yielding 1397 articles. to be included in the review, studies were screened using the title and abstract. studies had to include thn programs that trained opioid users in od prevention and reported on od outcomes. after eliminating duplicates, non-english, and irrelevant articles, 36 papers were found. the exclusion criteria included: 1) case studies, 2) papers that reported on buprenorphine/naloxone, 3) papers that did not report primary research data, and 4) papers that did not report on heroin/opioid users, naloxone, or od. upon final analysis, 22 articles were identified to be used in the systematic review. data was extracted using the strengthening the reporting of observational studies in epidemiology (strobe) checklist and analyzed for study quality. fifteen of the 22 articles were conducted in the united states, two in canada, four in the united kingdom, and one in both the united kingdom and germany, providing a geographically diverse population. there was a large variation between studies in terms of size (n=24-2912; median=203) and quality (study quality score=4-7 out of 8). authors reported that many articles were more descriptive reports rather than structured study designs. although these reports were beneficial for communications to other practitioners, these reports lacked structure in design and analytic rigor. only 9 of the 22 studies included systematic follow-ups with participants after thn administration. since the sample sizes were so small, follow-up data was not included because it was not representative of all studies, posing a threat to external validity. the inconsistency in study design and reporting posed a threat to the internal validity and as a result, small variances exist within the methods of the studies included. a narrative synthesis was used instead of a meta-analysis for the analysis of the 22 studies. effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 summary of intervention this systematic review analyzed studies that distributed thn programs. although rcts are considered best practice in research, this would not be ethical for determining the effectiveness of thn. consequently, none of the studies included a control group of individual participants selected to not receive thn. instead, some studies used community-based control comparison groups, or communities in which thn had not been implemented or offered. studies were analyzed under the assumption that communities had equal variances. all the studies evaluated were retrospective and examined the overall effectiveness of thn for participants that used it after overdosing. included studies reported descriptive statistics on the number of thn administrations, overdose reversals, and adverse events. these values were used as a proxy to represent the effectiveness and safety of thn. summary of outcomes the authors of the guiding systematic review used the bradford hill criteria and the who “evidence to action report” to analyze the included studies. the bradford hill criteria is a list of nine items analyzed to determine causality when only correlational data is available.9 the nine items (table 1) included strength of association, temporality, consistency, specificity, doseresponse relationship, biological plausibility, coherence, experimental evidence, and analogy. the bradford hill criteria is often used to assess impact for public health interventions when random control trials are not practicable.9 analysis of five additional criteria were included and related to feasibility and implementation: cost-effectiveness, absence of negative consequences, feasibility of implementation/ expansion/ coverage, unanticipated benefits, and special populations (table 2). these additional criteria have been valuably applied in a who “evidence to action” report analyzing the effectiveness of needle-exchange interventions in reducing hiv. findings and clinical implications all 22 studies analyzed provided empirical evidence to meet all nine of the bradford hill criteria in support of thn intervention in nonspecific healthcare settings explained in the following sections. in 17 of the 22 studies reporting thn administrations following an od, 2336/2249 (96.3%) successful od reversals were reported. this implies a strong association between thn and successful opioid od reversals. studies that lacked control groups make it hard to definitively conclude that od reversals happened because of thn rather than the body filtering and metabolizing the drug. an interrupted time series analysis (regarded as the strongest design for quasi-experimental research) done in massachusetts distributed thn programs to 2912 participants across 19 communities.10 each community with a thn program served as its own geographic control prior to implementation, and those without thn served as time controls. this study revealed the temporality of thn and significant reduction in od mortality in communities that had thn programs. consistency for thn programs effectiveness is demonstrated through the stability of od reversal rates across the various geographical regions that data was collected from. 15 different regions, states and countries provided significant support for the consistency of thn programs. biological plausibility, known as the biological or pharmacological mechanism to explain the outcome of a treatment, is significant in the therapeutic effect of naloxone. naloxone is an opioid antagonist that binds to opioid receptors and blocks the effects of the drug. the successful reversal of 2249 opioid ods across all but one of the analyzed studies shows the strong support of biological plausibility. evidence-to-practice review 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 table 1. bradford hill criteria and application to take-home naloxone criterion take-home naloxone (thn) strength of association how strong is the association between thn and od reversal? temporality did the distribution of thn precede a reduction in od deaths? consistency have there been multiple observations of od reversals because of thn provision? specificity does thn have the unique effect of reversing opioid ods? dose-response relationship does increased thn supply go together with more od reversals? biological plausibility is it biologically plausible that a reduction in od deaths occurs when thn is available? coherence are there documented examples of opioid od mortality declining without thn availability? if so, does this empirical evidence conflict with the assumed association between thn and od prevention? experimental evidence is there (semi)experimental evidence to support the hypothesized impact of thn on od mortality? analogy is there a treatment like thn that leads to an outcome like od reversal? an australian study demonstrated the decline in opioid od between 2001 and 2002 before naloxone became available in 2011. however, 21 studies reported successful reversal rates of opioid od which contributes to the coherence criteria. the specificity of thn throughout the studies analyzed that naloxone is specifically for opioid reversal and has no effect on those suffering from a cocaine od or other type of drug od. all 22 studies reported on heroin use and one with long-acting opioid use, all displaying strong specificity for naloxone and opioid reversal. dose-response relationship criteria was only assessed in one of the 22 studies, resulting in only partially fulfilling the criteria. in the massachusetts study, the 19 communities broken into three categories for thn implementation: zero, low (1100 enrollments) and high (>100 enrollments). low and high implementation resulted in reduced deaths from ods compared to communities without implementation, providing limited, but supporting evidence for dose-response impact. in athletic training practice, take-home naloxone programs may be compared to other emergency medications such as adrenaline (epinephrine) injection kits for allergic reactions or glucagon for insulin od. training in the use of naloxone is also compared to the use of automatic external defibrillators and cardiopulmonary resuscitation for those likely to experience these emergencies regardless of their medical background. like these, time is critical in administration and thus fulfills the analogy criteria. the who “evidence to action” criteria were all fully or partially fulfilled in support of thn programs. studies conducted in the united states and russia revealed thn interventions are cost-of opioid ods).11,12 across the studies analyzed in this systematic review, thn interventions had a low number of adverse events. the studies which did report adverse events showed these to be associated more with symptoms of withdrawal rather than due to the naloxone. the implementation of thn programs across several evidence-to-practice review 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 table 2. feasibility and implementation criteria and application to take-home naloxone criterion take-home naloxone (thn) cost-effectiveness is thn for lay od reversal cost-effective compared to treatment as usual (no intervention)? absence of negative consequences does the distribution of thn to users bear the risk of adverse events? feasibility of implementation/expansion/coverage is it feasible to introduce thn distribution in diverse settings, including resource-poor settings, and scale up implementation? unanticipated benefits does the distribution of thn to users lead to unanticipated benefits? special populations how successful are thn programs in reaching special populations that have been identified as particularly ‘at-risk’ opioid users? locations and circumstances shows the feasibility of implementation, expansion, and coverage. the rapid expansion of community naloxone distribution programs was observed in san francisco in the 2000s especially in places with low resources.13 unanticipated benefits were seen in a few studies, ranging from participants entering treatment (25%) and decreasing drug use following their od reversal (53%), to participants being tested for comorbid conditions and family members being educated on the use of naloxone (28%).14 take-home naloxone programs were implemented in several different opioid populations including patients who were detoxing, the homeless, users of methadone, and the incarcerated. this provides evidence for thn programs to be used in special populations across several settings and various demographic populations. all these criteria provide support for athletic trainers to implement naloxone or thn programs at their clinical sites as a tertiary prevention strategy, or harm reduction, to opioid od. because athletic trainers have experience in the primary and secondary prevention of many health conditions, implementing other opioid od prevention strategies would not only be feasible but beneficial to combat the public health epidemic within their clinical practice and community. athletic trainers may do this through education and policy development and implementation. depending on different geographical locations, heroin use may be more prevalent in the community, and organizationwide education on naloxone administration may be valuable. regardless of location, long-acting opioid use remains of high concern. athletic populations prescribed these drugs as pain killers are at risk for dependence and od without the proper education on how to use them. in addition to the education provided by the prescribing practitioner, athletic trainers typically see their patients more frequently and should reiterate medication adherence. establishing clear guidelines in collaboration with other healthcare practitioners on how to properly administer and take opioid medication is important to prevent od. athletic training as a profession is already considered an aid to improving public health, by providing health services to various patient populations.15 to assist in the public health sector on opioid use, athletic trainers should focus on patient, organization member, and stakeholder education for prevention strategies and crisis response, as they do for other high-risk injuries like concussion management for athletes, coaches, and parents. effective policy development and implementation on opioid use and od prevention will help reinforce athletic training as a valuable effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 allied health profession. this systematic review supported the feasibility and benefits of implementing thn to reverse opioid od and should be considered by all athletic trainers due to its benefits to patients and the community clinical bottom line overall, thn programs were found to be effective in reducing deaths from opioid-induced ods. we recommend that athletic trainers include opioid crisis management equipment and procedures in a site-specific policies manual. naloxone administration may be compared to epinephrine-injections used for anaphylaxis or aed and cpr for cardiac emergencies. more than 90% of the ods witnessed (and reversed) in the review were heroin-induced, therefore clinical relevance is highly dependent on patient population and geographic location. recommendations from this review do not address applicability for individuals involved in organized sport where substances are regulated by a governing body. the authors suggest individuals in physically active settings who are prescribed opioids for pain management should be candidates for thn programs, particularly in areas highly affected by the opioid epidemic. primary preventative screening using self-report questionnaires (e.g. opioid-related overdose risk behavior scale [orbs]16 or alcohol, smoking and substance involvement screening test [assist]17) should be implemented by or in collaboration with prescribing physicians to assess patient need for thn. prior od risk screening may be especially useful if thn programs are not feasible for the patient due to socioeconomic factors and/or availability. if opioid medication is prescribed, patients should be thoroughly educated on medication adherence. guardians of minors prescribed opioids should be educated and encouraged to dispense the medication as instructed by a physician or pharmacist. athletic trainers involved in the care of individuals prescribed opioid medications should be educated on best practices for opioid crisis management and aware of state legislature regarding administration and distribution of naloxone/thn programs. if improvements in athletic training education and professional development on opioid use are executed, then the public may see improved patient safety and positive community-based responses. references 1. ahmad fb, escobedo la, rossen lm, spencer mr, warner m, sutton p. provisional drug overdose death counts. national center for health statistics. 2020. https://www.cdc.gov/nchs/nvss/vsrr/drugoverdose-data.htm. 2. scholl l, seth p, kariisa m, wilson n, baldwin g. drug and opioid-involved overdose deaths—united states, 2013–2017. morbidity and mortality weekly report. 2019;67(5152):1419. http://dx.doi.org/10.15585/mmwr.mm675 152e1. 3. mcdonald r, strang j. are take-home naloxone programmes effective? systematic review utilizing application of the bradford hill criteria. addiction. 2016;111(7):11771187. https://doi.org/10.1111/add.13326. 4. world health organization. community management of opioid overdose. https://www.who.int/publications/i/item/97 89241548816. 2014. 5. strang j, darke s, hall w, farrell m, ali r. heroin overdose: the case for take-home naloxone. bmj. 1996;312:1435. https://dx.doi.org/10.1136%2fbmj.312.70 44.1435. 6. office of the surgeon general. surgeon general's advisory on naloxone and opioid overdose. in: services udohah, ed2018. https://www.hhs.gov/surgeongeneral/priorit https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm http://dx.doi.org/10.15585/mmwr.mm675152e1 http://dx.doi.org/10.15585/mmwr.mm675152e1 https://doi.org/10.1111/add.13326 https://www.who.int/publications/i/item/9789241548816 https://www.who.int/publications/i/item/9789241548816 https://dx.doi.org/10.1136%2fbmj.312.7044.1435 https://dx.doi.org/10.1136%2fbmj.312.7044.1435 https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html effectiveness of take-home naloxone programs in athletic training: an evidence-to-practice review 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 ies/opioids-and-addiction/naloxoneadvisory/index.html. 7. veliz pt, boyd c, mccabe se. playing through pain: sports participation and nonmedical use of opioid medications among adolescents. am j public health. 2013;103(5):e28-e30. https://dx.doi.org/10.2105%2fajph.2013. 301242. 8. mcduff d, stull t, castaldelli-maia jm, hitchcock me, hainline b, reardon cl. recreational and ergogenic substance use and substance use disorders in elite athletes: a narrative review. br j sports med. 2019;53(12):754-760. https://doi.org/10.1136/bjsports-2019100669. 9. lucas rm, mcmichael aj. association or causation: evaluating links between "environment and disease". bull world health organ. 2005;83:792-795. 10. walley ay, xuan z, hackman hh, et al. opioid overdose rates and implementation of overdose education and nasal naloxone distribution in massachusetts: interrupted time series analysis. bmj. 2013;346:f174. https://doi.org/10.1136/bmj.f174. 11. coffin po, sullivan sd. cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. ann intern med. 2013;158(1):1-9. https://doi.org/10.7326/0003-4819-1581-201301010-00003. 12. coffin po, sullivan sd. cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in russian cities. j med econ. 2013;16(8):1051-1060. https://doi.org/10.3111/13696998.2013. 811080. 13. rowe c, santos gm, vittinghoff e, wheeler e, davidson p, coffin po. predictors of participant engagement and naloxone utilization in a community‐based naloxone distribution program. addiction. 2015;110(8):1301-1310. https://doi.org/10.1111/add.12961. 14. seal kh, thawley r, gee l, et al. naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. j urban health. 2005;82(2):303-311. https://doi.org/10.1093/jurban/jti053. 15. hoffman m, bovbjerg v, hannigan k, et al. athletic training and public health summit. j athl train. 2016;51(7):576-580. https://dx.doi.org/10.4085%2f10626050-51.6.01. 16. pouget er, bennett as, elliott l, et al. development of an opioid-related overdose risk behavior scale (orbs). subst abus. 2017;38(3):239-244. https://doi.org/10.1080/08897077.2017. 1282914. 17. world health organization. the assist project-alcohol, smoking and substance involvement screening test. https://www.who.int/publications/i/item/97 8924159938-2. 2010. https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html https://www.hhs.gov/surgeongeneral/priorities/opioids-and-addiction/naloxone-advisory/index.html https://dx.doi.org/10.2105%2fajph.2013.301242 https://dx.doi.org/10.2105%2fajph.2013.301242 https://doi.org/10.1136/bjsports-2019-100669 https://doi.org/10.1136/bjsports-2019-100669 https://doi.org/10.1136/bmj.f174 https://doi.org/10.7326/0003-4819-158-1-201301010-00003 https://doi.org/10.7326/0003-4819-158-1-201301010-00003 https://doi.org/10.3111/13696998.2013.811080 https://doi.org/10.3111/13696998.2013.811080 https://doi.org/10.1111/add.12961 https://doi.org/10.1093/jurban/jti053 https://dx.doi.org/10.4085%2f1062-6050-51.6.01 https://dx.doi.org/10.4085%2f1062-6050-51.6.01 https://doi.org/10.1080/08897077.2017.1282914 https://doi.org/10.1080/08897077.2017.1282914 https://www.who.int/publications/i/item/978924159938-2 https://www.who.int/publications/i/item/978924159938-2 abstract manuscript type disablement model case study 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study lucas bianco, dat, atc, cscs biokinetix, chicago, il abstract a 23-year-old male patient participating in intercollegiate basketball, suffered an acute shoulder dislocation. the patient was diagnosed with an anterior glenohumeral labral tear and was treated with an indirect approach to increase range of motion (rom) and function while decreasing pain. patient-related outcome (pro) measures were used along with clinician related outcome (cro) measures to discharge the patient. the immediate changes in rom and pain along with follow-up assessments of the disabilities of the arm, shoulder, hand (dash) scale achieved minimal clinically importance difference (mcid) levels. as rehabilitation specialists, athletic trainers have the opportunity to provide quality care to patients and recognize the repercussions of injury on the patient. the follow-up assessments support that the completed conservative indirect treatment for a patient with a glenohumeral anterior labral tear was effective at reducing pain, improving function, and improving pro in this isolated case. the individual was able to return to basketball activities at the same level as before to the diagnosis, within a three-week timeframe. the use of primal reflex release technique (prrt) to restore allostasis in the central nervous was effective based on available outcomes for this patient. then the continued re-education of pain-free functional movement patterns through reflexive neuromuscular stabilization provided the patient the ability to maintain his functional gains. clinically, considering the biopsychosocial components of injury can help guide intervention selection to provide a patient-centered model of care and ensure an optimal outcome. key phrases college and university patient population, patient-reported outcomes, therapeutic exercise correspondence dr. lucas bianco, 3205 street lynchburg, va 24501.e-mail: lucasbianco4915@gmail.com full citation bianco l. conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study. clin pract athl train. 2022;5(1): 46-52. https://doi.org/10.31622/2022/0005.01.7. submitted: august 9, 2020 accepted: april 6, 2021. introduction anterior shoulder dislocations are the most common shoulder dislocation. the most appropriate treatment for patients following a first-time dislocation remains unclear; surgery and rehabilitation are the two most common treatments. patients participating in college athletics suffer shoulder dislocations at a rate of 2.58 per 10,000 exposures.1 with 29.6% of these patients deciding to have surgery following their shoulder dislocation.1 the rehabilitation time and return-to-play progression often last longer with patients following a surgery shoulder stabilization (6-12 weeks) compared to other nonoperative management (4-8 weeks).1 primal reflex release technique is a treatment paradigm that is used to evaluate and release nociceptive startle reflexes.2 a clinician begins the session with a nociceptive exam to determine hypersensitive areas on the body. these nociceptive startle reflexes (nsr) could be created during a flight, fight, or freeze moment that caused the muscle to reflexively react. the muscles are then left in the hyperarousal state with increased tension in the muscle either effecting the involved area and/or another area of the body. like the theory of regional interdependence, where seemingly unrelated area of the body may contribute or be associated with the patient’s primary concern. through a series of reflexive stimulations with manual techniques the nsr and central nervous system (cns) can be downregulated to restore an allostasis state in the area.2 currently, the literature on conservative treatment versus surgical intervention does not provide one optimal evidence-based practice.3,4 this case study shares a scenario where a neurophysiological intervention was utilized. the treatment plan successfully restored the patient’s perceived function as well as improve quality of life and alleviated pain. https://doi.org/10.31622/2022/0005.01.7 conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 patient information the patient in this case is a 23-year-old male collegiate basketball player. the patient suffered a right shoulder dislocation two weeks before returning to campus for preseason workouts. the mechanism of injury was a posterior to anterior force by an opposing player while reaching to intercept a pass. following a trip to the emergency department, the physicians sedated the patient to relocate his glenohumeral joint. upon arrival to the athletic training clinic, the patient was still using the sling and was very apprehensive. initial evaluation supported the diagnosis of sub-acute right anterior shoulder dislocation with limited range of motion and strength in all shoulder motions. stress tests included a positive empty can, o’brien’s test, apprehension test, and load and shift test; the yergerson’s test and speed’s test were negative. during the previous season, the patient did not participate fully in games as he was recovering from a complication during surgery. the complication left him with shortness of breath and difficulty catching his breath during strenuous exercise. through the year and a half, following this event, the patient worked with breathing exercises and neurological resets to retrain his breathing and autonomic nervous system to prepare for strenuous exercise. the strategies the patient learned from the previous interventions could have assisted in the current recovery from the anterior shoulder dislocation. this example of how the patient-centered care for this patient may have led to the most optimal outcome. differential diagnosis and evaluation the patient was not on campus or in the state at the time of the incident. the emergency department physician who first evaluated the patient reported no fractures were present based on the x-ray images. the treating clinician evaluated the patient six days after the dislocation upon his return to the clinic. following the evaluation by the treating clinician the patient was referred to the team physician. the team physician reported similar instability findings and ordered an mri arthrogram to rule out anterior labrum tear. based on the mri arthrogram, the patient sustained an anterior labrum tear with a hill-sachs lesion to the humeral head. based on the size and shape of the labrum tear, the team physician recommended rest and gradual return-to-play. the patient expressed an interest in continuing to play as long as he was able. the differential diagnosis included fracture, contusion, biceps tendon rupture, and rotator cuff strain/ tear. the patient supported the two-week conservative treatment plan, to determine if function could be improved. the next day, the patient began an intervention program designed to restore the balance of his cns. body structure and function due to the nature of injury, onset, time to the season, and the finding from physical examination and the mri arthrogram; it was determined that the patient could attempt conservative interventions to manage his shoulder pain and lack of function. based on the tissue healing timeframes for the structural damage to the cartilage, evident on mri, the plan of care was directed at restoring function through balancing the cns with no expectation of tissue healing. subsequently, a secondary evaluation was completed to assess the patient perception on his ability to perform functional and basketball activities. the patient specific functional scale (psfs) and dash were completed (table 1). the patient report zero function in his ability to ‘dunk,’ ‘shoot,’ ‘dribble,’ and ‘complete one pushup.’ he did report raising his arm ‘arm raise’ as a three out of ten on a functional scale. along with the dash, the dash sport sub-scale was also completed (table 1). the patient recognized the scores that he entered on the dash sport sub-section were low and that he needed substantial improvements before he would play basketball at his desired level. activity and participation conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 to gather an outcome for the patient’s healthrelated quality of life the disablement in the physically active scale (dpas) was completed. the starting point for this dpas was higher than previous measures demonstrating that his healthrelated quality of life had improved from the first condition that sidelined him for more than a year. in his current state, the dpas was scored at 39. in the wellness section, a meaningful finding was the perceived lack of support from teammates. this finding served as one of the biopsychosocial components of injury that helped guide the intervention selection. environmental and personal factors the patient dealt with a significant transition period of his life while recovering from this injury. after two years of playing college basketball as the son of the head coach, he was preparing to be on a team with a new head coach. before the injury, the patient was concerned about being able to play for the new coach. his environment and personal relationships were shifting while he was trying to comprehend his college basketball career. interventions the first intervention was prrt. it was selected to down-regulate the nervous system to restore allostasis in the cns of the patient. the reflexive muscle inhibition and innervation techniques were applied over two treatments. once the patient had decreased nsr and movement began to return, reflexive neuromuscular stabilization was provided. the arm raise was the movement that was addressed. three treatments of the prrt and rns were performed with the patient on the first three treatment days. then the next two treatment days were focused on upper extremity neuromuscular stabilization exercises progressing from a closed-chain position to an open-chain position. the exercises focused on the areas of function that the patient expressed were lacking in the psfs. during these treatment sessions, visualization, biofeedback, and acupressure were used to help restore the patient’s trust and confidence in his shoulder. outcomes body structure and function after the initial treatment of prrt (figure 1) the patient had improved shoulder abduction. these improvements were maintained to the next day (figure 2) then further improvements occurred following the second prrt treatment paired with rns (figure 3). pain decreased to zero when at rest and two when it was the worst. over the time of three treatments the patient experienced an increase of 6.3 for the average of the psfs scores, which meets the mcid (table 1). activity and participation upon return to full unrestricted basketball-related activities, 13 days following the beginning of the initial intervention, the patient had verbalized that he was enjoying playing basketball and had a good balance with the rest of his life. the dpas score at that time was 5, which was a mcid, from the initial score (table 1). his focus had shifted from “can i play, or should i play with my shoulder injury” to “i want to play” and “i will control my focus and energy every day.” the patient reported increased support from this teammates and family during this time. environmental and personal factors after two weeks of completing unrestricted basketball related activities the patient began to reconsider his position on the team and the challenges of play under a new coach. he decided it was in his best interest to transfer to another college to continue his basketball career. after this decision was made, he did not complete any on-court basketball-related activities but remained physically active during weightlifting and conditioning sessions with the team. the patient continued to complete upper extremity neuromuscular stabilization exercises in the athletic training clinic as needed. conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 discussion this case describes the diagnosis and management of an intercollegiate basketball player following anterior shoulder dislocation and subsequent glenoid labrum tear with hill-sach lesion treated with neurophysiology interventions to decrease pain, improve function, and return to full unrestricted basketball activity. the interventions used in this case study have been used with similar patients, with lower extremity dysfunction.5 the physicians involved in this case were prepared to surgically repair the patient’s shoulder, if the two weeks of conservative care did not improve the patient’s outcomes. researchers are divided on the standard of care for patients with first-time shoulder dislocations. in this case, the innovative treatment plan benefited the patient and assisted the patient in reaching his goals without surgery. to confidently return the patient to unrestricted basketball-related activities, the medical team assessed the patient’s objective measurements (stress tests, range of motion, strength tests, functional capabilities, etc.) along with the pro scores (perceived function, pain scores, perceived difficulty in adls and basketball). utilizing these outcomes as a formal metric is valuable in the communication to stakeholders (patient, physicians, coaches, etc.). also, tracking these scores can further objectify the return-to-play protocol. these outcome measures have been used in other disablement case studies to determine the best treatment plan for a patient.6 clinical bottom line athletic trainers often take on the role of care provider from the “teams” and patients they work with. a portion of the care in this case study was rooted in psychological wellness. as the athletic training education continues to evolve and includes more courses on treating the bio figure 3. shoulder abduction one day post intervention figure 3. shoulder abduction after second intervention figure 3. shoulder abduction post initial intervention disablement model case study 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 1. patient-oriented outcome scores initial second treatment third treatment fourth treatment discharge two week follow-up outcome 2 days 4 days 9 days 13 days nrs wb 1 2 0 0 1 0 nrs nwb 1 2 0 2 0 0 nrs best 1 2 0 0 0 0 nrs worst 3 3 2 5 2 0 psfs total 0.5 2.3 6.8* 7.3 9 9.6 psfs arm raise 3 6* 8 8 9 10 psfs carrying bag 0 8 9 10* 10 10 psfs dunking 0 0 8 4 8 9.5 psfs shooting 0 0 5 6 8* 10 psfs dribbling 0 0 7 9 10* 8 psfs pushup 0 0 4 7* 9 10 dash 45 39.4 n/a 33* 17.7 3.8 dash sport 20 20 n/a 15 12 5* omne (tps) 10 6 6 2 5 2 dpas 39 n/a n/a n/a 5* 12 groc 4 5 n/a 2 3 6 nrs wb= numeric pain rating scale in weight-bearing; nrs nwb= numeric pain rating scale in nonweight-bearing; nrs best= lowest score throughout 24 hour period; nrs worst= highest score throughout 24 hour period; psfs total: average of patient-specific functional scale items for that session; psfs arm raise, carrying bag, dunking, shooting, dribbling, push-up: specific item selected and scored by the patient as part of the psfs; dash: disabilities of the arm, shoulder, and hand scale; dash sport: sport sub-scale; omne (tps)= one-minute nociceptive exam assessing number of tender points; dpas: disablement in the physically active scale; groc: global rating of change scale; mcid=* psychosocial component of an injured patient, it will be customary for clinicians to explore physical interventions that can assist with the traditional bio-psychosocial interventions. in this case, the use of prrt helped down-regulate, “calm” the patient’s cns to improve his pain, function, and pro scores. athletic trainers are competent in recognizing how biopsychosocial elements related to injury can navigate patient-centered care and intervention strategies that ensure an optimal outcome. patient perspective “as it relates to my shoulder injury specifically, i really saw improvements after every training session. it all happened fast, and some would say my return to basketball was too fast. the results were undeniable, and they allowed me to play even due to my unusual speedy recovery. i know exactly why i got better. i got better due to the revelation of the connection your essence has between the mind, body and soul that my athletic trainer very clearly explained to me. my athletic trainer did a phenomenal job of giving me information and communicating the same message in multiple different ways. i am a devout christian. with that being said, he was able to give me the biblical perspective to my health pertaining to my situation while also saying the same exact thing behind a physical training lens and then tying it all together with science, data, and fact. so many different lenses and perspectives that he used to tie everything together for the same message. he then showed me very clearly how all of these things are connected and similar along with how these elements tie into one another.” conservative care of a patient with initial anterior shoulder dislocation participating in an intercollegiate basketball: a disablement model case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 references 1. 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https://doi.org/10.1503/cjs.004014. 10. landsman jc, seitz wh, froimson ai, leb rb, bacher ej. splint immobilization of gamekeeper's thumb. orthopedics. 1995;18(12):1161-1165. https://doi.org/10.3928/0147-744719951201-06 11. kim j, sung dj, lee j. therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. j exerc rehabil. 2017;13(1):12. https://dx.doi.org/10.12965%2fjer.17328 24.412. 12. loghmani mt. the effects of instrumentassisted cross fiber massage on ligament healing [doctoral dissertation]. indiana university purdue university of indiana. 2010. http://dx.doi.org/10.7912/c2/2091. 13. loghmani mt, warden sj. instrumentassisted cross-fiber massage accelerates knee ligament healing. j orthop sports phys ther. 2009;39(7):506-514. https://doi.org/10.2519/jospt.2009.2997. 14. anderson m. foundations of athletic training: prevention, assessment, and management. vol 6th. philadelphia: wolters kluwer; 2017. 15. sitzler b. icf model: a framework for athletic training practice. national athletic trainer's association. https://www.nata.org/blog/beth-sitzler/icfmodel-framework-athletic-training-practice. published 2016. accessed december 28, 2020. 16. seffrin cb, cattano nm, reed ma, gardiner-shires am. instrument-assisted soft tissue mobilization: a systematic review and effect-size analysis. j athl train. 2019;54(7):808-821. https://doi.org/10.4085/1062-6050-48117. 17. howitt s, wong j, zabukovec s. the conservative treatment of trigger thumb https://doi.org/10.1007/978-3-319-52567-9_39 https://doi.org/10.1007/978-3-319-52567-9_39 https://doi.org/10.1097/jsm.0b013e3181d23710 https://doi.org/10.1097/jsm.0b013e3181d23710 https://doi.org/10.1177/036354659101900305 https://doi.org/10.1177/036354659101900305 https://doi.org/10.1007/s12178-017-9381-z https://doi.org/10.1007/s12178-017-9381-z https://doi.org/10.1097/jsm.0b013e318289c6ff https://doi.org/10.1097/jsm.0b013e318289c6ff 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all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 using graston techniques and active release techniques®. j can chiropr assoc. 2006;50(4):249. 18. hammer wi, pfefer mt. treatment of a case of subacute lumbar compartment syndrome using the graston technique. j manipulative physiol ther. 2005;28(3):199-204. https://doi.org/10.1016/j.jmpt.2005.02.01 0. 19. stow r. instrument-assisted soft tissue mobilization. int j sports phys ther. 2011;16(3):5-8. 20. thaman n. effect of graston technique on edema following a sprain to the lateral ankle ligaments [master’s thesis]. department of kinesiology indiana university; 2016. https://hdl.handle.net/2022/20916. 21. the numeric pain rating scale instructions. https://www.sralab.org/sites/default/files/ 201707/numeric%20pain%20rating%20scale% 20instructions.pdf. accessed march 3, 2020. 22. mccaffery m, beebe a. the numeric pain rating scale instructions. in: pain: clinic manual for nursing practice. mosby, st. louis; 1989. 23. bijur pe, latimer ct, gallagher ej. validation of a verbally administered numerical rating scale of acute pain for use in the emergency department. acad emerg med. 2003;10(4):390-392. https://doi.org/10.1111/j.15532712.2003.tb01355.x. 24. beaton de, wright jg, katz jn. development of the quickdash: comparison of three item-reduction approaches. j bone joint surg am. 2005;87(5):1038-1046. https://doi.org/10.2106/jbjs.d.02060. 25. jensen mp. hypnosis for chronic pain management: therapist guide. oxford university press; 2011. 26. salaffi f, stancati a, silvestri ca, ciapetti a, grassi w. minimal clinically important changes in chronic musculoskeletal pain intensity measured on a numerical rating scale. eur j pain. 2004;8(4):283-291. https://doi.org/10.1016/j.ejpain.2003.09.0 04. 27. werner bc, belkin ns, kennelly s, et al. injuries to the collateral ligaments of the metacarpophalangeal joint of the thumb, including simultaneous combined thumb ulnar and radial collateral ligament injuries, in national football league athletes. am j sports med. 2017;45(1):195-200. https://doi.org/10.1177/0363546516660 979. 28. bitra m, sudhan s. instrument assisted soft tissue mobilisation in the management of musculoskeletal pain: a literature review with implications for clinical practice guidelines. j clin diagn res. 2019;13(12). http://dx.doi.org/10.7860/jcdr/2019/42 687.13356. 29. garrett tr, neibert pj. graston technique® as a treatment for patients with chronic plantar heel pain. clin prac athl train. 2019;2(3):35-47. https://doi.org/10.31622/2019/0003.4. https://doi.org/10.1016/j.jmpt.2005.02.010 https://doi.org/10.1016/j.jmpt.2005.02.010 https://hdl.handle.net/2022/20916 https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://www.sralab.org/sites/default/files/2017-07/numeric%20pain%20rating%20scale%20instructions.pdf https://doi.org/10.1111/j.1553-2712.2003.tb01355.x https://doi.org/10.1111/j.1553-2712.2003.tb01355.x https://doi.org/10.2106/jbjs.d.02060 https://doi.org/10.1016/j.ejpain.2003.09.004 https://doi.org/10.1016/j.ejpain.2003.09.004 https://doi.org/10.1177/0363546516660979 https://doi.org/10.1177/0363546516660979 http://dx.doi.org/10.7860/jcdr/2019/42687.13356 http://dx.doi.org/10.7860/jcdr/2019/42687.13356 https://doi.org/10.31622/2019/0003.4 abstract evidence-to-practice review best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review nicolette a. harris, dat, lat, atc, cscs*; adriana peña, ms, lat, atc†; and sofia núñez rivera, ms, lat, atc *florida international university, miami; †sports leadership and management academy, miami, fl abstract sacroiliac joint (sij) pain serves as an under-recognized source of chronic low back pain. improvement in the accuracy of a clinical sij pain diagnosis lends a higher likelihood of appropriate treatment measures, better patient outcomes and decreased out-of-pocket costs. therefore, the overall purpose of this evidence to practice review was to highlight the main points of a systematic review on the clinical diagnosis of sij pain. searches of five electronic databases revealed 758 studies, nonetheless only six studies met final inclusion criteria. studies included were assessed by the authors for methodological quality using the quality assessment of diagnostic accuracy studies (quadas) tool. evidence suggests pain provocation tests including distraction, thigh thrust, compression, sacral thrust, and gaenslen’s are minimally useful individually at diagnosing sacroiliac joint pain. the thigh thrust test was the most sensitive and the distraction test was most specific. furthermore, the compression test carried the strongest positive likelihood ratio. the highest likelihood ratio was reported when three or more of the following pain provocation tests were positive: distraction, compression, thigh thrust, sacral thrust, and gaenslen’s test for both the right and left sides. a comparable likelihood ratio was found when any two of the remaining four tests were positive after excluding the left and right-side applications of the gaenslen’s test. prior to the performance of pain provocation tests, research suggests using mckenzie mechanical diagnosis and therapy to exclude pain of disc origin. the use of safe, efficient, and clinically effective diagnostic evaluation techniques is essential to the provision of high-quality patient care. key phrases diagnostic testing and physical examination: spine, thorax, and abdomen; low back pain; sacroiliac joint correspondence dr. nicolette a harris, florida international university, 11200 sw 8th st, wrc 145, miami, fl 33199. e-mail: nstallwo@fiu.edu twitter: @youngprof_at full citation harris na, peña a, núñez rivera s. best practices for clinical evaluation of sacroiliac joint pain: an evidence to practice review. clin pract athl train. 2021;4(1): 17-23. https://doi.org/10.31622/2021/0004.1.3. submitted: august 17, 2020 accepted: october 1, 2020. 17 original reference sivayogam a, banerjee a. diagnostic performance of clinical tests for sacroiliac joint pain. phys ther rev. 2011;16(6):462-467. summary clinical problem and question approximately 10-30% of all low back pain is originated from the sacroiliac joint (sij).1 the sij is a large, auricular-shaped, and arthrodial synovial joint formed by the connection of the sacrum to the right and left iliac bones.2 the primary function of the sij is to absorb shock and transfer forces between the upper and lower extremities.3 more extensive dorsally, the ligaments of the sij function to limit motion in all planes.3 while the sij lacks significant range of motion, patients may possess hypomobility or hypermobility of the sij articulation.2 the most common mechanism for acute sij pain results from a combination of axial compression and rapid rotation, such as with twisting while carrying a heavy object or falling.1 however, most athletes will experience a slow and progressive onset of symptoms resulting from repetitive activity performed over time.1 common pathologies arising from the sij include: sprains, strains and dysfunction of the joint secondary to insufficient or excessive mobility.1 factors that increase the risk of these conditions include leg length discrepancy, antalgic gait, scoliosis, and prolonged vigorous exercise.1 this multitude of triggers, makes low back pain of sij origin extremely challenging for the health care provider to clinically diagnose. copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 mailto:nstallwo@fiu.edu https://doi.org/10.31622/2021/0004.1.3 best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review 18 copyright © by indiana state university all rights reserved. issn online 2577-8188 clinical practice in athletic training volume 4 – issue 1 – february 2021 regrettably, no single history presentation, clinical examination finding, or diagnostic imaging technique can definitely establish a diagnosis of sacroiliac joint pain.4 however, previous research has studied these measures in an effort to improve accuracy in the diagnosis of sij pain.5 while many publications have referenced controlled local anesthetic blocks as the best available tool to determine the source of sij pain, these measures are invasive and expensive, making them clinically unpractical for routine use in the ambulatory care setting.5 there are a variety of “special” tests used by clinicians in the evaluation and diagnosis of sij pain. these include motion palpation and pain provocation tests.6 numerous studies have proposed palpation as a method to assess movement or asymmetry at the sij.7 however, generally their inter-examiner reliability has shown poor.7 this leaves clinicians to rely on pain provocation tests, which stress the structures of the sij and provoke reproduction of symptoms, as measures of non-invasive clinical evaluation of sij pain.7 common pain provocation tests used for clinical evaluation include distraction, compression, sacral thrust, thigh thrust, and gaenslen’s tests in addition to a host of others.7 the diagnostic accuracy of pain provocation tests has been called into question for its inability to discriminate pain of sacroiliac origin as compared to the reference standard.7 consequently, clinicians must be aware of both the sensitivity, or ability to distinguish subjects with the disease, as well as the specificity, or the ability to identify patients without the disease associated with the tests used for effective diagnosis of sij pain.8 therefore, the overall purpose of the guiding paper was to systematically review and synthesize evidence associated with the clinical diagnosis of sij pain. more precisely, this evidence to practice review aims to remedy the following research question: in patients with low back pain, which clinical evaluation tests are most accurate for diagnosing pain of sacroiliac origin? summary of literature authors of the systematic review performed a methodical search of medline, scopus, amed, cinahl, and embase databases to determine the diagnostic performance of clinical tests for sij pain. searches were filtered to include only articles published in english between 1990 and 2011. studies specifically addressing sij dysfunction rather than sij pain were excluded. single articles were included in the systematic review according to the following criteria: (1) patients were at least 18 years old, (2) had non specific and non-pregnancy related low back pain and/or buttock pain with or without radiation into the lower extremity, (3) used clinical tests with clear definitions of positive and negative test results, and (4) provided sensitivity and specificity data. initially 758 studies were identified, however 752 were excluded for failing to meet selection criteria. of the six studies included, two studies evaluated the validity of each individual test; three studies evaluated the validity of several composites of tests; and one study evaluated the validity of both individual and composites of tests. all six of the studies included used a contrast-enhanced intra-articular anesthetic block as the reference standard. the number of patients enclosed in the studies ranged from 34 to 140 with a mean age between 42 and 51 years old. summary of outcomes studies included in the guiding systematic review were assessed for methodological quality autonomously by both authors using the quality assessment of diagnostic accuracy studies (quadas) tool. the quadas tool consists of 14 items which can be answered with a yes, no, or unclear. nine of the 12 items relate to bias, while three of the 12 items related to the quality of the reporting and two of the 12 items conveyed variability. intra-articular administration of an anesthetic block into the sij bilaterally was best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review 19 copyright © by indiana state university all rights reserved. issn online 2577-8188 clinical practice in athletic training volume 4 – issue 1 – february 2021 agreed upon by the authors as the best available reference standard for fulfilling quadas item number 3 and correctly classifying sij pain. furthermore, to achieve item number 4 of the quadas and to rule out spontaneous recovery or progression to more severe pain, the acceptable gap was agreed on by both authors as no more than seven days between performance of clinical and reference tests. items 1,5, 10, 11, and 12 were scored using a 3 for yes; items 3 and 6 were marked 2 for yes; and all other items were counted 1 for yes.6 a quality score of 17 was assigned to five of 6 items, while a quality score of 18 was allocated to the sixth study.6 findings and clincial implications the systematic review guiding this paper aimed to assess the diagnostic performance of clinical tests commonly used to evaluate sij pain. for each clinical test, sensitivity and specificity were documented. in addition, positive predictive values (ppv) were included to describe how often a positive finding was correct, while negative predictive values (npv) were provided to consider the accuracy of a negative test result. furthermore, positive and negative likelihood ratios were extracted when available. positive likelihood ratios (lr+) were used to provide confidence in the fact that the pathology was present when a test was positive. likewise, negative likelihood ratios (lr-) express the probability that the condition was present despite a negative result on the diagnostic test. evidence revealed that when used in isolation, most clinical tests had poor diagnostic performance.9 clinical tests including the gillet, pain over sij or groin or buttock, sitting position, posterior superior iliac spine pointing, sacral spring, and sacral sulcus revealed poor clinical utility as result of low specificity, low sensitivity, and positive likelihood ratio.9 however, the high sensitivity and specificity values of faber, thigh thrust, and resisted abduction may make these tests better indicators of sij pathology.10 furthermore, evidence suggests pain provocation tests including distraction, compression, thigh thrust, sacral thrust, and gaenslen’s are not effective predictors of a positive intra-articular sij anesthetic block when used alone without any other tests.11 however the thigh thrust test was most sensitive, while distraction test was most specific and compression test carried the strongest positive likelihood ratio (table 1).6,11 clinicians should choose a composite of tests which may strengthen the likelihood of an accurate clinical diagnosis. evidence suggests an optimal ratio of pain provocation tests composites which can provide high specificity paired with low sensitivity while still maintaining a high likelihood ratio.11, 12 the highest likelihood ratio was reported when three or more of the following pain provocation tests were positive: distraction, compression, thigh thrust, sacral thrust, and gaenslen’s test for both the right and left sides.11 a comparable likelihood ratio was found when any two of the remaining four tests were positive after eliminating the left and right-side applications of the gaenslen’s test (figure 1).11 the inclusion of positive and negative likelihood ratios in the individual studies helped to formulate the conclusion that when in the presence of pain below the lumbosacral region or groin, the three prime tests for diagnosis for sij pain are distraction, thigh thrust and compression.6 only after all six sij pain provocation tests are negative, can sij pain be ruled out.11 using clinical examination techniques with high diagnostic accuracy can eliminate or significantly reduce the need to refer patients for diagnostic imaging. safe, effective, and efficient diagnostic techniques can help improve the quality of care. furthermore, the use of clinical evaluation techniques can decrease health care costs, making care more equitable for everyone. to further reduce false positives, research suggests using the mckenzie evaluation to exclude pain of disc origin prior to the performance of best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review 20 copyright © by indiana state university all rights reserved. issn online 2577-8188 clinical practice in athletic training volume 4 – issue 1 – february 2021 table 1. summary of diagnostic accuracy for individual clinical tests of sacroiliac joint pain intervention study sensitivity (95% ci) specificity (95% ci) + lr† thigh thrust dreyfuss et al.8 0.36 0.50 broadhurst and bond9 0.80 1.00 laslett et al.10 0.88 (0.64–0.97) 0.69 (0.82) 2.20 gaenslen’s dreyfuss et al.8 0.71 0.26 laslett et al.10 0.53 (0.30–0.75) r 0.71 (0.53–0.84) r 1.84 0.50 (0.27–0.73) l 0.77 (0.60–0.89) l 2.21 sacral thrust dreyfuss et al.8 0.53 0.29 laslett et al.10 0.63 (0.39–0.82) 0.75 (0.58–0.87) 2.50 distraction test laslett et al.10 0.60 (0.36–0.80) 0.81 (0.65–0.91) 3.20 compression laslett et al.10 0.69 (0.44–0.86) 0.69 (0.51) 2.20 note: *ci: confidence interval. †+lr: positive likelihood ratio. pain provocation tests.13 mckenzie mechanical diagnosis and therapy (mdt) is a well-studied technique which utilizes repeated movements to assess musculoskeletal disorders of the spine and extremities.14 by performing repeated movements during the examination, patients may develop a direction of preference (e.g., truck flexion, extension, or lateral bending) that is correlated to a movement which centralizes the pain from the extremities to the spinal midline.14,7 centralization has been reported as highly specific to discogenic pain, yet is not observed in patients with confirmed pain of sacroiliac origin.7 therefore, we strongly recommend the prerequisite use of mdt by clinicians to rule out discogenic pain prior to evaluation of the sij using pain provocation tests. moreover, current research suggests mdt can also be used in adjunct to pain provocation tests to as a method of alleviating pain and further strengthening sij pain diagnoses.14 patients may be further classified with sij pain when repeated anterior and posterior innominate rotation movements alleviate pain and symptoms from the region of the posterior superior iliac spine (psis).14 clinical bottom line diagnostic tests are a critical component of health care. information on the accuracy of diagnostic tests can help in clinical decision-making and assist in the provision of safe, timely, effective, efficient, and equitable care. based on the findings of this review, we suggest a framework for improved diagnosis in the evaluation of sij pain. evaluation of pain below the lumbosacral or groin region should begin with a thorough patient history. moving forward, a mckenzie mdt evaluation assessing for centralization should be performed to rule out pain of discogenic origin. this should be proceeded by the performance of 6 pain provocation tests: beginning with distraction, thigh thrust, and compression tests and continuing with the sacral thrust and gaenslen’s test for both the right and left sides as needed. the receipt of 3 or more positive tests provide the optimal balance between high specificity, low sensitivity, and a high likelihood ratio. we believe use of this criterion is best practice for establishing a highly accurate sij pain diagnosis. alleviation of the patient’s symptoms through repeated anterior and posterior innominate rotation may further validate diagnosis, but 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diagnosing painful sacroiliac joints: a validity study of a mckenzie evaluation and sacroiliac https://doi.org/10.1249/jsr.0000000000000410 https://doi.org/10.1249/jsr.0000000000000410 https://doi.org/10.1213/01.ane.0000180831.60169.ea https://doi.org/10.1213/01.ane.0000180831.60169.ea https://pubmed.ncbi.nlm.nih.gov/26431129/ https://pubmed.ncbi.nlm.nih.gov/26431129/ https://doi.org/10.1179/1743288x11y.0000000036 https://doi.org/10.1179/1743288x11y.0000000036 https://doi.org/10.1179/jmt.2008.16.3.142 https://doi.org/10.1179/jmt.2008.16.3.142 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4975285/ https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4975285/ https://doi.org/10.1097/00007632-199611150-00009 https://doi.org/10.1097/00007632-199611150-00009 https://pubmed.ncbi.nlm.nih.gov/9726305/ https://doi.org/10.1016/j.math.2005.01.003 https://doi.org/10.1016/j.math.2005.01.003 https://doi.org/10.1016/j.apmr.2005.09.023 https://doi.org/10.1016/j.apmr.2005.09.023 best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review 22 copyright © by indiana state university all rights reserved. issn online 2577-8188 clinical practice in athletic training volume 4 – issue 1 – february 2021 provocation tests. aust j physiother. 2003;49(2):89-97. https://doi.org/10.1016/s0004 9514(14)60125-2. 14. srivastava s, kumar dk, mittal h, dixit s. short-term effect of “mechanical diagnosis and therapy” in the management of sacroiliac joint pain. j clin diagn res. 2018;12(8): 1-4. 15. petersen t, laslett m, juhl c. clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews. bmc musculoskelet disord. 2017;18(1):188. 16. stanford g, burnham rs. is it useful to repeat sacroiliac joint provocative tests post-block? pain med 2010; 11:1774–6. https://doi.org/10.1111/j.1526 4637.2010.00968.x. https://doi.org/10.1016/s0004-9514(14)60125-2 https://doi.org/10.1016/s0004-9514(14)60125-2 https://doi.org/10.1111/j.1526-4637.2010.00968.x https://doi.org/10.1111/j.1526-4637.2010.00968.x best practices for clinical evaluation of sacroiliac joint pain: an evidence-to-practice review 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 figure 1. diagnostic algorithm for sacroiliac joint pain pain below lumbosacral and/or groin region6 pain at psis15 centralization via mdi14 distraction thigh thrust compression sacral thrust gaenslen’s evaluate for disc pathology evaluate for disc pathology thigh thrust compression compression sacral thrust sacral thrust gaenslen’s gaenslen’s sij pain diagnosis one or more positive tests11,6 sensitivity (95% ci) 1.00 specificity (95% ci) 0.44 lr+ 1.78 sij pain diagnosis two or more positive tests11,6 sensitivity (95% ci) 0.93 specificity (95% ci) 0.66 lr+ 2.73 sij pain diagnosis two or more positive tests11,6 sensitivity (95% ci) 0.93 specificity (95% ci) 0.66 lr+ 2.73 no (-) no (-) no (-) no (-) no (-) yes (+) no (-) yes (+) yes (+) yes (+) yes (+) yes (+) yes (+) yes (+) yes (+) yes (+) no (-) no (-) no (-) yes (+) yes (+) yes (+) no (-) no (-) yes (+) mdt: mckenzie mechanical diagnosis and therapy ci: confidence interval lr+: positive likelihood ratio harris_production abstract original reference summary summary of literature summary of outcomes findings and clincial implications clinical bottom line references harris_102_figure 1 final manuscript type evidence-to-practice review 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 dry needling and management of trigger points with low back pain: an evidence to practice review matthew j. drescher, dat, lat, atc; matthew j. rivera, dat, lat, atc; lindsey e. eberman, phd, lat, atc indiana state university, terre haute, in abstract low back pain is a common health concern. the development of myofascial trigger points due to low back pain can cause debilitating pain and loss of functional movement in patients. dry needling is a minimally invasive procedure that has shown to be useful in the treatment of myofascial trigger points when used with other forms of treatment. however, the literature surrounding dry needling and myofascial trigger points in patients with low back pain is lacking. the guiding systematic review and meta-analysis sought to analyze the effectiveness of dry needling for patients with low back pain. the review utilized eight databases for randomized controlled trials and selected 11 of 784 articles for analysis based on inclusion and exclusion criteria. a 6-subgroup meta-analysis was conducted on these studies, and 6 of the 11 studies were found to have high risk of bias. the included studies used both pain measurements and functional measurements including the visual analogue scale (vas), oswestry disability index (odi), and the roland-morris disability questionnaire (rdq). the studies did not include objective functional measurements. overall researchers found a clinically meaningful decrease in outcome scores in the short-term, but there were no significant differences in pain or functional outcomes through long-term follow-up. this seems to correlate with the current literature on dry needling and its inflammatory effects on the body, suggesting that dry needling alone does not provide any long-term effect on myofascial trigger points in patients with low back pain. dry needling should be combined with other treatments and high-quality rehabilitation to provide longer-lasting results and better treatment outcomes for patients with low back pain. key phrases functional testing, manual therapies, patientreported outocmes correspondence dr. matthew drescher, 567 nth 5th st, terre haute, in 47809. e-mail: mdrescher@sycamores.indstate.edu twitter: @matt_drescher full citation drescher mj, rivera mj, eberman le. dry needling and management of trigger points with low back pain: an evidence to practice review. clin pract athl train. 2021;4(2): 21-25. https://doi.org/10.31622/2021/0004.2.3. submitted: october 16, 2020 accepted: march 11, 2021. original reference liu l, huang qm, liu qg, thitham n, li lh, ma yt, zhao jm. evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis. arch. phys. med. rehabil. 2018, 1;99(1):144-52. summary clinical problem and question low back pain (lbp) is a common healthcare concern worldwide for both the patient and the healthcare system itself. this has subsequent burden, both socially and economically, to the patient and the healthcare system.1 in many cases, the development of myofascial trigger points (mtrps) due to chronic lbp can cause debilitating pain and loss of function in patients. mtrps are defined by simons et al. as a hyperirritable nodule within a taut band of muscular fibers, and these are typically painful to palpation.2 dry needling (dn) is a minimally invasive therapy that uses small monofilament needles to produce physiological changes in the patient, most often targeted at muscle tissue.3 it is widely accepted that the needle causes microtrauma in the tissue, resulting in a cascade of physiologic events that produce changes in the body. these changes include pain modulation (via gate-control and descending pain control theories), increased blood flow, and reduction in taut band activity in the muscle.4, 5 current physiological theory states that taut bands of muscle and mtrps cause ischemic conditions within the muscle leading to the increase in acetylcholine left in the interstitial tissue. this causes sensitization of peripheral pain receptors, mailto:mdrescher@sycamores.indstate.edu https://doi.org/10.31622/2021/0004.2.3 dry needling and management of trigger points with low back pain: an evidence to practice review 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 and it is hypothesized that long-term peripheral sensitization can cause central nervous system sensitization in the spinal cord leading to chronic pain.6, 7 previous literature suggests that dn treatment improves the outcomes in patients with mtrps when combined with other treatments.8 however, current literature on utilizing dn treatments on mtrps in patients with lbp is lacking. further, the quality of evidence is low due to low sample sizes. the guiding systematic review and meta-analysis sought to provide a quantitative analysis on the effectiveness of dn for patients with mtrps when compared to other treatments individually and in combination with other treatments. summary of literature the guiding review used eight databases and searched for randomized controlled trials that included patients with diagnosed lbp and mtrps, dn used as a treatment alone, and pain and or functional movement used as an outcome measure. while this review evaluated studies that compared dn to other treatments, these studies must have studied dn alone as well. this review did not include studies that compared different types of dry needling to each other, randomized control trials had no data, full text could not be obtained, or did not define mtrps by the criteria set by simons et al.2 two blind reviewers evaluated the validity of studies based on the methodologic quality criteria list. of the original 784 articles identified by the original search, 11 randomized control trials were selected for analysis. a 6-subgroup meta-analysis was conducted on the selected randomized control trials that evaluated pain outcomes and functional disability outcomes at post-intervention and follow-up. of the 11 studies included, 6 presented with high risk of bias due to lack of blinding of practitioners and patients, low trial numbers, or low patient recruitment. there is also limited information on objective measurement of functional scores or pain due to lack of integration in the studies reviewed. summary of outcomes the outcomes used within the included studies were pain intensity scores either by visual analogue scale (vas) or an alternate likert scale, and functional disability with either the oswestry disability index (odi) or the roland-morris disability questionnaire (rdq). one study utilized a custom likert scale model for pain intensity and functional disability. both ranged from 0-3, with 0 being no pain or restriction, respectively, and 3 being severe pain or restriction, respectively.9 overall, 10 studies utilized the vas,10-19 3 studies utilized the odi,16, 17, 19 and 7 studies utilized the rdq.10-15, 19 in the original studies, researchers identified clinically meaningful improvements in the outcome scores in all recorded outcome measures after the use of dn intervention. however, the differences ranged between studies, where some studies only found moderate changes and others showed large improvements. one study did not assess functional disability, focusing only on vas scores.18 findings and clinical implications at post-intervention, dn alone saw significant improvements in pain and functional disability outcomes compared to other treatments.20 however, at follow-up evaluation there were no significant differences in pain and functional disability outcomes between the two groups. only two of the studies compared dn alone with dn used in combination with other treatments. these studies found significant improvements in pain scale scores in the short term for dn used in combination with other treatments when compared to using dn alone. this evidence illustrates the usefulness in dn as a treatment in the short-term improvement of pain and functional disability, which could provide an opportunity for patients to see greater improvements during therapeutic exercise sessions. dry needling and management of trigger points with low back pain: an evidence to practice review 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 the results from treatment are mostly local physiological responses, similar to an acute laceration in the tissue. while there is no current literature on the healing response to dry needling specifically, it seems to reason that because dn has an acute inflammatory mechanism in the body, in terms of direct tissue disruption, the effects would only last for a short time. thus, without further treatment such as therapeutic exercise to solidify tissue changes due to this disruption during the subsequent healing phases, the relief gained from dry needling would only be short lived, and this is reflected by the results in both clinical trials and meta-analytical research both physiologically and functionally.5, 21 interestingly, current literature also shows that dn has been effective in eliciting higher passive peak torque, muscle compliance, and stretch tolerance in target tissues at immediate follow-up and at 15 minutes post-intervention compared to static stretching, and this may account for the improvement in functional disability scales immediately after treatment but not during longterm follow-up.22 this seems to be a distinct effect of dn separate from the local tissue disruption and inflammatory response, however other research suggests that dn has the same moderate to long-term effects on peak torque, muscle compliance, and stretch tolerance as static stretching.23 therefore, it seems that the dn response would not continue past the short-term without further stimulation such as follow-up therapeutic exercise. these factors shed light onto the short-term effects seen by studies investigating dn alone. furthermore, low back pain is often a multifactorial pathology. the multiple mechanisms of treatment that occur from dn may explain why there are beneficial effects for patients with lbp within the short-term window as shown by the guiding review.20 a majority of studies in this review had a high risk of bias due to lack of blinding of patients or practitioners. however, it is nearly impossible in clinical outcomes research, specifically with manual therapy, to blind study participants to the treatment. in addition, the clinicians must know what treatment they are performing to actually perform the treatment. while single-blind randomized controlled trials could be performed, there is still a necessary unblinding required for this type of research. clinical bottom line dry needling, while useful alone in the short-term to decrease pain and dysfunction, should be combined with other treatments and rehabilitation to provide longer-lasting results and better treatment outcomes in both the short-term and long-term treatment of lbp. while the risk of bias within manual therapy research is high, future research should endeavor to continue with highly rigorous research with focus on the physiological effects of dry needling. references 1. dagenais s, caro j, haldeman s. a systematic review of low back pain cost of illness studies in the united states and internationally. spine j. 2008;8(1):8-20. https://doi.org/10.1016/j.spinee.2007.10.0 05. 2. simons dg, travell jg, simons ls. travell & simons' myofascial pain and dysfunction: upper half of body. vol 1. lippincott williams & wilkins; 1999. 3. kalichman l, vulfsons s. dry needling in the management of musculoskeletal pain. j am board fam med. 2010;23(5):640-646. https://doi.org/10.3122/jabfm.2010.05.09 0296. 4. cagnie b, dewitte v, barbe t, timmermans f, delrue n, meeus m. physiologic effects of dry needling. curr pain headache rep. 2013;17(8):348. https://doi.org/10.1007/s11916-0130348-5. https://doi.org/10.1016/j.spinee.2007.10.005 https://doi.org/10.1016/j.spinee.2007.10.005 https://doi.org/10.3122/jabfm.2010.05.090296 https://doi.org/10.3122/jabfm.2010.05.090296 https://doi.org/10.1007/s11916-013-0348-5 https://doi.org/10.1007/s11916-013-0348-5 dry needling and management of trigger points with low back pain: an evidence to practice review 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 5. cagnie b, barbe t, de ridder e, van oosterwijck j, cools a, danneels l. the influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation. j manipulative physiol ther. 2012;35(9):685-691. https://doi.org/10.1016/j.jmpt.2012.10.00 5. 6. gerwin rd. the taut band and other mysteries of the trigger point: an examination of the mechanisms relevant to the development and maintenance of the trigger point. j muscskelet pain. 2008;16(12):115-121. http://dx.doi.org/10.1080/10582450801 960081. 7. dommerholt j. dry needling—peripheral and central considerations. j man manip ther. 2011;19(4):223-227. https://dx.doi.org/10.1179%2f10669811 1x13129729552065. 8. lari ay, okhovatian f, sadat naimi s, baghban aa. the effect of the combination of dry needling and met on latent trigger point upper trapezius in females. man ther. 2016;21:204-209. https://doi.org/10.1016/j.math.2015.08.00 4. 9. long j, zhuang x, tan s, yan l. clinical observation of needling of myofascial trigger points and acupoints for myofascial pain syndrome in the lower back. j guangxi univ chin med. 2012;15:17-9. 10. chen z. study on the super laser therapy on trigger points for low back myofascial pain syndrome. guangzhou univ chin med. 2014. 11. hirota s, itoh k, katsumi y. a controlled clinical trial comparing trigger point acupuncture with tender point acupuncture treatments for chronic low back pain-a pilot study on 9 elderly patients. j japn acupuncture moxibustion soc. 2006;56(1):68-75. http://dx.doi.org/10.3777/jjsam.56.68. 12. itoh k, katsumi y. effect of acupuncture treatment on chronic low back pain with leg pain in aged patients-a controlled trial about short-term effects of trigger point acupuncture. j japn acupuncture moxibustion soc. 2005;55(4):530-537. 13. itoh k, katsumi y, hirota s, kitakoji h. effects of trigger point acupuncture on chronic low back pain in elderly patients–a shamcontrolled randomised trial. acupunct med. 2006;24(1):5-12. https://doi.org/10.1136/aim.24.1.5. 14. itoh k, katsumi y, kitakoji h. trigger point acupuncture treatment of chronic low back pain in elderly patients–a blinded rct. acupunct med. 2004;22(4):170-177. https://doi.org/10.1136/aim.22.4.170. 15. kuang j. a research on acupuncture at trigger points treatment for chronic low back myofascial pain syndrome. guangzhou univ chin med. 2013. 16. mahmoudzadeh a, rezaeian zs, karimi a, dommerholt j. the effect of dry needling on the radiating pain in subjects with discogenic low-back pain: a randomized control trial. j res med sci. 2016;21. https://dx.doi.org/10.4103%2f17351995.192502. 17. shen c, ding j. clinical observation of effectiveness in the treatment of lumbar disc herniation with intramuscular stimulation therapy 30 cases reports. zhejiang j tradit chin med. 2015;50:676. 18. yang x, zhou y. clinical observation of effectiveness in the treatment of myofascial pain syndrome in the lower back with intramuscular stimulation therapy. chin j rural med pharm. 2010;17:44-5. 19. téllez-garcía m, de-la-llave-rincón ai, salom-moreno j, palacios-ceña m, ortegasantiago r, fernández-de-las-peñas c. neuroscience education in addition to trigger point dry needling for the management of patients with mechanical chronic low back pain: a preliminary clinical trial j bodyw mov https://doi.org/10.1016/j.jmpt.2012.10.005 https://doi.org/10.1016/j.jmpt.2012.10.005 http://dx.doi.org/10.1080/10582450801960081 http://dx.doi.org/10.1080/10582450801960081 https://dx.doi.org/10.1179%2f106698111x13129729552065 https://dx.doi.org/10.1179%2f106698111x13129729552065 https://doi.org/10.1016/j.math.2015.08.004 https://doi.org/10.1016/j.math.2015.08.004 http://dx.doi.org/10.3777/jjsam.56.68 https://doi.org/10.1136/aim.24.1.5 https://doi.org/10.1136/aim.22.4.170 https://dx.doi.org/10.4103%2f1735-1995.192502 https://dx.doi.org/10.4103%2f1735-1995.192502 dry needling and management of trigger points with low back pain: an evidence to practice review 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 ther. 2015;19(3):464-472. https://doi.org/10.1016/j.jbmt.2014.11.01 2. 20. liu l, huang q-m, liu q-g, et al. evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and metaanalysis. arch phys med rehabil. 2018;99(1):144-152. e2. https://doi.org/10.1016/j.apmr.2017.06.0 08. 21. gattie e, cleland ja, snodgrass s. the effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and metaanalysis. j orthop sports phys ther. 2017;47(3):133-149. https://doi.org/10.2519/jospt.2017.7096. 22. alaei p, ansari nn, naghdi s, fakhari z, komesh s, dommerholt j. dry needling for hamstring flexibility: a single-blind randomized controlled trial. j sport rehabil. 2020;1(aop):1-6. https://doi.org/10.1123/jsr.2020-0111. 23. mason js, crowell m, dolbeer j, et al. the effectiveness of dry needling and stretching vs. stretching alone on hamstring flexibility in patients with knee pain: a randomized controlled trial. int j sport phy ther. 2016;11(5):672. https://doi.org/10.1016/j.jbmt.2014.11.012 https://doi.org/10.1016/j.jbmt.2014.11.012 https://doi.org/10.1016/j.apmr.2017.06.008 https://doi.org/10.1016/j.apmr.2017.06.008 https://doi.org/10.2519/jospt.2017.7096 https://doi.org/10.1123/jsr.2020-0111 abstract manuscript type abstract presentation 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 telehealth optimization – role of clinical athletic trainers in orthopedic/sports medicine practice katie harbacheck, atc; laura grambo, ms, atc; shaun keefer, mha; eric klein, msc, mha; christine boyd, md; carolyn ford-hemann, mha; cameron d’alpe, msph; steve frick, md; kevin shea, md stanford children’s health, palo alto, ca full citation harbacheck k, grambo l, keefer s, klein e, boyd c, ford-hemann c, d’alpe c, frick s. telehealth optimization – role of clinical atcs in orthopedic/sports medicine practice. clin pract athl train. 2021;4(1):62-63. https://doi.org/10.31622/2021/0004.1.9. presented at the 4rd annual athletic trainers in the physician practice society meeting and conference, february 26-27, 2021. abstract background: prior to covid-19, telehealth (th) implementation in most health systems was minimal. the transition to high rates of th was dramatic in response to covid-19, and many health systems struggled to develop optimal, efficient th workflows. hypothesis/purpose: the primary purpose of this study was to evaluate the role of clinically integrated athletic trainers (ats) into the th transition of a major orthopedic academic center through growth of th visits as well as physician satisfaction. methods: workflows and tip sheets were designed to include considerations of th visit increases, adoption of appropriate technology platforms and optimal staff models. the rapid rate of th adoption by orthopedic providers as well as the rates of th visits were monitored. growth of th and in person (ip) visits was reviewed over a 4 month period. the percentage of th visits compared to total visits was calculated. these results were then subjectively reviewed by physician leadership for satisfaction and effectiveness of the th clinic. results: th became common practice in march due to covid-19 social distancing measures. in midmay, the organization lifted restrictions to allow for greater ip visits. march – june, th visits were 291, 702, 408 and 193, respectively. ip visits were 862, 393, 730 and 788 for months march – june, respectively. percentage of th visits was highest in april, accounting for 64% of all visits (figure 1). at the beginning of th implementation (march), the organizational electronic medical record platform was used for virtual visits. there was a high drop-rate, inability to share images and overall patient dissatisfaction. th visits were transitioned to a 3rd party platform in april. initial concerns were that it required more man-power to run: families had to be emailed a link, patients were manually checked-in/out, and documentation had to be collected. ats were used exclusively to coordinate and execute the visits. physician satisfaction for th visits resulted in compliance and increased desire to continue a virtual-based clinic. discussion/conclusion: while the future of th is not clear health systems will increasingly rely on this modality. developing optimal workflows will be critical for further acceptance, effectiveness, and managing the financial costs/returns of providing this service. a clinically integrated athletic training team can be utilized to develop, monitor and maintain a th system, both for sports medicine and general orthopedic practices. correspondence laura grambo, 5000 pleasanton ave, suite 200, pleasantonm ca, 94566. email: laura.grambo@gmail.com https://doi.org/10.31622/2021/0004.1.9 mailto:laura.grambo@gmail.com abstract presentation 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 figure 1. telehealth utilization in orthopedics 0% 10% 20% 30% 40% 50% 60% 70% 80% 0 20 40 60 80 100 120 140 160 telehealth utilization in orthopedics in person visits telehealth visits percentage of telehealth linear (percentage of telehealth) manuscript type comparison of the closed shoulder reduction techniques: an evidence-to-practice review 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 comparison of the closed shoulder reduction techniques: an evidence-to-practice review kaitlin sznajder, ms, atc; dylan arango, ms, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract the shoulder joint is one of the most dislocated joints in the body. it does not have substantial bony support which allows for a large range of motion. shoulder joints most commonly dislocate anteriorly, and less often dislocate posteriorly and inferiorly. there is a myriad of ways to reduce a shoulder dislocation including closed and open techniques. the purpose of this evidence-to-practice review is to summarize which closed shoulder reduction techniques are most effective and apply those results to an athletic training setting. the authors of this guiding systematic review studied multiple articles that compared different closed shoulder reduction techniques on the following criteria: pain experienced by the patient, ease of technique for clinician (time to reduce the shoulder joint), success rate, and complication rates. the authors chose to include randomized control trials, prospective studies, and retrospective studies. the literature revealed that the scapular manipulation technique had the best outcomes in all the criteria, however, every patient that had a shoulder dislocation that was reduced using that method also had intravenous analgesics. the fast, reliable, and safe (fares) method was found to be the third most successful and least painful during relocation and was often used without intravenous analgesics. based on rate of success and patient comfort during reduction, the fares method is the best option, suggesting that it should be taught to healthcare providers more often. depending on the state practice act and physician oversight, athletic trainers who are allowed to reduce dislocations should be informed and educated on how to properly reduce and also allow for the best possible outcome and comfort for the patient. key phrases general medical interventions, clinic and hospital patient population correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation sznajder k, arango d, winkelmann zk. comparison of the closed shoulder reduction techniques: an evidence-to-practice review. clin pract athl train. 2022;5(1): 58-66. https://doi.org/10.31622/2022/0005.01.9. submitted: april 23, 2020 accepted: january 25, 2021. original reference alkaduhimi h, van der linde ja, willigenburg nw, van deurzen dfp, van den bekerom mpj. a systematic comparison of the closed shoulder reduction techniques. arch orthop trauma surg. 2017;137(5):589-599. summary clinical problem and question shoulder dislocations account for over 50% of joint dislocations, making it the most commonly dislocated joint of the body.1,2 in the united states, glenohumeral dislocations occur at a rate of 23.9 per 100,000 person-years, of which 95% occur in an anterior dislocation.2,3 these injuries can cause a lot of pain for the patient, and improper relocation of the joint may cause complications such as tears of the biceps tendon, deep vein thrombosis, and iatrogenic fractures, and other neurological impairments.2 of the shoulder dislocations that presented to emergency departments in the united states between 20022006, 48.3% of them occurred during sport or recreation, and most of those occurring in sport or recreation occurred in males (86.7%).4 shoulder instability is often a result of a dislocation; an epidemiologic study of athletes at three universities demonstrated that football had the highest prevalence of shoulder instability at 29.3% of cases, followed by basketball, and wrestling.5 the same study found that the most common type of instability was an occasional, traumatic anterior dislocations, and the majority of shoulder dislocations and instability were traumatic in nature.5 the national athletic trainers’ association (nata) does not recommend reduction by an athletic trainer if the shoulder joint has dislocated posteriorly or if a fracture is mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.01.9 comparison of the closed shoulder reduction techniques: an evidence-to-practice review 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 suspected.1 posterior dislocations account for approximately 1-5% of all glenohumeral dislocations and are not common in athletics.1,2 the glenohumeral joint is the most commonly dislocated joint specifically in athletes competing in contact or collision sports.1 there are multiple ways that a clinician can choose to relocate a shoulder, all with varying levels of pain experienced by the patient, ease of technique for the clinician (time to reduce the joint), success rate, and complication rates. in this guiding systematic review, ease of the reduction technique for the clinician was determined by the time the technique took to reduce the dislocation.2 typically, the method chosen is a result of the provider’s knowledge, comfort in performing, or guidance from a collaborating physician. athletic trainers may come across an acute shoulder dislocation in the athletics setting, particularly in contact or collision sports. with the update to the 2020 commission on accreditation of athletic training education (caate) standards, specifically standard 70 stating that students must learn how to manage emergent conditions such as reductions of dislocations, more athletic trainers will be educated on those techniques. but this, does mean that there are many athletic trainers who are already certified and practicing without that knowledge, unless they have been instructed outside of their primary education.6 we believe there is a need for certified athletic trainers who were not taught these techniques to be knowledgeable on techniques to properly reduce joint dislocations to ensure improved patient outcomes. athletic trainers also often work in rural areas, where oftentimes emergency personnel can take a long time to arrive. this knowledge of how to properly reduce a shoulder dislocation may save one of their patients a lengthy ride in an ems truck and would also save the patient and their families money as the average cost of a closed shoulder dislocation is $2,200.7 research has explored various individual techniques in reduction but has not compared the techniques to each other. the purpose of this article was to summarize what the systematic review states and compare what the literature indicates about closed reduction techniques in anterior shoulder dislocations, and determine which technique had the best score in each of the previously mentioned categories of pain experienced by the patient, ease of technique for the clinician (time to reduce the shoulder joint), success rate, and complication rates. summary of literature the authors of this guiding article identified 2099 different studies. from that search, articles were included if they focused on shoulder reduction techniques written in english, german, dutch, and arabic. exclusion criteria included open reposition techniques and case reports, systematic reviews, meta-analyses, animal/cadaver/in vitro studies, biomechanical reports, letters to editors, and instructional courses. additionally, each article that was reviewed was graded and given a modified coleman methodology score, which assessed the included articles’ methodology on a scale of 0-90.2 a modified coleman methodology score of less than 50 was considered poor, between 50-64 was fair, between 65-79 was good, and between 80-90 was excellent.2 the coleman methodology score is a tool used by researchers to determine if a study’s methods and outcomes are considered to be of high or low quality, specifically for studies involving orthopedic injuries, surgeries, and rehabilitations; the authors of this systematic comparison modified it for their specific study.2 any study that was given a score of less than 50 points was also excluded from the review. the article list was further narrowed down to 13 articles (9 randomized control trials, 2 retrospective studies, 2 prospective nonrandomized comparative studies). once each article was selected, a comparison was done looking at reduction success, mean reduction time, mean hospital stays, pain, and complications. comparison of the closed shoulder reduction techniques: an evidence-to-practice review 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 summary of interventions the systematic review identified 23 different closed shoulder reduction techniques. however, only 10 reduction techniques were included from the 13 articles selected for the systematic comparison because the other techniques did not meet inclusion criteria or have not been researched. these techniques were then categorized into two groups: traditional and nontraditional. table 1 provides the list of traditional and non-traditional techniques that were included in this systematic comparison. table 2 provides the complete list of 10 reduction techniques including the name, procedure of each reduction technique, is accompanied by a photo demonstration of how each technique should be performed. there were three non-traditional techniques (boss-holzachmatter, bokor-billmann, and aufmesser’s techniques) that were mentioned but not examined in the guiding review article, and for that reason are not in table 2. however, due to the uniqueness of the methods, we have provided brief instructions on the methods. to perform the bossholzach-matter reduction technique, the patient sits with their hands around the knee on the same side of the affected shoulder, leans back, puts their neck into hyperextension, and shrugs the shoulders anteriorly creating a method of selfreduction.8 the bokor-billmann technique involves the practitioner holding the patient’s wrist in one hand, and their elbow in the other, the elbow is flexed to 90 degrees, followed by flexing the glenohumeral joint to 90 degrees, then the shoulder is adducted completely, and then an internal rotation pressure in applied until reduction is felt at about 30 degrees.9 for the aufmesser’s method, the patient is supine, the clinician holds the patient’s hand and fixes their acromion, applies traction to the arm while maintaining eye contact with instructions to relax, and if necessary the clinician’s trunk can be used as a fulcrum to provide extra force.10 summary of outcomes best clinical practice, in this case, was defined by which techniques had the best scores in the following categories: pain experienced by the patient, ease of technique for clinician, success rate, and complication rates. pain levels were determined using the visual analogue scale (vas) with a score between 1-10, with 1 being the least amount of pain and 10 being the greatest amount of pain.2 ease of technique was based on the length of time it took to complete the reduction; a reduction with a lower time was considered easier to perform.2 the success rate was determined by the percentage of reductions that were completed without further intervention, like having to proceed into an open reduction.2 complication risks were determined by any condition that followed and was associated with the reduction such as fracture, deep vein thrombosis, and neuropraxia.2 the aim of this guiding systematic comparison was to determine which closed reduction technique is the best in terms of success rate, ease of technique, complications, and patient reported pain.2 findings and clinical implications this guiding systematic comparison sought to determine which relocation technique was the most effective, efficient, least painful, and had the fewest complications for a patient with a shoulder dislocation. there are many techniques and maneuvers that a clinician needs to consider, along with their own comfort and experience with each. when looking at each article, there were some varying values for each outcome. the highest values for successful reduction (table 1) were the scapular manipulation (97%), the traction-countertraction (95%), the fares method (92%), the spaso technique (92%), and the external rotation maneuver (91%).2 the stimson’s technique was least likely to facilitate a successful reduction (28%).2 scapular manipulation was the quickest (mean time 1.75 min), while the stimson’s comparison of the closed shoulder reduction techniques: an evidence-to-practice review 61 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 1: reduction techniques techniques reduction style pain experienced by patient (vas 1-10) time to reduce shoulder (minutes) success rate (%) complications kocher maneuver traditional 4.68 ± 2.00 4.19 ± 1.25 85 1 spaso technique traditional 4.69 ± 1.26 2.65 ± 0.59 92 0 external rotation technique traditional 3.39 ± 0.40 3.06 ± 0.28 91 0 milch maneuver traditional 5.28 ± 0.54 4.29 ± 0.14 80 0 chair method traditional 4.00 ± 0.60 3.00 ± 0.30 78 0 tractioncountertraction traditional 4.75 ± 0.55 6.05 ± 2.49 95 0 scapular manipulation traditional 1.47 ± 0.44 1.75 ± 0.38 97 0 stimson’s technique traditional 5.30 ± 0.14 8.84 ± 0.30 28 0 hippocratic maneuver traditional 4.88 ± 0.54 5.55 ± 0.39 73 0 fast, reliable, and safe (fares) method non traditional 1.59 ± 0.46 2.24 ± 0.27 92 0 technique took the longest (mean time 8.84 min).2 only three studies looked at mean hospital stay. shoulders reduced with the milch maneuver had the shortest hospital stay (35 min), followed by those who were treated with scapular manipulation (92.4 min), the oxford chair (141 min), and the traction-countertraction maneuver (320.4 min).2 for patient experienced pain, the scapular manipulation technique tends to be the least painful during the reduction (vas=1.47 during reduction), followed by the fares method (vas=1.59 during reduction).2 the stimson’s method (vas=5.30; sd 0.14) and the milch method (vas=5.28) tend to be the most painful.2 only one study reported a complication which occurred during implementation of the kocher reduction technique, which was a fracture of the humeral neck.2 the authors of this systematic comparison also specifically mention that the kocher method has previously been associated with a rupture of the pectoral muscles or humeral fractures and that the hippocratic method has been associated with transient neuropraxia of the brachial nerve.2 evidence in this review identified that the fares method had the best outcomes without any analgesic use reported.2 the scapular manipulation technique had a lower patient pain rating during relocation, but all patients receiving that technique on their dislocation were also given intravenous analgesics. it is evident that the scapular manipulation technique and fares maneuver had the lowest amounts of pain during reduction and these two techniques also exhibited some of the highest rates of reduction success. the fares method is new and considered nontraditional compared to the scapular manipulation technique, but clearly shows promising outcomes in patient pain and reduction success.2 however, there are many limitations to this systematic comparison that need to be addressed. practitioner experience and bias were not examined, as some may be more likely to choose one method over another based-on patient characteristics or their own comfort and education in reduction. this analysis was done using studies that took place in the hospital setting, and therefore does not consider the hospital protocols, which could particularly influence the outcome of length of hospital stay. furthermore, many comparison of the closed shoulder reduction techniques: an evidence-to-practice review 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 methods used accompanying analgesics or anesthetics and it was not determined if the use of these had been determined by hospital protocol, physician order, or upon patient request. the authors concluded that the techniques that also used analgesics or anesthesia generally had higher rates of successful reduction; it makes sense that a person in less pain would also have less muscle guarding, allowing for a better chance at a successful reduction. along with the risks associated with closed reduction of a shoulder dislocation, the use of analgesics or anesthesia comes with its own set of concerns that affect patient comfort, such as vomiting and respiratory distress.2 this is relevant to athletic trainers because, depending on the standing orders from the team physician or laws of the state in which they are practicing, the athletic trainer may be in a situation in which they are called on to relocate a shoulder and knowledge of which technique to use is important for best patient outcomes. joint relocation has become part of the 2020 caate standards, leaving many athletic trainers who have already completed their education without this training. we believe that education on these shoulder reduction techniques should be taught to athletic trainers who are already certified; it may be possible to do so at either at a conference or as a professional development course, as this is likely where many athletic trainers can gather for education. however, an online class, while more attainable, may not be the best option as techniques like this require firsthand practice. based on the findings of the guiding systematic comparison and our own clinical analysis, we believe that the fares method is the most clinically applicable for athletic trainers while also being cautious of patient comfort. the fares method is simple and does not require intravenous analgesics, which some athletic trainers are not allowed to provide based on state practice acts and physician oversight. in our experience, athletic trainers may come across an acute shoulder dislocation in the athletics setting, particularly in contact or collision sports. clinical bottom line there are several techniques to reduce a shoulder dislocation. choosing which technique to use depends on clinician training, access to extraneous assistance such as intravenous analgesics, the direction of dislocation, and the setting that the clinician is providing care. according to this review, the fares technique was the most successful, least painful, and quickest when the use of intravenous analgesics was not available.2 although the scapular manipulation method of reduction had the best results across all categories, all patients were treated with intravenous analgesics, which is not readily available in many athletic training settings. also, athletic trainers are often not able to provide the intravenous analgesics so additional assistance may be required and is not always an option. the other techniques are valid but are not as effective based on the criteria. we believe that athletic trainers need more access to education on joint reduction techniques. further research should include dislocation reductions involving athletic trainers and their prehospital care in a variety of patients that reflect an athletic trainers’ patient population. references 1. rozzi sl, anderson jm, doberstein st, godek jj, hartsock la, mcfarland eg. national athletic trainers' association position statement: immediate management of appendicular joint dislocations. j athl train. 2018;53(12):1117-1128. https://doi.org/10.4085/1062-6050-9712. 2. alkaduhimi h, van der linde ja, willigenburg nw, van deurzen dfp, van den bekerom mpj. a systematic comparison of the closed shoulder reduction techniques. arch orthop trauma surg. 2017;137(5):589-599. https://doi.org/10.4085/1062-6050-97-12 https://doi.org/10.4085/1062-6050-97-12 comparison of the closed shoulder reduction techniques: an evidence-to-practice review 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 https://doi.org/10.1007/s00402-0172648-4. 3. guler o, ekinci s, akyildiz f, et al. comparison of four different reduction methods for anterior dislocation of the shoulder. j orthop surg res. 2015;10:80. https://doi.org/10.1186/s13018-0150226-4. 4. zacchilli ma, owens bd. epidemiology of shoulder dislocations presenting to emergency departments in the united states. jbjs. 2010;92(3):542-549. https://doi.org/10.2106/jbjs.i.00450. 5. wagstrom e, raynor b, jani s, et al. epidemiology of glenohumeral instability related to sporting activities using the feds (frequency, etiology, direction, and severity) classification system: a multicenter analysis. orthop j sports med. 2019;7(7):2325967119861038. https://doi.org/10.1177/2325967119861 038. 6. commission on accreditation of athletic training education. 2020 standards for accreditation of professional athletic training programs: master’s degree programs. accessed january 25, 2021. https://caate.net/wpcontent/uploads/2019/08/2020standards-final-7-15-2019.pdf 7. comadoll sm, landry jarvis d, yancey hb, graves br. the financial burden associated with multiple shoulder dislocations and the potential cost savings of surgical stabilization. jses int. 2020;4(3):584-586. https://doi.org/10.1016/j.jseint.2020.04.02 3. 8. marcano-fernández fa, balaguer-castro m, fillat-gomà f, ràfols-perramon o, torrens c, torner p. teaching patients how to reduce a shoulder dislocation: a randomized clinical trial comparing the boss-holzach-matter self-assisted technique and the spaso method. j bone joint surg am. 2018;100(5):375-380. https://doi.org/10.2106/jbjs.17.00687. 9. bokor-billmann t, lapshyn h, kiffner e, goos mf, hopt ut, billmann fg. reduction of acute shoulder dislocations in a remote environment: a prospective multicenter observational study. wilderness environ med. 2015;26(3):395-400. https://doi.org/10.1016/j.wem.2014.12.02 7. 10. dreu m, aufmesser w, aufmesser h, dolcet c, feigl g, sadoghi p. a simple and gentle technique for reduction after anterior shoulder dislocation. arch orthop trauma surg. 2015;135(10):1379-84. https://doi.org/10.1007/s00402-0152279-6. https://doi.org/10.1007/s00402-017-2648-4 https://doi.org/10.1007/s00402-017-2648-4 https://doi.org/10.1186/s13018-015-0226-4 https://doi.org/10.1186/s13018-015-0226-4 https://doi.org/10.2106/jbjs.i.00450 https://doi.org/10.1177/2325967119861038 https://doi.org/10.1177/2325967119861038 https://caate.net/wp-content/uploads/2019/08/2020-standards-final-7-15-2019.pdf https://caate.net/wp-content/uploads/2019/08/2020-standards-final-7-15-2019.pdf https://caate.net/wp-content/uploads/2019/08/2020-standards-final-7-15-2019.pdf https://doi.org/10.1016/j.jseint.2020.04.023 https://doi.org/10.1016/j.jseint.2020.04.023 https://doi.org/10.2106/jbjs.17.00687 https://doi.org/10.1016/j.wem.2014.12.027 https://doi.org/10.1016/j.wem.2014.12.027 https://doi.org/10.1007/s00402-015-2279-6 https://doi.org/10.1007/s00402-015-2279-6 comparison of the closed shoulder reduction techniques: an evidence-to-practice review 64 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 2: how to perform each reduction technique included in systematic comparison technique name performance process photo of technique 1. kocher maneuver 1. patient is supine, arm adducted, and elbow flexed to 90 degrees 2. clinician externally rotates arm until resistance is felt 3. clinician flexes arm in external rotation 4. clinician returns to adducted position 2. spaso technique 1. patient is supine, shoulder flexed to 90 degrees 2. clinician pulls traction 3. clinician externally rotates shoulder while maintaining traction until relocation is felt 3. external rotation technique 1. patient is supine with arm adducted and elbow flexed to 90 degrees each 2. clinician flexes shoulder to 20 degrees 3. clinician moves shoulder into external rotation until reduction is felt comparison of the closed shoulder reduction techniques: an evidence-to-practice review 65 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 4. milch maneuver 1. patient is supine 2. clinician holds arm at the wrist 3. clinician abducts and externally rotates arm until relocation is felt 5. chair method 1. patient’s axilla is placed over back of a chair 2. clinician holds arm from wrist and elbow 3. clinician pulls downward traction until relocation occurs 6. traction-countertraction 1. patient lies supine with a sheet or belt around thorax and around contralateral side of affected shoulder and clinician 2. patient elbow and shoulder are each flexed to 90 degrees 3. clinician applies traction 4. typically requires two clinicians comparison of the closed shoulder reduction techniques: an evidence-to-practice review 66 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 7. scapular manipulation 1. patient is prone with shoulder hanging off the table at 90 degrees of flexion 2. patient holds weight in hand to provide traction 3. clinician rotates scapula medially 8. stimson’s technique 1. patient is prone 2. arm hangs off edge of the table 3. manual or weighted traction is placed on the hanging arm 4. held for 10-20 min until shoulder relocates 9. hippocratic maneuver 1. patient is supine 2. clinician places foot into injured side axilla 3. traction is applied while arm is abducted to 30 degrees 10. fast, reliable, and safe (fares) method 1. patient is supine 2. clinician holds arm at the wrist 3. clinician slowly abducts the arm while providing constant traction and oscillation abstract manuscript type evidence-to-practice review 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 rater reliability of the functional movement screen: an evidence-topractice review nate orth, ms, scat, atc; adam graham, ms, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract the purpose of this evidence-to-practice review is to summarize a systematic review on the interand intrarater reliability of the functional movement screen (fms). reliability is crucial to the fms, as clinicians may retest to view a patient’s changes and improvements in movement patterns. this review and analysis looked at 7 studies which showed that both interand intrarater reliability were good. studies were only included if the primary focus was on interand intrarater reliability. clinicians had varying levels of familiarity with the fms process. athletic training students with less than one year to no experience were found to have poor reliability. the findings also supported that clinicians who treated the same patient would have similar results about 80% of the time. the same clinician completing several screenings with the different patient would have reliable results about 85% of the time. interrater reliability is an important aspect to a clinician’s ability to monitor progress or modifications that a patient may exhibit. overall, the fms has good interand intrarater reliability and can be a predictor of injury risk and mobility. for both interand intrarater reliability to improve, it is beneficial for clinicians to have clinical experience and practice using the test to aid in accurate scoring. certification in fms is a way to develop repetition training from a reliable source, but it is unclear from these studies if certification changes reliability. the fms screening serves as a useful tool because it allows for unlimited testing, video recordings for patient education or additional clinician evaluation, and is reliable among clinicians. we suggest that components of the fms be used clinically for injury prevention, such as pre-participation exams and return-to-play criteria for injuries if scored by a formally trained clinician with experience assessing patient functional movement. key phrases preparticipation exams and screening, injury risk reduction, functional testing correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation orth n, graham a, winkelmann zk. rater reliability of the functional movement screen: an evidence-topractice review. clin pract athl train. 2021;4(2): 5863. https://doi.org/10.31622/2021/0004.2.9. submitted april 20, 2020 accepted: november 16, 2020. original reference cuchna jw, hoch mc, hoch jm. the interrater and intrarater reliability of the functional movement screen: a systematic review with meta-analysis. phys ther sport. 2016;19:5765. summary clinical problem and question the functional movement screen (fms) is a standardized movement screen for individuals using a score to predict risk of injury and mobility.1-3 it uses a series of 7 tests including the deep squat, hurdle step, in-line lunge, shoulder mobility, active straight leg raise, trunk stability push-up, and rotatory stability.1,3 each test is scored 0-3 with a score of 3 meaning that there is no compensation, a score of 2 meaning there is compensation during the movement, a score of 1 meaning the movement is not fully completed as instructed, and a score of 0 meaning there is pain with the associated movement.1 the use of the fms as an clinical assessment tool to identify limitations and restrictions in athletic movement has previously come under scrutiny due to rater reliability.2,4,5 interrater reliability is the measure that assesses how different evaluators agree or disagree upon the grading, while intrarater reliability assesses how reliable grading is by the same evaluator at different points in time.6 in theory, high rates of reliability for the fms are necessary to be able to identify score differences over time or among a team of clinicians in physical medicine (athletic training and physical therapy). if the interrater reliability is not adequate, the use of multiple clinicians can misrepresent intervention mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.2.9 rater reliability of the functional movement screen: an evidence-to-practice review 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 outcome scores. if the intrarater reliability is not adequate, interventions over time may be misrepresented when the patient is re-tested. due to the increased popularity of the movement screening in clinical practice,7 there is a need to review the evidence specific to interand intrarater reliability of the fms. summary of literature the focus of the guiding systematic review8 was to determine the interand intrarater reliability of the fms in clinical practice. articles that were selected included active populations (secondary school and collegiate athletes). the included studies had to use the original scoring system1,7 and incorporated all 7 tests that make up the standard movement screen for the fms, with or without the three clearing tasks.3,7 the fms clearing tasks (shoulder clearing, extension clearing, and flexion clearing) are pain provocation tests that take a joint through a full range of motion and meant to provide a clear stopping point when a medical referral is necessary. no studies involving injured athletes or that measured reliability as part of a larger study were included. the authors originally retrieved 110 articles and narrowed to 14 studies based off the purpose of the study. after author review, was narrowed to 7 studies that met specific inclusion criteria for the purpose of the study. summary of outcomes of these 7 articles included, 6 studies evaluated interrater reliability and 6 studies evaluated intrarater reliability. all 7 of the studies went through rigorous risk bias using a quality appraisal of reliability studies (qarel) checklist. the qarel checklist further identified the quality of the studies included in the final grouping. after article selection and quality appraisal, the results from all included studies were meta-analyzed to identify fms reliability. the sample size of clinicians in the included articles was also assessed (range=1-38), with 5 of the 7 articles reporting 1-5 clinicians. the studies also included a mixture of assessment procedures that used real-time assessments and video recordings. findings and clinical implications the meta-analysis identified that the fms has good interand intrarater reliability.8 the intraclass coefficient (icc), or the measure of how a score closely matches up to another score, value for interrater reliability was 0.843. a value closer to 1 indicates similarity between different tests for a single rater. the 95% confidence interval for the interrater reliability icc value was 0.797 to 0.882. the icc value for intrarater reliability was 0.869 with a 95% confidence interval between 0.854 to 0.885. there was a moderate level of quality evidence showing good interrater reliability. there was only one study9 that found it to be fair or poor, but did not lower the overall average. from the one fair/poor study,9 the authors identified poor reliability in clinicians that were limited in their fms experience, which ranged from self-taught to less than 1 year of experience. however, the study did not mention if the clinicians had been formally certified in fms. the guiding systematic review findings8 indicated formal training paired with experience as the best way to achieve accurate results. it is unclear if certification is necessary, based on these studies, other than that a certification course provides the formal training and educational resources.3 the other aspect analyzed was clinical experience with the studies including healthcare providers and students from various fields including physical therapy,9-13 athletic training,9,14,15 strength & conditioning9,15 with certified and non-certified fms testers of various experiences (0-4 years). based off the data from the guiding systematic review, when the rater had greater experience with fms scoring the interrater reliability subsequently increased.9,11 rater reliability of the functional movement screen: an evidence-to-practice review 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 intrarater reliability received similar results to interrater, which identified a moderate level of quality evidence for good reliability on the fms. there was one study that was deemed fair, but the clinicians were athletic training students with no previous fms experience.14 based on the findings, it was determined that experience played a significant role in the intrarater reliability for many of the same reasons as interrater reliability. several reiterations with the same patient would also be a major benefit for the clinician, as observing how different movements are completed could indicate which muscles are activated. interand intrarater reliability were assessed with real time and video recorded scoring. both scoring methods were deemed good. the finding suggests that scoring could be completed several times and by several clinicians if needed, or videos could be sent to a certified fms tester for screening confirmation if additional input was warranted. formal certification can be expensive with current level 1 fms training costing $400.3 certification is a reasonable option for situations where analysis is needed, and the clinician will be primarily involved in correction strategies. however, sending videos to a more experienced fms tester could also be an option for newly trained clinicians and athletic training students to obtain experience while receiving feedback on their scoring assessment. video review may also be a viable option for fms scorers who do not receive many repetitions of the test but still have a desire to implement the outcome measure. clinical bottom line one domain of athletic training practice is injury and illness prevention and wellness promotion.16 through this domain, athletic trainers should seek to minimize the risk of injury, which has often been linked to mechanisms such as pre-participation exams, screening practices, and maintaining a safe environment for activities.17 one specific screening mechanism, the fms, has been used as an established method to evaluate movement quality and subsequent insufficiencies.1,11 however, there is conflicting evidence whether the fms tests can predict specific or overall injury risk using the scoring criteria.4,5,18 the issue is that the test is scored by a rater for movement quality at specific joints and through the kinetic chain on a graded scale which does not account for sport specific movements.7 additionally, previous research has noted that there are conflated reports of injury prediction modeling leading to questions specific to its ability to screen for injury.2 in the guiding systematic review, the fms test has shown good interrater and intrarater reliability which provides support to clinicians for long term outcome measures and evaluation.8 however, despite the data supporting the reliability, the external resources often call into question if the fms test has the predictive capabilities or screening sensitivity necessary for that of directing prevention resources towards a targeted population.19 more specifically, the fms has also been used as a tool to monitor and evaluate rehabilitation progress. as the fms seems not to have the screening or preventative nature necessary for sports medicine, we suggest that raters incorporate the fms as a baseline screening not for injury prevention planning but as a model for return-to-activity basis. the data supports the use of video recording for fms testing,8 as well as during injury rehabilitation as a means to reduce the psychosocial impact of fear avoidance movements.20 we suggest that athletic trainers wishing to implement the fms as a screening tool do so for all patients, regardless of injury, and video record their movements. after doing so, if the patient sustains an injury, the clinician could use the video recording of the fms as a baseline for movement quality pre-injury and a goal setting technique for the rehabilitation phases. rater reliability of the functional movement screen: an evidence-to-practice review 61 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 however, the issue still with the fms is the subjective nature of the objective scoring.7 while, as an outcome measure, the fms provides a specific and measurable goal for the patient to achieve following their injury. the fms score alone leaves a lot to be desired, since there are many factors that lead to a specific score; thus, clinician interpretation is crucial. factors such as range of motion across multiple joints and muscle recruitment are all integrated to create one numerical score, as well as observation from a singular vantage point through dynamic movement is of concern.15 the main takeaway of the fms is to identify if there is an issue; however the unique biomechanical movements of specific athletes cannot be viewed in a score. the score also must be supplemented by commentary by a trained clinician who interprets the scoring to identify associated weaknesses and steps to strengthen primary muscle movers. the fms does not guarantee the clinician will always notice the weakness either. for example, a clinician watching a deep squat might score a 2 for an athlete that has excessive forward lean as a compensatory movement. while this score would be correct, if another clinician received that score without any notes, it would be difficult to know where the incorrect movement occurred. a qualified individual scoring the fms would be able to take that score and implement changes to ankle dorsiflexion to eliminate the compensatory movement, retest, and determine if further changes were necessary. since the fms has strong inter and intrarater reliability suggesting that it has a place in clinical practice, we suggest that athletic trainers wishing to incorporate it see the score as one piece of the data and that notes or qualitative explanations of the movement insufficiencies be explained in detail for clarity on the scoring, intervention planning, and later reevaluation of the test. the guiding systematic review suggested that for both interand intrarater reliability to improve, clinicians must have opportunities to use the fms test with repetitions and directed feedback in their scoring.8 the use of feedback and deliberate practice requires time, which athletic training has continued to identify as a limitation in implementing evidence-based practice.21 however, we believe that the use of video to record the patient throughout the testing movements would allow multiple clinicians to score the patient outside of real time. the proposal would be best integrated during pre-season or a pre-participation exam. a clinician among the healthcare team, whether that be within the same college/university or hospital outreach team, or even a cohort of students within an athletic training program, could evaluate and score the videos from multiple angles (frontal and sagittal planes of the body) with specific feedback on the movement quality noted. not only would this allow for a future clinician to get the needed practice with the current patient population, but it also removes the burden from a singular formally trained clinician with experience assessing patient functional movement. overall, the data supports that there is reliability with the scoring within and between raters. however, clinicians have begun to adopt the fms as the singular screening tool to predict injury, which is not supported by the literature. we must be creative in our pursuits of using objective outcome measures, such as the fms, not as a number based criteria for injury prevention planning or ruling out risk, but as a means to have baseline data among the team of raters in case of an injury occurring for future return-to-activity therapeutic interventions. references 1. cook g, burton l, hoogenboom b, voight m. pre-participation screening: the use of fundamental movements as an assessment of rater reliability of the functional movement screen: an evidence-to-practice review 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 function-part 1. n am j sports phys ther. 2006;1(2):62–72. 2. warren m, lininger mr, chimera nj, smith ca. utility of fms to understand injury incidence in sports: current perspectives. open access j sports med. 2018;9:171. https://doi.org/10.2147/oajsm.s149139. 3. functional movement systems. https://www.functionalmovement.com. accessed march 31, 2020. 4. bonazza na, smuin d, onks ca, silvis ml, dhawan a. reliability, validity, and injury predictive value of the functional movement screen: a systematic review and metaanalysis. am j sports med. 2016;45(3):725– 32. https://doi.org/10.1177/0363546516641 937 5. dorrel b, long t, shaffer s, myer gd. the functional movement screen as a predictor of injury in national collegiate athletic association division ii athletes. j athl train. 2018;53(1):29-34. https://doi.org/10.4085/1062-6050-52815. 6. lange r. inter-rater reliability. encyclopedia of clinical neuropsychology. 2011:1348. http://dx.doi.org/10.1007/978-0-38779948-3_1203. 7. wright aa, stern b, hegedus ej, tarara dt, taylor jb, dischiavi sl. potential limitations of the functional movement screen: a clinical commentary. br j sports med. 2016. https://doi.org/10.1136/bjsports-2015095796. 8. cuchna jw, hoch mc, hoch jm. the interrater and intrarater reliability of the functional movement screen: a systematic review with meta-analysis. phys ther sport. 2016;19:57-65. https://doi.org/10.1016/j.ptsp.2015.12.00 2. 9. shultz r, anderson sc, matheson go, marcello b, besier t. test-retest and interrater reliability of the functional movement screen. j athl train. 2013;48(3):331-336. https://doi.org/10.4085/1062-605048.2.11. 10. gulgin h, hoogenboom b. the functional movement screening (fms)™: an inter‐rater reliability study between raters of varied experience. int j sports phys ther. 2014;9(1):14. 11. teyhen ds, shaffer sw, lorenson cl, et al. the functional movement screen: a reliability study. j ortho sports phys ther. 2012;42(6):530-540. https://doi.org/10.2519/jospt.2012.3838. 12. smith ca, chimera nj, wright nj, warren m. interrater and intrarater reliability of the functional movement screen. j strength cond res. 2013;27(4):982-987. https://doi.org/10.1519/jsc.0b013e31826 06df2. 13. parenteau-g e, gaudreault n, chambers s, et al. functional movement screen test: a reliable screening test for young elite ice hockey players. j phys ther sport. 2014;15(3):169-175. https://doi.org/10.1016/j.ptsp.2013.10.00 1. 14. gribble pa, brigle j, pietrosimone bg, pfile kr, webster ka. intrarater reliability of the functional movement screen. j strength cond res. 2013;27(4):978-981. https://doi.org/10.1519/jsc.0b013e31825 c32a8. 15. onate ja, dewey t, kollock ro, et al. realtime intersession and interrater reliability of the functional movement screen. j strength cond res. 2012;26(2):408-415. https://doi.org/10.1519/jsc.0b013e31822 0e6fa. 16. henderson j. the 2015 athletic trainer practice analysis study. omaha, ne.: board of certification; 2015. https://bocatc.org/system/document_version s/versions/23/original/boc-comparison-ofhttps://doi.org/10.2147/oajsm.s149139 https://www.functionalmovement.com/ https://doi.org/10.1177/0363546516641937 https://doi.org/10.1177/0363546516641937 https://doi.org/10.4085/1062-6050-528-15 https://doi.org/10.4085/1062-6050-528-15 http://dx.doi.org/10.1007/978-0-387-79948-3_1203 http://dx.doi.org/10.1007/978-0-387-79948-3_1203 https://doi.org/10.1136/bjsports-2015-095796 https://doi.org/10.1136/bjsports-2015-095796 https://doi.org/10.1016/j.ptsp.2015.12.002 https://doi.org/10.1016/j.ptsp.2015.12.002 https://doi.org/10.4085/1062-6050-48.2.11 https://doi.org/10.4085/1062-6050-48.2.11 https://doi.org/10.2519/jospt.2012.3838 https://doi.org/10.1519/jsc.0b013e3182606df2 https://doi.org/10.1519/jsc.0b013e3182606df2 https://doi.org/10.1016/j.ptsp.2013.10.001 https://doi.org/10.1016/j.ptsp.2013.10.001 https://doi.org/10.1519/jsc.0b013e31825c32a8 https://doi.org/10.1519/jsc.0b013e31825c32a8 https://doi.org/10.1519/jsc.0b013e318220e6fa https://doi.org/10.1519/jsc.0b013e318220e6fa https://bocatc.org/system/document_versions/versions/23/original/boc-comparison-of-pa7-to-rd-pa6-20170612.pdf?1497278853 https://bocatc.org/system/document_versions/versions/23/original/boc-comparison-of-pa7-to-rd-pa6-20170612.pdf?1497278853 rater reliability of the functional movement screen: an evidence-to-practice review 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 pa7-to-rd-pa620170612.pdf?1497278853. 17. guindon cc, winkelmann zk, eberman le, games ke. practice of and barriers to prevention by secondary school athletic trainers. internet j allied health sci pract. 2018;16(4):4. 18. moran rw, schneiders ag, mason j, sullivan sj. do functional movement screen (fms) composite scores predict subsequent injury? a systematic review with meta-analysis. br j sports med. 2017;51(23):1661-1669. https://doi.org/10.1136/bjsports-2016096938. 19. bushman tt, grier tl, canham-chervak mc, anderson mk, north wj, jones bh. pain on functional movement screen tests and injury risk. j strength cond res. 2015;29:s65-s70. https://doi.org/10.1519/jsc.00000000000 01040. 20. podlog l, dimmock j, miller j. a review of return to sport concerns following injury rehabilitation: practitioner strategies for enhancing recovery outcomes. phys ther sport. 2011;12(1):36-42. https://doi.org/10.1016/j.ptsp.2010.07.00 5. 21. welch ce, hankemeier da, wyant al, hays dg, pitney wa, van lunen bl. future directions of evidence-based practice in athletic training: perceived strategies to enhance the use of evidence-based practice. j athl train. 2014;49(2):234-244. https://dx.doi.org/10.4085%2f10626050-49.2.15. https://bocatc.org/system/document_versions/versions/23/original/boc-comparison-of-pa7-to-rd-pa6-20170612.pdf?1497278853 https://bocatc.org/system/document_versions/versions/23/original/boc-comparison-of-pa7-to-rd-pa6-20170612.pdf?1497278853 https://doi.org/10.1136/bjsports-2016-096938 https://doi.org/10.1136/bjsports-2016-096938 https://doi.org/10.1519/jsc.0000000000001040 https://doi.org/10.1519/jsc.0000000000001040 https://doi.org/10.1016/j.ptsp.2010.07.005 https://doi.org/10.1016/j.ptsp.2010.07.005 https://dx.doi.org/10.4085%2f1062-6050-49.2.15 https://dx.doi.org/10.4085%2f1062-6050-49.2.15 abstract manuscript type evidence-to-practice review 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the validity and reliability of assessments through telemedicine: an evidence-to-practice review connor l. givens, ms, atc*; gabrielle a. griffin, ms, atc†; matthew d. johnson. ms, atc‡; zachary k. winkelmann, phd, atc§ *orthopaedic medical group of tampa bay, tampa, fl; †east carolina university, greenville, nc; ‡moore orthopedics and sports medicine, morehead city, nc; §university of south carolina, columbia, sc abstract the validity and reliability of telemedicine assessments has been explored through numerous studies. telemedicine is a diagnostic tool that combines visual technology, audio technology, and tools for assessment. the assessment of musculoskeletal disorders is a key portion in the field of athletic training. the development of telemedicine assessment tools has improved over time but has not yet been perfected. data was collected via four databases that included articles examining validity, interand intrarater reliability, and telemedicine assessment for musculoskeletal tests. the reviews of the systematic review used quality assessment of diagnostic accuracy studies (quadas) and quality appraisal tool for studies of diagnostic reliability (qarel) to assess the quality of the selected articles. the results from the guiding systematic review revealed good concurrent validity and great reliability for range of motion (rom), muscle strength, pain, and gait assessments. however, it revealed low to moderate concurrent validity for assessments such as orthopedic special tests and assessments of neurological disorders. based on these findings, the recommendations for telemedicine include the need to create a standardized measure to ensure consistency between both interand intraraters and a need for advancement in technology for the enhancement of diagnostic accuracy in patients with musculoskeletal disorders. it is feasible for athletic trainers to incorporate telemedicine into their clinical practices, while increasing their technological skills of assessment to continue improving patient-centered care. content focus: health information technology correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation givens cl, griffin ga, johnson md, winkelmann zk. the validity and reliability of assessment through telemedicine: an evidence-to-practice review. clin pract athl train. 2023;6(1): 51-54. https://doi.org/10.31622/2022/0006.01.7. original reference mani s, sharma s, omar b, paungmali a, joseph l. validity and reliability of internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review. j telemed telecare. 2017;23(3):379-391. doi:10.1177/1357633x16642369 summary clinical problem and question telemedicine is an emerging form of healthcare delivery provided from a distance using various forms of technology for prevention, evaluation, diagnosis, and treatment.1 many clinicians are not able to successfully perform a musculoskeletal assessment due to the limited reliability and validity of the methods used.2 other barriers for clinicians to the performance of telemedicine assessments include limited internet access, lack of adequate digital health literacy and skills, and socioeconomic status. though many would assume that the majority of adults would have adequate computer skills, approximately 40% of healthcare workers are not specifically trained in computer skills, which implies a deficit in the ability to adopt telemedicine practices.3 in order to further progress into the use of telemedicine, more clinicians must have the adequate skills to perform not only reliable evaluations but also prescribe effective rehabilitation protocols. the ability to use specific software or online measurement tools may also improve the diagnostic accuracy of the assessment, and in turn improve the likelihood of adopting telemedicine practices.4 teleassessment focused on the mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0006.01.7 the validity and reliability of assessments through telemedicine: an evidence-to-practice review 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 different levels of validity and reliability when assessing the parts of the body. the assessments included low back, shoulder, elbow, ankle, and knee. the variation of reliability and validity is due to the limited nature of clinicians not being physically present during an exam. the adoption of telemedicine is crucial in reaching underserved populations with limited access to healthcare.5 the purpose of the reviewed study was to evaluate the validity and reliability of rom, mmt, special tests, and postural assessments via telemedicine. summary of literature the authors of the guiding systematic review completed an article search using pubmed, embase, psycinfo, cochrane library and cinahl databases. the primary key terms for the search was, ‘telerehabilitation or tele-rehabilitation or teleassessment’.6 the search was then focused using individual search terms elaborating on the specific areas of the body (“...shoulder, elbow, wrist, neck pain etc.…”) and terms to identify the test/tester (“...inter tester, inter examiner, intra tester, intra examiner and test retest”).6 the same search terms were utilized in each of the electronic databases. the guiding systematic review’s authors also searched the reference lists of the main article for information pertaining to the topic. literature that was included in the article was of the english language, measured the validity and/or reliability of musculoskeletal disorders assessment using telerehabilitation, and was published between from january 2000 and may 2015. the exclusion criteria for the guiding systematic review included unpublished manuscripts, letters, guidelines, conference proceedings, theses, other descriptive publications, and published literature on telerehabilitation assessments focused on neurological and other chronic conditions.6 after using the above criteria, the total number of identified articles was 898. after exclusion of duplicate articles and screening the articles for reliability of relevance to the topic using quadas and qarel, 11 studies were included in the guiding systematic review. of the 11 studies, two examined low back pain, one examined shoulder disorders, one examined lower limb musculoskeletal disorders, one examined elbow disorders, one examined total knee replacement, one examined ankle disorders, and examined four cases with no prior ailments.6 summary of intervention telemedicine is an area of healthcare that allows for remote access to healthcare using visual and audio technology. technological access to healthcare not only increases care to remote geographical locations, but also increases care to populations in low socioeconomic situations.7 telemedicine combines a variety of services used via technology to accomplish therapy in a setting that can be outside of the clinic that is conducive to patient needs. telemedicine can be used for applications such as assessment of musculoskeletal conditions, and well as rehabilitation of stroke or neurological disorders.8 summary of outcomes the authors of the guiding systematic review used different types of statistical methods to determine the validity and reliability of a variety of telemedicine assessments. the data from five of the studies were converted. the data were used to calculate the association between telemedicine and face-to-face assessment methods. the data from all studies assessed validity and both intraand inter-rater reliability for the telemedicine assessment. assessments were determined to have either poor, moderate, good, or excellent validity and reliability. the studies did not include a range of scores that would give a grade for the validity and reliability of assessments through telemedicine: an evidence-to-practice review 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 validity and reliability. for an assessment to be favored, either teleassessment or face-to-face, there must be a significant difference present between the two methods. knee rom assessed using a universal goniometer placed on the computer screen was found to have good concurrent validity (0.80).6 however, the internet goniometer used through a computer program was found to have good-to-excellent vailidity.6 when assessing straight leg raise (slr), the results found good validity with endurance (0.80) and excellent validity with motor control (0.97) between face to face (ftf) assessments and teleassessments.6 special orthopedic tests (sot) were demonstrated, looking for the percentage of agreement (pa) found between ftf and teleassessments, the results showed 75% for elbow conditions, 76% for shoulder conditions, 82.9% for lower-limb musculoskeletal injuries and 99.3% for ankle injuries.6 four studies looked at different techniques to assess strength via teleassessments, using static muscle resistance. these four studies showed good-to-excellent agreement in muscle strength assessment.6 findings and clinical implications the guiding systematic review assessed the evidence that supports the use of telemedicine as a valid and reliable method to complete musculoskeletal assessments. the focus of the reviewed studies encompasses the elbow, ankle, knee joints in the musculoskeletal system, as well as various methods to assess musculoskeletal injuries: rom, postural assessment, strength and endurance, special orthopaedic tests, etc. measuring rom has found to have high achievability due to the minimal differences in measurement by both universal goniometers on digital images and/or videos and using specific programs designed to measure the joint angles.9,10 range of motion is one of the primary foundations for musculoskeletal assessment and can be thought of as setting the basis of the assessment, which makes it a critical aspect of the telemedicine assessment process. performing a manual muscle test on a patient via telemedicine is difficult to assess muscle strength.6 however, the use of a telemedicine facilitator to carry-out the manual muscle test allows for the clinician to use a third party individual with the patient to perform an assessment which has yielded positive results.11 the limitation of poor bandwidth proves to be one of the most common issues faced when assessing the concurrent validity of telemedicine.11-14 a clear view of the patient is crucial in determining the abnormalities that may be present upon evaluation. if there is lack of clarity, there may be signs that are not logistically visible to the clinician. having access to adequate video cameras is another limitation faced by clinicians when performing a telemedicine assessment.15 this would lead us to the assumption that more research needs to be conducted in order to further investigate the probability of being able to correctly assess posture via telemedicine. the evidence suggests that postural assessments are less likely to have good concurrent validity.6 without the ability to connect to patients, there can be no assessments. barriers such as this may impede the ability to further examine the validity and reliability of telemedicine assessments. the guiding systematic review identified a slr to assess strength, endurance, and motor control of the low back pain population. the study demonstrated that there was good validity in endurance (α=0.80) and excellent validity in motor control (α=0.97), as well as good validity (α=0.85) in lower limb functional strength in total knee arthroplasty population.6 with the increased levels of validity and reliability, the authors showed that the transition from face-to-face to teleassessment would still be beneficial in doing the strength, endurance and motor control portions of the examination process. the straight leg raise test is easy to demonstrate and have a patient reproduce to observe discrepancies in a musculoskeletal assessment. the validity and reliability of assessments through telemedicine: an evidence-to-practice review 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the guiding systematic review also explored the relationship between teleassessments and face-to-face orthopedic selective tissue tests. teleassessments include performing objective assessments in order to diagnose patients properly and effectively with a musculoskeletal disorder (msd).9 face-to-face orthopedic selective tissue tests are performed in person with the patient present, with the goal of diagnosing the patient with msd. the authors identified that the reported percentage of agreement ranged from 75% (elbow and shoulder disorders) to 99% (ankle conditions).6 these findings demonstrate that while some selective tissue tests may be difficult to perform, technology-based orthopedic assessments do produce similar results as a face-to-face patient encounter. clinical bottom line the guiding systematic review suggests there is potential for the inclusion of telemedicine in physical medicine which includes athletic training. for example, rom measures completed with the use of an internet goniometer displayed an excellent level of concurrent validity and interand intra-rater reliability. assessment of posture displayed good results with intraand inter-rater reliability but did not produce good results in the aspect of validity. muscle strength demonstrated a good level of concurrent validity and reliability. functional outcome measures displayed exceptional levels of both concurrent reliability and inter and intrarater reliability. regarding both balance and gait, each assessment reported excellent levels of concurrent validity and interand intrarater reliability. although there were a lot of positives in most aspects of telemedicine assessment, there were some assessments that did not report clinically meaningful findings with respect to validity and reliability. scar assessments, selective tissues tests, and neurodynamic tests all demonstrated moderate levels of concurrent validity, with no significant change to face-to-face assessment. athletic trainers can apply the skills they already possess and use them in telemedicine to continue patient care beyond the clinic. the guiding systematic review delved into a wide variety of different assessments that are commonly used in telemedicine and face-to-face encounters. it can be determined that telemedicine may be used as an appropriate method of assessment, but only regarding functional outcomes and gait, balance, rom, pain, swelling, and muscle strength of certain musculoskeletal disorders. in athletic training, these assessments are cornerstones to the orthopedic evaluation process. there are many pros and cons to telemedicine, but the systematic review was able to determine that telemedicine may be used to substitute or supplement faceto-face assessments when necessary. we suggest that athletic trainers seeking to implement telemedicine into their clinical practice use this review to substantiate the framework for their digital clinical practice alongside continual conversations with supervising physicians and state regulatory agencies. the key to integration could be from the innovative and creative mindset to perform selective tissue test in a nontraditional format. if athletic trainers can utilize telemedicine, it could drastically improve patient-centered care especially to populations that have limited access to healthcare services. references 1. scott kruse c, karem p, shifflett k, vegi l, ravi k, brooks m. evaluating barriers to adopting telemedicine worldwide: a systematic review. j telemed telecare. 2018;24(1):4-12. https://doi.org/10.1177/1357633x1667408. 2. kimberlin cl, winterstein ag. validity and reliability of measurement instruments used in research. am j health syst pharm. 2008;65(23):2276-2284. https://doi.org/10.2146/ajhp070364. https://doi.org/10.1177/1357633x1667408 https://doi.org/10.2146/ajhp070364 the validity and reliability of assessments through telemedicine: an evidence-to-practice review 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 3. cilliers l, & flowerday, s. . will computer literacy affect telemedicine acceptance among health care workers? . research network for e-skills conference, premier hotel regent, east london, south africa.; 2011. 4. wochatz m, tilgner n, mueller s, et al. reliability and validity of the kinect v2 for the assessment of lower extremity rehabilitation exercises. gait posture. 2019;70:330-335. https://doi.org/10.1016/j.gaitpost.2019.03.020. 5. grimmer k, bowman p. differences between metropolitan and country public hospital allied health services. aust j rural health. 1998;6(4):181-188. https://doi.org/10.1111/j.14401584.1998.tb00310.x. 6. mani s, sharma s, omar b, paungmali a, joseph l. validity and reliability of internet-based physiotherapy assessment for musculoskeletal disorders: a systematic review. j telemed telecare. 2017;23(3):379-391. https://doi.org/10.1177/1357633x16642369. 7. kahn jm. virtual visits--confronting the challenges of telemedicine. n engl j med. 2015;372(18):16841685. https://doi.org/10.1056/nejmp1500533. 8. amatya b, galea mp, kesselring j, khan f. effectiveness of telerehabilitation interventions in persons with multiple sclerosis: a systematic review. mult scler relat disord. 2015;4(4):358-369. https://doi.org/10.1016/j.msard.2015.06.011. 9. russell t. goniometry via the internet. aust j physiother. 2007;53(2):136. https://doi.org/10.1016/s0004-9514(07)70051-x. 10. durfee wk, savard l, weinstein s. technical feasibility of teleassessments for rehabilitation. ieee trans neural syst rehabil eng. 2007;15(1):23-29. https://doi.org/10.1109/tnsre.2007.891400. 11. lade h, mckenzie s, steele l, russell tg. validity and reliability of the assessment and diagnosis of musculoskeletal elbow disorders using telerehabilitation. j telemed telecare. 2012;18(7):413-418. https://doi.org/10.1258/jtt.2012.120501. 12. russell t, truter p, blumke r, richardson b. the diagnostic accuracy of telerehabilitation for nonarticular lower-limb musculoskeletal disorders. telemed j e health. 2010;16(5):585-594. https://doi.org/10.1089/tmj.2009.0163. 13. russell tg, blumke r, richardson b, truter p. telerehabilitation mediated physiotherapy assessment of ankle disorders. physiother res int. 2010;15(3):167-175. https://doi.org/10.1002/pri.471. 14. lemaire ed, boudrias y, greene g. technical evaluation of a low-bandwidth, internet-based system for teleconsultations. j telemed telecare. 2000;6(3):163-167. https://doi.org/10.1258/1357633001935266. 15. cabana f, boissy p, tousignant m, moffet h, corriveau h, dumais r. interrater agreement between telerehabilitation and face-to-face clinical outcome measurements for total knee arthroplasty. telemed j e health. 2010;16(3):293-298. https://doi.org/10.1089/tmj.2009.0106. https://doi.org/10.1016/j.gaitpost.2019.03.020 https://doi.org/10.1111/j.1440-1584.1998.tb00310.x https://doi.org/10.1111/j.1440-1584.1998.tb00310.x https://doi.org/10.1177/1357633x16642369 https://doi.org/10.1056/nejmp1500533 https://doi.org/10.1016/j.msard.2015.06.011 https://doi.org/10.1016/s0004-9514(07)70051-x https://doi.org/10.1109/tnsre.2007.891400 https://doi.org/10.1258/jtt.2012.120501 https://doi.org/10.1089/tmj.2009.0163 https://doi.org/10.1002/pri.471 https://doi.org/10.1258/1357633001935266 https://doi.org/10.1089/tmj.2009.0106 abstract manuscript type clincal outcomes research 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 body tempering and its effect on ankle dorsiflexion and power neal ori ms, scat, atc*; justin goins, phd, scat, atc, cscs†; jay patel, phd, cscs, tsac-f, ces*; robbie ingle, ms, scat, atc‡, *university of south carolina, columbia, sc; †university of alabama, tuscaloosa, al; ‡ prisma health, lexington, sc abstract body tempering (bt) is a newer myofascial release (mfr) technique that is used by athletes and healthcare professionals. the effects of bt are stated to be similar to foam rolling (fr) and other mfr techniques, but there is minimal research assessing the effects of bt on power and range of motion (rom). the purpose of this study was to determine the effect of bt on ankle dorsiflexion rom and power, as well as to compare the effects of bt to traditional fr. twenty college-aged participants (10 males-10 females) were tested before and after intervention on three measurements of the broad jump (single-leg and double-leg) and weight bearing lunge test. week one, each participant was randomly assigned to a 30-second treatment (bt or fr) performed on both calves, simultaneously, at a pace of 1 pass every 2 seconds. week two, the treatment that was not received in session one, was administered. paired sample ttests between post-intervention and baseline measurements, as well as bt and fr showed statistically significant differences in fr and bt between pre and post single-leg jump averages for the left leg (fr-pre: 93.22 cm, post: 96.77 cm; p = .046) (bt-pre: 94.53 cm, post: 100.27 cm; p = .03) and the right leg (fr-pre: 92.28 cm, post: 99.38 cm; p= .007) (bt-pre: 94.22 cm, post: 99.83 cm; p= .036). average rom was only found to be statistically significantly different for bt on the right leg (pre: 8.32 cm, post: 8.80 cm; p = .035). there were no statistically significant differences in power (p= .293 -left leg; p= .894 -right leg; p= .362 -bilaterally) or rom (p= .791 -left leg; p=.825 -right leg) when comparing the bt to fr interventions. when throwing, jumping, and running, single leg power is important, and these techniques could increase muscle performance needed during activity. key phrases clinician-rated outcomes, manual techniques, college and university patient population, body tempering, foam rolling correspondence neal ori, university of south carolina, 1300 wheat street, columbia, sc 29208. e-mail: nrori95@yahoo.com twitter: @realneal35 full citation ori n, goins j, patel j, ingle r. body tempering and its effect on ankle dorsiflexion and power. clin pract athl train. 2022;5(1): 12-21. https://doi.org/10.31622/2021/0005.01.3. submitted: may 25, 2020 accepted: april 14, 2021. introduction functional movement and power are vital to an athlete’s performance, but these qualities can be hampered by myofascial adhesions or decreased rom of muscle and fascia.1 to help the body perform at maximum capacity these myofascial adhesions need to be treated or released.1 mfr is a process by which pressure is applied to tissue, supplying increased blood flow to the area and reducing myofascial adhesions once the pressure is released.2 fascia exhibits the phenomenon of thixotropy, in which it becomes more fluid or soft when it is moved or disturbed and more solid when it sits undisturbed.3 therefore, mfr allows tissue to relax and become more elastic.1,4 there are several mfr techniques, all of which can be divided into two categories: invasive and noninvasive. invasive techniques include injection therapy and dry needling, and noninvasive techniques include massage, stretching, myofascial release, ischemic bands, graston, deep tissue massage, neuromuscular therapy, therapeutic ultrasound, and laser.5 the exertion of mechanical pressure that many of these techniques provide is theorized to decrease myofascial adhesions between tissue layers, improve muscular compliance and decrease muscle stiffness of the muscle fibers.2 this in turn will be beneficial to performance and mobility. in previous studies, common techniques, such as dry needling,6 ischemic bands,7 graston,8 deep tissue massage,9 and fr1 have been shown to improve performance and mobility. body tempering (bt) is a new, noninvasive tool used to accelerate sport activity performance and recovery by combating soft tissue restrictions similar to the effects of fr.10 although the effects mailto:nrori95@yahoo.com https://doi.org/10.31622/2021/0005.01.3 body tempering and its effect on ankle dorsiflexion and power 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 of bt have been compared to fr, there is minimal research on the modality because it is so new. the manual provided at the body tempering™ certification course states, “while body tempering does not have a body of literature to directly support it as a specific method, its biomechanical effects are very similar to spinal/joint mobilizations, fr, instrument assisted soft tissue mobilization, and soft tissue mobilization.”10 bt is performed using a heavy metal cylinder placed on the respective muscle(s), which is then passively rolled along the length of that muscle.10 bt’s main technique, dynamic tempering, refers to having a clinician roll out the muscle in a manner similar to fr but the device is laid on top of the body, allowing the body to relax instead of having activated musculature like when a patient completes fr their self.10 with the use of the weighted cylinder and passive movement, it is stated in the manual that trigger points and myofascial adhesions cannot hold up to the bt cylinder like they could with less aggressive methods such as fr.10 despite bt’s increasing popularity with athletes in the nfl, ncaa, and crossfit, there is minimal research available to support its use to improve performance and rom compared to other mfr techniques.10 therefore, the purpose of this study was to examine the bt mfr technique’s effectiveness in improving mobility and power. the secondary purpose was to examine the effects of the bt mfr technique compared to fr and a control session (warm-up only). participants twenty participants completed the study (10 males: 23.20 ± 3.68 years, 179.07 ± 9.06 cm, 86.86 ± 10.66 kg; 10 females: 22.80 ± 1.48 years, 161.8 ± 5.75 cm, 64.37 ± 6.12 kg). inclusion criteria included male and female recreational athletes, defined as someone who exercises at the cdc recommended levels of 2-3 hrs/week on average, between ages 18-35 years old.11 participants were excluded if they had the following: a current lower extremity orthopedic injury, a lower extremity orthopedic injury in the previous six months, osteoporosis with or without unexplained non-traumatic fracture, lymphatic/fluid retention disorders, impaired sensation, copd/lung pathology, blood pressure/cardiac issues, or rashes/skin deformities including but not limited to open wounds.10 participants were recruited through email, posters, and word of mouth. this study was approved by the institutional review board (irb) of the xxx and all participants provided consent prior to participating in the study. outcome measures instruments and measurements pre-participation demographic questionnaire before participating, each participant completed a questionnaire providing their age, gender, selfreported height and weight, and previous injury history. weight bearing lunge test participants were in a lunge position (knee on ground) facing a wall without shoes with the test foot and knee perpendicular to a wall.12 while maintaining this position, participants performed a lunge in which the knee was flexed with the goal of making contact between the anterior knee and the wall while keeping the heel firmly planted on the floor. valgus and varus collapse were not specifically controlled for, but the pi observed the knees throughout the test to ensure proper motion. the participants continued to move their foot back slowly until their heel could no longer stay in contact with the ground at the same time their knee was touching the wall. 13 according to bennell et al. (1998), the weight bearing lunge body tempering and its effect on ankle dorsiflexion and power 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 test has intra-rater intraclass correlation coefficients (icc) ranged from 0.97 to 0.98 and the inter-rater icc value was 0.99.12 for assessing ankle dorsiflexion these results have excellent reliability. broad jump a tape measure was laid out on the floor and participants started with their toe on the starting mark. the contralateral leg was positioned with the hip and knee angles at approximating 90 degrees of flexion and their hands were placed on their hips. a single maximal hop was executed without swinging the contralateral leg or removing the hands from the hips. the participants were encouraged to achieve maximal horizontal distance and to land on the same foot without simultaneously placing the opposite foot down for support. once their landing foot touched down, however, they were free to extend the opposite leg to avoid falling.14 for double-leg jumps, participants were allowed to use a counter movement jump technique and participants were asked to jump out as far as possible each time. they were to hold the position until the investigator told them to move. measurements were taken from the back of the heel closest to the starting point and were measured to the closest half centimeter. if the participant did not stabilize after their jump, they were asked to repeat the attempt. the broad jump is used to measure power output, specifically horizontal power output. the alpha health‐related fitness test battery protocol was followed when administering the test.15 markovic et al. (2004) concluded that double cmj (horizontal) is the most reliable and valid field test for the estimation of explosive power of the lower limbs in physically active men.16 the single leg horizontal distance test has a high test-retest reliability, with icc values between 0.88 to 0.96.17 statistical analysis data analysis for this study included descriptive statistics that were calculated for the demographic information and dependent variables. comparisons were made between the baseline measurements performed before each session and the measurements performed after each intervention, as well as between the measurements assessed after each intervention. these comparisons were performed using a paired-samples t-test with an alpha set to < 0.05. ibm spss statistics package 26 was utilized for the analysis. intervention body tempering roller the bt roller (forge; watkinsville, ga) is a large metal cylinder (22.68 kg) used to apply pressure to the identified muscle tissue (figure 1).18 figure 1. bt device used in the study. in this study, a 10 lb. plate was added to each side of the device to make the total weight 50 lbs. (the device itself weighs 30 lbs.). foam roller the participants used a 15.24 cm x 91.44 cm polyethylene foam roller (power systems, highdensity foam rollers, knoxville, tn). the foam roller was a high-density, pre-molded piece of foam in the shape of a cylinder.19 body tempering and its effect on ankle dorsiflexion and power 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 procedures this study consisted of two separate interventions/sessions, with at least one-week inbetween each. the same procedures were followed at each session, and the only thing that changed was the intervention device that was used (i.e., bt-session one and fr-session two, or vice versa) participants arrived on the first day and completed the consent form and demographic questionnaire. once they agreed to participate, participants were randomly assigned to initially participate in either the bt group or the fr group. each participant began with a general warm up on a bike, pedaling at 60 rpm at a self-selected resistance for 3-4 minutes.20 participants then engaged in a 5 min standardized warmup consisting of dynamic mobility (e.g., walking knee lift and lunge walk) and calisthenics (e.g., skipping and jumping jacks) exercises (table 1).21 after completing the warmup, participants rested for 2 minutes before participating in three baseline measurements of active dorsiflexion (adf) rom on each ankle. this was assessed using the weightbearing lunge test with the participant selfselecting which ankle was assessed first. unilateral and bilateral broad jump were assessed next, to examine power. single-leg (unilateral) jumps were performed before the double-leg (bilateral), with each participant self-selecting to start on the right or left. depending on the group each participant was assigned to either a 30 second bt treatment or a 30 second fr treatment was, then, applied to the triceps surae muscle group.2,21-23 the treatment was performed at a pace of one pass every 2 seconds (4 seconds for a complete cycle).10,24 participants reported for a second session at least one week after the first in order to complete the other intervention. all treatments were held at approximately the same time of day and participants were instructed to maintain their normal exercise routine. the pi attended each treatment session and performed all bt interventions. during the bt intervention, participants laid prone on a soft surface (figure 2).25 the pi rolled a cylinder proximally and distally on both triceps surae muscle group, simultaneously, for approximately 30 seconds.1,2,10,26,27 those participating in the fr intervention rolled both triceps surae muscle group at the same time for 30 seconds at the same tempo as the bt group.24 after the treatment period, each participant rested for 1 min and then the pi reassessed the doubleand single-leg broad jump and ankle dorsiflexion. figure 2. application of bt device table 1. standardized warm-up exercises sets yards jog 1 30 backpedal 1 30 skip 1 30 quad stretch walk/knee hug walk 1 15/15 fwd lunge/bkwd lunge 1 15/15 shuffle right/left 1 15/15 rdl walk/straight leg march 1 15/15 high knees/ butt kickers 1 15/15 carioca right/left 1 15/15 sprint 1 30 body tempering and its effect on ankle dorsiflexion and power 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 the participants tested both the broad jump (double and single legs) and ankle dorsiflexion three times,28 and the best score and the averages were recorded. results paired sample t-tests were used to compare postintervention and baseline measurements, as well as bt to fr. detailed results can be found in tables 2-5. statistically significant differences (p ≤ .05) were found between preand post-fr single leg jump averages for the left leg (pre: 93.22 ± 23.32 cm, post: 96.77 ± 20.54 cm; p = .046) and the right leg (pre: 92.28 ± 22.81 cm, post: 99.38 ± 22.52 cm; p = .007). statistically significant differences were also found between preand post-bt single leg jump averages for the left leg (pre: 94.53 ± 21.65 cm, post: 100.27 ± 19.79 cm; p = .03) and the right leg (pre: 94.22 ± 20.74 cm, post: 99.83 ± 19.48 cm; p = .036). average rom was only found to be statistically significantly different for bt on the right leg (pre: 8.32 ± 3.08 cm, post: 8.80 ± 3.20 cm; p = .035), which 19 of the 20 participants indicated was their dominant leg. there were no statistically significant differences in power or rom when comparing the bt to fr interventions. discussion the purpose of this study was to determine the effect of bt on ankle dorsiflexion and power. the secondary purpose was to compare the effects of bt to traditional fr. the results of our study showed statistically significant improvement in the unilateral jump on the left and right leg after both bt and fr. these results are important for those who participate in many sports that require a participant to have single leg explosiveness to accomplish a task successfully, including running, throwing, and jumping. that explosiveness is known as the word power. with power being defined as work over time,29 the quicker the athlete can move a certain distance, the more powerful they are. the ability for the athlete to produce more power could lead to greater success in their competitive arena, thus making these results intriguing for the athlete. although our study resulted in statistically significant differences in single-leg jumps, no statistically significant differences were found between the results of the baseline measurements and either intervention for the double-leg jump. aligning with the double-leg results from our study, in a systematic review assessing effects of self-mfr, beardsley et al. (2015) found all but two of the reviewed documents to show no changes in double leg performance measures after a session of self-mfr.22 it has been shown in research that the mechanical output per leg is less in two-leg jumps than in one-leg jumps, and thus has been given the name bilateral deficit.30 this same effect can be seen in our study as the patients saw statistically significant increase in their single leg jump, but there was no statistically significant changes when looking at the doubleleg jump. in terms of adf rom, only the pre-intervention to post-intervention of bt on the right limb showed statistically significant difference. in the macdonald et al. (2013) study, they found an increase in rom in both limbs two and ten minutes after completing the treatment session after rolling both limbs individually.1 our results may have been different due to rolling both limbs at the same time. in the skarabot et al. (2015) study, they assessed fr by itself, and compared it to fr plus a static stretching intervention. fr by itself resulted in no increase in rom, while the combination showed a statistically significant increase.23 nineteen of the twenty participants in our study stated that the right leg was their dominant leg. the lack of rom on the dominant leg due to increased usage may have allowed for greater improvement compared to the less used non body tempering and its effect on ankle dorsiflexion and power 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 2: preand post-measurements for average jumping distance (mean + sd) intervention pre-measurement (cm) post-measurement (cm) p-value foam rolling left avg 93.22± 23.32 96.77 ± 20.54 0.046* longest 101.35 ± 24.90 102.35 ± 20.42 0.628 right avg 92.28± 22.81 99.38 ± 22.53 0.007* longest 99.45 ± 22.962 103.60 ± 22.86 0.137 both avg 184.77 ± 33.92 180.98 ± 35.17 0.464 longest 189.50 ± 34.32 186.73 ± 36.27 0.586 body tempering left avg 94.53 ± 21.65 100.27 ± 19.79 0.030* longest 101.13 ± 21.42 105.98 ± 21.25 0.069 right avg 94.22 ± 20.74 99.83 ± 19.48 0.036* longest 101.53 ± 20.49 105.78 ± 17.72 0.130 both avg 187.38 ± 34.28 186.41 ± 36.24 0.497 longest 192.78 ± 34.31 191.63 ± 35.55 0.489 *=significant finding (p < 0.05) table 3: post intervention measurement comparison (fr and bt) (mean + sd) intervention fr (cm) bt (cm) p-value avg jump distance left 96.767 ± 20.540 100.267 ± 19.790 0.293 right 99.375 ± 22.525 99.833 ± 19.481 0.894 both 180.975 ± 35.165 186.408 ± 36.242 0.362 longest jump distance left 102.350 ± 20.415 105.975 ± 21.249 0.334 right 103.600 ± 22.857 105.775 ± 17.720 0.533 both 186.725 ± 36.274 191.625 ± 35.554 0.414 table 4: preand post-measurements for rom (mean + sd) intervention pre-measurement (cm) post-measurement (cm) p-value foam rolling left 8.567 ± 3.122 8.833 ± 2.974 0.069 right 8.325 ± 3.011 8.725 ± 2.909 0.073 body tempering left 8.517 ± 2.918 8.930 ± 3.113 0.079 right 8.321 ± 3.078 8.800 ± 3.201 0.035* *=significant finding (p < 0.05) table 5: post intervention rom comparison (fr and bt) (mean + sd) intervention fr (cm) bt (cm) p-value rom left 8.833 ± 2.974 8.930 ± 3.113 0.791 right 8.725 ± 2.909 8.800 ± 3.201 0.825 body tempering and its effect on ankle dorsiflexion and power 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 dominant leg. in a previous study on frequency of injury in soccer athletes, it was shown there was no difference in rom between either leg, but the dominant (shooting leg) was more likely to get injured.31 because this leg is more dynamic in use, it is injured more often. during the injury process, tissue goes through a remodeling phase which can be extremely prolonged, and even when finished, it might not heal correctly or align the best possible way.32 the participants could have had previous injuries, past the six month criteria, that affected the tissue in their dominant leg. this tissue healing could have caused an underlying deficit that the bt device aided upon intervention. because the non-dominant side was uninjured and there was no underlying deficit there was no improvement that could be seen whether that was with the bt or the fr. fr the calves consists of a lot of upper body and core strength, as the participant needs to hold themselves in a proper position throughout the duration of the treatment. this ability, or lack thereof, can change the amount of force the participant has on the intended tissue. because this study was completed on the general population and not athletes, many of the participants struggled to complete a treatment session for 30 seconds due to lack of strength. this lack of ability to hold oneself up to provide force into the calf could have caused a lack of change in the tissue when fr. this would explain why adf rom was statistically significantly different in the dominant leg while bt, but not while fr. a potential limitation of this study is that the weight used for the bt device was not able to be adjusted because we were testing with just fifty pounds. it is stated in the bt manual that a high pain level should be achieved to see benefits.10 to ensure consistency in the study, we used one weight the entire time. changing the weights out based on individual pain scale might have elicited different results. a second potential limitation of this study is the participants ability fr ability, and therefore force applied, was linked to their strength and being able to hold themselves up. many of these participants did not have the strength to hold themselves up and complete a 30 second treatment session, causing a lack of force into the foam roller, and therefore affecting the results. a third potential limitation is the sample size. while the power of the study was met, this is still considered a small number of participants. including more participants would increase the strength of this study. a fourth, and final, limitation is that only the triceps surae group had the intervention completed on it. jumping was tested during this study and jumping requires more than just the triceps surae group (i.e., quadriceps, hamstrings, hip flexors, and extensors). if all the lower extremity musculature was worked on, then the jumping data could have been different. future studies should focus on the number of treatments per session. only one treatment was completed per session, and the participants expressed that they did not feel much different before or after the intervention. increasing the number of treatments per session could elicit a greater benefit or even a benefit that was not seen during the singular treatment. in the study, participants, also, often mentioned, “oh, it’s already done.” this indicated that the length of the treatment might change outcomes for the athlete and is something that can be focused on. throughout the literature on fr there is varying lengths of treatment that are executed, usually thirty seconds to two minutes.22 while there are a few studies that show changes under thirty seconds, there is a general consensus that one should spend thirty seconds of treatment time when fr.2,22,23 after two minutes there seemed to be detrimental effects in one study.21 while this study looked at thirty second treatment lengths there is time to play with while still staying under that two min period. using that lengthened time period is something that can be examined to see if greater effects are seen when bt. throughout body tempering and its effect on ankle dorsiflexion and power 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 the study, pain was assessed during treatment for safety purposes, but led to another idea. one participant said bt was significantly more painful than it was for the other participants; they then stated they felt a lot better and “looser” in their calves (which the others did not state). the individual data for this participant made significant improvements from pre intervention to post intervention for bt; comparing it to fr makes it even more apparent. assessing the difference in pain level between the amount of weight on the bt device might elicit an interesting connection between pain and benefit for the athlete. conclusion/clinical application athletes, coaches, and clinicians should understand the effects these treatments will have and determine if they will benefit the subsequent performance individually. in this study, bt and fr both showed an improvement in power development in individual legs, but not when the double leg jump was completed. single-leg power is used when competing in many athletic events (throwing, jumping, running) and applying bt or fr pre-contest could increase muscle performance needed during activity. both techniques were comparative in the effects on power and dorsiflexion rom, thus showing while both techniques worked, one may not be better than the other. using this information, athletes preparing for power-type movements could benefit from bt or fr. although an increase in power was noted in both techniques, only an increase in adf rom was recorded in the r leg while bt. while there was some benefit to rom, it is inconclusive whether it would have a real benefit to the athlete pre-activity. with the aforementioned stated, bt is a passive technique and could be more appealing to the athlete than fr (active technique), thus motivating them to complete these myofascial activation activities. giving the athlete another option to incorporate into their routine could lead to their success and good health, which in the end is what all clinicians and coaches want to see for the individual. on top of that, there were no detrimental effects noted in this study, leaving the athlete the freedom to use these techniques before activity, without fear of harm to their subsequent performance. references 1. macdonald gz, penney md, mullaley me, et al. an acute bout of self-myofascial release increases range of motion without a subsequent decrease in muscle activation or force. j strength cond res. 2013;27(3):812821 https://doi.org/10.1519/jsc.0b013e3182 5c2bc1. 2. kalichman l, david cb. effect of selfmyofascial release on myofascial pain, muscle flexibility, and strength: a narrative review. j bodyw mov ther. 2017;21(2):446451. https://doi.org/10.1016/j.jbmt.2016.11.00 6. 3. proske u, morgan dl, gregory je. thixotropy in skeletal muscle and in muscle spindles: a review. prog neurobiol. 1993;41(6):705-721. https://doi.org/10.1016/03010082(93)90032-n. 4. abels km. the impact of foam rolling on explosive strength and excitability of the motor neuron pool. university of texas libraries: kinesiology 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https://doi.org/10.2519/jospt.1997.26.4.1 84. 15. ruiz jr, castro-piñero j, españa-romero v, et al. field-based fitness assessment in young people: the alpha health-related fitness test battery for children and adolescents. bjsm. 2011;45(6):518-524 https://doi.org/10.1136/bjsm.2010.07534 1. 16. markovic g, dizdar d, jukic i, cardinale m. reliability and factorial validity of squat and countermovement jump tests. j strength cond res. 2004;18(3):551-555. https://doi.org/10.1519/15334287(2004)18<551:rafvos>2.0.co;2. 17. swearingen j, lawrence e, stevens j, jackson c, waggy c, davis ds. correlation of single leg vertical jump, single leg hop for distance, and single leg hop for time. phys ther sport. 2011;12(4):194-198. https://doi.org/10.1016/j.ptsp.2011.06.00 1. 18. forge t. 2020 september 25, 2019 [cited may 23, 2020]; available from: https://www.instagram.com/p/b21ab6unct s/?utm_source=ig_web_copy_link. 19. cheatham sw, kolber mj, cain m, lee m. the effects of self‐myofascial release using a foam roll or roller massager on joint range of motion, muscle recovery, and https://doi.org/10.1016/j.ijosm.2006.07.007 https://doi.org/10.1016/j.ijosm.2006.07.007 https://doi.org/10.3233/bmr-150624 https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://research.edgehill.ac.uk/ws/portalfiles/portal/20215134/the+effects+of+%e2%80%98tack+and+floss%e2%80%99+active+joint+mobilisation+on+ankle+dorsiflexion+range+of+motion+using+voodoo+floss+bands.pdf https://doi.org/10.4085/1062-6050-52.6.s1 https://doi.org/10.4085/1062-6050-52.6.s1 https://doi.org/10.1089/acm.2005.11.1093 https://doi.org/10.1089/acm.2005.11.1093 https://www.cdc.gov/physicalactivity/basics/age-chart.html https://www.cdc.gov/physicalactivity/basics/age-chart.html https://doi.org/10.1016/s0004-9514(14)60377-9 https://doi.org/10.1016/s0004-9514(14)60377-9 https://doi.org/10.1016/j.math.2011.02.012 https://doi.org/10.1016/j.math.2011.02.012 https://doi.org/10.2519/jospt.1997.26.4.184 https://doi.org/10.2519/jospt.1997.26.4.184 https://doi.org/10.1136/bjsm.2010.075341 https://doi.org/10.1136/bjsm.2010.075341 https://doi.org/10.1519/1533-4287(2004)18%3c551:rafvos%3e2.0.co;2 https://doi.org/10.1519/1533-4287(2004)18%3c551:rafvos%3e2.0.co;2 https://doi.org/10.1016/j.ptsp.2011.06.001 https://doi.org/10.1016/j.ptsp.2011.06.001 https://www.instagram.com/p/b21ab6uncts/?utm_source=ig_web_copy_link https://www.instagram.com/p/b21ab6uncts/?utm_source=ig_web_copy_link body tempering and its effect on ankle dorsiflexion and power 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 performance: a systematic review. int j sports phys ther. 2015;10(6):827. https://doi.org/pmc4637917. 20. attia a, hachana y, chaabène h, et al. reliability and validity of a 20-s alternative to the wingate anaerobic test in team sport male athletes. plos one. 2014;9(12):e114444. https://doi.org/10.1371/journal.pone.0114 444. 21. phillips j, diggin d, king dl, sforzo gajjos, research c. effect of varying self-myofascial release duration on subsequent athletic performance. j strength cond res. 2018. https://doi.org/10.1519/jsc.0000000000 002751. 22. beardsley c, škarabot j. effects of selfmyofascial release: a systematic review. j bodyw mov ther 2015;19(4):747-758. https://doi.org/10.1016/j.jbmt.2015.08.00 7. 23. škarabot j, beardsley c, štirn i. comparing the effects of self‐myofascial release with static stretching on ankle range‐of‐motion in adolescent athletes. int j sports phys ther. 2015;10(2):203. https://doi.org/pmc4387728. 24. grabow l, young jd, alcock lr, et al. higher quadriceps roller massage forces do not amplify range-of-motion increases nor impair strength and jump performance. j strength cond res. 2018;32(11):30593069. https://doi.org/10.1519/jsc.0000000000 001906. 25. forge t. 2020 june 14, 2019 [cited may 23, 2020]; available from: https://www.instagram.com/p/bytjn1ehar4 /?utm_source=ig_web_copy_link. 26. peacock ca, krein dd, antonio j, sanders gj, silver ta, colas m. comparing acute bouts of sagittal plane progression foam rolling vs. frontal plane progression foam rolling. j strength cond res. 2015;29(8):2310-2315. https://doi.org/10.1519/jsc.0000000000 000867. 27. richman ed, tyo bm, nicks cr. combined effects of self-myofascial release and dynamic stretching on range of motion, jump, sprint, and agility performance. j strength cond res. 2019; 33(7):1795-1803 https://doi.org/10.1519/jsc.0000000000 002676. 28. horiuchi m, endo j, sato t, okita k. jump training with blood flow restriction has no effect on jump performance. biol sport. 2018;35(4):343 https://doi.org/10.5114/biolsport.2018.78 053. 29. newton ru, kraemer wj. developing explosive muscular power: implications for a mixed methods training strategy. strength cond j. 1994;16(5):20-31. http://www.hydragym.com/research/rsh_developingexplosiv emuscluarpowerwithmixedmethodsoftraining .pdf. 30. bobbert mf, de graaf ww, jonk jn, casius lr. explanation of the bilateral deficit in human vertical squat jumping. j appl physiol. 2006;100(2):493-499 https://doi.org/10.1152/japplphysiol.0063 7.2005. 31. ekstrand j, gillquist j. the frequency of muscle tightness and injuries in soccer players. am j sports med. 1982;10(2):7578. https://doi.org/10.1177/0363546582010 00202. 32. velnar t, bailey t, smrkolj v. the wound healing process: an overview of the cellular and molecular mechanisms. int j med res. 2009;37(5):1528-1542 https://doi.org/10.1177/1473230009037 00531. https://doi.org/pmc4637917 https://doi.org/10.1371/journal.pone.0114444 https://doi.org/10.1371/journal.pone.0114444 https://doi.org/10.1519/jsc.0000000000002751 https://doi.org/10.1519/jsc.0000000000002751 https://doi.org/10.1016/j.jbmt.2015.08.007 https://doi.org/10.1016/j.jbmt.2015.08.007 https://doi.org/pmc4387728 https://doi.org/10.1519/jsc.0000000000001906 https://doi.org/10.1519/jsc.0000000000001906 https://www.instagram.com/p/bytjn1ehar4/?utm_source=ig_web_copy_link https://www.instagram.com/p/bytjn1ehar4/?utm_source=ig_web_copy_link https://doi.org/10.1519/jsc.0000000000000867 https://doi.org/10.1519/jsc.0000000000000867 https://doi.org/10.1519/jsc.0000000000002676 https://doi.org/10.1519/jsc.0000000000002676 https://doi.org/10.5114/biolsport.2018.78053 https://doi.org/10.5114/biolsport.2018.78053 http://www.hydra-gym.com/research/rsh_developingexplosivemuscluarpowerwithmixedmethodsoftraining.pdf http://www.hydra-gym.com/research/rsh_developingexplosivemuscluarpowerwithmixedmethodsoftraining.pdf http://www.hydra-gym.com/research/rsh_developingexplosivemuscluarpowerwithmixedmethodsoftraining.pdf http://www.hydra-gym.com/research/rsh_developingexplosivemuscluarpowerwithmixedmethodsoftraining.pdf https://doi.org/10.1152/japplphysiol.00637.2005 https://doi.org/10.1152/japplphysiol.00637.2005 https://doi.org/10.1177/036354658201000202 https://doi.org/10.1177/036354658201000202 https://doi.org/10.1177/147323000903700531 https://doi.org/10.1177/147323000903700531 abstract manuscript type disablement model case study 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study rachel m. gordon, ms, lat, atc*; amy f. hand, phd, scat, atc*; rebecca m. hirschhorn, phd, atc, nraemt†; allison b. smith, phd, lat, atc‡; sonya j. fuemmeler, ms, scat, atc** *university of south carolina, columbia, sc; †louisiana state university, baton rouge, la; ‡university of louisiana at lafayette, lafayette, la; **hammond school, columbia, sc abstract this disablement model case study outlines a unique thumb pathology of a high school football player in his non-dominant hand and will detail the benefits of quick referrals for patient with extreme laxity and swelling around the 1st metacarpal. initially, the patient presented with laxity of the 1st metacarpophalangeal joint and swelling along the 1st metacarpal. radiographs showed floating bone fragments in the first metacarpophalangeal joint indicating gamekeeper’s thumb, an acute injury to the 1st metacarpophalangeal ulnar collateral ligament, complicated by a stener lesion, requiring surgical repair. the patient was scheduled for surgery in the following week and was casted for four weeks which posed many physical, occupational, and social problems. many 1st metacarpal injuries may present similarly making it important to be familiar with the structure and function of the 1st metacarpal and metacarpophalangeal joint and concomitant injuries that may occur in the surrounding area. a stener lesion is often missed due to the evaluator assuming that the injury is a basic 1st metacarpophalangeal ulnar collateral ligament sprain. the best way to rule in or out the involvement of a stener lesion is by radiograph; therefore, it is in the best interest of the athlete to refer for a radiograph anytime a grade iii ulnar collateral ligament sprain of the 1st metacarpophalangeal joint is suspected. furthermore, the main purpose of this paper is to detail the importance of a quick referral when there is little to no ability to use the thumb and the effects the lack of movement can have on a young student-athlete. correspondence rachel m gordon, ms, lat, atc, 1300 wheat street, columbia, sc 29208. e-mail: rgordon@srhs.com full citation gordon rm, hand af, hirschhorn rm, smith ab, fuemmeler sj. gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study. clin pract athl train. 2022;5(2): 40-44. https://doi.org/10.31622/2022/0005.02.7. submitted: march 16, 2021 accepted: august 23, 2021. introduction gamekeeper’s thumb, also known as skier’s thumb, is an acute rupture of the ulnar collateral ligament (ucl) at the 1st metacarpophalangeal (mcp) joint of the hand and is a common injury among alpine skiers.1 repetitive valgus stresses, or forced hyperextension and abduction of the thumb, are the primary mechanisms of injury in the gamekeeper’s thumb.1 gamekeeper’s thumb makes up 86% of all thumb injuries and occurs about 200,000 times a year globally.1 the severity of the injury is characterized into three grades.1 grade i injuries occur when the ucl is stretched but still fully intact. a grade ii injury is a partial tear of the ucl, and a grade iii injury is the complete rupture of the ucl.1 the ucl is composed of two ligaments, the proper collateral ligament (pcl) and the accessory collateral ligament (acl), which are taught in different ranges of motion throughout the thumbs movement and helps ensure the stability of the 1st mcp joint on the ulnar surface.1 the adductor pollicis muscle acts as the dynamic stabilizer of the thumb and attaches to the 1st proximal phalanx.1 the ucl is most commonly injured at its distal attachment on the 1st proximal phalanx. a grade iii injury to the ucl results in a bony avulsion fracture in about 20-30% of all similar pathologies.2 the strong forces required to rupture this ligament can cause the ends of the ucl to retract and lay on the adductor pollicis, causing the ucl to become wedged in the mcp joint and hinder the joint’s ability to be reduced or for the ligament to heal. this is known as a stener lesion, which occurs in 64-87% of all grade iii ucl injures.2,3 mailto:rgordon@srhs.com https://doi.org/10.31622/2022/0005.02.7 gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 in acute injuries to the 1st phalange, patients may present with mild swelling, discoloration, and tenderness to palpation along the 1st metacarpal and mcp joint.2 applying a valgus force to the mcp joint, looking for excessive laxity when compared bilaterally, can test the integrity of the ligament.2 if excessive movement at the mcp joint is present upon evaluation, a radiograph is indicated. in gamekeeper’s thumb, the radiograph will typically show avulsed bony fragments displaced one millimeter or more away from the distal attachment site of the ucl1. if no avulsed bone fragments are seen, but gamekeeper’s thumb is still suspected, the patient should be referred for magnetic resonance imaging, or a high-resolution ultrasound for further imaging of the affected area.1 treatment of the area varies depending on the grade of the injury and whether or not the ucl was displaced. a displaced (folding over of the ligament onto the adductor aponeurosis) ucl requires surgical intervention to repair the injury, whereas a non-displaced injury would need to be immobilized for four to six weeks.1 the rate at which the patient is seen for their injury has a major effect on how favorable their outcome may be; the longer the patient waits from the time of initial injury, the less likely it is that they will regain full function of that joint. patient information the patient was a healthy 18-year-old, male, high school football player who was in the middle of his first preseason game of the season, when he caught an interception and fell straight on his right hand forcing his thumb into hyperextension and abduction (figure 1). the patient had no previous injuries to his dominant right hand. differential diagnosis and evaluation the patient complained of 6/10 pain and swelling along the 1st metacarpal and 1st mcp joint. upon evaluation, he presented with tenderness to palpation along the 1st metacarpal and 1st mcp joint, a 1/5 manual muscle test (mmt) of the opponens pollicis, and a positive valgus stress test for laxity of the ucl. the patient was treated with ice and asked to return the following day for re-evaluation. the next day, he presented with increased pain and swelling along the 1st metacarpal and 1st mcp joint. the differential diagnoses consisted of 1st mcp joint ucl sprain, 1st metacarpal fracture, 1st proximal phalanx fracture, or opponens pollicis strain. body structure and function the patient was tender to palpation along the 1st metacarpal and 1st mcp joint and presented with edema surrounding the 1st metacarpal and the muscle belly of the opponens pollicis. compared bilaterally, he presented with a 1/5 mmt for opponens pollicis, testing for 1st mcp joint opposition, and tested positive for 1st mcp joint valgus stress test for laxity of the ucl. activity and participation the patient was a starting linebacker and kicker for his high school football team, as well as an elite soccer player. he was in his senior year at the time of injury and a member of a two-time reigning state football championship team who was relying on him for a victory three years in a row. a year prior, the patient figure 1. patient positioning during fall. gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 fractured the 3rd metacarpal on his opposite hand, benching him for most of the season. the patient stated that he was excited to get back to playing football this year and was hoping for an injury-free season. sustaining an injury in the first preseason game of this season took a toll on the patient; he was worried that he would be letting his team down for the second year in a row, especially being the captain and leader of the team during his senior year. he also worried about how it would affect team morale and their ability to succeed in future games. environmental and personal factors the patient had a previous history of a fracture in his left hand from an injury in football the previous year, which caused him to miss most of the season. along with being upset about missing his senior year of high school football, the patient was also nervous on how this injury would affect his ability to do school work as he had injured his dominant hand. as a leader on the team and someone that people in the school looked up to, he felt as though he was letting people down as the hype of the new season was beginning. the preseason game was a tough loss for the team, and with the added stress of losing their starting linebacker he was unsure how people would react. interventions the injury occurred on the patient’s dominant hand. due to the increased swelling, pain, and loss of function after the initial evaluation and a history of trauma to the opposite hand, the patient was referred to a hand specialist for a second opinion and further imaging three days post-injury. radiographs showed a rupture of the ucl with displaced bone fragments, indicating an avulsion from the proximal phalanx (i.e., stener lesion), requiring surgical intervention. surgery was scheduled for a week later, ten days post-injury. the surgery consisted of releasing the adductor aponeurosis and anchoring the avulsed ucl to its insertion with a mitek suture by passing it through the ligament. additional reinforcement was accomplished by repairing the aponeurosis. after the surgery, the patient was placed in a padded splint, with the thumb flexed and fully adducted, to keep his thumb immobile while swelling decreased before he was placed in a cast. a week after the surgery, the patient was placed in a hard cast for four weeks. extra support around the thumb was applied within the cast to ensure that there was no movement and that the repaired ligament could heal; any excess movement of the thumb could result in failure of the surgery and loss of function in the thumb. while in the cast, the patient was able to participate in non-contact activities. as the team kicker and linebacker, the patient was still able to participate in football practice and games with a padded cast as the punter and place kicker. after four weeks, the patient was able to return to full contact as long as he wore a padded brace during games and practices. the patient returned to his starting position as linebacker and kicker for his high school football team with no additional rehabilitation. outcomes body structure and function the patient had surgery on his hand within a week of the initial injury and was placed in a soft splint for one week and a hard cast for four weeks. the patient was right-handed; therefore, he was unable to use his dominant hand for five weeks. after the cast was removed, the patient tested 5/5 for the manual muscle tests for opponens pollicis, testing for opposition and had no laxity when the ucl was tested. the physician stated there was no need for rehabilitation, and the patient could return to normal activity as he saw fit. no patient-reported outcome measures were used during the patient’s recovery. the patient denied having any pain but was nervous about re-injury upon returning to play and the potential to lose function of his thumb. gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 therefore, the patient continued to wear the splint during activity for the remainder of the season. the splint was provided by the physician and padded by the athletic trainer for games and practices. the sports medicine staff at the school discussed the fear he was having and any underlying concerns he had about reinjury which also helped him overcome that fear. activity and participation the patient was removed from all contact participation in football practices and games but did not have to stop playing football altogether while he was recovering. because of his position, he was able to participate in kick-off, field goal, and extra point attempts. in addition to playing football for his high school, he was also an elite soccer player for his high school. realizing that he did not want to lose cardiovascular fitness during his off time from football, he focused on running to stay fit for both sports. being able to stay interactive with the football team and focus on keeping up his fitness level was good for the mental health of this young player. he stated he enjoyed feeling like a part of the team on and off the field. along with being beneficial to the patient, his hard work kept the spirits high for all of those still playing. understanding that their teammate was working hard to get back and stay involved encouraged them to play hard and kept morale high until he was able to return to full participation. environmental and personal factors since writing was difficult, the school issued him a laptop to use to help complete his assignments in class and at home. teachers also made accommodations, such as giving him more time to complete tests and assignments, to assist him. the school is competitive academically with high expectations for all students; missing a day of school can set the student far behind. the stress of having to miss a couple of days due to surgery and the inability to use his dominant hand was something the patient expressed worry about. after communicating with his teachers, he soon realized that they would not allow his injury to set him behind. he was able to stay up to date on all assignments and easily completed homework and notes with the use of the issued laptop. discussion although a gamekeeper’s thumb injury is common in some athletic events, this injury at this severity is not well known in the world of football causing athletic trainers in this role to be less familiar with the treatment. when treating a gamekeeper’s thumb injury that has not been displaced, there is a possibility of a nonsurgical option. when treating a gamekeeper’s thumb injury in a non-surgical, more conservative method, the thumb is immobilized for 4-6 weeks in a plaster cast or splint in the position of slight flexion and ulnar deviation of the mcp joint with the 1st interphalangeal joint kept free for movement. when patients were asked if they preferred the cast or splint, most patients preferred the splint due to its superior comfort.6 gamekeeper’s thumb complicated by a stener lesion has likely occurred in this sport before; however, current literature reports minimal instances relating to football players. the treatment of this injury does not differ in that of a high school football player as opposed to a skier suffering from a similar injury. it is important, as athletic trainers, to identify the signs of a gamekeeper’s thumb injuries and be able to take the appropriate steps in a timely manner. if a stener lesion complicates the pathology, treatment and referral of the injury should be timely to avoid any further complications, such as weakness or loss of function. gamekeeper’s thumb with stener lesion in a high school football player: a disablement model case study 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 an injury to the thumb that may seem insignificant at first glance can have a huge impact on a patient’s life in athletics, the classroom, and daily life. athletic trainers should be mindful of patient-centered care and take the time to identify interventions to assist making the injury and its complications less stressful. clinical bottom line the purpose of this case study is to inform health care professionals about a common injury such as the gamekeeper’s thumb, with a not so common pathology like a stener lesion, in an even less common patient population (high school football player). there is little documented evidence regarding gamekeeper’s thumb in football players.1,2 the prevalence of a stener lesion in a gamekeeper’s thumb is low compared to the amount of injuries that are seen yearly, about 60% of all gamekeeper’s thumb injuries among athletes and everyday people are considered to be a grade iii injury.1,2 the treatment of this type of injury is different than that of a typical gamekeeper’s thumb injury and requires surgical intervention. due to the in-depth evaluation of the patient by the athletic trainer the proper referral was made in a timely manner to catch this particular injury and help the patient regain all mobility of his thumb. health care providers should be aware of this diagnosis and misdiagnosis of this injury could result in long-term complications in range of motion and strength. references 1. schroeder ns, goldfarb ca. thumb ulnar collateral and radial collateral ligament injuries. clin sports med. 2015;34(1):117-26. https://doi.org/10.1016/j.csm.2014.09.004. 2. mahajan m, rhemrev sj. rupture of the ulnar collateral ligament of the thumb a review. int j emerg med. 2013;6(1):31. https://doi.org/10.1186%2f1865-1380-6-31. 3. lark me, maroukis bl, chung kc. the stener lesion: historical perspective and evolution of diagnostic criteria. hand. 2016;12(3):283-289. https://doi.org/10.1177/1558944716661999. 4. kundu n, asfaw s, polster j, lohman r. the stener lesion. eplasty. 2012;12: ic11. 5. rhee pc, jones db, kakar s. management of thumb metacarpophalangeal ulnar collateral ligament injuries. j bone joint surg am. 2012;94(21):2005-12. https://doi.org/10.2106/jbjs.k.01024. 6. madan ss, pai dr, kaur a, dixit r. injury to ulnar collateral ligament of thumb. orthop surg. 2014; 6(1):1-7. https://doi.org/10.1111/os.12084. https://doi.org/10.1016/j.csm.2014.09.004 https://doi.org/10.1186%2f1865-1380-6-31 https://doi.org/10.1177/1558944716661999 https://doi.org/10.2106/jbjs.k.01024 https://doi.org/10.1111/os.12084 abstract manuscript type evidence-to-practice review 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review breanna ferguson, ms, atc; erica schulman, ms, atc; matthew zimmerman, ms, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract blood flow restriction training (bfrt) is low-level resistance training while partially occluding proximal blood flow. it is well documented that this style of training leads to increased muscle size as well as strength. it is theorized that these size and strength gains are due in part to the decreased oxygen environment. this results in increased muscular stress without the need for increased external load making this style of resistance training ideal for individuals who have restrictions due to musculoskeletal disorders. the guiding systematic review examined the safety of bfrt when used as a therapeutic intervention for patients with a variety of musculoskeletal disorders. currently, there are no definitive set of parameters for clinicians to follow to ensure safe and effective use of bfrt. the purpose of the guiding review was to evaluate the safety and possible adverse events that may occur from different bfrt parameters in the rehabilitation or musculoskeletal disorders. there are many different types of devices used when implementing bfrt, but safety parameters suggest using a device that can measure the exact pressure so that occlusion can be personalized for each patient. using a predetermined pressure for all patients could result in full occlusion, depriving the muscle of all oxygen and creating too much muscular stress. conversely, not enough occlusion could result in a lack of muscular stress occurring to lead to muscular adaptations, ultimately rendering the treatment pointless. additionally, timing of the exercises, which is work-torest ratios, as well as the frequency of training, is an important component for safe and effective use. finally, the movement selection, load, and volume contribute to the parameters for safe and effective use of bfrt. adverse reactions found in the guiding systematic review ranged from discomfort or dull pain to rhabdomyolysis. following recommended safety guidelines decreased the risk of adverse reactions. correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation ferguson b, schulman e, zimmerman m, winkelmann zk. safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review. clin pract athl train; 5(2): 11-17. https://doi.org/10.31622/2022/0005.02.3. submitted: december 7, 2020 accepted: july 1, 2021. original reference minniti mc, statkevich ap, kelly rl, et al. the safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: a systematic review. am j sports med. 2020;48(7):1773-1785. doi:10.1177/0363546519882652 summary clinical problem and question blood flow restriction therapy (bfrt) is a relatively new therapeutic technique that can be utilized in a variety of musculoskeletal injuries. the guiding systematic review examined 19 studies with eight randomized control trials, seven case report studies, three case series, and one prospective longitudinal quasi-experimental study. of the eight randomized control studies, four studies diagnosed participants with knee osteoarthritis, three studies of post-surgical anterior cruciate ligament (acl) reconstruction and non-reconstructive arthroscopy, and a final study on anterior knee pain. this evidence to practice review will discuss the safety and adverse effects associated with all 19 articles, however there will be particular focus placed on the mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.02.3 safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 randomized control trials of patients with post-surgical acl reconstruction and non-reconstructive arthroscopy. this is due not only to randomized control trials offering higher levels of evidence than the other study designs, but also due to acl rupture being a common injury seen in athletic populations. the acl prevents the tibia from moving anteriorly in relation to the femur. when the acl is torn, the patient can feel instability with certain motions.1 surgical repair or reconstruction is sometimes needed to correct the instability. in an 18-month period, 2793 acl surgeries in norway were performed at an incidence rate of 85 per 100,000 of those in the main at-risk age group.2 due to this relatively high incidence rate, acl rehabilitation is a commonly researched subject with an emphasis being placed on finding increasingly effective therapeutic techniques.1,3 even with the high incident rate for acl rupture and reconstruction, there is no gold standard for a specific rehabilitation plan following surgical intervention. commonly examined factors include time and ability to return to preinjury functional levels. for traditional athletes, acl rehabilitation can cause them to miss 6-9 months or longer due to rehabilitation needs which can equate to their entire season.4,5 while most patients want a quick return-to-activity, it is the athletic trainer’s responsibility to ensure the knee is able to handle the stresses of returning to high level activity without the risk of performance deficits or reinjury.4 a major consequence of acl injury and subsequent surgery is thigh muscle atrophy and subsequent strength deficits in the first 12 weeks post-surgery and can remain for over 2 years post operation.6,7 traditional resistance training requires increasing external load on a muscle resulting in increased muscular stress allowing for hypertrophy and strength adaptations to occur. however, heavy external load is unsafe for an extended period following acl reconstruction due to graft weakness and overall knee instability. the use of bfrt would allow the patient to provide adequate muscular stress for training adaptations to occur while bypassing the need for heavy external loads. blood flow restriction therapy is the partial occlusion of blood vessels using a tourniquet or, more commonly, an inflatable cuff around a limb to train a distal muscle using low-level resistance exercises.8 the cuff decreases the amount of oxygen supplied to the muscle which could have detrimental effects if not applied correctly. these detrimental effects can range from mild pain and discomfort to more rare but serious conditions such as rhabdomyolysis (0.008%) and deep vein thrombosis (0.055%).9 due to the possibility of serious detrimental effects resulting from improper application of bfrt, it is vital to examine the necessary parameters for bfrt that result in the safest application of this therapeutic device. although use of bfrt does not seem to have adverse side effects when used correctly on adults with musculoskeletal knee conditions, the benefits of the intervention have not been fully examined.10 therefore, the purpose of this evidence to practice review was to examine the safety and possible adverse events that can occur from different bfrt parameters in order to help guide clinicians in the rehabilitation of patients with musculoskeletal disorders with an emphasis on post-surgical acl reconstruction.3 summary of literature the authors of the guiding systematic review, minniti et al., conducted a literature search for articles related to bfrt using medline, cinahl, and embase with a comprehensive list of keywords. the studies had to satisfy the following inclusion criteria: (1) bfrt was the clinical intervention, (2) participants were patients with musculoskeletal system disorders, (3) adverse events are discussed by the authors, (4) studies were published in english, (5) all subjects were human. exclusion criteria included systematic or narrative reviews. safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 the literature search yielded 5,692 studies plus an 8 additional from hand searching. duplicates, articles that did not meet the search criteria, and studies that did not include a qualitative synthesis were excluded which yielded 19 studies. three reviewers were utilized, with two reviewing the articles for quality and the third was utilized to settle disputes. of the 19 studies, the study design of 8 articles were randomized controlled trials (rct), 1 article was a prospective longitudinal quasi-experimental study, 3 articles were case series, and the final 7 articles were case reports. two independent reviewers evaluated the rct studies and the prospective longitudinal quasi-experimental study for bias. of these 9 studies, two studies met the downs and black rating of ‘‘excellent,’’ and the remaining 7 met the rating of ‘‘good”.10 summary of intervention parameters of bfrt used in each study varied slightly based on application and musculoskeletal system disorder. in the rcts and case reports, the frequency of bfrt ranged from 1 to 6 sessions per week and 1 to 4 times per week, respectively. the intensity during the rcts was 20-30% of the subjects calculated 1 repetition maximum (1rm). in the case-control designs, intensity was based on 15rm, 25rm, 20% 1rm, and 30% 1rm. for rcts, the intervention lasted between 1 and 16 weeks while for case control studies it lasted between 1 and 12 weeks. for rcts and case-control studies, intervention sessions varied from 1 to 5 sets of 15 to 30 repetitions or until failure. rest intervals ranged from 30 seconds to 1 minute between sets. there was 1 case control study that reported no rest and 2 reported occlusion for 30 minutes to 1 hour. the bfrt devices included sports rehab tourniquet®, delphi pts ii portable tourniquet system®, kaatsu master®, hokanson ag101 cc17 thigh cuff™, 180 x 80 mm cuff size, 150 mm cuff size, 34-inch tourniquet, and knee wraps.10 parameters for the bfrt device for the rcts ranged from 160-200 mmhg or 70% to 80% occlusion. however, the case series and case report designs varied between 100-110 mmhg or 50% to 80% occlusion. exercise selection in the rcts included leg press, leg extensions, reverse press, or a combination of the exercises. in the case series and case reports, exercise selection included leg press, knee extensions, reverse leg press, squats, half squats, leg curls, resisted ankle eversion, seated, and standing calf raises, and romanian deadlifts. however, exercise progression was not mentioned in all studies. in the rcts, training load, final exercise occlusion pressure, and volume were altered. in the case series and case reports, load was altered so that the patient could not perform >15 repetitions, increased 10% if patient could perform 1 set in >2 minutes, and increased by 5 kg if the patient could perform >15 repetitions in the second set. summary of outcomes to examine the safety of bfrt, the authors for the guiding systematic review divided the results of the studies based on the reported events. reported events were defined here as what adverse effects occurred during treatment if any. the data were categorized into one of 3 categories: no adverse events, common adverse events, and rare adverse events. no adverse events were defined as a study that reported no adverse effects from the intervention.11 common adverse events were defined as effects that were no more than moderate severity, short term, had no impact on the patient’s function, all effects are transient or reversible, and there was no alteration to therapy needed due to the short term nature of the effects. rare adverse events were defined as being severe, long term, distressing to the subject, and/or those that required further treatment to correct.12 to separate the data, the authors used a modified scale that included qualitative descriptions as well as incidence rates for each event. the modified scale was based off previous literature that investigated adverse effects for other therapeutic interventions.13 specifically related to bfrt no adverse events were defined, as having had no harmful effects and the patient was able to complete the intervention as prescribed. common adverse effects were defined as temporary muscle soreness, acute safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 muscle pain, acute fatigue, intolerance to intervention, slight discomfort, or dull pain. rare adverse events were those that had an incidence rate between 1 and 10 in 10,000 cases as well as those where a serious medical condition occurred.10 findings and clinical implications the guiding systematic review identified that bfrt was a safe intervention for adult patients based on predetermined safety recommendations.10,14 table 1 provides the recommended safety guidelines. these recommendations specified cuff application, cuff type, occlusion pressure, exercise stimulus, type, and load, training volume, rest time, and training frequency.14,15 a rct performed by tennent et al. on postoperative non-reconstructive knee arthroscopy patients utilized single and multi-joint leg exercises at 30% of the subjects one rep max (1rm) at 80% limb occlusion pressure.16 these subjects completed 4 sets of 30, 15, 15, 15 reps separated by 1 minute of rest in between sets twice a week for six weeks.16 this study followed all 9 safety guidelines outlined below and no adverse events were reported.16 similarly, a rct performed by ferraz et al. studied patients with knee osteoarthritis followed similar protocols to the previous rct, followed all 9 of the safety guidelines, and also found no adverse effects.17 another rct performed by hughes et al. compared bfrt with light exercise to high intensity resisted exercise alone on participants following acl reconstruction and a non-injured control.8 they followed 8 of the 9 recommended guidelines for bfrt as described in this review and had no adverse reactions.8,10 six rct and four case series found no adverse effects from bfrt.10 eight of these studies followed 7 or more of the 9 guidelines. the studies performed by bryk et al. and gaunder et al. following 6 and 5 respectively.18,19 participants in a total of 6 studies, 3 rcts and 3 case studies, had common adverse effects. the rct conducted by ohta et al. in 2003 compared the use of bfrt with exercise to the same exercises without bfrt for participants with acl reconstruction but only followed 6 of the 9 recommendations.20 discomfort and dull pain in the limb after 12 minutes of occlusion caused two participants to withdraw from the study. table 1. bfrt recommended guidelinesa type guidelines cuff application around the limb proximal to the muscle(s) being trained cuff type wider for the leg (6-13.5 cm) and narrower for the arm (3-6 cm) occlusion pressure upper extremity: 40% to 50% of limb occlusion pressureb lower extremity: 50% to 80% of limb occlusion pressurea,b exercise stimulus aerobic: minor increase or maintenance of muscle mass and strength low-load resistance: substantial increase in muscle mass and strength type of exercise singleand multi-joint exercises are beneficial exercise loads ~20-40% 1 rep max training volume 50-80 repetitions/exercise rest time 30-45 seconds; maintain occlusion training frequency 2-4 sessions/week with the addition of high-load resistance without bfrt for more active patients abbreviation: bfrt = blood flow restriction training aguidelines adapted from scott, loenneke, slattery, and dascombe (2015).14 bguideline adapted from patterson, hughes, warmington, et al. (2019).15 safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 they used a single pressure of 180 mmhg for all patients.20 likewise two studies, one with male subjects and one with female subjects, performed by segal et al. examined the use of bfrt in patients with knee osteoarthritis. these studies used the same parameters outlined above by tennent et al., however these studies used a standard 160-200 mmhg for all participants instead of a percentage of the individuals total limb occlusion pressure.21,22 each study had a single participant drop out due to inability to tolerate bfrt, but no other participants exhibited any adverse effect.21,22 utilizing a single pressure does not fall within the recommended guidelines of 50%-80% occlusion pressure.10 the pressure applied to the limb must be calculated for each patient. five of these studies followed 7 or more of the 9 guidelines, with the final study following 6 guidelines. the final three case reports experienced rare adverse events. in two of the three cases with adverse events, it was stated that the individual had a preexisting condition. a case report by noto et al. saw a patient develop paget-schroetter syndrome when only 1 out of the 9 guidelines was followed.23 however, the authors noted that this patient had a history of localized edema in the left clavicle.10 the lack of guidelines followed, including occlusion of the upper extremity for long durations of 30 minutes to 1 hour, and preexisting condition are both factors that lead to the patient’s development of paget-schroetter syndrome.10,23 a case report by iverson et al. of a patient knee articular cartilage resection and microfracture and a case report by krieger et al. of a patient with an ankle sprain, reported that the patient developed rhabdomyolysis after just a singular treatment.24,25 in both cases, the authors concluded that this was a freak occurrence and both subjects made a full recovery and were able to continue bfrt training.24,25 additionally, the subject of the case report by iversen et al. had a history of deep vein thrombosis after knee surgery.10,24 once this subject had been treated and recovered from rhabdomyolysis, they were able to return to the study and complete bfrt without any further complications. in the case by krieger et al., the subject did not have any known preexisting conditions, but it should be noted that the exercise load is not specified.25 preexisting conditions should not be seen as an absolute contraindication for bfrt use and individuals with preexisting conditions are still able to experience the benefits of bfrt. to limit adverse events, future research should explore in depth safety precautions and guidelines, specifically for at-risk populations with specific factors or indicators, while continuing to explore mechanisms to improve clinician and patient adherence to the guidelines already outlined.10 this available research indicates that there is no greater risk for patients who use properly implemented bfrt than those who only use traditional therapeutic techniques. it is suggested that if the 9 guidelines are followed, the worst adverse effect that a patient would experience is mild discomfort and transient muscle pain. however, the use of bfrt is not completely devoid of risk and therefore only healthcare practitioners who wish to implement bfrt into their rehabilitation should be properly trained on the parameters and safety guidelines.10 clinical bottom line blood flow restriction therapy has been found to have little to no adverse effects on patients with knee related musculoskeletal disorders.10 the risk of adverse effects is minimal when the 9 safety guidelines are followed as well as ensuring that the patient does not have a history of vascular disorders such as deep vein thrombosis.10 in particular, bfrt can be particularly useful in rehabilitation of post-operative acl reconstruction. hughes and colleagues found that although muscle pain was higher for both the acl reconstruction bfrt and the non-injured bfrt groups, knee pain was less than that of the acl reconstruction without bfrt.8 as discussed, bfrt can be a useful therapeutic intervention; however, certain parameters safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 should be followed during use. most importantly, the athletic trainer must be trained by the accredited medical device manufacturer before using the bfrt device. the athletic trainer should choose the appropriately sized cuff for the patient to ensure that the bfrt device can function as intended. it is critical that cuff pressure be individualized to each patient as well as using cuffs that disperse the occlusion pressure around the circumference of the given extremity for not only safe, but effective implementation of bfrt. in addition to cuff size and cuff type, the guidelines of cuff application, limb occlusion pressure, exercise stimulus, type of exercise, exercise loads, training volume, rest, and training frequency should be followed in order to ensure safe implementation of bfrt.10 further research is needed to make definitive conclusions about the absolute safety in all patient populations and for other injuries such as upper extremities and low back pain. based on the findings in the guiding systematic review, athletic trainers should use caution when considering the use of cuffs for postoperative patients. first, they should be required to take the recommended training offered by the manufacturing company in order to be trained in cuff selection and application for the bfrt device. next, clinical guidelines should be created for bfrt cuff use for low-load use during rehabilitation so that the proper protocols are followed including but not limited to individualized cuff pressure. finally, athletic trainers should record observations and results for patient outcome analysis related to the efficiency of bfrt on a case-to-case basis to inform future clinical decision making. references 1. serpell bg, scarvell jm, ball nb, smith pn. mechanisms and risk factors for noncontact acl injury in age mature athletes who engage in field or court sports: a summary of the literature since 1980. j strength cond res. 2012;26(11):3160-3176. https://doi.org/10.1519/jsc.0b013e318243fb5a. 2. renstrom p, ljungqvist a, arendt e, et al. non-contact acl injuries in female athletes: an international olympic committee current concepts statement. br j sports med. 2008;42(6):394-412. https://doi.org/10.1136/bjsm.2008.048934. 3. anderson mj, browning wm, 3rd, urband ce, kluczynski ma, bisson lj. a systematic summary of systematic reviews on the topic of the anterior cruciate ligament. orthop j sports med. 2016;4(3):2325967116634074. https://doi.org/10.1177/2325967116634074. 4. hewett te, ford kr, hoogenboom bj, myer gd. understanding and preventing acl injuries: current biomechanical and epidemiologic considerations update 2010. n am j sports phys ther. 2010;5(4):234-251. 5. paterno mv, ford kr, myer gd, heyl r, hewett te. limb asymmetries in landing and jumping 2 years following anterior cruciate ligament reconstruction. clin j sport med. 2007;17(4):258-262. https://doi.org/10.1097/jsm.0b013e31804c77ea. 6. mason mjs, owens jg, brown lwj. blood flow restriction training: current and future applications for the rehabilitation of musculoskeletal injuries. tech orthop. 2018;33(2):71. https://doi.org/10.1097/bto.0000000000000301. 7. hughes l, rosenblatt b, paton b, patterson sd. blood flow restriction training in rehabilitation following anterior cruciate ligament reconstructive surgery: a review. tech orthop. 2018;33(2):106-113. https://doi.org/10.1097/bto.0000000000000265. 8. hughes l, paton b, haddad f, rosenblatt b, gissane c, patterson sd. comparison of the acute perceptual and blood pressure response to heavy load and light load blood flow restriction resistance exercise in anterior cruciate ligament reconstruction patients and non-injured populations. phys ther sport. 2018;33:54-61. https://doi/org/10.1016/j.ptsp.2018.07.002. 9. nakajima t, kurano m, iida h, et al. use and safety of kaatsu training: results of a national survey. int j kaatsu train res. 2006;2(1):5-13. https://doi.org/10.3806/ijktr.2.5. https://doi.org/10.1519/jsc.0b013e318243fb5a https://doi.org/10.1136/bjsm.2008.048934 https://doi.org/10.1177/2325967116634074 https://doi.org/10.1097/jsm.0b013e31804c77ea https://doi.org/10.1097/bto.0000000000000301 https://doi.org/10.1097/bto.0000000000000265 https://doi/org/10.1016/j.ptsp.2018.07.002 https://doi.org/10.3806/ijktr.2.5 safety of blood flow restriction training for musculoskeletal disorders: an evidence-to-practice review 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 10. minniti mc, statkevich ap, kelly rl, et al. the safety of blood flow restriction training as a therapeutic intervention for patients with musculoskeletal disorders: a systematic review. am j sports med. 2020;48(7):1773-1785. https://doi.org/10.1177/0363546519882652. 11. white a, hayhoe s, ernst e. survey of adverse events following acupuncture. acupunct med. 1997;15(2):67-70. https://doi.org/10.1136/aim.15.2.67. 12. carnes d, mullinger b, underwood m. defining adverse events in manual therapies: a modified delphi consensus study. man ther. 2010;15(1):2-6. https://doi.org/10.1016/j.math.2009.02.003. 13. brady s, mcevoy j, dommerholt j, doody c. adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. j man manip ther. 2014;22(3):134-140. https://doi.org/10.1179/2042618613y.0000000044. 14. scott br, loenneke jp, slattery km, dascombe bj. exercise with blood flow restriction: an updated evidence-based approach for enhanced muscular development. sports med. 2015;45(3):313-325. https://doi.org/10.1007/s40279-014-0288-1. 15. patterson sd, hughes l, warmington s, et al. blood flow restriction exercise: considerations of methodology, application, and safety. front physiol. 2019;10:533. https://doi.org/10.3389/fphys.2019.00533. 16. tennent dj, burns tc, johnson ae, owens jg, hylden cm. blood flow restriction training for postoperative lower-extremity weakness: a report of three cases. curr sports med rep. 2018;17(4):119-122. https://doi.org/10.1249/jsr.0000000000000470. 17. ferraz rb, gualano b, rodrigues r, et al. benefits of resistance training with blood flow restriction in knee osteoarthritis. med sci sports exerc. 2018;50(5):897-905. https://doi.org/10.1249/mss.0000000000001530. 18. bryk ff, dos reis ac, fingerhut d, et al. exercises with partial vascular occlusion in patients with knee osteoarthritis: a randomized clinical trial. knee surg sports traumatol arthrosc. 2016;24(5):15801586. https://doi.org/10.1007/s00167-016-4064-7. 19. gaunder cl, hawkinson mp, tennent dj, tubb cc. occlusion training: pilot study for postoperative lower extremity rehabilitation following primary total knee arthroplasty. us army med dep j. 2017(217):39-43. 20. ohta h, kurosawa h, ikeda h, iwase y, satou n, nakamura s. low-load resistance muscular training with moderate restriction of blood flow after anterior cruciate ligament reconstruction. acta orthop scand. 2003;74(1):62-68. https://doi.org/10.1080/00016470310013680. 21. segal n, davis md, mikesky ae. efficacy of blood flow-restricted low-load resistance training for quadriceps strengthening in men at risk of symptomatic knee osteoarthritis. geriatr orthop surg rehabil. 2015;6(3):160-167. https://doi.org/10.1177/2151458515583088. 22. segal na, williams gn, davis mc, wallace rb, mikesky ae. efficacy of blood flow-restricted, lowload resistance training in women with risk factors for symptomatic knee osteoarthritis. pm r. 2015;7(4):376-384. https://doi.org/10.1016/j.pmrj.2014.09.014. 23. noto t, hashimoto g, takagi t, et al. paget-schroetter syndrome resulting from thoracic outlet syndrome and kaatsu training. intern med. 2017;56(19):2595-2601. https://doi.org/10.2169/internalmedicine.7937-16. 24. iversen e, røstad v. low-load ischemic exercise-induced rhabdomyolysis. clin j sport med. 2010;20(3):218-219. https://doi.org/10.1097/jsm.0b013e3181df8d10. 25. krieger j, sims d, wolterstorff c. a case of rhabdomyolysis caused by blood flow-restricted resistance training. j spec oper med. 2018;18(2):16-17. https://doi.org/10.55460/1yxc-izh1. https://doi.org/10.1177/0363546519882652 https://doi.org/10.1136/aim.15.2.67 https://doi.org/10.1016/j.math.2009.02.003 https://doi.org/10.1179/2042618613y.0000000044 https://doi.org/10.1007/s40279-014-0288-1 https://doi.org/10.3389/fphys.2019.00533 https://doi.org/10.1249/jsr.0000000000000470 https://doi.org/10.1249/mss.0000000000001530 https://doi.org/10.1007/s00167-016-4064-7 https://doi.org/10.1080/00016470310013680 https://doi.org/10.1177/2151458515583088 https://doi.org/10.1016/j.pmrj.2014.09.014 https://doi.org/10.2169/internalmedicine.7937-16 https://doi.org/10.1097/jsm.0b013e3181df8d10 https://doi.org/10.55460/1yxc-izh1 abstract manuscript type disablement model case study 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 disablement model case study: running with postural orthostatic tachycardia syndrome jordan fenney ms, lat, atc, ces*†; wendy reitz lat, atc*; hayley m. ericksen phd, lat, atc** *aurora sports health, west bend, wi; **university of wisconsin-milwaukee, milwaukee, wi; †muscle and movement therapy, cedarburg, wi abstract a 17-year-old high school female cross-country runner and basketball player presented with syncope following longendurance exercise. the syncope episodes started when the patient was 13 years old during a basketball game. after the first episode, the patient fainted every time she crossed the finish line of a cross-country meet. her symptoms included increased heart rate, shortness of breath, and paresthesia in her hands and legs during exercise. the patient also experienced some dizziness when quickly sitting or standing during activities of daily living. the patient was first misdiagnosed with exercise induced asthma and prescribed a rescue inhaler to take prior to competition races, however the syncope episodes persisted. a referral was made to a cardiologist who performed the q sweat response (qsr) and tilt table tests. the test results, and clinical symptoms were consistent with a diagnosis of postural orthostatic tachycardia syndrome (pots). metoprolol was prescribed to slow her heart rate and fludrocortisone to increase blood volume. the patient took these medications daily and also took an extra half-a-tablet of metoprolol before exercising in hot conditions. the patient’s syncope following long endurance races was managed by a coach who would catch the patient after she crossed the finish line, lay her down and elevate her legs until she regained consciousness. once consciousness was regained, her heart rate and oxygen were monitored using a pulse oximeter. pots is a unique condition that can be managed with strong communication between healthcare professionals. proper management allows for continued competition with some modifications made by the athlete and close monitoring by the athletic trainer. it is important for athletic trainers to be educated on the signs and symptoms of pots and understand that it can affect each athlete differently. key phrases diagnostic testing and physical examination: nonmusculoskeletal conditions; interprofessional practice; secondary schools patient population correspondence dr. hayley ericksen, 3409 n. downer ave, milwaukee, wi 53201. e-mail: erickseh@uwm.edu twitter: @hayericksen_atc full citation feeney j, reitz w, ericksen hm. disablement model case study: running with postural orthostatic tachycardia syndrome. clin pract athl train. 2021;4(2): 45-51. https://doi.org/10.31622/2021/0004.2.7. submitted: october 29, 2020 accepted: february 9, 2021. introduction postural orthostatic tachycardia syndrome (pots) is an autonomic nervous system (ans) disorder which can cause symptoms the following symptoms: light‐headedness, fatigue, sweating, anxiety, heart palpitations, exercise intolerance and near syncope when standing.1 pots is a unique condition affecting approximately 500,000 people in the united states, with predominance in young females.2 there are two classifications associated with pots: primary pots and secondary pots. primary pots is thought to be idiopathic, occurring on its own without association with another disease, whereas with secondary pots symptoms are experienced as a results of another disease diagnosis.3 primary pots can be classified deeper into partial dysautonomia and hyperadrengic.3 proper classification of pots can help with better management of the patient’s symptoms. clinicians should conduct a thorough history to determine if a patient may be experiencing primary or secondary pots. when the ans is functioning properly, orthostatic stability is maintained when moving from supine or prone to seated by increasing heart rate by 10 to 20 beats per minute (bpm).1 the increase in heart rate allows the body to maintain blood pressure and supply oxygenated blood to the brain and other vital organs.1 this orthostatic stability is achieved within 60 seconds under normal conditions.1 in a patient diagnosed with pots, the innervation of the veins or the vein’s response to sympathetic stimulation is impaired. 1 this dysfunction leads to mailto:erickseh@uwm.edu https://doi.org/10.31622/2021/0004.2.7 disablement model case study: running with postural orthostatic tachycardia syndrome 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 over-dilation of the blood vessels and venous pooling in the legs, thereby reducing venous return to the heart, which subsequently reduces the arterial flow of oxygenated blood to the brain.1,4 for approximately 10 minutes after standing, someone with pots will experience a heart rate increase of 30 bpm or more resulting in a heart rate greater than 120 bpm as the ans attempts to increase cardiac output and blood pressure to supply the brain and vital organs with oxygenated blood. with the increase in heart rate, a decrease in blood pressure can occur. this will lead to less blood flow to the brain and result in symptoms such as light‐headedness, fatigue, sweating, anxiety, palpitations, exercise intolerance, and in some cases syncope.1 symptoms of pots can impair a patient’s ability to engage in physical activity and activities of daily living, and therefore, can greatly affect the patient’s overall quality of life. patient information a 17-year-old female cross-country runner and basketball player presented with syncope following long-endurance exercise. the patient’s other symptoms included increased heart rate, shortness of breath, and paresthesia in her hands and legs during and after exercise. the syncope episodes first started during a middle school basketball game in 2014, at the age of 13 years old. the patient stated that while playing in the game, she was running backwards and she tripped and fell. when she got back up, she had trouble breathing, so she was substituted out of the game. her mother came down from the bleachers and as they were walking out of the gym, the patient fainted. the patient’s mother took her to a primary care physician where the patient was first misdiagnosed with exercise induced asthma and given a rescue inhaler. the following year, at the age of 14, the patient used the prescribed rescue inhaler following cross-country practices when she continued to experience symptoms of increased heart rate, shortness of breath, and paresthesia in her hands and legs. the inhaler treatment provided no symptom relief. the patient returned to her primary care physician and was referred to a specialist at a children’s hospital where she was then misdiagnosed with a "once in a lifetime throat spasm.” the patient continued to participate in cross-country, but when she had two more syncope episodes during practice, the coach and athletic trainer decided that she would be unable to continue participation without a proper diagnosis. the patient was finally referred to a cardiologist who specializes in pots and the correct diagnosis was made in 2016, two years after her symptoms began. activity and participation throughout the patient’s high school career, she competed in two sports: basketball and cross country. the symptoms of her pots diagnosis impacted her participation in practices and competition in different ways. throughout her freshman and sophomore year, she had fainting spells during all activity until she received a proper diagnosis in 2016. with the correct diagnosis and medication, most of her symptoms were under control; however, one symptom, syncope, persisted and continued to plague her at the end of each cross-country competition. she was able to finish her race but would faint into the arms of her coach at the finish line. the nature of a cross-country finish linean abrupt stop, caused a quick drop in the patient’s blood pressure, which decreased blood flow to the brain and triggered a syncope episode. after which, the patient explained that she felt numbness and tingling in her hands and feet for about ten minutes before her symptoms would improve. during basketball practices and games, the patient did not experience syncope episodes but did have increased heart rate, shortness of breath, and paresthesia in hands and feet. when she began having these symptoms, she was able to stop participating, sit down, and hydrate while slowly decreasing her heart rate, thus avoiding a disablement model case study: running with postural orthostatic tachycardia syndrome 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 syncope episode. the patient was able to work through and manage her symptoms with proper recognition and recovery techniques. the support of medications and other modifications to her routine also helped her to manage her symptoms and allowed her to continue participating in physical activity. differential diagnosis and evaluation the differential diagnosis list for this case included: tachycardia syndrome, chronic fatigue syndrome, anxiety, asthma, vasovagal syncope, orthostatic hypotension, or cardiac arrhythmias. the patient was first misdiagnosed with exercise induced asthma and treated with a rescue inhaler which did not improve her symptoms. the patient then saw a cardiologist, whom after evaluating her signs and symptoms, performed a series of tests to help determine a correct diagnosis. the cardiologist was able to rule out chronic fatigue syndrome, anxiety and orthostatic hypotension based on evaluation of the patient’s signs and symptoms. the patient’s ekg results were unremarkable, which helped rule out tachycardia syndrome and cardiac arrhythmias. the cardiologist suspected she may be suffering from pots and ordered several tests to confirm the diagnosis. the q sweat response (qsr) test was performed to evaluate the sweat response of the sympathetic nervous system. the qsr test uses iontophoresis to stimulate the sweat glands to release acetylcholine, resulting in and increased sweat response.5 the standard testing sites include forearm, proximal leg, distal legs, and dorsum of the foot.6 the amount of sweat is measured by the change in humidity in the sweat capsule from baseline to 15 minutes post stimulation.6 in normal individuals, the sweat output increases for about 5 minutes until it reaches an inflection point and then slowly decreases. if a patient has a loss of sympathetic nerve terminals, the terminals will not release as much acetylcholine resulting in decreased sweat.5 the results of this patient’s qsr test showed a normal volume of sweat on the forearm and proximal leg, increased volume on the distal leg, and decreased volume of sweat on the foot compared to the proximal leg. the decreased volume of sweat on the foot compared to the proximal leg shows that the patient has a sympathetic nervous system abnormality. the cardiologist summarized these results to indicate abnormal postganglionic sudomotor function showing a mild impairment in the autonomic nerves, a result that is consistent with a diagnosis of pots. the tilt table test measures heart rate and blood pressure while the body is in different positions.7 the test is meant to mimic the sudden change in posture resulting in syncope. the test begins with a 10-15 minute baseline period of lying in a supine position.7 the table is slowly raised to seventy degrees while blood pressure and heart rate are measured.7 with the tilt table test the doctor is looking for two changes, a decrease in blood pressure and/or heart rate as the table is tilted upright.7 if the patient can lay at seventy degrees without symptoms the clinician will introduce a sympathetic medication called isoproterenol. this patient was tested with a sympathetic medication that caused the heart to beat stronger and faster. the patient’s results with the medication showed an abnormal response to seventy degrees head-up tilt, increased heart rate during the second ten minutes of upright tilt, and variable blood pressure during upright tilt compared to supine baseline. her tilt table test showed that she has hyperadrenergic pots because her results varied after the sympathetic drug was introduced. the cardiologist’s summary of these findings stated that the patient had normal cardiovagal function, but she was abnormal when the medication was introduced. this is consistent with the fact that she only experienced syncope episodes when under stress such as long-endurance events. body structure and function disablement model case study: running with postural orthostatic tachycardia syndrome 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 pots affects the ans, which is the reflexive and involuntary division of the central nervous system.8 it is responsible for conducting nerve impulses from the central nervous system to cardiac muscle, smooth muscle, and glands.8 the basic functions of the ans include regulation of one’s heart rate and contraction of smooth muscle in the digestive tract.8 pots causes an exaggerated sympathetic response when changing orthostatic positioning. environmental and personal factors additional factors that may exacerbate the symptoms of pots include, decreased fluid intake, dehydration, exercise, morning hours, fever and high ambient temperatures.7 prior to running in hot conditions, the patient would take an extra dose of metoprolol. in extreme heat, the sympathetic nervous system dilates the blood vessels, which brings the blood closer to the skin’s surface and heat is lost through radiation from the body’s surface. the body also reacts to heat by sending a signal, via the sympathetic nerves, to the sweat glands in the skin and then heat is lost by sweat evaporation.9 one of the main symptoms of pots includes increased heart rate so the extra half-a-tablet of metoprolol was needed to decrease the patient’s heart rate when exercising in hot conditions. metoprolol is a beta-1 adrenergic receptor blocker which decreases one’s heart rate by decreasing the force of contraction in the heart.10 this allows the blood to flow easier, preventing tachycardia. when exercising in hot conditions, sweating and tachycardia is exacerbated warranting the need for an extra half-a-tablet of metoprolol for this patient. the patient came from a healthy, supportive family who encouraged her to do what she loves. in the patient’s mind, quitting was not an option and she was willing to do what it took to compete while staying healthy. the patient was diligent in taking her medications and performing modifications if needed. the communication between physician, athlete, parents, and the athletic trainer was strong, which helped the patient to manage her conditions while still participating in her sport. interventions upon being accurately diagnosed with pots, the patient was prescribed metoprolol to aid in slowing her heart rate and fludrocortisone to increase blood volume. the patient was asymptomatic at rest and during daily activities. during and after exercise is when the patient’s symptoms become problematic. it was recommended that she prolong her cross-country race finish to slowly decrease her heart rate without a sudden drop in blood pressure. due to the nature of a cross country race, the athletes have approximately 10-20 yards to stop following crossing the finish line. this made it difficult for the athlete to slowly decrease her speed and heart rate without a sudden stop. the coach, patient and her parents, and the athletic trainer discussed the patient’s situation and needs and it was determined that an assistant coach would provide support to the patient at the finish line by catching her at the conclusion of her races. after catching the patient at the finish line, the coach would lay her down and the athletic trainer would help to monitor her heart rate and oxygen levels. once the patient's heart rate was below 130 beats per minute, she was able to stand. following each race, the patient’s heart rate returned to normal and she recovered approximately 10 minutes after finishing the race. outcomes this patient’s freshman and sophomore years of high school athletics were challenging in managing her symptoms until a correct diagnosis was obtained. when the correct doses of medication were prescribed and the patient and her healthcare team better understood her condition, the patient did not experience any episodes of disablement model case study: running with postural orthostatic tachycardia syndrome 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 syncope while participating in basketball. in her junior and senior year, the episodes of syncope were only experienced after completing a crosscountry race. her coach was able to catch her following her finish. the coach and athlete would monitor her heart rate and oxygen levels via pulse oximeter. support provided by the cross-country coaches and the athletic trainer at the finish line helped her to recover quickly and she was able continue competing throughout her high school career. discussion this case is unique because it is endurance and adrenaline driven. in fact, 50% of pots patients show signs of a hyperadrenergic or high adrenaline state.11 hyperadrenergic pots patients have high levels of nor-epinephrine in their blood which are natural stimulants in the body.11 this can lead to an increase in heart rate and blood pressure. this patient experienced syncope episodes following long-endurance crosscountry races due to the abrupt stop at the finish line and resultant rapid drop in heart rate . her tilt table test showed that she has hyperadrenergic pots because her results varied after the sympathetic drug, isoproterenol, was introduced. additionally, the patient would always pass the finish line before fainting, supporting the hyperadrenergic pots diagnosis. following the correct diagnosis and dosages for the patient’s medication, she would only faint after running a cross-country race. during cross country practices or basketball games, the patient was able to slowly decrease activity and reduce her heart rate through breathing techniques. during basketball games and practices, she was able to tell when her heart rate was too high, so she would let her coach know she needed a substitution. after coming out of the game or practice she would sit on the bench and hydrate until her heart rate was under control. compared to other cases, this patient had a mild case of pots, which was managed through medications and modifications to sport participation. some cases of pots are more severe and have a greater effect on the patient’s daily activities. for example, two cases were presented detailing the symptoms of two young, caucasian females. the first case included a 20year-old female who showed acute onset episodes of fainting upon sitting up, dizziness, slowing of speech, and the inability to contract muscles in the bladder.12 this patient was treated with 20 mg of propranolol, which is similar to the beta blocker the patient in the current case was prescribed. with the help of the medication, the patient only had short periods of dizziness following the diagnosis.12 the second case included a 19-year-old who showed acute onset of dizziness with syncope events.12 this patient was first treated with fludrocortisone and compression stockings. the patient also received 500 mg of methylprednisolone for five days for suspected autonomic neuropathy.12 these two cases were unique because they started with an acute onset and the symptoms were fully disabling. variation in onset, intensity and type of symptoms in those experiencing pots could make diagnosis difficult. if pots is not properly treated, the syndrome can greatly impact not just athletic activity, but activities of daily living. proper communication between providers on the healthcare team can speed the delivery of an accurate diagnosis, aid in the development of a patient care plan, and assist the athlete in managing their symptoms. this case presented with strengths and limitations. overall, the patient and her family were very well informed and cooperative in providing information to inform this case. for being so young in experiencing a health condition such as pots, this patient was a very good communicator and became an advocate for her own healthcare. educating and empowering high school patients to communicate and manage their own health disablement model case study: running with postural orthostatic tachycardia syndrome 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 conditions is extremely important. athletic trainers, parents, and coaches can work together to help the high school patient-athlete in how to best manage their condition to be able to compete at a desired level. this patient took time to understand her condition, understand her condition, learned how to manage her symptoms, and she communicated well with all athletic trainers involved in her care – at home, and while traveling for competitions. clinical bottom line although pots is not extremely prevalent in athletic training clinical practice, it is vital for athletic trainers to be educated on the signs and symptoms of pots and understand that it can affect each patient differently. the signs and symptoms of pots may mimic many other pathologies which may lead to misdiagnoses and ineffective treatments. athletic trainers should urge patients and their parents to seek several opinions when symptoms include light‐headedness, fatigue, sweating, anxiety, palpitations, exercise intolerance and syncope or near-syncope when standing or after exercise. when correctly diagnosed, pots can be managed with patient education, advocacy and strong communication. further, collaboration between healthcare providers to create an individual plan for the patient can also contribute to the management of pots. in this case, the patient’s cardiologist, parents, coaches, athletic trainers, and the patient were all closely involved in her care plan. with a few simple modifications to an athlete’s procedure, close monitoring by athletic trainers, and routine checkups with a cardiologist, pots symptoms can be managed and patientathletes can continue competing at high levels in various endurance sports. references 1. agarwal ak, garg r, ritch a, sarkar p. postural orthostatic tachycardia syndrome. postgrad med j. 2007;83(981):478-480. https://doi.org/10.1136/pgmj.2006.05504 6. 2. grubb bp. postural tachycardia syndrome. circulation. 2008;117(21):2814-2817. https://doi.org/10.1161/circulationaha.107 .761643. 3. grubb bp, kanjwal y, kosinski dj. the postural tachycardia syndrome: a concise guide to diagnosis and management. j cardiovasc electrophysiol. 2006;17(1):108112. https://doi.org/10.1111/j.15408167.2005.00318.x. 4. benarroch ee. postural tachycardia syndrome: a heterogeneous and multifactorial disorder. mayo clin proc. 2012;87(12):1214-1225. https://doi.org/10.1016/j.mayocp.2012.08 .013. 5. sletten dm, weigand sd, low pa. relationship of q-sweat to quantitative sudomotor axon reflex test (qsart) volumes. muscle nerve. 2010;41(2):240-246. https://doi.org/10.1002/mus.21464. 6. illigens bm, gibbons ch. sweat testing to evaluate autonomic function. clin auton res. 2009;19(2):79-87. https://doi.org/10.1007/s10286-0080506-8. 7. fedorowski a. postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. j intern med. 2019;285(4):352-366. https://doi.org/10.1111/joim.12852. 8. waxenbaum ja, reddy v, varacallo m. anatomy, autonomic nervous system. treasure island (fl): statpearls publishing; 2021. https://www.ncbi.nlm.nih.gov/books/nbk53 9845/. 9. greaney jl, kenney wl, alexander lm. sympathetic regulation during thermal stress in human aging and disease. auton neurosci. 2016;196:81-90. https://doi.org/10.1016/j.autneu.2015.11. 002. https://doi.org/10.1136/pgmj.2006.055046 https://doi.org/10.1136/pgmj.2006.055046 https://doi.org/10.1161/circulationaha.107.761643 https://doi.org/10.1161/circulationaha.107.761643 https://doi.org/10.1111/j.1540-8167.2005.00318.x https://doi.org/10.1111/j.1540-8167.2005.00318.x https://doi.org/10.1016/j.mayocp.2012.08.013 https://doi.org/10.1016/j.mayocp.2012.08.013 https://doi.org/10.1002/mus.21464 https://doi.org/10.1007/s10286-008-0506-8 https://doi.org/10.1007/s10286-008-0506-8 https://doi.org/10.1111/joim.12852 https://www.ncbi.nlm.nih.gov/books/nbk539845/ https://www.ncbi.nlm.nih.gov/books/nbk539845/ https://doi.org/10.1016/j.autneu.2015.11.002 https://doi.org/10.1016/j.autneu.2015.11.002 disablement model case study: running with postural orthostatic tachycardia syndrome 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 10. information ncfb. pubchem compound summary for cid 4171, metoprolol. https://pubchem.ncbi.nlm.nih.gov/compound /metoprolol. accessed october 14, 2020. 11. arnold ac, ng j, raj sr. postural tachycardia syndrome diagnosis, physiology, and prognosis. auton neurosci. 2018;215:3-11. https://doi.org/10.1016/j.autneu.2018.02. 005. 12. chung hy, essig f, wickel j, et al. acute onset and severe manifestation of postural orthostatic tachycardia syndrome two cases. clin neurophysiol. 2020;131(1):158-159. https://doi.org/10.1016/j.clinph.2019.11.0 01. https://pubchem.ncbi.nlm.nih.gov/compound/metoprolol https://pubchem.ncbi.nlm.nih.gov/compound/metoprolol https://doi.org/10.1016/j.autneu.2018.02.005 https://doi.org/10.1016/j.autneu.2018.02.005 https://doi.org/10.1016/j.clinph.2019.11.001 https://doi.org/10.1016/j.clinph.2019.11.001 abstract manuscript type evidence-to-practice review 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 the functional movement screen and injury risk in sporting populations: an evidence-to-practice review taylor niles, ms, scat, atc; federico rossi, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract the functional movement screen (fms) is a functional test, which aims to identify dysfunctional, asymmetrical, and painful movements that could contribute to future injuries. medical professionals can clinically use this information to implement appropriate, specialized prehabilitation training aimed at reducing the dysfunctional, asymmetrical, and painful movements, to help prevent injury risk. research on this tool, however, has contradictory findings regarding fms composite score and future risk of injury. it is unclear to what extent fms can predict those with future injury risk, and whether there are factors, such as age, sex, or sport-type, which may be contributing to these varying findings. therefore, the purpose of this review was to identify which factors, if any, may contribute to the contradictory findings regarding the relationship between fms composite score and subsequent injury risk in physically active populations. the review aimed to include any study which performed an fms test at baseline on physically active individuals competing at any level, and determined risk groups based on composite scores, using odds ratios, sensitivity, and specificity as outcome measures. subgroups were assessed based on athlete age, sex, sport-type, injury definition and injury mechanism. reviewed participants were split into two age groups, senior (18+ years old) and junior (9-18 years old) athletes. it was found that age, sex, and sport-type explained some of the variable findings in the literature, however, effect sizes were often small in magnitude. functional movement screen composite scores and asymmetry seemed to be the most useful in estimating injury risk for senior athletes, as well as individuals participating in rugby, american football, and ice hockey. there were many gaps identified in the research that may help get a consensus on optimal populations and uses for fms. thus, we recommend utilizing appropriate clinical judgment when determining if fms would be a beneficial tool for identifying those with higher injury risk at your clinical site and with your patient population. key phrases preparticipation exams and screening, functional testing, injury risk reduction correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation niles t, rossi f, winkelmann zk. the functional movement screen and injury risk in sporting populations: an evidence-to-practice review. clin pract athl train. 2021;4(2): 52-57. https://doi.org/10.31622/2021/0004.2.8. submitted april 20, 2020 accepted: march 8, 2021. original reference moore e, chalmers s, milanese s, fuller jt. factors influencing the relationship between the functional movement screen and injury risk in sporting populations: a systematic review and meta-analysis. sports med. 2019;49(9):1449-1463 summary clinical problem and question musculoskeletal screening tests such as the functional movement screen (fms), are designed to identify modifiable risk factors so that healthcare providers can implement appropriate training strategies to reduce the incidence of injury.1,2 the fms is composed of 7 subtests, including the squat, step over, in-line lunge, reach, leg raise, push-up, and rotary stability, where each test is scored on a scale 1-3, to produce a maximum score of 21. functional movement screen pain and asymmetry are dichotomous outcomes based on the presence or absence of pain during fms testing and at least one fms test difference between left and right sides of the body, respectively. while fms is one of the more popular injury risk screening tools, there is little agreement on what factors of the test contribute to injury risk; therefore, the primary purpose of this meta-analysis was to identify factors that contribute to the investigated relationship mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.2.8 the functional movement screen and injury risk in sporting populations: an evidence-to-practice review 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 between fms and injury risk in sporting populations, especially the difference between the senior (18+ years old) and junior (9-18 years old) athletes. the second aim of this study was to examine the results of studies that have assessed the relationship between fms asymmetry and injury risk. summary of literature the authors for the guiding systematic review and meta-analysis conducted a systematic search of medline, scopus, ebscohost (including sportdiscus, academic search premiere, health source: consumer edition, health source: nursing/academic edition), embase and web of science databases, to identify whether participant age, sex, sport-type, injury definition and mechanism contributed to the variable findings. studies that were included in the systematic review had to meet the following inclusion criteria: 1) peer reviewed and published in the english language, 2) participants were competing at any level of sporting competition, 3) prospective cohort study design that assessed fms performance at baseline using the complete fms test battery and subsequently observed participants during sports training and competition, 4) identified risk groups based on fms composite score, asymmetry or pain, and 5) outcome measures were injury incidence that could be categorized within the six injury level classifications provided by orchard and hoskins.3 systematic database searches identified 1028 potential studies that, after screening, resulted in 36 studies included in the systematic review. nine of 36 studies did not explicitly state that participants were injury-free at the time of testing. five of 36 studies were deemed to not describe the injury surveillance method in enough detail. four of 36 studies used a follow-up period that was less than one complete competitive season. twenty-three studies were unclear whether follow-up was completed for all participants, and 18 were unclear whether strategies to account for incomplete follow-up were implemented. six studies did not utilize statistical analysis that resulted in the reporting of injury-risk statistics. summary of outcomes this review looked at the odds ratio for injury risk given a specific criteria of fms testing, to see if any differences in effect size existed between participant age, sex, sport type, injury definition or injury mechanism. the review also looked at the sensitivity and specificity based on risk groups determined by the different fms testing criteria. the fms criteria analyzed included a 1) fms composite score threshold of < 14, 2) >1 subtest with reported asymmetry, or 3) >1 subtest with reported pain. injury mechanism was grouped as either all-cause injury or non-contact injury. injury definitions were divided into tissue damage or presentation to medical staff, limited or loss of training/match, and limited or loss of match only. findings and clinical implications this review looked to identify factors that contribute to the contradictory findings regarding fms composite score and subsequent injury risk in sporting populations. kiesel et al found that individuals with a composite score of < 14 have an 11 times greater injury risk, while a systematic review by bonazza, et al. reported a 3-fold or smaller increase in injury risk.4,5 there could be a few reasons for the differences in the findings between these studies. for example, the systematic review mentions how only 2 other studies replicated the findings of kiesel, et al. via independent roc curves. the review also identifies how there may be an effect of sex and population characteristics on a cutoff. this could have contributed to the differences between the studies, as kiesel, et al. focused only on male professional football players who form one individual team, while bonazza, et al. included studies with men and women, as well as athletes the functional movement screen and injury risk in sporting populations: an evidence-to-practice review 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 and non-athletes. overall, this review identified that there were few studies that show a significant relationship between composite scores and subsequent future injury risk, and many of the results that were significant were only of small effect size. while the general understanding is that fms testing’s purpose is to identify dysfunctional, asymmetrical, and painful movements that could contribute to future injuries, more focused research is needed investigating which aspects of fms testing work best at identifying risk and for which subgroups of individuals. there are several gaps in the literature that still need to be identified to justify fms use in many settings. first, of the studies used in this review, 3 studies used only female participants,1-3 while 18 used only males,4-21 which leaves a sex bias in the literature, making it difficult to generalize females. it should also be considered that individual subtests of the fms may have stronger association with injury risk due to the differing demands and injury risks presented in varying sports. more consideration should be focused on whether poor scores for specific subtests are more strongly associated with injury to the region of the body that was tested. while there are a few studies which investigate this,6-9 there is still a general lack of literature looking into subtests and their relation to specific injury types and body regions. finally, the results of this study showed a smaller effect for junior athletes (or = 1.03 [0.67–1.59]; p = 0.881) compared to senior athletes (or = 1.80 [1.17–2.78]; p = 0.008), however, there is little research that explains why we see this difference. based on the findings of this meta-analysis, our own review of the evidence, and clinical expertise, we suggest that clinicians consider their patient population and possible contributing risk factors which may lead to injury in their setting before implementing fms. the contradictory findings of research on this topic, as well as the lack of clinically significant findings of this meta-analysis, identify various gaps in the research on fms testing. a composite score threshold of < 14 was only found to have significant increase in injury risk for males, senior athletes, male and female rugby players, and baseball players. composite scores were also found to be a better predictor of allcause injuries, than non-contact injuries. there is not enough evidence to support a relationship between subtest and corresponding injury to subtest body region, though we recommend looking at the individual subtest scores, rather than just the composite score to best understand where an individual's movement deficiencies lie. because of these findings, we suggest clinicians consider fms testing for senior male athletes, especially those who participate in rugby or baseball. although the findings were not significant for other sport-types and subgroups, we recommend that sports or groups which have higher incidence of all-cause injuries should consider fms testing as well. functional movement screen testing is a feasible test, so the general loss and harm of implementing fms, even for subgroups that did not have a significant relationship to injury risk prediction, is minimal. clinical bottom line functional testing has the potential to be a helpful tool in identifying at-risk individuals for future injury, thus allowing healthcare providers to create tailored prevention programs to address movement disparities identified by the screening tool. it should be considered, however, that fullbody movement screens, such as the fms, may not be the best tool for all population groups. due to inconsistent and unclear methodology of the various research into fms testing, it is difficult to create a clear consensus on the effectiveness of the tool as a predictor for future injury in many subgroups of individuals. overall, most effect sizes were only small in magnitude and unlikely to be clinically meaningful in most sports, except for rugby, american football, and ice hockey. this could be due to the similarities between these the functional movement screen and injury risk in sporting populations: an evidence-to-practice review 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 sports mentioned and the 7 components of the fms test. it may be beneficial for clinicians to consider assessing for movement quality based on the subtests instead of the composite score. different subtests assess for different movement qualities, such as range of motion, strength, or balance. identifying movement qualities that are crucial to specific sports and using only the fms subtests which assess those movement qualities may be more beneficial for sport types that did not have significant results with the composite score. similarly, if a sport consists of upper extremity use, it may be more beneficial for clinicians to focus the examination on the movement quality of the upper extremity using subtests that specifically assess the upper extremity. we are not suggesting that injury prevention be hyperfocused to a singular joint, rather there is a need to examine the kinetic chain and how movement patterns at the ankle can affect the hip, and so on. we suggest that clinicians consider the individual subtest of the fms as a better tool than the composite score of the fms. for example, the hurdle step of the fms is a multi-joint assessment that could be very helpful for a lower extremity activity like ballet or soccer, which the guiding review did not identify as having a clinically meaningful finding. reviewing subtests individually would allow the clinician to identify movement patterns which most affect the patient, rather than performing a complete fms test to get a composite score. the composite score and presence of asymmetry are strong predictors of injury risk in senior compared to junior athletes, though again, this effect size was small in magnitude. junior cohorts may benefit from a lower composite score threshold, as suggested by the consistent null findings in junior athletes. there have been many false positives in junior cohort studies, in relation to fms composite scores and injury risk, so creating a new composite threshold for junior athletes may produce more significant findings and make the screening tool more useful in these cohorts. it is likely that the painful scores seen in junior athletes is related to poor neuromuscular control as they develop, rather than dysfunctional movements. many of the fms subtests use body weight and asymmetrical movements are a result of motor control deficits which may lead to increased injury risk. since senior athletes are exposed to higher game speeds and increased force impacts, a stronger relationship between fms composite scores and injury risk in this population may be expected. injury mechanism and definition do not have a significant impact on the relationship between fms testing and injury risk, and due to the sex bias in the literature, findings from this review indicate a stronger correlation with male athletes than female athletes. references 1. cook g, burton l, hoogenboom b, voight m. pre-participation screening: the use of fundamental movements as an assessment of function-part 1. n am j sports phys ther. 2006;1(2):62–72 2. cook g, burton l, hoogenboom b, voight m. functional movement screening: the use of fundamental movements as an assessment of function-part 2. int j sports phys ther. 2014;9(4):549–63 3. moore e, chalmers s, milanese s, fuller jt. factors influencing the relationship between the functional movement screen and injury risk in sporting populations: a systematic review and meta-analysis. sports med. 2019;49(9):1449-1463. https://doi.org/10.1007/s40279-01901126-5. 4. kiesel k, plisky p, voight m. can serious injury in professional football be predicted by a preseason functional movement screen? n am j sports phys ther. 2007;2(3):147–58 5. bonazza na, smuin d, onks ca, silvis ml, dhawan a. reliability, validity, and injury https://doi.org/10.1007/s40279-019-01126-5 https://doi.org/10.1007/s40279-019-01126-5 the functional movement screen and injury risk in sporting populations: an evidence-to-practice review 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 predictive value of the functional movement screen: a systematic review and metaanalysis. am j sports med. 2016;45(3):725– 32. https://doi.org/10.1177/0363546516641 937. 6. tee jc, klingbiel jf, collins r, lambert mi, coopoo y. preseason functional movement screen component tests predict severe contact injuries in professional rugby union players. j strength cond res. 2016;30(11):3194–203. https://doi.org/10.1519/jsc.0000000000 001422. 7. hotta t, nishiguchi s, fukutani n, tashiro y, adachi d, morino s, et al. functional movement screen for predicting running injuries in 18-to 24-year-old competitive male runners. j strength cond res. 2015;29(10):2808–15. https://doi.org/10.1519/jsc.0000000000 000962. 8. rusling c, edwards kl, bhattacharya a, reed a, irwin s, boles a, et al. the functional movement screening tool does not predict injury in football. prog orthop sci. 2015;1(2):41–6. https://doi/org/10.5455/pos.2015080311 3054. 9. schroeder j, wellmann k, stein d, braumann km. the functional movement screen for injury prediction in male amateur football. dtsch z sportmed. 2016;67(2):39–43. https://doi.org/10.5960/dzsm.2015.200. 10. chorba rs, chorba dj, bouillon le, overmyer ca, landis ja. use of a functional movement screening tool to determine injury risk in female collegiate athletes. n am j sports phys ther. 2010;5(2):47. 11. clay h, mansell j, tierney r. association between rowing injuries and the functional movement screen™ in female collegiate division i rowers. int j sports phys ther. 2016;11(3):345. 12. walbright pd, walbright n, ojha h, davenport t. validity of functional screening tests to predict lost-time lower quarter injury in a cohort of female collegiate athletes. int j spots phys ther. 2017;12(6):948. 13. kiesel kb, butler rj, plisky pj. prediction of injury by limited and asymmetrical fundamental movement patterns in american football players. j sport rehabil. 2014;23(2):88-94. https://doi.org/10.1123/jsr.2012-0130. 14. chalmers s, fuller jt, debenedictis ta, et al. asymmetry during preseason functional movement screen testing is associated with injury during a junior australian football season. j sci med sport. 2017;20(7):653657. https://doi.org/10.1016/j.jsams.2016.12.0 76. 15. chalmers s, debenedictis ta, zacharia a, et al. asymmetry during functional movement screening and injury risk in junior football players: a replication study. scand j med sci sports. 2018;28(3):1281-1287. https://doi.org/10.1111/sms.13021. 16. lee c-l, hsu m-c, chang w-d, et al. functional movement screen comparison between the preparative period and competitive period in high school baseball players. j exerc sci fit. 2018;16(2):68-72. https://dx.doi.org/10.1016%2fj.jesf.2018. 06.004. 17. azzam mg, throckmorton tw, smith ra, graham d, scholler j, azar fm. the functional movement screen as a predictor of injury in professional basketball players. curr orthop pract. 2015;26(6):619-623. http://dx.doi.org/10.1097/bco.00000000 00000296. 18. martin c, olivier b, benjamin n. the functional movement screen in the prediction of injury in adolescent cricket pace bowlers: an observational study. j sports rehabil. 2017;26(5):386-395. https://doi.org/10.1123/jsr.2016-0073. 19. slodownik r, ogonowska-slodownik a, morgulec-adamowicz n. functional movement screen™ and history of injury in https://doi.org/10.1177/0363546516641937 https://doi.org/10.1177/0363546516641937 https://doi.org/10.1519/jsc.0000000000001422 https://doi.org/10.1519/jsc.0000000000001422 https://doi.org/10.1519/jsc.0000000000000962 https://doi.org/10.1519/jsc.0000000000000962 https://doi/org/10.5455/pos.20150803113054 https://doi/org/10.5455/pos.20150803113054 https://doi.org/10.5960/dzsm.2015.200 https://doi.org/10.1123/jsr.2012-0130 https://doi.org/10.1016/j.jsams.2016.12.076 https://doi.org/10.1016/j.jsams.2016.12.076 https://doi.org/10.1111/sms.13021 https://dx.doi.org/10.1016%2fj.jesf.2018.06.004 https://dx.doi.org/10.1016%2fj.jesf.2018.06.004 http://dx.doi.org/10.1097/bco.0000000000000296 http://dx.doi.org/10.1097/bco.0000000000000296 https://doi.org/10.1123/jsr.2016-0073 the functional movement screen and injury risk in sporting populations: an evidence-to-practice review 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 the assessment of potential risk of injury among team handball players. j sports med phys fitness. 2017;58(9):1281-1286. https://doi.org/10.23736/s00224707.17.07717-9. 20. avery m, wattie n, holmes m, dogra s. seasonal changes in functional fitness and neurocognitive assessments in youth icehockey players. j strength cond res. 2018;32(11):3143-3152. https://doi.org/10.1519/jsc.00000000000 02399. 21. dossa k, cashman g, howitt s, west b, murray n. can injury in major junior hockey players be predicted by a pre-season functional movement screen–a prospective cohort study. j can chiropr assoc. 2014;58(4):421. 22. duke sr, martin se, gaul ca. preseason functional movement screen predicts risk of time-loss injury in experienced male rugby union athletes. j strength cond res. 2017;31(10):2740-2747. https://doi.org/10.1519/jsc.00000000000 01838. 23. hotta t, nishiguchi s, fukutani n, et al. functional movement screen for predicting running injuries in 18-to 24-year-old competitive male runners. j strength cond res. 2015;29(10):2808-2815. https://doi.org/10.1519/jsc.00000000000 00962. 24. tee jc, klingbiel jf, collins r, lambert mi, coopoo y. preseason functional movement screen component tests predict severe contact injuries in professional rugby union players. j strength cond res. 2016;30(11):3194-3203. https://doi.org/10.1519/jsc.00000000000 01422. 25. kolodziej m, jaitner t. single functional movement screen items as main predictors of injury risk in amateur male soccer players. ger j exerc sport res. 2018;48(3):349-357. https://doi.org/10.1007/s12662-0180515-2. 26. philp f, blana d, chadwick ek, et al. study of the measurement and predictive validity of the functional movement screen. bmj open sport exerc med. 2018;4(1):e000357. https://dx.doi.org/10.1136%2fbmjsem2018-000357. 27. rusling c, edwards k, bhattacharya a, et al. the functional movement screening tool does not predict injury in football. prog orthop sci. 2015;1(2):41-46. http://dx.doi.org/10.5455/pos.201508031 13054. 28. smith pd, hanlon mp. assessing the effectiveness of the functional movement screen in predicting noncontact injury rates in soccer players. j strength cond res. 2017;31(12):3327-3332. https://doi.org/10.1519/jsc.00000000000 01757. https://doi.org/10.23736/s0022-4707.17.07717-9 https://doi.org/10.23736/s0022-4707.17.07717-9 https://doi.org/10.1519/jsc.0000000000002399 https://doi.org/10.1519/jsc.0000000000002399 https://doi.org/10.1519/jsc.0000000000001838 https://doi.org/10.1519/jsc.0000000000001838 https://doi.org/10.1519/jsc.0000000000000962 https://doi.org/10.1519/jsc.0000000000000962 https://doi.org/10.1519/jsc.0000000000001422 https://doi.org/10.1519/jsc.0000000000001422 https://doi.org/10.1007/s12662-018-0515-2 https://doi.org/10.1007/s12662-018-0515-2 https://dx.doi.org/10.1136%2fbmjsem-2018-000357 https://dx.doi.org/10.1136%2fbmjsem-2018-000357 http://dx.doi.org/10.5455/pos.20150803113054 http://dx.doi.org/10.5455/pos.20150803113054 https://doi.org/10.1519/jsc.0000000000001757 https://doi.org/10.1519/jsc.0000000000001757 abstract manuscript type disablement model case study 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study s. andrew cage, edd., lat, atc*; robert michael galbraith, do, ccfp (sem)†‡, rebecca peebles, do, caqsm, faafp†‡; payton williams, ms, lat, atc*; brandon warner, m.ed., lat, atc§ *the university of texas at tyler, tyler, tx; †the university of texas health science center at tyler, tyler, tx; ‡ut health east texas, tyler, tx §grand canyon university, phoenix, az abstract the purpose of this disablement model case report was to detail the case of a patient suffering from rhabdomyolysis and hypothyroidism. despite swelling, cramping, and loss of range of motion at the wrists, hands, and fingers, the patient did not seek physician evaluation until their athletic trainer encouraged them. while hypothyroidism is a relatively common condition, there has been little literature published that associate hypothyroidism with rhabdomyolysis. in this case, the patient reported to the athletic training staff reporting swelling, cramping, and loss of range of motion at the wrists, hands, and fingers. after evaluation by the team physician and subsequent testing, the patient was diagnosed with hypothyroidism and rhabdomyolysis. the patient was hospitalized and treated with intravenous hydration and oral levothyroxine. after a 10-day hospitalization, the patient had improved enough to be discharged. as the patient remained adherent with his levothyroxine prescription, the patient continued to improve to the point of being able to resume sport-specific activities. when evaluating a patient with swelling, cramping, and loss of range of motion after intense physical activity or muscular trauma, the clinician should consider rhabdomyolysis as a potential factor. patients presenting with these symptoms should be referred for emergency care. content focus: health care competency correspondence s. andrew cage, the university of texas at tyler, 11325 preakness drive, flint, tx 75762. email: sacage@uncg.edu. full citation cage sa, galbraith rm, peebles r, williams p, warner b. rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study. clin pract athl train. 2023;6(2): 37-42. https://doi.org/10.31622/2023/0006.02.6. introduction hypothyroidism is a relatively common pathology related to thyroid hormone deficiency.1 hypothyroidism is classified based on the biochemical characteristics of the patient.1 subclinical hypothyroidism describes patients with thyroid stimulating hormone (tsh) slightly above normal limits. clinical primary hypothyroidism describes patients whose tsh concentrations are above normal limits and free thyroxine levels are below normal limits.1 diagnosing hypothyroidism is often relatively simple, with blood draws confirming tsh and free thyroxine levels.1,2 common signs and symptoms indicating the need for this blood work include cold intolerance, unexplained weight gain, constipation, dry skin, bradycardia, and slow mental processing.2 more rare signs and symptoms of hypothyroidism include hypothermia, congestive heart failure, blood clotting issues, depression, seizures, and pseudo-obstructions of the intestinal tract.2 once diagnosed, treating hypothyroidism is relatively straightforward, consisting of oral levothyroxine sodium.1,2 to ensure the patient receives the proper dose, follow-up blood work is usually required to ensure that tsh and free thyroxine levels respond appropriately.1,2 while hypothyroidism is a treatable condition, unchecked hypothyroidism can lead to various complications, including life-threatening diseases such as myxedema coma.1,2 in rare cases, hypothyroidism can be a comorbidity of rhabdomyolysis.3-5 rhabdomyolysis is a severe and potentially fatal condition characterized by damage to the myocyte membrane.6 this damage can lead to increased intracellular calcium and muscle and organ tissue destruction.6 to date, the available research on this correlation between hypothyroidism and rhabdomyolysis has been reported in case reports. this appears to indicate that this combination of pathologies is, in fact, rare.7 therefore, the purpose of this case report is to describe a case of mailto:sacage@uncg.edu https://doi.org/10.31622/2023/0006.02.6 rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 rhabdomyolysis in a collegiate hammer thrower who was also suffering from hypothyroidism. this case report will detail the pathological presentation, diagnosis, treatment, patient-reported disablements, and outcomes. patient information patient the patient was a 20-year-old male, a collegiate hammer thrower. the patient reported a history of hypothyroidism, specifically his mother, maternal grandmother, and paternal aunt. the patient sought medical care from the team physician with reports of swelling, cramping, and tightness in his forearms, hands, and fingers. approximately one month before seeking medical care, the patient moved into a new apartment. the patient reported minimal fluid intake while carrying heavy objects into his apartment. the patient noted that he initially felt muscle cramping in his legs, back, latissimus region, forearms, hands, and fingers about two days after the move. the cramping in the patient’s legs and back improved, but swelling and cramping persisted in the patient’s forearms, hands, and fingers. differential diagnosis and evaluation initial evaluation revealed strength within normal limits, mild loss of motion in all directions within the wrist and fingers, mild paresthesia extending into the right thumb, and visible swelling in the hands and fingers (figures 1 & 2). intake screening also revealed the patient’s blood pressure was 140/70 mm hg. although the patient did not report any muscular weakness, he did state that he had to alter his upper body exercises in the weight room due to loss of motion in his wrist and fingers. despite needing to make these modifications, the patient did not seek medical care from the sports medicine staff until the swelling in his wrists, hands, and fingers worsened. the differential diagnosis included rhabdomyolysis, exertional compartment syndrome, forearm muscle tendinopathy, and radial nerve compression. because symptoms did not resolve with rest or have pain, exertional compartment syndrome, forearm muscle tendinopathy, and radial nerve compression were quickly removed from the differential diagnosis list. figure 1 & 2. images of the patient’s swollen right hand. given the patient’s symptoms, the team physician ordered blood and urine analysis to assess for rhabdomyolysis. these lab results revealed several abnormal findings, which are presented in table 1. after reviewing the results, the team physician immediately referred the patient to the emergency department at the local hospital for admittance. rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 table 1. blood testing results value reading normal range wbc rbc hemoglobin mcv mch mchc rdw mean platelet volume 7.1 4.51 14.5 91.1 32.2 35.3 13.2 12.8 4.5-13.5 10*3/ul 3.90-5.90 10*6/ul 14.0-18.0 g/dl 80.0-95.0 fl 30.0-37.0 pg 33.0-37.0 g/dl 11.5-14.5% 7.4-10.4 fl* neutrophils 46.5 42.4-72.6% lymphocytes 38.9 20.5-51.1% monocytes 8.5 1.7-11.7% eosinophils 4.9 0.0-6.3% basophils 0.8 0.0-1.2% glucose 68 74-106 mg/dl* creatinine 1.9 0.5-1.2 mg/dl* aspartate aminotransferace 282 0-41 u/l* alanine aminotransferace 134 0-41 u/l* creatine kinase 15,049 80-1083 u/l* tsh 148.1 0.27-3.20 ulu/ml* free thyroxine < 0.10 0.93-1.70 ng/dl* *abnormal result body structure and function given the patient’s symptoms, the primary diagnostic techniques used to determine the need for blood and urine analysis were comprehensive patient history, family history, and strength and range of motion tests. at the time of presentation, the patient presented with limited wrist and finger motion and full strength in all motions when compared bilaterally. throughout the presentation of symptoms, the patient did not exhibit any signs or symptoms of kidney, liver, or other systemic dysfunction. activity and participation despite experiencing symptoms for over a month, the patient did not report to the sports medicine staff until he began altering his activities. the patient stated that he had to modify how he lifted weights with his upper extremities due to his loss of range of motion. the patient had not noticed a perceived change in his ability to perform the hammer throw at that time. additionally, the patient’s measured performance had not diminished despite his decreased range of motion. after conversations with his primary athletic trainer, the patient finally agreed to seek evaluation by the team physician. environmental and personal factors outside of hammer-throwing-related activities, the patient stated that his swelling and decreased range of motion affected his daily living activities. specifically, the patient expressed having to alter how he completed grooming tasks. the patient also reported that when his fingers swelled, he had difficulty typing rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 for school assignments. the swelling was so significant at one point that the patient said he could not use a keyboard without touching four keys at a time. this difficulty led to the patient expressing concern about completing the required schoolwork on time. interventions upon admittance to the hospital, the patient’s treatment began with intravenous hydration and oral levothyroxine 150 mcg once a day. while the patient was hospitalized, the athletic training staff worked with the institution’s faculty athletics representative to communicate with the patient’s professors to ensure reasonable accommodations for assignment due dates were provided. over the next ten days, the team physician collaborated with the treating hospitalist and nephrologist to ensure optimal patient care. his blood and urine analyses improved as the patient continued his course of intravenous fluids and levothyroxine. when discharged ten days after admittance, the patient’s blood pressure had improved to 104/56 mm hg. the patient’s creatine kinase levels had also improved to 4,050 u/l. at discharge, the nephrologist instructed the patient to follow up with the team physician and an endocrinologist for further treatment. upon consultation with the endocrinologist, it was concluded that the patient did not require any further pharmacological intervention to resolve his condition. outcomes body structure and function two weeks after being admitted to the hospital, the team physician reevaluated the patient. at this time, the patient reported feeling better overall. while the patient continued swelling in his hands and upper extremities, the swelling had visibly improved, and the patient reported feeling like he had more energy. nineteen days after being admitted to the hospital, the patient had a follow-up appointment with an endocrinologist. during this visit, the patient reported feeling much better. he noted he had gained a significant amount of weight after beginning to experience symptoms. during preparticipation physical examinations, the patient weighed 272 pounds. at one point, the patient had weighed over 300 pounds. since the patient had begun taking levothyroxine, the patient’s weight had decreased to 291 pounds. after evaluation, the endocrinologist recommended that the patient gradually increase physical activity and schedule a follow-up appointment for two months from that date. forty-five days after the patient had been admitted to the hospital, the patient had another follow-up appointment with the team physician. the patient’s weight had decreased to 274 pounds, and he reported feeling continually improving energy levels and no recurrence of swelling in his upper extremities. the patient had begun to participate in moderate physical activity, and the team physician recommended increasing the frequency, intensity, and volume of activity provided blood work and urine analysis levels continued to improve. the blood and urine analysis revealed a creatine kinase level of 237 u/l and a tsh level of 31.87 ulu/dl. at this time, the team physician stated that he saw no reason why the patient would not be able to resume complete activities upon completion of a gradual return to activity and continued compliance with the prescribed course of levothyroxine. activity and participation after the patient’s follow-up evaluation with the endocrinologist, physical activity gradually increased. exercise began with resistance training at 50% of maximum effort. the patient started with a light cardiovascular workout on the stationary bike before progressing to short sprint drills of less than 40 yards rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 and ladder drills for activity. given that hammer throwing did not exacerbate his symptoms and the anaerobic nature of the sport, the patient was then able to return to practice at this time as well. the patient’s athletic trainer scheduled regular meetings with the strength and conditioning coaching staff to ensure the weightlifting restrictions were followed. aside from training for the hammer throw, the patient reported that his activities of daily living became easier when his swelling and range of motion improved. had the patient not sought medical treatment, these issues would likely have continued to worsen and have an increasing effect on his activities of daily living. fortunately, the patient has remained compliant with his levothyroxine prescription and continues to improve. environmental and personal factors given the patient’s concern about being able to complete coursework with his limitations, the sports medicine staff and faculty athletics representative worked closely with the institution's faculty. while hospitalized, the patient’s professors extended deadlines, allowing him to complete his coursework once his symptoms had resolved. because the medical staff could work with the faculty athletics representative, institutional policies and procedures for accommodating students with temporary disabilities could be used. discussion this case details the diagnosis and management of a patient suffering from rhabdomyolysis exacerbated by undiagnosed hypothyroidism. while hypothyroidism is a relatively common condition, it has rarely been associated with rhabdomyolysis.3-5 furthermore, in this case, the patient’s hypothyroidism was discovered due to his rhabdomyolysis. the patient’s family history of hypothyroidism gave the physician cause for suspicion. however, the signs and symptoms of hypothyroidism at the time might have been mild enough that the patient would not have noticed them if he had not experienced rhabdomyolysis. overall, the patient’s willingness to be evaluated by the team physician led to an appropriate course of treatment that led to good outcomes. had the patient chosen to forego physician evaluation, it is possible that his symptoms would have continued to worsen. with unchecked rhabdomyolysis and hypothyroidism, the patient may have been at risk for worse conditions. clinical bottom line within the scope of clinical practice, clinicians may encounter patients with undiagnosed conditions. these conditions may be well reported in the literature but may have mild symptoms that are not relatively apparent. sometimes, these conditions can predispose patients to other conditions with more obvious signs and symptoms. collaboration between healthcare providers is crucial for delivering optimal patient care. when there are academic concerns at an institution of higher learning, clinicians should explore available resources for patient support, including faculty athletics representatives. clinicians should always prioritize their patient’s safety and personal concerns when determining their course of treatment. based on these values, clinicians may need to employ available resources to advocate for their patient population. references 1. chaker l, bianco ac, jonklaas j, peeters rp. hypothyroidism. lancet. 2017;390:1550-1562. http://dx.doi.org/10.1016/s0140-6736(17)30703-1 2. roberts cg, landenson pw. hypothyroidism. lancet. 2004;363:793-803. https://doi.org/10.1016/s0140-6736(04)15696-1 http://dx.doi.org/10.1016/s0140-6736(17)30703-1 https://doi.org/10.1016/s0140-6736(04)15696-1 rhabdomyolysis and hypothyroidism in a collegiate hammer thrower: a disablement model case study 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 3. boryushkina v, ahmed s, quadri k, ramdass a. recurrent rhabdomyolysis induced by severe hypothyroidism. cureus. 2019;11(6). https://doi.org/10.7759/cureus.4818. 4. gurula d, rajdey k, acharya r, idiculla ps, habib s, kryzak m. rhabdomyolysis in a young patient due to hypothyroidism without any precipitating factor. case rep endocrinol. 2019. https://doi.org/10.1155/2019/4210431 5. salehi n, agoston e, munir i, thompson gj. rhabdomyolysis in a patient with severe hypothyroidism. am j case rep. 2017;18:912-918. https://doi.org/10.12659%2fajcr.904691. 6. zimmerman jl, shen mc. rhabdomyolysis. chest. 2013;144(3):1058-1065. https://doi.org/10.1378/chest.12-2016. 7. chang zy, boo ay, tulsidas h. rhabdomyolysis: a rare complication of hypothyroidism. proc singap healthc. 2015;24(3):188-190. https://doi.org/10.1177/201005815598456. https://doi.org/10.7759/cureus.4818 https://doi.org/10.1155/2019/4210431 https://doi.org/10.12659%2fajcr.904691 https://doi.org/10.1378/chest.12-2016 https://doi.org/10.1177/201005815598456 abstract patient-centered care commentary 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 nutritional considerations for transgender patients mitchell anderson, ms, at, atc* ;emma nye, dat, lat, atc† *university of toledo, toledo, oh; †grand view university, des moines, ia key phrases emotional wellness and mental health, comorbidities correspondence dr. emma nye, select medical, grand view university, 3164 sw arlan lane, ankeny ia, 50023. e-mail: enye@grandview.edu twitter: @eanye15 submitted: november 11, 2020 accepted: november 15, 2021. full citation anderson m, nye e. nutritional considerations for transgender patients. clin pract athl train. 2022;5(1): 8-11. https://doi.org/10.31622/2022/0005.01.2. commentary athletic trainers (ats) serve as a key resource regarding nutritional information for active patient populations. both in traditional and emerging settings, the ats role often includes educating patients on proper nutrition, both for enhancing sport performance and maintaining healthy lifestyles. according to the commission on accreditation of athletic training education (caate) 2020 standards, ats must practice in collaboration with other health care and wellness professionals. one vital partnership among health care providers (hcps) is that of ats and nutrition professionals. personalized nutrition, particularly in athletic populations, has been used by dieticians (rd) and nutritionists (unregulated nutrition specialist) in an effort to enhance performance and improve health outcomes.1 it is imperative for ats to possess a level of knowledge to appropriately answer patient questions, provide guidance and recommendations, and collaborate with other professionals in this area. recently, the joint position statement by the american college of sports medicine, the academy of nutrition and dietetics, and the dietitians of canada, highlighted the importance of developing nutritional interventions that take into consideration the uniqueness of each individual, to improve health outcomes.2 the recognition and knowledge about unique nutritional considerations for patients is crucial in sports medicine. more importantly, when treating patient in the lgbtq+ community, ats and hcps need to be aware of the contributing factors that can influence nutrient absorption. athletic trainers have a unique opportunity to be a resource for nutritionalrelated concerns for this population, and specifically for those who identify as transgender. lgbtq+ patients face disproportionately high levels of food insecurity, obesity, and disordered eating while also facing barriers to accessing affirming and knowledgeable healthcare providers.3 the purpose of this commentary is to provide awareness and inform ats and other hcps about the unique nutritional considerations for patients who identify as transgender. further, the commentary will serve as a call to action for ats and other hcps to research and develop transgender specific nutritional recommendations as a mechanism to reduce health care disparities for this population. transgender individuals are people whose gender identity and/or gender expression differs from what is typically associated with the sex they were assigned at birth.3 patients who identify as transgender represent a growing and underserved population in the u.s., and the percentages of the general population that identify as transgender continue to increase.4 as such, hcps must become aware of the specific needs of this population. an important piece of transgender health care is the role of nutritional interventions in relation to hormone therapy, mental health and wellness, and chronic illness. historically, nutritional principles have been primarily focused on cisgender patients, those whose gender identity aligns with their assigned mailto:enye@grandview.edu https://doi.org/10.31622/2022/0005.01.2 nutritional considerations for transgender patients 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 sex at birth.3 as athletic training and other healthcare professions work towards providing patient-centered and culturally competent care, a foundational level of understanding in transgender health care is vital. as identities within athletic populations become more diverse, ats must focus efforts on providing holistic healthcare, which may include developing nutritional guidelines hormone therapy in an effort to improve transgender individuals’ access to quality nutrition care, it is important to first understand conditions for which this population is most at risk. oftentimes, those who identify as transgender will undergo hormone therapy, and are at risk for adverse effects.4 testosterone therapy for transgender males (assigned female at birth) may lead to weight gain, decreased lean body mass, decrease in lipid mass, increased ldl cholesterol, decreased hdl cholesterol, and increase hemoglobin and hematocrit.4 additionally, long-term effects of testosterone may significantly reduce or eliminate the menstrual cycle, impacting iron needs for that patient. for transgender females (assigned male at birth), estrogen therapy may present with weight gain, an increase in hdl cholesterol, a decrease in ldl cholesterol, and increased bone mineral density.4,5 for transgender adolescents, hormone therapy may impact bone health, where supplementation with calcium and vitamin d may be warrented.4 in order to reduce the impact of the negative side effects, ats may intervene and collaborate with nutritionists and dieticians to implement nutritional interventions that best align with the patients’ needs. in patients taking testosterone therapy, we often see an increase in ldl cholesterol, a cessation of menstruation, weight gain, and increased blood viscosity13, which may require advising patients to limit saturated fats and address other fatty meals with alternatives to decrease ldls.6 due to the increase in hematocrit and hemoglobin, fluid retention may occur.7 monitoring the intake and elimination of liquids may be important when advising appropriate hydration before, during, and after activity. weight gain, another side effect of testosterone therapy, may be managed by understanding the demands of a patient’s activity and advising appropriate weight gain, loss, or maintenance strategies. transgender patients may also have a decrease or cessation in menstruation, warranting a conversation regarding bone health imperative. athletic trainers should encourage the increase in calcium and vitamin d with dairy-rich foods, adequate sun light, and if necessary, supplements among this population. for transgender patients prescribed estrogen therapy, weight gain, increases in hdl and decreases in ldl, increases in bone mineral density, as well as cardiovascular side effects are common concerns. in addition to monitoring and encouraging physical activity for patients on estrogen therapy, nutrition interventions can also be implemented into their specific treatment plan to reduce potential cardiovascular pathologies. a key issue surrounding nutrition assessment of transgender people is that nearly all equations used by dieticians and nutritionists are gendered.8 calculating the appropriate amount of nutrients a transgender person needs is multifaceted, as oftentimes transgender people are taking hormones and have modified nutritional needs due to physiological changes, causing inaccuracies in estimating energy expenditure rates. the premise of nutritional needs being calculated solely on gender has also been explored by rahman and linsenmeyer.8 in their study, the authors note differences in gender-specific diet and nutrition related considerations have only compared cisgender heterosexual males vs cisgender heterosexual females.8 furthermore, a study by smalley, et al8, discussed significant variations in health risk behaviors within each subcategory of sexual orientation, which highlights the need for ats and other hcps to further explore the dietary needs of sexual minorities nutritional considerations for transgender patients 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 rather than through group membership.8 historically, patients who are viewed in a minority group, or a category that is differentiated and often discriminated against, have negative health outcomes and face additional barriers to health care as compared to the majority, further suggesting the need to develop nutritional guidelines that are not limited by the confines of binary gender. mental health and wellness additional considerations for transgender patients should also focus on mental health and wellness, and the link between diet and more positive mental health outcomes.2 the etiology of eating disorders in the transgender population is not clearly delineated, as relationships among sexuality, gender identity, body image, and eating disorders are complex.8 according to the national transgender discrimination survey, those who are transgender have an increased risk of eating disorders and an increased risk of abusing diet pills because of social norms.9 this increased prevalence affects transgender females disproportionately compared to transgender males, and is related to feeling the need to meet ideal body standards, emotional trauma from the process of accepting gender identity, and stress from social stigma and discrimination.10 research exists to suggest weight gain is a side effect in the transgender population in those individuals undergoing hormone therapy.8 antiandrogen and estrogen therapies cause an increase in body fat, and a decrease in muscle mass.8 diemer et al10 demonstrated a higher rate of self-reported eating disorders, vomiting, use of diet pills, and use of laxatives among transgender college students compared with their cisgender counterparts. in addition, transgender individuals have high rates of binge eating, fasting, and vomiting for weight loss.10 differences in health outcomes exist between transgender patients and their cisgender counterparts; however disparities between transgender women and transgender men propose unique considerations for individualized healthcare.11 these disparities, coupled with the knowledge gap regarding best practices surrounding caloric needs of transitioning individuals, lends to additional barriers for transgender individuals receiving individualized nutritional planning.10 chronic illness patients who identify as transgender may be at increased risk of chronic illness, like hiv or cardiovascular disease, which can impact their specific nutritional if their transition process includes the use or hormone therapies.12 human immunodeficiency virus (hiv) and cardiovascular disease are two of the conditions most researched within the transgender population; however, other chronic illnesses impact the patients’ body, including type 2 diabetes, cancer, obesity, depression, asthma, chronic obstructive pulmonary disease, and chronic kidney disease.13 the literature suggests that transgender people may be at higher risk for cardiovascular disease due to exposure of oral ethinyl estradiol, a common hormone prescribed to transgender females.13 a substantial amount of literature links dietary factors to increased risk of chronic disease.2,7,9-10 although this correlation is well documented, there is a gap in knowledge regarding the nutritional needs and interventions to decrease the risk of chronic disease, specifically in the transgender population. healthcare providers should understand how these illnesses have the potential to affect patients who identify as transgender, and more research should be completed to evaluate what nutritional interventions can aid in the healing process of such diseases. a need exists for understanding physiological changes within the bodies of patients who identify as transgender. understanding the impact of hormone therapy, mental health and wellness, and chronic disease are three main influencers to consider when educating and developing nutritional considerations for transgender patients 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 individualized nutritional care for patients who identify as transgender. references 1. guest ns, horne j, vanderhout sm, et al. sport nutrigenomics: personalized nutrition for athletic performance. front. nutr. 2019 feb 19; 6(8). https://doi.org/10.3389/fnut.2019.00008. 2. thomas dt, erdman ka, burke lm. american college of sports medicine joint position statement. nutrition and athletic performance. med sci sports exerc. 2016 mar;48(3):54368 https://doi.org/10.1249/mss.0000000000 000852. 3. fergusson p, greenspan n, maitland l, et al. towards providing culturally aware nutritional care for transgender people: key issues and considerations. can j diet pract res. 2018 mar 15;79(2):74-9.2. https://doi.org/10.3148/cjdpr-2018-001. 4. quinn gp, sutton sk., winfield b, et al. lesbian, gay, bisexual, transgender, queer/questioning (lgbtq) perceptions and health care experiences. j gay lesbian soc serv. 2019 apr 15; 27(2), 246-261. https://doi.org/10.1080/10538720.2015. 1022273. 5. rothman ms, iwamoto sj. bone health in the transgender population. clin rev bone miner metab. june 2019;17(2):77-85. https://doi.org/10.1007/s12018-01909261-3. 6. rahman r, linsenmeyer wr. caring for transgender patients and clients: nutritionalrelated clinical and psychosocial considerations. j acad. nutr. diet. 2019 may 1;119(5):727-32. https://doi.org/10.1016/j.jand.2018.03.00 6. 7. stachenfeld ns. sex hormone effects on body fluid regulation. exerc sport sci rev. 2008 jul ;36(3):152-159. https://doi.org/10.1097/jes.0b013e3181 7be928. 8. linsenmeyer wr, rahman r. diet and nutritional considerations for a ftm transgender male: a case report. j am coll health. 2018;66(7):533-536. https://doi.org/10.1080/07448481.2018. 1431917. 9. grant j, mottet l, tanis j, et al. national transgender discrimination survey report on health and health care. 2010. accessed: november 8th, 2021. 10. diemer ew, grant jd, munn-chernoff ma, et al. gender identity, sexual orientation, and eating-related pathology in a national sample of college students. j. adolesc. health. 2015 aug 15; 57(2):144-9. https://doi.org/10.1016/j.jadohealth.2015. 03.003. 11. wanta jw, niforatos jd, durbak e, et al. mental health diagnoses among transgender patients in the clinical setting: an all-payer electronic health record study. transgender health. 2019;4(1):313-315. https://doi.org/10.1089/trgh.2019.0029. 12. white hughto, jm, reisner sl. a systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. transgender health. 2016 jan 1;1(11):21-31. https://doi.org/10.1089/trgh.2015.0008. 13. irwig ms. testosterone therapy for transgender men. the lancet diabetes & endocrinology. 2017;5(4):301-311. https://doi.org/10.1016/s22138587(16)00036-x. https://doi.org/10.3389/fnut.2019.00008 https://doi.org/10.1249/mss.0000000000000852 https://doi.org/10.1249/mss.0000000000000852 https://doi.org/10.3148/cjdpr-2018-001 https://doi.org/10.1080/10538720.2015.1022273 https://doi.org/10.1080/10538720.2015.1022273 https://doi.org/10.1007/s12018-019-09261-3 https://doi.org/10.1007/s12018-019-09261-3 https://doi.org/10.1016/j.jand.2018.03.006 https://doi.org/10.1016/j.jand.2018.03.006 https://doi.org/10.1097/jes.0b013e31817be928 https://doi.org/10.1097/jes.0b013e31817be928 https://doi.org/10.1080/07448481.2018.1431917 https://doi.org/10.1080/07448481.2018.1431917 https://doi.org/10.1016/j.jadohealth.2015.03.003 https://doi.org/10.1016/j.jadohealth.2015.03.003 https://doi.org/10.1089/trgh.2019.0029 https://doi.org/10.1089/trgh.2015.0008 https://doi.org/10.1016/s2213-8587(16)00036-x https://doi.org/10.1016/s2213-8587(16)00036-x manuscript type clincal outcomes research 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 using the mulligan mobilization with movement and fibular repositioning to treat high school patients with a grade one lateral ankle sprain alexander zettlemoyer, dat, lat, atc *; rich patterson, dat, lat, atc†; russell baker phd, dat, atc‡; alan nasypany, edd, lat, atc‡ *mechanicsburg area school district, mechanicsburg, pa; †clarion university, clarion, pa; ‡ university of idaho, moscow, id abstract ankle injuries are common among high school athletics with the highest incidence rates in boys and girls basketball and boys football. novel treatment paradigms like the mulligan mobilization with movement (mwm) in conjunction with fibular repositioning tape have shown promising results in reducing pain, disability, and time lost due to lateral ankle sprains (las). however, research focusing on mulligan treatment strategies and ankle swelling following a las is limited. therefore, the purpose of this case series was to evaluate the combined effects of the mwm and fibular repositioning taping on swelling, function, and pain in high school patients with an acute grade 1 las. a convenience sample of seven (4 females, 3 males, 5 right ankle, 2 left ankle injuries) consecutive high school patients (15.9± 1.4 years of age; range = 14-18 years) were evaluated following an acute las and treated with the mwm and fibular repositioning tape. subjective evaluation of pain, selfreport function and disability were assessed throughout the treatment process utilizing proms. specifically, the numeric pain rating scale, disablement in the physically active scale, foot and ankle ability measure and the foot and ankle ability measure sport subscale were included throughout the treatment protocol along with the figure-of-eight ankle girth measurement to assess the amount of swelling following each treatment session. all seven patients returned to unrestricted participation following an average of 2.9±0.8 treatments (range 2-4 treatments) and presented an average decrease in ankle girth of 24.7±13.7mm from baseline to return to participation. overall, the mwm and fibular repositioning tape produced an immediate change in pain, disability, function and swelling following an acute grade 1 las. key phrases manual techniques, clinician-rated outcomes, patientreported outcomes correspondence mechanicsburg area senior high school, 500 south broad street, mechanicsburg, pa 17055 e-mail: szettlemoyer@mbgsd.org twitter: @realneal35 full citation zettlemoyer a, patterson r, baker r, nasypany a. using the mulligan mobilization with movement and fibular repositioning to treat high school patients with a grade one lateral ankle sprain. clin pract athl train. 2022;5(3): 22-30. https://doi.org/10.31622/2021/0005.01.4. submitted: january 17, 2021 accepted: april 14, 2021. introduction with a peak ankle incident rate between the ages of ten and nineteen, high school athletes are specifically susceptible to ankle sprains, accounting for 22.6% of all sports related musculoskeletal injuries.1,2 the highest incidence in high school sports of ankle sprains occurs in boys basketball (7.74 per 10,000 exposures), followed by girls basketball (6.93 per 10,000 exposures) and boys’ football (6.52 per 10,000 exposures).2 approximately 85% of ankle injuries occur after excessive inversion and plantarflexion of the foot combined with external rotation of the distal leg, which results in damage to the lateral ligament complex.3 of the three lateral ligaments, the anterior talofibular ligament (atfl) is the weakest and is more frequently involved in ankle sprains than the calcaneofibular ligament or the posterior talofibular ligament.3,4 following an acute lateral ankle sprain (las), ankle joint ligamentous and muscular dynamic stability are compromised to varying degrees based on the extent of the injury. one factor that may contribute to increased dysfunction associated with las is the anatomical position of the fibula in relation to the tibia within the ankle mortise.5–7 this post-injury variation was first hypothesized by brian mulligan, founder of the mulligan concept (mc), as a positional fault in which the distal fibula is displaced in the anterior, inferior and medial direction.8 following las, the fibula may become stuck anteriorly resulting in an increase in accessory movements such as gliding and rolling of talus in the ankle mortise.9 these mailto:szettlemoyer@mbgsd.org https://doi.org/10.31622/2021/0005.01.4 using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 altered arthrokinematic motions lead to abnormal physiological motions which increase ligamentous stress and when left untreated may lead to delayed healing and chronic ankle instability.10 immediate conservative treatment of las commonly includes protection, optimal loading, ice, compression and elevation (police)11 in conjunction with early mobilization and nonsteroidal anti-inflammatory medication.12 this intervention is recommended based on the tissuehealing model that clinicians believe must occur post-las. however, given the previous research on the presence of positional faults post-las,5,10,13 it appears that commonly used conservative methods fail to address the position of the fibula which may lead to delayed recovery and the development of ankle instability. the early application of mc mobilization with movement (mwm) and the fibular repositioning taping technique, which are designed to provide an immediate and long-lasting correction of the previously mentioned positional fault, may improve patient outcomes following las. if a painfree, immediate, and long-lasting (p.i.l.l) mobilization applied to the distal fibula in a posterior, superior and lateral direction while active or passive range of motion is performed with overpressure at the end-range, resolves patient-reported pain and improves range of motion, then the clinician should continue to utilize the technique as part of the treatment protocol following mc guidelines.8 the majority of the evidence on this technique includes description studies, but initial reports have documented positive effects of the mwm and fibular repositioning tape on pain and dysfunction in patients suffering from acute las.14– 17 studies evaluating patient outcomes for swelling or edema reduction post mwm or fibular repositioning taping application post-las were not identified. thus, there is a paucity of research on the effects of mwms in patients who have suffered acute las. therefore, the purpose of this case series was to evaluate the combined effects of the mwm and fibular repositioning taping on swelling, function, and pain in high school patients with an acute grade 1 las. patient population a convenience sample of seven (4 females, 3 males, 5 right ankle, 2 left ankle injuries) consecutive high school patients (15.9± 1.4 years of age; range = 14-18 years) were evaluated by an athletic trainer following an acute inversion ankle injury. initial examination occurred within 72 hours of the acute las. prior to beginning the study, each patient agreed to complete the las treatment protocol, as well as the associated patient reported outcome measures (proms). patients were included if they suffered an acute (i.e., must report within 72 hours of initial onset) inversion ankle sprain as well as self-reported functional limitations resulting from the injury. patients were excluded if they had any concomitant injuries or contraindications to manual therapy such as: systemic or local infection, fracture, malignancy, acute circulatory conditions, pregnancy, or hyper joint mobility. patient history of las was not controlled for during the study. all patients completed the approved consent process (i.e., minor participant assent and parental consent) prior to participation in the study. the study was approved by the high school’s institutional review board. clinical evaluation and intervention initial evaluation consisted of a standardized bilateral physical examination of the ankle, which included a detailed history, physical exam, the ottawa ankle rules to rule out ankle fracture, girth measurement (figure-of-eight), and baseline proms. preand post-intervention proms included the numeric pain rating scale (nprs), the disablement in the physically active (dpa) scale, foot and ankle ability measure (faam) and the foot and ankle ability measure sport subscale (faam-s). a second athletic trainer, who using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 was blinded to the results of the primary investigator, performed a secondary examination to confirm the original diagnosis and verify patient inclusion criteria. diagnosis of a grade 1 las was defined by mild swelling along the distal lateral malleolus, tenderness on palpation, pain along the atfl during the anterior drawer test with the patient seated and the foot in neutral, and inversion stress testing with a firm end-feel (i.e., without ligament laxity).18 following the initial evaluation and acknowledgment of consent, patients completed the baseline proms and were treated using the mulligan distal fibular anterior-posterior (a-p) mwm followed by the fibular repositioning taping technique. this technique was carried out by placing the patient supine with the involved ankle off the end of the treatment table. the mwm technique required a pain-free sustained anterior to posterior, slightly superior and lateral glide of the distal fibular in relation to the ankle mortise (figure 1), which was performed by placing the thenar eminence of the clinician on the patient’s fibula just anterior to the distal, lateral malleolus. in conjunction with the sustained glide, the patient actively plantar-flexed and inverted the foot for 3 sets of 10 repetitions to the end of active range, followed by pain-free overpressure by the clinician. immediately following the mwm, fibular repositioning tape was applied to maintain the corrected positional fault.8 two-inch (5.0cm) bsn medical cover-roll® was loosely applied anterior to the distal fibula and continued in a posterior-superior direction, wrapping around the distal tibia ending approximately oneinch (2.5cm) superior to the starting position along the anterior aspect of the tibia. one and onehalf (3.84cm) inch leukotape® was then applied directly to the cover-roll in the same direction as the glide to maintain the position of the fibula until the next scheduled treatment (figure 2).8 figure 2. mc lateral fibular repositioning taping technique each patient was seen for a minimum of two visits, with one day between visits. during each follow-up visit the patient was re-evaluated for change in ankle girth measurements (figure-ofeight) as described by tatro-adams et al19 by both clinicians which were blinded to the results followed by completion of the nprs. the patient was again treated with the mulligan distal fibular a-p mwm in the same method as previously described. the fibular repositioning tape remained in place for the duration of the study but was reinforced if slippage was identified. the use of standard conservative treatment such as police was not controlled by the investigators. the patients were instructed to continue activities of daily living (adls) as tolerated but refrain from participation in sports. figure 1. mulligan technique: anterior to posterior, slightly superior and lateral glide of the distal fibular using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 following the treatment intervention, each patient completed the dpa scale, faam and the faam-s outcome measures. patients were monitored throughout the study for signs warranting additional medical care, but no such patient existed during the duration of the study. as a condition of discharge, each patient had to perform functional non-standardized sportsspecific activities evaluated by the original clinicians. the activities were performed with the mulligan fibular repositioning tape applied and included running, cutting/lateral movement, jumping and single-leg hop on the involved extremity. outcome measures subjective evaluation of pain, self-report function and disability were assessed throughout the treatment process utilizing proms. specifically, the nprs, dpa scale, faam and the faam-s were included throughout the treatment protocol. clinician oriented evidence included the figure-ofeight ankle girth measurement to assess the amount of swelling following each treatment session. numeric pain rating scale and disablement in the physically active scale patient oriented evidence including pain and global disablement was collected utilizing the nprs and dpa scale. the nprs is an 11-point self-report pain scale ranging from 0-10, where 0 is “no pain” and 10 is the “worst pain imaginable.” the patient indicates intensity of current pain, worst pain and best pain over the last 24-hours which is averaged to identify a pain score.20 the dpa scale is a 16 item, multidimensional, outcome instrument based on the disablement model which uses a 5-point likert scale where 0 represents “no problem” and 4 represents “severe” disability.21 with a scoring range of 0-64, the higher the score the higher the level of disability.21 the minimally clinically important difference (mcid) represents the ability of the instrument to reflect the patient’s perception of change in the disease process over time. the mcid for the nprs and dpa scale has been previously calculated as a 2-point change22 and 9-points in acute participants respectively.21 these instruments were chosen because they have demonstrated consistent validity among patients with similar musculoskeletal conditions such as acute las.21,23 foot and ankle ability measure the faam is a region-specific prom divided into the faam-adl (activities of daily living) and the faam-s subscales. the faam evaluates activity limitations and patient disability on a 5-point likert scale (0-4, 0=no difficulty and 4=unable to do). scores range from 0-84 (faam-adl) and 028 (faam-s) which are written as a percentage with 100% representing no functional loss. the mcid for the faam-adl and faam-s is an 8point and 9-point change respectively.24 similarly, the faam-adl and faam-s have shown reliability and validity for patients with a broad range of lower limb, ankle and foot dysfunctions.24 ankle girth measurements figure-of-eight ankle girth was measured by applying the figureof-eight method while each foot was maintained in a neutral position. tatro-adams et al19 described the figure-of-eight as the following procedure; with the ankle in a neutral dorsiflexion position, a flexible 1-centimeter tape starts midway between the tibialis anterior tendon and the lateral malleolus and is then drawn medially across the instep and placed just distal to the tuberosity of the navicular and then pulled across the arch and up just proximal to the base of the 5th metatarsal. the tape is then placed across the tibialis anterior tendon and continues around the ankle joint just distal to the distal tip of the medial malleolus, crosses the achilles tendon, and is placed just distal to the distal tip of the lateral malleolus ending at the starting position.19 the using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 icc was previously determined to be 0.99 for both inter-tester and intra-tester reliability for this method of measuring ankle swelling.19 ankle girth measurements were in millimeters and taken three times during the initial treatment and following each subsequent treatment with the average of the three measures recorded. results patient demographic data was analyzed using mean and standard deviation (table 1). all seven patients were evaluated and treated for las and returned to unrestricted participation following an average of 2.9±0.8 treatments (range 2-4 treatments). figure-of-eight measurements were taken at baseline and following each treatment. baseline figure-of-eight measures for the involved ankle were 587.5±15.0mm compared to the uninvolved ankle 559.9±11.3mm. between baseline treatment and final figure-of-eight measures, patients demonstrated a decrease in ankle girth of 24.7±13.7mm (table 2) and presented a final ankle girth of 562.7±11.6mm. all seven patients also reported changes across all prom taken between baseline and final measure which met the mcid for the nprs (2-points), dpa (9-points), faam (8-points) and faam-s (9points) (table 3). discussion application of the mwm treatment protocol in combination with the fibular repositioning tape on patients presenting with an acute grade 1 las demonstrated improvement across all outcome instruments and a reduction in swelling as measured by the figure-of-eight girth method over approximately 3 treatments. as we hypothesized, restoring the normal relative position of the distal fibula through the mwm and fibular repositioning tape was an effective intervention for the treatment of pain and disability in high school patients with acute grade 1 las. all seven patients also met or exceeded the mcid on the included outcome instruments indicating clinically significant improvements from baseline to discharge for pain, measured by the nprs, disablement measured by the dpa scale, and function which was measured by the faam and faam-s (table 3). these meaningful improvements in proms are consistent with patient measures reported in previous studies.14– 17, 25–28 acute las are frequently accompanied by swelling around the ankle joint and foot.12 the figure-of-eight ankle girth measurement is a reliable and cost-effective method for measuring ankle swelling regardless of ankle position.5,29 hubbard and hertel5 found a correlation between the anterior position of the fibula and the amount of swelling in individuals with sub-acute ankle sprains using fluoroscopy. however, it should be noted that the amount of swelling does not directly table 1. patient demographic information patient days from initial injury to evaluation and treatment patient age sex sport involved ankle number of treatments to discharge 1 1 15 f wbb r 3 2 1 17 f wbb r 4 3 1 15 m mbb l 2 4 3 18 m soc l 3 5 2 15 f wp r 2 6 1 17 m soc r 2 7 1 14 f vb r 4 * wbb= women’s basketball, mbb= men’s basketball, soc= men's soccer, wp= women’s water polo, vb= women’s volleyball clincal outcomes research 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 2: figure-of-eight measures injured uninjured patient baseline girth (mm) girth at discharge (mm) change in girth (mm) baseline girth (mm) 1 581.6 556.2 25.4 555.2 2 582.8 546.6 36.2 544.8 3 595.5 580.3 15.2 576.7 4 588 565.7 22.3 566 5 564.9 553.2 11.7 548 6 585.2 572.1 13.1 567.4 7 614.3 565.3 49 561.3 average 587.5 562.8 24.7 559.9 sd (±) 15.0 11.6 13.7 11.3 table 3. patient-rated outcome measure results: initial, discharge and mean change patient # 1 2 3 4 5 6 7 mean change and sd mcid nprs baseline 6.00 8.00 4.33 5.00 4.00 6.33 5.00 nprs discharge 1.33* 1.67* 3.00 2.33 2.00* 1.00* 0.33* 3.86±1.86 2 faam baseline 40 28 47 35 42 13 54 faam discharge 80* 79* 79* 64* 64* 84* 83* 39.12±16.87 8 faam-s baseline 1 7 7 0 12 3 7 faam-s discharge 22* 21* 19* 18* 24* 24* 22* 16.14±3.89 9 dpa baseline 37 36 27 29 42 57 30 dpa discharge 3* 6* 7* 12* 3* 4* 14* 29.86±13.48 9 *achieved mcid correlate with the self-reported function following an ankle injury.30 therefore, measures of swelling may not represent a functional outcome but could be useful in establishing a baseline which can be tracked throughout the rehabilitation process. while our research design does not include diagnostic testing, repositioning of the fibula and ankle mobilization did demonstrate a decrease in swelling over the short treatment duration. the reduction in ankle swelling following the intervention represents a positive effect on mechanical properties, regardless of the influence of swelling on self-reported function suggesting that pain, rather than swelling is the limiting factor in acute las.30 the addition and quantity of swelling during the plantarflexion/inversion mechanism for lass may influence the relative position of the fibula on the tibia in the ankle mortise. hubbard and hertel5 found nine of 11 patients with subacute ankle injuries to have an anterior positioned fibula and suggested that the amount of swelling was correlated with the amount of using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 anterior fibular displacement. these results coincide with mavi et al13 and kavanagh6 who both reported an anterior displacement of the distal fibula following ankle injury through radiographic imaging. suggested treatment for the anterior fibular displacement includes mobilization and has been documented in case reports with positive outcomes in rom, patient reported pain and function.15,28 fibular repositioning taping has also been evaluated in limited fashion and reported to have no effect on static or dynamic balance31 but may help to prevent recurrent ankle sprains.32 our study demonstrated a decrease in both pain and ankle girth, but the limited number of participants makes it difficult to draw a statistical correlation. this is consistent with collins, teys & vicenzino,28 who evaluated the acute effects of the dorsiflexion mwm on subacute ankle sprains, and found significant improvements in ankle dorsiflexion but no change in hypoalgesic effects following a single treatment session. in contrast, our study included the mwm in conjunction with fibular repositioning tape on acute ankle patients and included multiple mwm treatments. the subtle changes in fibular position combined with active movement may have a greater influence on the mechanical response to acute injury while pain receptors are not inhibited by this technique. additional research is warranted to clarify this potential change following the mwm and fibular repositioning taping. the case series design (level 4) of this study presents some limitations. the lack of short-term follow-up does not give sufficient insight into the long-term consequences of the treatment. all patients returned to participation with no reported ankle complications for the remainder of the competitive season, but no additional proms were administered as a follow-up. this case series included a standardized treatment intervention of mwm and fibular repositioning, but the lack of a control group does not strictly prove that the mulligan concept caused an improvement in the outcome measures but does indicate that an association exists. since all subjects in the study were high school students, the generalizability of the results to various age and activity levels also has limitations. in addition, clinicians were not blinded to the results of their figure-or-eight ankle girth measurements which could result in measurement bias in subsequent applications. future research should include a longitudinal design with larger sample size, inclusion of a control group, and a more diverse patient population. clinical application the results of this case series demonstrate that the inclusion of the mc fibular repositioning tape and mwm produce an immediate change in pain, disability, function and swelling following an acute grade 1 las. over the course of 2-4 treatments, patients were returned to unrestricted participation with no reported ankle impairments. the application of the mc treatment intervention early in the acute phase of healing had a meaningful impact on patient and clinician evidence for patients presenting with acute grade 1 las. by addressing the acute positional fault early in the rehab process, the clinician may impede the inflammatory response to reduce the amount of edema following injury. the reduction of edema may lead to improved outcomes and a more efficient return to healthy participation. based on the outcome of our study, clinicians looking to efficiently treat acute grade 1 las may benefit from the inclusion of the mc in their therapeutic approach. references 1. waterman br, owens bd, davey s, zacchilli ma, belmont pj. the epidemiology of ankle sprains in the united states. j bone joint surg am. 2010;92(13):2279-2284. https://doi.org/10.2106/jbjs.i.01537. https://doi.org/10.2106/jbjs.i.01537 using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 2. nelson aj, collins cl, yard ee, fields sk, comstock rd. ankle injuries among united states high school sports athletes, 20052006. j athl train. 2007;42(3):381-387. 3. ferran na, maffulli n. epidemiology of sprains of the lateral ankle ligament complex. foot ankle clin. 2006;11(3):659662. https://doi.org/10.1016/j.fcl.2006.07.002. 4. kofotolis nd, kellis e, vlachopoulos sp. ankle sprain injuries and risk factors in amateur soccer players during a 2-year period. am j sports med. 2007;35(3):458-466. https://doi.org/10.1177/0363546506294 857. 5. hubbard tj, hertel j. anterior positional fault of the fibula after sub-acute lateral ankle sprains. man ther. 2008;13(1):63-67. https://doi.org/10.1016/j.math.2006.09.00 8. 6. kavanagh j. is there a positional fault at the inferior tibiofibular joint in patients with acute or chronic ankle sprains compared to normals? man ther. 1999;4(1):19-24. 7. berkowitz mj, kim dh. fibular position in relation to lateral ankle instability. foot ankle int. 2004;25(5):318-321. https://doi.org/10.1177/1071100704025 00507. 8. mulligan b. manual therapy: nags, snags, mwms, etc. 6th ed. wellington (nz): plane view services; 2010. 9. denegar cr, hertel j, fonseca j. the effect of lateral ankle sprain on dorsiflexion range of motion, posterior talar glide, and joint laxity. j orthop sports phys ther. 2002;32(4):166-173. https://doi.org/10.2519/jospt.2002.32.4.1 66. 10. hubbard tj, hertel j, sherbondy p. fibular position in individuals with self-reported chronic ankle instability. j orthop sports phys ther. 2006;36(1):3-9. https://doi.org/10.2519/jospt.2006.36.1.3. 11. glasgow p, phillips n, bleakley c. optimal loading: key variables and mechanisms. br j sports med. 2015;49(5):278-279. https://doi.org/10.1136/bjsports-2014094443. 12. kaminski tw, hertel j, amendola n, et al. national athletic trainers’ association position statement: conservative management and prevention of ankle sprains in athletes. j athl train. 2013;48(4):528-545. https://doi.org/10.4085/1062-605048.4.02. 13. mavi a, yildirim h, gunes h, pestamalci t, gumusburun e. the fibular incisura of the tibia with recurrent sprained ankle on magnetic resonance imaging. saudi med j. 2002;23(7):845-849. 14. hudson r, baker rt, may j, reordan d, nasypany a. novel treatment of lateral ankle sprains using the mulligan concept: an exploratory case series analysis. j man manip ther. 2017;25(5):251-259. https://doi.org/10.1080/10669817.2017. 1332557. 15. mau h, baker rt. a modified mobilizationwith-movement to treat a lateral ankle sprain. int j sports phys ther. 2014;9(4):540-548. 16. may jm, nasypany a, paolino j, baker r, seegmiller j. patient outcomes utilizing the mulligan concept of mobilization with movement to treat intercollegiate patients diagnosed with lateral ankle sprain: an a priori case series. j sport rehabil. 2017;26(6):486-496. https://doi.org/10.1123/jsr.2015-0204. 17. lawson bl, williamson jd, baker r, may j, larkins l, nasypany a. examining the effect of the mulligan concept fibular repositioning taping technique after a lateral ankle sprain. athletic training & sports health care. 2018;10(1):41-45. https://doi.org/10.3928/1942586420170816-02. https://doi.org/10.1016/j.fcl.2006.07.002 https://doi.org/10.1177/0363546506294857 https://doi.org/10.1177/0363546506294857 https://doi.org/10.1016/j.math.2006.09.008 https://doi.org/10.1016/j.math.2006.09.008 https://doi.org/10.1177/107110070402500507 https://doi.org/10.1177/107110070402500507 https://doi.org/10.2519/jospt.2002.32.4.166 https://doi.org/10.2519/jospt.2002.32.4.166 https://doi.org/10.2519/jospt.2006.36.1.3 https://doi.org/10.1136/bjsports-2014-094443 https://doi.org/10.1136/bjsports-2014-094443 https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.4085/1062-6050-48.4.02 https://doi.org/10.1080/10669817.2017.1332557 https://doi.org/10.1080/10669817.2017.1332557 https://doi.org/10.1123/jsr.2015-0204 https://doi.org/10.3928/19425864-20170816-02 https://doi.org/10.3928/19425864-20170816-02 using the mulligan mwm and fibular repositioning to treat high school patients with grade one lateral ankle sprain 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 18. lynch sa. assessment of the injured ankle in the athlete. j athl train. 2002;37(4):406412. 19. tatro-adams d, mcgann sf, carbone w. reliability of the figure-of-eight method of ankle measurement. j orthop sports phys ther. 1995;22(4):161-163. https://doi.org/10.2519/jospt.1995.22.4.1 61. 20. mccaffery m, beebe a. the numeric pain rating scale instructions. pain: clinic manual for nursing practice. 1989. 21. vela li, denegar cr. the disablement in the physically active scale, part ii: the psychometric properties of an outcomes scale for musculoskeletal injuries. j athl train. 2010;45(6):630-641. https://doi.org/10.4085/1062-605045.6.630. 22. farrar jt, young jp, lamoreaux l, werth jl, poole rm. clinical importance of changes in chronic pain intensity measured on an 11point numerical pain rating scale. pain. 2001;94(2):149-158. https://doi.org/10.1016/s03043959(01)00349-9. 23. ferreira-valente ma, pais-ribeiro jl, jensen mp. validity of four pain intensity rating scales. pain. 2011;152(10):2399-2404. https://doi.org/10.1016/j.pain.2011.07.00 5. 24. martin rl, irrgang jj, burdett rg, conti sf, van swearingen jm. evidence of validity for the foot and ankle ability measure (faam). foot ankle int. 2005;26(11):968-983. https://doi.org/10.1177/1071100705026 01113. 25. bianco l, fermin s, oates r, may j, cheatham sw, nasypany a. use of the mulligan concept in the treatment of lateral ankle sprains in the active population: an exploratory prospective case series. j can chiropr assoc. 2019;63(3):154-161. 26. vicenzino b, branjerdporn m, teys p, jordan k. initial changes in posterior talar glide and dorsiflexion of the ankle after mobilization with movement in individuals with recurrent ankle sprain. j orthop sports phys ther. 2006;36(7):464-471. https://doi.org/10.2519/jospt.2006.2265. 27. o’brien t, vicenzino b. a study of the effects of mulligan’s mobilization with movement treatment of lateral ankle pain using a case study design. man ther. 1998;3(2):78-84. https://doi.org/10.1016/s1356689x(98)80022-2. 28. collins n, teys p, vicenzino b. the initial effects of a mulligan’s mobilization with movement technique on dorsiflexion and pain in subacute ankle sprains. man ther. 2004;9(2):77-82. https://doi.org/10.1016/s1356689x(03)00101-2. 29. petersen ej, irish sm, lyons cl, et al. reliability of water volumetry and the figure of eight method on subjects with ankle joint swelling. j orthop sports phys ther. 1999;29(10):609-615. https://doi.org/10.2519/jospt.1999.29.10. 609. 30. man iow, morrissey mc. relationship between ankle-foot swelling and selfassessed function after ankle sprain. med sci sports exerc. 2005;37(3):360-363. https://doi.org/10.1249/01.mss.00001554 35.10686.04. 31. hopper d, samsson k, hulenik t, ng c, hall t, robinson k. the influence of mulligan ankle taping during balance performance in subjects with unilateral chronic ankle instability. phys ther sport. 2009;10(4):125130. https://doi.org/10.1016/j.ptsp.2009.07.00 5. 32. moiler k, hall t, robinson k. the role of fibular tape in the prevention of ankle injury in basketball: a pilot study. j orthop sports phys ther. 2006;36(9):661-668. https://doi.org/10.2519/jospt.2006.2259. https://doi.org/10.2519/jospt.1995.22.4.161 https://doi.org/10.2519/jospt.1995.22.4.161 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.4085/1062-6050-45.6.630 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.1016/s0304-3959(01)00349-9 https://doi.org/10.1016/j.pain.2011.07.005 https://doi.org/10.1016/j.pain.2011.07.005 https://doi.org/10.1177/107110070502601113 https://doi.org/10.1177/107110070502601113 https://doi.org/10.2519/jospt.2006.2265 https://doi.org/10.1016/s1356-689x(98)80022-2 https://doi.org/10.1016/s1356-689x(98)80022-2 https://doi.org/10.1016/s1356-689x(03)00101-2 https://doi.org/10.1016/s1356-689x(03)00101-2 https://doi.org/10.2519/jospt.1999.29.10.609 https://doi.org/10.2519/jospt.1999.29.10.609 https://doi.org/10.1249/01.mss.0000155435.10686.04 https://doi.org/10.1249/01.mss.0000155435.10686.04 https://doi.org/10.1016/j.ptsp.2009.07.005 https://doi.org/10.1016/j.ptsp.2009.07.005 https://doi.org/10.2519/jospt.2006.2259 abstract manuscript type evidence-to-practice review 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 rest and therapeutic interventions following sport-related concussion: an evidence-to-practice review alyssa l. bolno, scat, atc*; brittni g. hoover, ms, atc*; ryan j. michels, scat, atc*; allison b. smith, phd, atc†; zachary k. winkelmann, phd, scat, atc* *university of south carolina, columbia, sc; †university of louisiana – lafayette, lafayette, la abstract sport-related concussion (src) is among the most common injuries seen in both sports and recreation, especially collision and full contact sports. however, there has been controversy surrounding which recovery protocol would be best used in the rehabilitation of a person who has suffered from src. symptoms and dysfunctions can vary from patient to patient. the average recovery time for adults is 14 days post incidence. although most patients recover over the first few days/weeks post-injury, 15% reported recovery time of 30 or more days. previous research determined a need for cognitive and physical rest of 24-48 hours, or until acute symptoms resolve to then begin a six-step progressive returnto-activity. evidence from recent research shows that prolonged physical and cognitive rest may not be as effective as previously determined for concussion and postconcussion syndrome management. multiple studies have shown that a multimodal active recovery helps patients diagnosed with concussion or post-concussion syndrome have a timely return-to-activity, as well as increases improvement in overall symptoms. within these studies, researchers have determined that patients should avoid exacerbating symptoms by staying below their symptom threshold, which can be determined through the implementation of the buffalo concussion treadmill test. although not all research has shown an increase in recovery from src using active rehabilitation, a substantial number of researchers have seen a positive effect. even with the limited amount of research and evidence, clinicians should highly consider the use of active rehabilitation following a 24 to 48 hour period of rest for src. therefore, primary purpose of this article is to evaluate the evidence related to determining if rest is beneficial following a concussion, and what the optimal duration of rest should be. the secondary purpose is to evaluate the evidence of active treatment, and rehabilitation effectiveness, for athletes who have experienced src. key phrases therapeutic exercise; functional testing correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation bolno al, hoover bg, michels rj, smth ab, winkelmann zk. rest and therapeutic interventions following sport-related concussion: an evidence-topractice review. clin pract athl train. 2021;4(3): 1016. https://doi.org/10.31622/2021/0004.3.3. submitted: december 3, 2020 accepted: may 6, 2021. original reference schneider kj, leddy jj, guskiewicz km, seifert t, mccrea m, silverberg nd, feddermanndemont n, iverson gl, hayden a, makdissi m. rest and treatment/rehabilitation following sport-related concussion: a systematic review. br j sports med. 2017;51(12):930-934. https://doi.org10.1136/bjsports-2016097475. summary clinical problem and question sport-related concussion (src) is among the most common injuries seen in sports and recreation, especially in collision and full contact sports and has been defined as external or biomechanical force causing neurological and altered brain function impairments along functional disturbances leading to clinical signs and symptoms.1,2 sportrelated concussion has a heterogeneous clinical presentation representing multiple subtypes of disease. at the time of suspected src, a multifaceted assessment starts with immediate considerations such as cervical spine injury and neurological assessment followed by extensive concussion assessment including orientation, memory, cognition, balance, and vestibular oculomotor screening (voms) completed by a licensed healthcare provider with training and education in sport-related concussion management.2 symptoms and neurological problems following a concussion can vary from patient to patient with typical recovery time for adults being reported around 14 days.1,3 although most patients recover over the first 1014 days following the injury, 15% have reported trajectory of 30 days or more.3 as of 2019, mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.3.3 https://doi.org10.1136/bjsports-2016-097475 https://doi.org10.1136/bjsports-2016-097475 rest and therapeutic interventions following sport-related concussion: an evidence-to-practice review 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 rehabilitation guidelines are based on expert opinion found in a consensus documents based on group meetings from concussion experts including researchers in clinical medicine, sports medicine, neuroscience, neuroimaging, athletic training and sports science.2,4 these individuals concluded a need for a period of cognitive and physical rest of 24-48 hour, or until acute symptoms resolve, followed by a progressive six-step return to academics and sport, is the best course of action.2 this period of rest is critical due to the pathophysiological changes in the brain during the first 48 hours such as: ion influx leading to migraines and headaches; a decrease in glucose metabolism and metabolite n-acetylaspartate (naa) in frontal white matter leading to increased risk of second injury; and finally impaired neurotransmission leading to impaired cognition, slowed processing, and slowed reaction time.5 due to this critical period being recommended, the primary purpose of this article was to evaluate the evidence related to determining if rest is beneficial following a concussion and what the optimal duration of rest (after the 48-hour period) should be. the secondary purpose of this article was to evaluate the evidence of active treatment and rehabilitation effectiveness for athletes who have experienced src.3 summary of literature the initial search terms selected for the search strategy were created and modified by the original authors of the systematic review. the following electronic databases were used for the search strategy: medline, cinahl, psycinfo, cochrane central register of controlled trials, sportdiscus, embase and proquest dissertations and theses global.3 inclusion criteria for the review included (1) original research, (2) the focus of the study had src as a source of injury, and (3) the study evaluated the effect of rest or treatment.2 the downs and black (db) checklist was used to evaluate the risk of bias in the articles and it was used in cases when the authors did not agree on a decision. a total of 28 studies with 3218 participants were included in the systematic review, which included five randomized control trials, nine cohort studies, two quasi-experimental studies, and 12 case studies.3 summary of outcomes there were various interventions and treatment options listed within the nineteen studies. research determined strict rest after src decreases energy and patients had longer symptom period of more than 10-14 day average.2 however, there is conflicting data that shows the efficiency of rest following a concussion that aids the recovery of function and symptom resolution, studies that researched treatments for concussion were categorized into rehabilitation, exercise, medical and other (symptom-free waiting period). rehabilitation treatment was divided into multimodal physiotherapy, collaborative care, cognitive rehabilitation, and multifaceted physical therapy with exercise. multifaceted rehabilitation included treatment regimens such as adaptation, balance, musculoskeletal, aerobic, anaerobic, and sport specific.3 other areas within rehabilitation that were mentioned were vestibular and manual therapy, specifically exercises that focus on improving pain and function for patients with cervical spine symptoms. vestibular therapies were reported to have a positive effect on symptoms and recovery, such as improving neck pain, headaches and dizziness. active recovery treatment involved exercise which introduced subsymptom submaximal aerobic exercise multiple times per week, which did not exacerbate symptoms but rather improved symptom scores and the time for return to baseline cognitive scores. medical treatment was divided into either interventional or traditional pharmacological measures to help with post-traumatic headaches.3 treatment in these categories only showed minimal benefits. all these interventions were rest and therapeutic interventions following sport-related concussion: an evidence-to-practice review 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 compared against rest and a symptom-free waiting period to determine which intervention helped decrease src symptoms and facilitate a safe and timely return-to-activity. findings and clinical implications the guiding systematic review compared articles that were focused on concussion research that analyzed the overall effects of rehabilitation, medical, and other forms of post-concussion treatment on patients.3 individuals who experience concussions can experience neurological, vestibular, oculomotor, along with physical ailments due to the etiology of the injury. of these treatment types, none were found to have better outcomes over the other. as a result of these findings, additional research may be required on these treatments. however, there is data that suggest that post-concussion patients can begin to partake in physical and cognitive functions after 24 to 48 hours of rest.3 manual therapy, such as cervical lateral glides and occipital muscle energy, combined with specific exercises involving either balance, adaptation, or low level aerobics were found to improve function and pain in patients with src.2 clinicians need to understand the importance of completing these tasks in which the individual stays under the symptom exacerbation threshold to avoid increasing symptoms,3 which can be done by implementing the buffalo concussion treadmill test (bctt) as demonstrated in figure 1. by using this test, clinicians can determine the exact level of aerobic activity and heart rate that exacerbates symptoms. the completion of the bctt can correlate to the duration of clinical recovery as well as give an estimate on the stage of return-toplay (rtp) process and to help understand how much rehabilitation exercise to prescribe within each treatment session for the patient.6 regardless of the treatment chosen, it is important for both the clinician and patient to keep the symptoms underneath the exacerbation during post-concussion assessment.3 from the research conducted, indications for rehabilitation programs involving a controlled symptom threshold limit, with submaximal exercise for athletes who have persistent symptoms, may be of long-term benefit.3 clinicians should return athletes gradually to their non-sport activities, as tolerated while making sure the patient does not have any return of symptoms 24 hours before progressing in the process, and should avoid heavy exertion related activities until fully cleared.1,7,8 specifically, the 2016 berlin consensus statement, recommended a five stage return-to-learn (rtl) protocol in which children and adolescents should gradually resume academics before returning to sport or other physical activity. the consensus statement did agree that while gradually returning the athlete to school, the patient could begin an early introduction into symptoms limited activity, such as low cardiovascular exercises determined by bctt, following the 24 to 48 hours rest period.1,8 the rtl process is important due to the changes in attention, cognitive processing speed, short term memory and executive function that makes learning difficult following an src. clinicians should introduce the rtl prior to rtp as integration of learning may exacerbate neurological changes which can in return affect the overall rtp process.8 in terms of specific rehabilitation options, vestibular rehabilitation was found to show positive effects, especially with patients who have persistent vestibular findings after src.3 examples of vestibular rehabilitation used include cawthorne-cooksey exercises, sensory integration balance training, gaze stabilization, ocular tracking, vestibular ocular reflex training, and dynamic gate. other technology that can be used in vestibular rehabilitation includes dynavision d2, fit light system, geobard, and the interactive metronome neurotiming.3 if clinicians are looking for confirmation of vestibular oculomotor dysfunction following a src, clinicians should look to use to voms, which has unique rest and therapeutic interventions following sport-related concussion: an evidence-to-practice review 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 aspects for determining vestibular function not assessed by other post-concussion test.3 before performing the voms, clinicians either need to be trained in administering the exam or refer to a healthcare professional who is trained in administering the exam for the most accurate results.9 there is little to no evidence to support the use of pharmacological management strategies such as analgesics, non-steroidal antiinflammatory drugs, or acetaminophen for treating src.3,10 every individual is different and there is no standard timeline for how and when a patient can and will recover from a concussion. the return-to-activity decision should be decided by an interprofessional healthcare team, and all factors closely analyzed. clinical bottom line evidence from recent reviews suggest that prolonged physical and cognitive rest may not be as effective as previously thought for concussion and post-concussion syndrome management.11 multiple studies have shown that a multimodal active recovery, including progressive levels of exercise difficulty that increase throughout rtp, helps athletes diagnosed with concussion or postconcussion syndrome efficiently return-to-activity and helps with their overall symptoms and recovery time.12-14 one research study concluded that prolonged rest could impede athlete recovery and lead to mood and/or anxiety disorders.14 grabowski et al. (2017) was able to further suggest supervised physical rehabilitation, involving sub-symptom cardiovascular exercise, vestibular/oculomotor therapy, and cervical spine rehabilitation, improved symptoms scores in exercise tolerance and on graded exercise testing and balance.12 other studies, such as chrisman et al. (2017) who used the balke treadmill test, which is similar to the bctt, demonstrated symptoms decreased exponentially following a progressive aerobic exercise program regardless of symptoms duration at presentation and none of the subjects had worsening of symptoms throughout the program.13 implementation of lowlevel activity including sub-symptom cardiovascular exercise including biking, walking, and jogging, are a few ways to avoid excessive rest following concussion.11 overall, it is becoming clear that prolonged and sustained rest from all activity following a concussion is not beneficial and could potentially be harmful to the recovery process. previously, patients were instructed on complete rest from both physical and mental activity until all symptoms were no longer present. the recent research indicates a change in treatment for src to a more active approach after 24-to-48-hour rest, may aid in recovery. although there is some conflicting evidence on active rehabilitation providing a benefit towards src recovery, it should still be considered due to its potential use in clinical practice. clinicians should still follow the protocol of 24 to 48 hours of rest post src before they begin incorporating active rehabilitation. vestibular rehabilitation such as: cawthornecooksey exercises, sensory integration balance training, and vestibulo-ocular reflex, or cervical manual therapy, have shown the most positive effects in regards to overall symptom recovery and faster rtp of all the different concussion related interventions.3 the use of exercise tolerance in the active rehabilitation protocol can be useful for the differential diagnosis of patients with potential post-concussion syndrome and can also act as a physiological sign of readiness to rta.11 if active rehabilitation is the chosen path of src treatment, the clinician should always be aware and ensure the patient's symptoms are staying under the original reported symptom scores after the initially recorded src. symptom scores should be taken daily while going through the rehabilitation process to ensure the symptoms are resolving and not over the scores from the initially recorded src.6 despite the inconclusive findings on the effectiveness for active rehabilitation in the evidence-to-practice review 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 table 1: key information, helpful tips, and take-home messages of management of sport-related concussion (src) key information ● src is among the most common injuries seen in sports and recreation, especially in collision and full contact sports.1 ● typically, recovery time for adults has been reported as 14 days.1 ● symptoms decrease exponentially following a progressive aerobic exercise program, regardless of symptoms duration at presentation, and all of the subjects were without symptom exacerbation throughout the program.9 helpful tips ● at the time of suspected src, a multifaceted assessment starts with ruling out considerations such as cervical spine injury and neurological assessment followed by extensive concussion assessment including orientation, memory, cognition, balance, and vestibular ocular motor screening. all should be completed by a credentialed medical professional who has specialized training in src diagnosis and management. ● an efficient way of ensuring the patient’s symptoms stay below the limit of symptoms worsening would be to implement the buffalo concussion treadmill test. by using this test, you can find the exact level of aerobic activity and heart rate that exacerbates symptoms, which may also correlate to the duration of clinical recovery.3 take-home messages for clinician ● follow the guidance of the medical staff, in collaboration with utilizing evidence-based practice. ● clinicians should return athletes gradually to their non-sport activities, as tolerated, and should avoid heavy exertion related activities until fully cleared. activities allowed should be based on patient symptoms but can include light cardiovascular or vestibular exercises. ● specifically, the berlin consensus statement (2016) recommended a 5 stage return-to-learn protocol in which children and adolescents should gradually be returned to academics before rtp.4 ● the return-to-play decision should be managed as a collaborative effort amongst healthcare providers such as athletic trainers, team physician and src specialist and all factors such as neurological function, symptom checklist, and performance on concussion assessment should be closely analyzed. management of a src, athletic trainers should consider the use of the bctt due to its ability to objectively measure aerobic exercise capacity.6 the bctt can be used safely on either a treadmill or a stationary bike. while the paradigm of rest and symptom recovery has been well adopted in sports medicine for concussion management, the guiding systematic review identified positive effects in most of the studies (16/19) for postconcussion treatment.3 we recommend that athletic trainers and other sports medicine professionals managing src to evolve their practice away from complete rest and move towards an integration of active rehabilitation. overall, we suggest that clinicians use active rehabilitation following a 24 to 48 hour period of rest for src. the management of a src is also complex and multifaceted meaning an integrated approach is necessary from multiple providers. as athletic trainers begin to reconsider the management process through a collaborative and interprofessional lens, we suggest using table 1 take home and key messages to guide your discussions. following the discussions, we suggest the sports medicine team integrate a quality improvement process whereby small changes, including policy and implementation of active rehabilitation strategies, are undertaken segmentally to learn more about the necessary skills and resources for the changes to their care plan. references 1. mccrory p, meeuwisse w, dvořák j, et al. consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in berlin, october 2016. br j sports med. 2017;51(11):838-847. https://doi.org/10.1136/bjsports-2017097699. 2. schneider kj. concussion part ii: rehabilitation the need for a multifaceted https://doi.org/10.1136/bjsports-2017-097699 https://doi.org/10.1136/bjsports-2017-097699 rest and therapeutic interventions following sport-related concussion: an evidence-to-practice review 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 approach. musculoskelet sci pract. 2019;42:151-161. https://doi.org/10.1016/j.msksp.2019.01.0 06. 3. schneider kj, leddy jj, guskiewicz km, et al. rest and treatment/rehabilitation following sport-related concussion: a systematic review. br j sports med. 2017;51(12):930-934. https://doi.org/10.1136/bjsports-2016097475. 4. mccrory p, meeuwisse wh, aubry m, et al. consensus statement on concussion in sport: the 4th international conference on concussion in sport held in zurich, november 2012. j am coll surg. 2013;216(5):e55-71. https://dx.doi.org/10.4085%2f10626050-48.4.05. 5. giza cc, hovda da. the new neurometabolic cascade of concussion. neurosurgery. 2014;75 suppl 4(0 4):s24-33. https://doi.org/10.1227/neu.0000000000 000505. 6. haider mn, leddy jj, wilber cg, et al. the predictive capacity of the buffalo concussion treadmill test after sport-related concussion in adolescents. front neurol. 2019;10:395. https://doi.org/10.3389/fneur.2019.00395 . 7. harmon kg, drezner ja, gammons m, et al. american medical society for sports medicine position statement: concussion in sport. br j sports med. 2013;47(1):15-26. https://doi.org/10.1136/bjsports-2012091941. 8. harmon kg, clugston jr, dec k, et al. american medical society for sports medicine position statement on concussion in sport. br j sports med. 2019;53(4):213-225. https://doi.org/10.1136/bjsports-2018100338. 9. yorke am, smith l, babcock m, alsalaheen b. validity and reliability of the vestibular/ocular motor screening and associations with common concussion screening tools. sports health. 2017;9(2):174-180. https://doi.org/10.1177/1941738116678 411. 10. larsen el, ashina h, iljazi a, et al. acute and preventive pharmacological treatment of post-traumatic headache: a systematic review. j headache pain. 2019;20(1):98. https://doi.org/10.1186/s10194-0191051-7. 11. leddy jj, wilber cg, willer bs. active recovery from concussion. curr opin neurol. 2018;31(6):681-686. https://doi.org/10.1097/wco.0000000000 000611. 12. grabowski p, wilson j, walker a, enz d, wang s. multimodal impairment-based physical therapy for the treatment of patients with post-concussion syndrome: a retrospective analysis on safety and feasibility. phys ther sport. 2017;23:22-30. https://doi.org/10.1016/j.ptsp.2016.06.00 1. 13. chrisman spd, whitlock kb, somers e, et al. pilot study of the sub-symptom threshold exercise program (sstep) for persistent concussion symptoms in youth. neurorehabilitation. 2017;40(4):493-499. https://doi.org/10.3233/nre-161436. 14. mahooti n. sports-related concussion: acute management and chronic postconcussive issues. child adolesc psychiatr clin n am. 2018;27(1):93-108. https://doi.org/10.1016/j.chc.2017.08.005. https://doi.org/10.1016/j.msksp.2019.01.006 https://doi.org/10.1016/j.msksp.2019.01.006 https://doi.org/10.1136/bjsports-2016-097475 https://doi.org/10.1136/bjsports-2016-097475 https://dx.doi.org/10.4085%2f1062-6050-48.4.05 https://dx.doi.org/10.4085%2f1062-6050-48.4.05 https://doi.org/10.1227/neu.0000000000000505 https://doi.org/10.1227/neu.0000000000000505 https://doi.org/10.3389/fneur.2019.00395 https://doi.org/10.3389/fneur.2019.00395 https://doi.org/10.1136/bjsports-2012-091941 https://doi.org/10.1136/bjsports-2012-091941 https://doi.org/10.1136/bjsports-2018-100338 https://doi.org/10.1136/bjsports-2018-100338 https://doi.org/10.1177/1941738116678411 https://doi.org/10.1177/1941738116678411 https://doi.org/10.1186/s10194-019-1051-7 https://doi.org/10.1186/s10194-019-1051-7 https://doi.org/10.1097/wco.0000000000000611 https://doi.org/10.1097/wco.0000000000000611 https://doi.org/10.1016/j.ptsp.2016.06.001 https://doi.org/10.1016/j.ptsp.2016.06.001 https://doi.org/10.3233/nre-161436 https://doi.org/10.1016/j.chc.2017.08.005 evidence-to-practice review 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 prior to testing start: 1) inform the patient about test procedures and what to expect during the test 2) explain and demonstrate the borg rating of perceived exertion (rpe) scale and obtain resting scores (see graphic representation below) 3) remind patient that they will be asked to rate exertion and symptom severity at each minute during exercise 6-7 very, very light 8-9 very light 10-11 fairly light 12-13 somewhat hard 14-16 hard 17-18 very hard 19 very, very hard 20 max exertion patient stands on end of treadmill height (in) of patient is taken >5.5” = 3.6 mph <5.5” = 3.2 mph incline = 0° after each minute, increase incline by 1° rate rpe and symptom severity or heart rate *1-point is given for any worsening syptom, 1-point is given for any new symptom treadmill incline increases at 1°/minute athletic trainer should note the likert scale reason/symptom that sparked increase maximum incline = 15° or 12° at modified test speed increases by 0.4 mph each minute with no incline change terminate the test when rpe is reported at 19.5 or once patient reports inability to continue due to symptoms *max time on treadmill: 20 minutes once test has been terminated, reduce speed to 2.5 mph and incline reduced back to 0° for a 2 minute cooldown patient should rest until symptoms return to prebctt value modified iteration of schneider kj, leddy jj, guskiewicz km, seifert t, mccrea m, silverberg nd, feddermann-demont n, iverson gl, hayden a, makdissi m. rest and treatment/rehabilitation following sport-related concussion: a systematic review. br j sports med. 2017;51(12):930-934. doi: 10.1136/bjsports-2016-097475. figure 1: buffalo concussion treadmill test protocol abstract editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 the state of work in athletic training: a conversation k. ellis f. mair, edm, atc*; lindsey e. eberman, phd, lat, atc† *go4, philadelphia, pa; † indiana state university, terre haute, in key phrases work place culture, employment, work force, employer, employee correspondence ellis mair and dr. lindsey eberman, 567 nth 5th street, terre haute, in 47802. e-mail: ellis.mair@gmail.com twitter: @go4ellis full citation mair kef, eberman, le. the state of work in athletic training: a conversation. clin pract athl train. 2022;5(1): 1-7. https://doi.org/10.31622/2021/0005.01.1. editorial recent employment reports have suggested that 18% of healthcare workers left their respective professions since the onset of the pandemic and another 12% have been laid off.1 although current data about the impact of the pandemic on the athletic training workforce has not been released from the strategic alliance, an early study indicated that 20% of athletic trainers were out of work.2 editor-in-chief, lindsey eberman, engaged in a conversation with ellis mair, cofounder and vice president of medicine/community at go4 (formerly go4ellis) about the state of work in athletic training. lee: what is your current sense of work in athletic training? kefm: historically, i think this has always been an interesting question because the title of athletic trainer applies to many different people doing many different jobs. we have athletic trainers that work clinically with patients in traditional athletics settings but also we’ve seen a big expansion into physician practice, the performing arts, public safety and the industrial setting. we also have people working in education and research that are still athletic trainers, however their day-to-day looks much different than someone who works providing direct patient care every day. i think the definition of “work” in athletic training has changed tremendously. lee: do you think that it gives us an advantage in terms of retaining folks in the profession, the variety that one could explore, because of those different ways that we can define ourselves as athletic trainers? kefm: yes. but i think it's commonly misunderstood. i don't know if we do the best job of selling all the different skills we have and how our skills can be used in various settings. i think it is amazing that our patients can be anyone from an astronaut to an acrobat or factory worker or even a middle schooler. but i don't think that is necessarily something the general public knows. sometimes athletic trainers put on scrubs and go into an operating room and sometimes you are teaching in a classroom. we all look very different from setting to setting and i think one of the harder aspects about our profession is to describe how we fit into each of these settings and understand that we have the ability to transition from one setting to another. lee: i also think we actually struggle to communicate it within our own profession. that seems to be obvious with so many athletic trainers leaving the profession. and that's a historic trend, not just a pandemic trend. we have not taught people resilience, or what options, they have available because so much of professional preparation is in the college/university and secondary school settings cause those are clinical sites of convenience. exposure outside of that is infrequent in professional preparation and i think an early career athletic trainer has have a lot of courage to go into a brand new setting and mailto:ellis.mair@gmail.com https://doi.org/10.31622/2021/0005.01.1 the state of work in athletic training: a conversation 2 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 explore, especially in the current financial climate and likely student debt. i think as much as we struggle to communicate it to the public, we're equally struggling to communicate it to ourselves. kefm: i agree and experienced this first hand in the pandemic. when the pandemic hit, the go4 platform lost a million dollars in business in a span of four days. at the time, we were largely based in youth sports and every single tournament, practice and camp in the country was cancelled. i called my colleague and said, “half of the users on the platform are healthcare workers who are currently sidelined. this is a perfect time for them to get involved.” and we got straight to work because we had over 10,000 healthcare professionals that could be activated with the click of a button and i just had to find someone who believed me. i had some amazing conversations with athletic trainers who were reaching out to me to say, “let me know where you need me and i will go. i know i can help and i want to be involved.” people were calling from texas and oklahoma offering to fly across the country to help in new york! we were working around the clock emailing every department of health trying to get someone to take our call. i ended up in meetings with the health commissioners, chief nursing officers and directors of hr for large urban health systems. i was having conversations with people who essentially were saying, “i have no idea who you are, what you do as a profession and why the heck should i trust you right now?” convincing them to trust us wasn’t easy at first but when it came down to it, it was a simple conversation about skills and what we could to help them. we were able to pivot and ended up working primarily in the public health realm, whether it was in hospitals or screening and testing sites, we saw the same athletic trainers that were used to working camps excelling alongside nurses and physicians in the pandemic. i think that may changing, but i don't think that a lot of the general medical community understands how we can fit into the healthcare hierarchy and what a massive help we can be to them and their practice.i think that communication and advocacy is as important a skill for athletic trainers as many of our hard clinical skills. lee: you mentioned having to pivot with the pandemic. do you see currently a worker shortage in athletic training and why doesn't it feel like we're not talking about it more? kefm: there definitely is and i believe this is partly because of how people managed their athletic trainers when the pandemic began. in early april of 2020, we ended up interfacing with the human resource director of new york city health and hospitals. her daughter was an athletic training student down in florida, so while she had a nursing background understood who athletic trainers are and how they could help new york city health and hospitals. this organization is the largest hospital system in the country and they were utilizing athletic trainers from the very beginning. if it could happen in new york, there is no reason it shouldn’t happen everywhere. the other large healthcare organizations that are having trouble today are the ones that neglected to empower and utilize their athletic trainers. historically they’ve employed athletic trainers as loss leaders and had never realized the actual value of athletic trainers. whether it was a departmental decision or an administrative one they chose to furlough or lay off athletic trainers instead of utilizing our skills in another way. all over the country, athletic trainers we were setting up the facilities for safe patient flow, conducting screenings and temperature checks and even doing covid testing and vaccinations. but these organizations chose to furlough their athletic trainers and now that sports are back, they can’t find the ats that used to work for them. some people faced geographic challenges where their cost of living was so high that they could not stay in their communities without employment. we also have seen large expansion of the industrial setting in the past few years. as the the state of work in athletic training: a conversation 3 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 pandemic raged on, the need to protect our supply chain workers became very real and demand for athletic trainers here grew. many athletic trainers changed settings; some on a per diem basis but for many it progressed into a full time job. while there may be a worker shortage in some settings, there is growth in others. we've also seen a lot of people working per diem until they can find a job that they like. the demand for healthcare workers has grown over the last two years and therefore we've seen those pay rates go up astronomically. per diem work has been able to keep a lot of people afloat and work a flexible schedule that works for them while they can find the right job to go back full time. some organizations also realized how much they needed an athletic trainer. traditional athletics, although paused, did not go away so there is still a need in college and secondary school athletics. but some athletic trainers got used to a different approach to working and are asking themselves, “do i want a regular schedule or more control over my schedule, or do i want to go back to what i was doing before?” lee: that really fits people with a dynamic life or those with a family. per diem seems to have given people the opportunity to earn money but at their own will versus a traditional athletic training setting, which often makes the worker feel like they are at the will of others. lee: how do you think the workforce itself has changed in the last two years? demographics of the population but also individual people? how have we changed as athletic trainers within the healthcare system? kefm: a lot of people liked the transition to work from home. many athletic trainers were shifted into the student health or physician practice realm. they were engaged in the public health and prevention side. anecdotally, people seemed to really like that shift. they may have been doing more healthcare administration and organizations relied on them to be decision-makers. the other leaders “at the table” were looking at athletic trainers saying, “who are you? you see things through a completely different lens and you're great at this!” i think that that's been awesome. it has been really amazing to watch friends excel in positions of leadership that they suddenly found themselves in. we haven’t always been afforded the opportunity to be in the boardroom and this helped a lot of athletic trainers realize their range of skills too. they were put in positions that they succeeded in and going into it they didn't necessarily realize that they could do the things they ended up doing. lee: that is an in interesting observation. recently the boc produced the practice analysis 8th edition,3 which serves as the blueprint for the certifying exam, characterizing the knowledge, skills, and abilities for entry-level practice. the weight of the healthcare administration and professional responsibility (7th ed.) domain,4 now the health administration and professional administration (8th ed.) domain, decreased from 13% to 8%.3,4 two years of a pandemic, where people had to go work from home, build policy, implement policy, have a policy for when people broke policy, develop testing procedures, figure out to enhance safety in a facility. where i would have thought there would be an increase, there was a 5% decrease! kefm: that is shocking. i feel like so much of what we’ve done in the pandemic is to help develop policies and then rip them up and then create another one based on whatever change was thrown our way. lee: how do you think employers have changed? you mentioned inviting athletic trainers to the table, so obviously there's been some openness about how athletic trainers can contribute to the bigger picture, but do you feel like employers are valuing athletic trainers more or not? kefm: i think this is a case by case situation. we talked earlier about how many different jobs exist the state of work in athletic training: a conversation 4 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 that are all considered working as an athletic trainer. there are some people that were able to forge new relationships as they gained new colleagues in student health service or at their local department of public health. i also think that these new colleagues will continue to seek out that athletic trainer's input because they were a reliable source of information and a creative problem solver. some employers are realizing how much they need athletic trainers and they’re willing to pay more than they would have in the past to have them come back to work. i also think that we are starting to dig in and realize that we are not willing to come back for what we were previously earning, especially if they were mistreated prior to or during the pandemic. lee: retention data has taught us that there's a salary at which athletic trainers are willing to put up with the typical chaos and work-related stress attached to the sport industrial complex… i think that we have to figure out what that point is. the national athletic trainers’ association just published the executive summary of the 2021 salary survey. although the summary requires some methods clarification, the general premise is that the average salary is around $61,000 and that number has risen about $10,500 since 2011, but the gender gap is concerning (-$11,000).5 unfortunately no data are provided for minoritized populations, at the time of this publication. what is the salary someone should be earning to also accept the unstructured work of traditional athletics? there are so many jobs available in the traditional settings without sufficient workers to fill the jobs based on popular listservs and the career center. i'm wondering whether we're going to hit a tipping point in these traditional settings where employers are willing to reconsider compensation models, much like we have seen in the per diem compensation. unfortunately, we had seen trends of assistantships shifting to internships that exploit the least experienced athletic trainers, instead of converting these positions to full-time staff positions. the patient need is still there, so i think we need innovation in both compensation and healthcare delivery structure. we need to identify what our priorities are and consider how to focus our staff if we are unable to bring folks back in and compensate them accordingly. kefm: i think candidates have the pick of the litter right now, and i think that it's very important that they know that. we've talked about this for years and it's really only addressing half of the problem, “say no to low paying jobs!”. but that is not the solution. this blame is misdirected and cannot be solely assigned to the person taking a low paying job. we, the athletic trainers that are behind the hiring, need to stop offering low paying jobs. employers have a responsibility to pay their employees appropriate salaries for the work that they are being asked to do. candidates are going to be graduating soon and there are jobs everywhere. i think they have a lot of leverage to negotiate. especially with the proliferation of legislation that requires an athletic trainer to be present if you have certain activities occurring at a facility, it is no longer a luxury to have an athletic trainer, it is a legislative necessity. when those employers are struggling to find someone to fulfill those duties, they are going to have to offer more so that they can find someone willing to do the job for an appropriate pay rate. we've seen the average rate on go4 rise from $35/hour a few years ago to $50/hour and some rates are as high as $100/hour in some areas. it has been a long two years for the profession and if an employer wants someone to get off the couch at the end of a long hard work week, they are going to have to pay them a rate worth their valuable time. i think graduating candidates need to know that there are going to be a plethora of jobs available to them and they shouldn’t take something that they are not excited about. there are great the state of work in athletic training: a conversation 5 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 employers and great work experiences out there and you’ve got to do the work to find one that meets all of your needs. at the annual meeting in june, there will be dozens of companies who are looking to hire athletic trainers. they will be looking to recruit graduates right there on the expo floor. for the longest time, positions were easy to fill but times have changed and these companies are having to put in the work and reconfigure these jobs if they want to find the best candidates. lee: employees should be able to make decisions in their best interest. i work primarily with folks who are in their early career and many of them want to go into college/university athletic training and i'll be curious to see how this setting adapts. historically these job postings require previous college/university setting experience; often 3 to 5 years. however, we lack evidence to support that criteria as leading to retention of improved health outcomes. it seems arbitrary and i am not sure there will be enough candidates with those experiences, at least in the short-term hiring cycle. they will see far more early-career athletic trainers applying and securing those positions, but this setting does not seem to have demonstrated the same radical adaptability the other settings have when it comes to increasing compensation and adjusting workplace climate. i would not encourage any of our early-career athletic trainers to take those positions at the rate being offered. how do you think candidates can leverage themselves in the landscape? kefm: first, they cannot be afraid to negotiate and tell the employer what you believe you are actually worth. companies may be posting the position for $41,000 but if they interview 10 candidates who say they are worth the national average at $61,000, they are going to have to go back to human resources. the employer will have to advocate directly to human resources that great candidates are unwilling to work for their listed salary. candidates need to know the number that works for them. employers need that feedback and they’re going to have to reassess. lee: compensation has long been our problem in athletic training, but compensation is not the only indicator of job quality. i tell students that they need to weigh three things; geography, autonomy, and compensation. if the most important thing to you is the ability to have your weekends off and climb mountains. then you should be looking for a job that geographically allows you to do that. if you want to be in control of your time and how you focus your attention, choose a job that gives you that autonomy. but sometimes these three factors are in conflict with one another, but the important thing is for a candidate to know what their priorities are. they get to decide, but they should certainly not be sacrificing all three. for me, i prioritize autonomy, and in that i sacrifice geography, living away from family. in my work with early-career athletic trainers, i have noticed they are so fearful of negotiating. i think they think the employer will take away the offer, the moment we push them a bit. they are offering the job they have. as an employee, we have a responsibility to push the employer higher, for long term professional health. i encourage folks to negotiate for at least 10% more even if the salary is a good offer. the higher your salary goes the more valuable everybody around you becomes because eventually those salaries will be raised to match yours. you mentioned people having an affinity toward work from home, some of the administration components of athletic training, and other kinds of workplace climate changes that have happened as a result of the pandemic that are an advantage to the employee. let’s talk more about those. kefm: we got out of the rhythm of the chaos and the overwhelming hours we typically work. we got used to a more normal schedule and i think now that athletics are back, it has been really the state of work in athletic training: a conversation 6 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 hard to adjust. i think it’s making departments realize they are wildly understaffed and more than they have been in the past. i'm hoping that we will see more jobs created because people are realizing the need is not matched by the workforce, in terms of total personnel. i also think people realize the importance of personal time. this is something candidates should be asking on interviews as well. “what does vacation actually mean? can i take it when i want it? am i allowed to engage in life events?” i think athletic trainers do not think labor laws apply to us, but the issue is practice not policy and this culture must change. people are realizing that time is theirs and asking for it back. people are being more protective over their time, and i think that's a good thing. candidates can really advocate for paid time off in an appropriate way and use it when they need and want to, not at the convenience of the employer or team they work with. lee: athletic trainers have historically said, “rain or shine, sick or not, i’m willing to come to work.” now, i hope every human on the planet no longer feels an obligation to work sick. the ramifications are far bigger than you. what do you think employers could be doing to embrace some of these changes and ensure that workplace culture matches worker need? kefm: retaining personnel is less expensive. if someone is leaving, it is to their advantage to conduct an exit interview and ask why that person is leaving and how they could improve the experience of working there. staff that stay and thrive creates an overall better experience for everybody. they should be gathering information from candidates, those leaving, and those staying. find out what their needs are and figure out how you can meet them. we are seeing workers across all kinds of industries organizing for better work environments. look at the amazon workers unionizing and the nurses moving into traveling positions. people are not going to work for low wages or in abusive cultures anymore, because it is just not worth it. to create a successful workplace, you need to listen to what people want and what they need, and how you can make their lives better. we know happy healthcare providers provide better patient care. lee: some of this includes rethinking how we deploy staff. we have, for far too long, provided coverage instead of healthcare and this is a turning point, if we allow it to be, to consider how to deliver athletic healthcare differently. kefm: absolutely. we do not always need to be focused on coverage. people find more fulfillment in working with patients one on one and seeing them improve. lee: i think it's about identifying what the need is; what is the need and then organizing staff to meet those needs. i also am hopeful that folks will realize that we shouldn't be the only person assigned to a team, which often means the only provider available to those patients. there are many challenges within the american healthcare system, but a strength is personal choice. our traditional approach to deploying personnel in athletic training has withheld choice from patients. kefm: those models also allow us to leverage specialization. we don’t have to be able to know everything and it is nice to have colleagues you can rely on for complex patient cases. it creates a collaborative environment that can improve workplace culture. lee: ideal athletic healthcare has generalists, advanced generalists, specialists, and subspecialists; all of which bring important contributions to the system. i’m looking forward to this shift in how we approach athletic training. acknowledgements special thanks to christine benz and justin young for their transcription support. the state of work in athletic training: a conversation 7 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 references 1. galvin g. nearly 1 in 5 health care workers have quit their jobs during the pandemic. morning consult. accessed on february 9, 2022. available at: https://morningconsult.com/2021/10/04/he alth-care-workers-series-part-2-workforce/. 2. winkelmann zk, games ke. athletic trainers' job tasks and status during the covid-19 pandemic: a preliminary analysis. j athl train. 2021;56(1):20-30. 3. practice analysis (7th ed). board of certification, inc. accessed on april 8, 2022. available at: https://bocatc.org/candidates/exampreparation-tools/practiceanalysis/practice-analysis 4. content outline for practice analysis (8th ed). board of certification, inc. accessed on april 8, 2022. available at: https://bocatc.org/candidates/exampreparation-tools/practiceanalysis/practice-analysis 5. nata 2021 salary survey executive summary. national athletic trainers’ association. accessed on april 8, 2022. available at: https://www.nata.org/careereducation/career-center/salary-survey https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ https://morningconsult.com/2021/10/04/health-care-workers-series-part-2-workforce/ https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://bocatc.org/candidates/exam-preparation-tools/practice-analysis/practice-analysis https://www.nata.org/career-education/career-center/salary-survey https://www.nata.org/career-education/career-center/salary-survey manuscript type validation case study 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study sarah jakubek, ma, atc*; elena robinson, dat, lat, atc;† annette d. monk, dat, lat, atc‡; *trinity international university, deerfield, il;†university of nebraska kearney, kearney, ne; ‡eastern kentucky university, richmond, ky abstract the purpose of this case validation study was to examine the effects of instrument-assisted soft tissue mobilization (iastm) on the ankle. the patient population consisted of nine participants (2 females, 7 males, age = 16± 2 years) from a suburban high school in illinois. each patient completed an iastm treatment program, incorporating the graston technique (gt). the program was completed over a three-week period with 2 sessions occurring each week, for a total of 6 sessions. data collection of ankle dorsiflexion range of motion (dfrom) occurred after the completion of the gt. this was assessed by performing the weight-bearing lunge test at the start and end of each treatment day. results demonstrated that ankle dfrom did improve by the last session. the findings from this case validation study suggest that the use of gt is an effective intervention for increasing joint dfrom. key phrases manual techniques, clinician-rated outcomes, secondary schools patient population correspondence sarah jakubek, ma, atc, international university, department of health sciences deerfield, il, 60015. e-mail: sjakubek3124@gmail.com full citation jakubek s, robinson e, monk ad. improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study. clin pract athl train. 2022;5(2): 3-10. https://doi.org/10.31622/2022/0005.02.2. submitted: may 13, 2021 accepted: march 24, 2022. article citation and summary seffrin cb, cattano nm, reed ma, gardiner-shires am. instrument-assisted soft tissue mobilization: a systematic review and effect-size analysis. j. athl. train. 2019;54(7):808-821. doi:10.4085/1062-6050481-17 introduction we selected a systemic review1 regarding the use of instrument-assisted soft tissue mobilization (iastm). the authors completed a literature search from the years 2000 through 2016, using the following databases: academic search premier, alt healthwatch, cinahl, cochrane library, medline, nlm pubmed, physical education index, pedro, sportdiscus, and the web of science. the studies were evaluated and included if they met the following criteria: (1) the study was a randomized controlled trial, (2) range of motion (rom), pain, strength, or patient-reported function was measured pre-intervention and post-intervention, (3) studies were written in english, (4) human patients were assessed, and (5) iastm was compared with a control group (no iastm). thirteen of the initial 1,279 studies were included in the review and of these, 6 examined the upper extremities, 6 examined the lower extremities and 1 examined the thoracic spine. six studies assessed outcomes in uninjured patients and the remaining studies assessed outcomes in injured patients. the review concluded that iastm improves rom in uninjured individuals as well as pain and patient-reported function for certain injuries. mailto:sjakubek3124@gmail.com https://doi.org/10.31622/2022/0005.02.2 improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 objective the purpose of the validation case study was to examine whether the use of the graston technique (gt) improves ankle dorsiflexion range of motion (dfrom) in secondary school (grades 9-12) participants from a variety of athletic programs. patient population the setting was a secondary school in suburban illinois. female and male athletes from football, volleyball, and basketball programs were recruited to participate. nine participants (2 females, 7 males, age = 16± 2 years) completed the gt treatment. participants were included in the treatment program if they had 10 cm or less of ankle dfrom while performing the weight-bearing lunge test (wblt) and were in a school sponsored athletic program. less than 10 cm of dfrom while performing the wblt has been cited as an indicator of ankle equinus.2 participants were excluded from the treatment program if their dfrom was greater than 10 cm.2 participants were also asked if they had any previous history of ankle injuries. if the ankle injury was on the right ankle they were excluded from the study (figure 1). however, if the ankle injury was on the left ankle and their right ankle dfrom was less than 10 cm while performing the wblt, they were included in the study. figure 1. participant flow chart athlete had a previous right ankle injury yes no athlete was excluded from study n=1 athlete was included in study and began intervention n=9 females n=2 males n=8 secondary school athlete approached for study n= 25 weight-bearing lunge test < 10cm included in study n=10 weight-bearing lunge test > 10cm excluded from study n=15 improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 intervention in this study, gt was performed by the primary investigator, who was certified in the technique, while being supervised by the head athletic trainer. the treatment protocol was based on previous work of gt on chronic ankle instability to increase ankle dfrom.3 this program was initiated in the middle of the fall sports season and consisted of a 3-week phase for each participant. the 3-week phase required participants to complete 6 sessions, twice per week for approximately 10 minutes total per session. there was a minimum of 48 hours between each session of gt. participants received treatment one hour before the start of their athletic practice time. this gave each participant enough time to receive treatment before heading to practice. before the start of each treatment session, each participant performed the wblt4 for ankle dfrom with all measurements taken on the right ankle. for this study, the right leg was chosen because all participants were right leg dominant and was used most often as their leading or kicking foot within the participants associated sports. documentation of their dominant leg was asked before measurements. all measurement were taken using a tape measurer in centimeters. the tape measurer in this study acted as our measuring tool instead of a goniometer. research shows that using either a goniometer or tape measure when measuring ankle drfom are both reliable tools.4 the wblt was performed in a kneeling position with the heel in contact with the ground, the knee in line with the second toe. the great toe was placed at 10 cm away from the wall (figure 2). participants were asked to lunge forward touching their knee to the wall, without removing their heel from the ground. if the participants were not able to touch, their knee to the wall or the heel was removed from the ground, their foot was moved forward 1 cm until the participant was able to touch the wall with their knee without lifting their heel from the ground. this measurement was then recorded. the participants then completed a warmup on a stationary bike for five minutes before the gt was applied. it is recommended that participants either use a modality or perform an active warm-up prior to gt administration.5 the gt was then performed at four different locations, all on the right ankle, for a total of 8 minutes (2 minutes each site)1 (table 1). the four locations were the full length of the achilles tendon, the gastrocnemius/soleus, the dorsum of the foot, the fibularis longus and the flexor digitorum longus. three gt instruments were selected (gt2, gt3, gt4) to treat the restricted areas in the fascia, muscle, tendon, or ligaments both in a prone position (figures 3, 4) and in a supine position (figures 5, 6). restrictions were acknowledged as soft tissue lesions and fascial restrictions.14 instruments gt2 and gt4 were used primarily to sweep and fan each specific location, whereas gt3 was used for performing fanning, brushing, and jstroke when a restricted area was found.3 the wblt4 was then re-assessed at the end of each treatment session. table 1. graston instrument assisted soft tissue mobilization graston instruments patient position strokes and anatomical area gt 4, knob of gt 2 and gt 3 (figure 3,4) prone, foot over end of table sweep plantar fascia and gastrocnemius/ soleus gt 4, knob of gt 2 and gt 3 (figure 5, 6) supine, foot over end of table sweep dorsum of foot and anterior tibialis frame medial and lateral malleoli statistical analysis a two-way repeated measures analysis of variance (anova) was used to examine differences in each ankle dfrom measure over time and weeks. post hoc comparisons were completed using paired samples timproving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 test to examine pairwise differences within each week and from baseline through week 3. hedges’ g effect size (ess) with 95% confidence intervals (cis) were calculated for our post-hoc comparisons. a positive es indicated an increase in ankle dfrom after the application of gt while a negative es indicated a decrease in ankle dfrom. a weak es is considered < .40, while a moderate es is .41 to .69.8 a strong es is considered > .59.8 significance level for all analyses was set at p ≤ .05. statistical analysis was completed using spss (version 27, spss inc., chicago, il), and excel 2016 (microsoft inc., redmond, wa). figure 2. weight-bearing lung test measurement figure 3. gt2 achilles tendon and fibula figure 4. gt3 gastrocnemius/soleus and achilles tendon figure 5. gt4 anterior tibialis and dorsum of the foot figure 6. gt2 medial and lateral malleoliknob of gt2 improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 main findings during the three-week intervention, no injuries were sustained and there were no changes in the number of participants. a significant time main effect was found for right ankle dfrom (p < 0.001) with the wblt. all participants except one improved in ankle dfrom from day-to-day and week-to-week (table 2). post hoc analysis identified a significant change in ankle dfrom from pre-to-post of week 1 (p = .001), pre-to-post of week 2 p < .001, to pre-to-post week 3 (p = .001). the results indicated that there was an improvement with right ankle dfrom within each week. the significant results were associated with medium to large effect sizes (0.58-4.12) (table 3). table 2. means (±standard deviations) for ankle dorsiflexion, numbers represent degrees w 1/d 1 w 1/d 2 w 2/d 1 w 2/d 2 w 3/d 1 w 3/d 2 right ankle 4.74 ±5.42 7.10 ±4.80 10.91 ±5.33 15.60 ±4.32 21.2 ±5.53 24.4 ±5.63 table 3. effects size with associated confidence intervals p-value effect size lower bound upper bound pre-post wk1 0.001 0.55 -0.39 1.49 pre-post wk2 <0.001 1.45 0.41 2.49 pre-post wk3 0.001 1.02 0.03 2.01 prewk1-post wk3 <0.001 3.91 2.28 5.54 discussion the results from this study suggest that the application of gt alone may have an acute improvement on ankle dfrom. similar improvements have been found in other studies which also evaluated the effects of gt on ankle dfrom.8-10 literature11 has established normal range for ankle dfrom as 0-16.5 degrees for nonweight bearing measurement and 7.1-34.7 degrees during weight-bearing measurement. traditionally, less than 10 degrees of ankle dfrom has been cited as a noticeable deficit.2 decreased dfrom can alter motor control and cause a lack of neuromuscular control. this deficit can also lead to a higher risk of injury of the lower limb in athletes, especially in the ankle, knee and hip region.11 therefore, improvement of ankle dorsiflexion may assist in lower extremity injury prevention. one category of therapeutic interventions that can be used to increase dfrom is manual therapy, specifically gt.15 there are many other reported benefits with gt, some of which have shown to increase the fibroblast response in healing to produce more collagen with the controlled movement of the instruments.12 the theory behind the gt benefits is that the technique improves the extensibility of the tissues by treating the tissue restrictions, along with decreasing inflammation after an acute injury.14 when heat is created from friction by the instrument, the viscosity of the tissue decreases, making it more pliable.15 physiologically, a decrease in the viscosity of tissue improves rom.16 changes in rom as a result of gt may also be explained with the hypothesis that the mechanical stress applied on the muscle fascia can cause the fascia to become stimulated.14 this change in stimulation alters the proprioceptive input sent to the central nervous system, which in turn changes the tension in the tissue.17 in a cross comparison of studies, palmer et al.8 found improvements with ankle dfrom when gt was combined with stretching. in our study, the gt group received a total of ten minutes for the gt treatment from the proximal gastrocnemius to the metatarsal heads. palmer et al.8 completed a comprehensive treatment that focused on the anterior and posterior structures of the foot and the ankle, noting that these improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 locations of gt have a greater influence on ankle dorsiflexion. similarly, stanek et al.9 through the use of the wblt, identified dfrom improvements after the application of a single session of gt at two different locations, the achilles tendon and the soleus/gastrocnemius region. rowlett et al.8 also identified significant improvements in dfrom with a single session of gt when rom was measured using the wblt. rowlett et al.10 also found that both gt and stretching appear to have a greater effect on the muscle flexibility than just gt alone. overall, these studies found an acute increase in dfrom after completing one application of gt. 8-10 implementing a gt program in a secondary school setting may be challenging if the athletic trainer does not have gt instruments, as one must be certified14 in the technique and have the financial means to attain the tools. however, implementing a general iastm intervention, instead of specifically gt, may be more feasible as there is a wider variety of instruments and courses from which one can choose. specifically, general iastm tools may be more reasonable in terms of cost, access, and certification standards. in this current study, we focused on 10-minute treatment sessions which was time efficient. similarly, other studies810 attained acute results with dfrom when performing short treatment sessions that were done 1-2x/week with a minimum of 48 hours in between each session. it is recommended that gt treatment sessions have a minimum of 48 hours in between each session to allow the tissues to heal.19 following the use of gt, other treatments may be used in conjunction.3,8,10 these treatments may include exercise such as stretching and strengthening, to aid in the tissue healing.20 rowlett et al.10 also found that both gt and stretching appear to have a greater effect on the muscle flexibility than just gt alone. nevertheless, including supplemental therapy or exercise can require more time commitment from the participant, coach, and the athletic trainer, and time itself is considered a limitation of prevention programs.21 since higher compliance rates can positively affect outcomes for the participants, it is important to create a supervised and efficient prevention program.22,23 in this study, we chose to implement the program before the start of practice as pre-practice treatment sessions were already established throughout all sports. furthermore, the participants gained the supplemental benefits of exercise as the participants could immediately begin warm-up drills and sportspecific activities post-gt treatment. however, each participant may have different degrees of dfrom along with various histories of previous ankle injuries that may bring additional symptoms that must be addressed. therefore, athletic trainers should evaluate the needs of the patient when deciding complimentary treatments for gt. additionally, there are limitations within this study that needs to be addressed. first, having a small sample size may influence the results when examining the effects of gt on dfrom. future studies will benefit from obtaining a larger sample size when completing a case validation study. the participants were recruited from a convenience sample within the traditional fall and winter athletics seasons. the athletic demands of the represented sports vary greatly, and therefore may have influenced inclusion and exclusion factors. future case validation studies may benefit from investigating the effects of the intervention on individuals participating in other sports. clinical bottom line the findings from this case validation study concur with the guiding systematic review that the use of iastm and gt is an effective intervention for increasing joint rom at the ankle1 when assessing rom with the wblt. healthy ankle rom is an important part of an injury prevention program, and gt may be an effective way of improving functional limitations. athletic trainers should examine their patient population to determine the feasibility of using iastm as a treatment. improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 references 1. seffrin cb, cattano nm, reed ma, gardiner-shires am. instrument-assisted soft tissue mobilization: a systematic review and effect-size analysis. j athl train. 2019;54(7):808-821. https://doi.org/10.4085/1062-6050-481-17. 2. young r, nix s, wholohan a, bradhurst r, reed l. interventions for increasing ankle joint dorsiflexion: a systematic review and meta-analysis. j foot ankle res. 2013;6(1):46. published 2013 nov 14. https://doi.org/10.1186/1757-1146-6-46. 3. schaefer jl, sandrey ma. effects of a 4-week dynamic-balance-training program supplemented with graston instrument-assisted soft-tissue mobilization for chronic ankle instability. j sport rehabil. 2012;21(4):313-326. https://doi.org/10.1123/jsr.21.4.313. 4. konor mm, morton s, eckerson jm, grindstaff tl. reliability of three measures of ankle dorsiflexion range of motion. int j sports phys ther. 2012;7(3):279-287. 5. cheatham sw, baker r, kreiswirth e. instrument assisted soft-tissue mobilization : a commentary on clinical practice guidelines for rehabilitation professionals. int j sports phys ther. 2019;14(4):670682. 6. composite measures: onc-samhsa behavioral health clinical quality measures technical expert panel meeting august 9, 2012. available at: https://www.healthit.gov/sites/default/files/pdf/2012-08-09-behavioral-health-clinical-qualitymeasures-technical-expert-panel-composite-measures.pdf. accessed on: december 11, 2020. 7. vicenzino b. mobilisation with movement: the art and the science. churchill livingstone; 2011. 8. palmer tg, wilson d bradley, kohn m, miko s. the effect of graston massage therapy on talocrural joint range of motion. ijatt. 2017;22(3):66-75. https://doi.org/10.1123/ijatt.20150096. 9. stanek j, sullivan t, davis s. comparison of compressive myofascial release and the graston technique for improving ankle-dorsiflexion range of motion. j athl train. 2018;53(2):160-167. https://doi.org/10.4085/1062-6050-386-16/. 10. rowlett ca, hanney wj, pabian ps, mcarthur jh, rothschild ce, kolber mj. efficacy of instrumentassisted soft tissue mobilization in comparison to gastrocnemius-soleus stretching for dorsiflexion range of motion: a randomized controlled trial. j bodyw mov ther. 2019;23(2):233-240. https://doi.org10.1016/j.jbmt.2018.02.008. 11. baggett bd, young g. ankle joint dorsiflexion. establishment of a normal range. j am podiatr med assoc. 1993;83(5):251-254. https://doi.org/10.7547/87507315-83-5-251. 12. gonell ac, romero jap, soler lm. relationship between the y balance test scores and soft tissue injury incidence in a soccer team. int j sports phys ther. 2015;10(7):955-966. 13. davidson cj, ganion lr, gehlsen gm, verhoestra b, roepke je, sevier tl. rat tendon morphologic and functional changes resulting from soft tissue mobilization. med sci sports exerc. 1997;29(3):313–319. pubmed https://doi.org/10.1097/00005768-199703000-00005. 14. benefits of graston technique® therapy. graston techniques. accessed december 10, 2020. https://grastontechnique.com/patients/ 15. kim j, sung dj, lee j. therapeutic effectiveness of instrument-assisted soft tissue mobilization for soft tissue injury: mechanisms and practical application. j exerc rehabil. 2017;13(1):12-22. https://doi.org/10.12965/jer.1732824.412. 16. markovic g. acute effects of instrument assisted soft tissue mobilization vs. foam rolling on knee and hip range of motion in soccer players. j bodyw mov ther. 2015;19(4):690-696. https://doi.org/10.1016/j.jbmt.2015.04.010. https://doi.org/10.4085/1062-6050-481-17 https://doi.org/10.1186/1757-1146-6-46 https://doi.org/10.1123/jsr.21.4.313 https://www.healthit.gov/sites/default/files/pdf/2012-08-09-behavioral-health-clinical-quality-measures-technical-expert-panel-composite-measures.pdf https://www.healthit.gov/sites/default/files/pdf/2012-08-09-behavioral-health-clinical-quality-measures-technical-expert-panel-composite-measures.pdf https://doi.org/10.1123/ijatt.2015-0096 https://doi.org/10.1123/ijatt.2015-0096 https://doi.org/10.4085/1062-6050-386-16/ https://doi.org10.1016/j.jbmt.2018.02.008 https://doi.org/10.7547/87507315-83-5-251 https://doi.org/10.1097/00005768-199703000-00005 https://grastontechnique.com/patients/ https://doi.org/10.12965/jer.1732824.412 https://doi.org/10.1016/j.jbmt.2015.04.010 improving ankle range of motion with the use of instrument assisted soft tissue mobilization: a validation case study 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 17. ostojic sm, vukomanovic b, calleja-gonzalez j, hoffman jr. effectiveness of oral and topical hydrogen for sports-related soft tissue injuries. postgraduate medicine. 2014;126(5):188-196. https://doi.org/10.3810/pgm.2014.09.2813. 18. schleip r. fascial mechanoreceptors and their potential role in deep tissue manipulation. j bodyw mov ther. 2003;7:104-116. 19. graston technique. summit orthopedics. accessed april 29, 2021. https://www.summitortho.com/services/physical-therapy/physical-therapy-advancedtechniques/grastontechnique/#:~:text=how%20frequently%20graston%20treatments%20are,4 8%20hours%20in%20between%20sessions. 20. graston technique treatment: what to expect. spine-health. accessed april 29, 2021. https://www.spine-health.com/treatment/chiropractic/graston-technique-treatment-what-expect 21. soligard t, nilstad a, steffen k, et al. compliance with a comprehensive warm-up programme to prevent injuries in youth football. br j sports med. 2010;44(11):787793. http://dx.doi.org/10.1136/bjsm.2009.070672. 22. van reijen m, vriend i, van mechelen w, finch cf, verhagen ea. compliance with sport injury prevention interventions in randomized controlled trials: a systematic review. sports med. 2016;46:1125-1139. https://doi.org/10.1007%2fs40279-016-0470-8. 23. steffen k, meeuwisse wh, romiti m, et al. evaluation of how different implementation strategies of an injury prevention program impact team adherence and injury risk in canadian female youth football players: a cluster-randomized trial. br j sports med. 2013;47(8):480-487. https://doi.org/10.1136/bjsports-2012-091887. https://doi.org/10.3810/pgm.2014.09.2813 https://www.summitortho.com/services/physical-therapy/physical-therapy-advanced-techniques/grastontechnique/#:%7e:text=how%20frequently%20graston%20treatments%20are,48%20hours%20in%20between%20sessions https://www.summitortho.com/services/physical-therapy/physical-therapy-advanced-techniques/grastontechnique/#:%7e:text=how%20frequently%20graston%20treatments%20are,48%20hours%20in%20between%20sessions https://www.summitortho.com/services/physical-therapy/physical-therapy-advanced-techniques/grastontechnique/#:%7e:text=how%20frequently%20graston%20treatments%20are,48%20hours%20in%20between%20sessions https://www.spine-health.com/treatment/chiropractic/graston-technique-treatment-what-expect http://dx.doi.org/10.1136/bjsm.2009.070672 https://doi.org/10.1007%2fs40279-016-0470-8 https://doi.org/10.1136/bjsports-2012-091887 abstract disablement model case study 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 total motion release® for restoring normal knee function after acl reconstruction: a case study diane l. stankevitz, dat, atc, cscs, emt* & lindsey larkins, dat, cscs, prt-c† * east los angeles college, monterey park, ca; † university of idaho, moscow, id abstract the objective of this study was to illustrate the case of an intercollegiate soccer player who sustained a grade 3 anterior cruciate ligament (acl) injury and underwent surgical repair at 4 months. the patient engaged in her regular daily activity prior to the surgical procedure. one week prior to surgery the patient produced 140° of active knee flexion and -1° of active knee extension, and scored 69.0 on the international knee documentation committee subjective knee evaluation (ske). one day post-acl reconstruction by semitendinosus autograft, the patient’s knee range of motion (rom) was 40° of flexion and 20° of extension and reported a score of 21.8 on the ske. the patient began rehabilitation immediately following surgery with the goal to increase rom of the involved limb. a total motion release® (tmr ®) rehabilitation protocol was implemented for the first four weeks in lieu of a traditional acl reconstruction rehabilitation protocol. three sessions were completed each week over a four-week period, for a total of 12 sessions. rehabilitation sessions consisted of 15 minutes of ice massage of the quadriceps with simultaneous quadriceps contraction/relaxation immediately followed by tmr ®. the patient ended each session with progressive exercise: 5 minutes of half rotations on the bike on day one, progressing to a 20 minute light jog on the treadmill by week four. patient was re-assessed by the orthopedic surgeon at a one and six month post-operative follow-up appointments. changes in flexion and extension rom and ske were assessed weekly prior to treatment to evaluate knee rom. four weeks following the tmr® protocol, knee range of motion was restored demonstrating the effectiveness of tmr®. key phrases exercise, surgery, patient outcomes correspondence dr. diane l, stankevitz, 875 perimeter dr, moscow, id 83843 e-mail: stankedl@elac.edu full citation stankevitz dl & larkins l. total motion release® for restoring normal knee function after acl reconstruction: a case study. clin pract athl train. 2020;3(6):46-54. https://doi.org/10.31622/2020/0003.3.7. submitted: march 26, 2020 accepted: june 29, 2020 introduction recovery from anterior cruciate ligament (acl) reconstruction is a time-consuming undertaking both for patient and clinician.1-14 in the past decade, researchers have studied and published rehabilitation protocols that vary in effectiveness and duration, with an average total timeline of 69 months to return to pre-injury activity.1-8 in the first four weeks alone, patients can expect to spend anywhere from 30-150 minutes in a single rehabilitation session and complete several sessions per week.2,8,12,14 furthermore, neuromuscular electrical stimulation devices,2,3,5,8,9,12,14 and continuous passive motion (cpm) machines are commonly used in addition to supervised rehabilitation sessions.1,2,6-8,14 the cpm machine is sometimes used for several hours each day immediately following surgery with the goal to restore range of motion (rom) quickly and avoid the formation of unnecessary scar tissue in the joint.1-3,8,14 across the literature regarding acl reconstruction rehabilitation protocols, patients achieved similar results by the fourth week after surgery. the patient should be capable of bilateral pain-free step-up progressions to 60°, stationary biking, swimming, and proprioception drills (e.g. balance boards).1,4-9,11,13-15 to accomplish this, patients begin rehabilitation with a two-week postoperative phase that includes bracing and crutches, with the goal to reduce pain and swelling.1-8 during weeks two through four, rehabilitation goals are to progress the patient to achieve weight-bearing with a normal gait, appropriate patellar mobility, and knee flexion rom of 0° to 130°.1-14 the most common rehabilitation exercises to achieve normal gait during the first four weeks begin with a straight leg raises and gait training.1-6,8-12,14,15 mailto:stankedl@elac.edu https://doi.org/10.31622/2020/0003.3.7 total motion release® for restoring normal knee function after acl reconstruction: a case study 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 with such a strong emphasis on restoring joint rom and muscular strength, it is important that clinicians have appropriate, effective, and time efficient tools to accomplish rehabilitation goals. in addition to local modalities (e.g., mobilizations, cmp), clinicians can incorporate techniques that utilize the central nervous system to improve rom and increase strength at the involved joint and throughout the body. total motion release® (tmr®) is a treatment approach that utilizes contralateral movements to influence neural coupling and the nervous system’s interpretation of electrical signals to the injured body segment.16 referred to as cross education, this mechanotransduction is a means by which a movement force (e.g. stretching, resistance) applied to the muscle fiber can influence balance of the neuromusculoskeletal system, helping to realign imbalances in strength and rom. 17-19 tmr® attempts to sustain a dynamic center of gravity as part of a unified system by treating imbalances in the body.17,20 patients with pain, deficiencies, or impairments in one area of the body can be influenced by movements performed elsewhere in the body. the technique incorporates the use of contralateral exercises to the unaffected side to promote therapeutic results in the affected side.17 although tmr® research is still in its infancy, some researchers have provided insight into the positive effects of tmr® on shoulder pain, range of motion, and muscle reeducation, while reducing rehabilitation session duration.20-23 this case study includes the outcomes of a rehabilitation protocol in which a patient was treated with tmr® following acl reconstruction surgery to restore normal knee range of motion. patient information the patient was a 20-year old female intercollegiate soccer player who suffered an injury of her left (non-dominant) knee during a game via a non-contact mechanism attempting to decelerate to avoid a collision with an opponent. the patient was referred to an orthopedic surgeon for magnetic resonance imaging (mri) which identified an isolated grade iii acl sprain. the patient underwent a semitendinosus autograft surgical reconstruction approximately four months later. the four month delay was contributed to a combination of the patient’s schedule and insurance authorization. the patient did not implement a detailed pre-surgery rehabilitation protocol except for activities of daily living and general conditioning. the patient reported to the clinic one week prior to surgery to assess her function prior to surgery. outcomes utilized to assess knee function were range of motion (rom) with goniometer 1,3,5-8,9,1113 and the international knee documentation committee subjective knee evaluation (ske).2,24,25 initial outcomes were assessed one week prior to surgery and were repeated one day post-surgery and weekly for four weeks. outcomes were also assessed at the one month and the six month follow-up. active flexion and extension rom of the knee were measured using a standard goniometer (scale marked in 1° increments; model 12-1002; meyerdctm, hudson, oh). the same clinician conducted flexion and extension measurements prior to the commencement of the rehabilitation session at the beginning of each week.13,26 the rom measurement was performed as follows: • flexion: the patient started in a supine position with full knee extension and the hip in neutral. the axis of the goniometer was placed on the lateral epicondyle of the femur. the proximal arm was placed at the midline of the femur aligned with the greater trochanter. the distal arm was placed at the midline of the fibula and aligned with the lateral malleolus and the fibular head. the patient then flexed the knee as far as possible while flexing the hip.1 • extension: the patient started in a supine position with full knee extension and the hip in neutral. a bolster was placed under the ankle. the axis of the goniometer was placed on the lateral epicondyle of the femur. the proximal arm was placed at the midline of the femur total motion release® for restoring normal knee function after acl reconstruction: a case study 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 aligned with the greater trochanter. the distal arm was placed at the midline of the fibula and aligned with the lateral malleolus and the fibular head.1 the ske is a patient-completed questionnaire designed to detect improvement or impairment of symptoms, function, and sports activities due to a variety of knee conditions (e.g. acl injuries).2,24,25 the ske form is divided into three domains: 1) symptoms (i.e., pain, stiffness, swelling, locking/catching, and giving way); 2) sports and daily activities; and 3) current knee function and knee function prior to knee injury. these domains are comprised of 18 items (1 for current knee function, 1 for sport participation, 7 for symptoms, and 9 for daily activities). responses vary for each item. item 6 requires a yes or no response. items 1, 4, 5, 7, 8, and 9 use 5-point likert scales. items 2, 3, and 10 use 11-point numerical rating scales by which the responses to each item are scored using 0 to indicate the lowest level of function or highest level of symptoms, and the highest number to indicate no symptoms and full function. items 2 and 3 are related to pain and the responses are scored in reverse where “constant” is assigned a score of 0, and “never” is assigned a score of 10. the response to item 10a is not included in the overall score as it relates to pre-injury function. the results are summed (excluding item 10a) and the score transformed to a scale ranging from 0 to 100 (figure 1). higher scores represent higher levels of function and lower levels of symptoms, with a score of 100 interpreted as no limitations and no symptoms.24 ske score = � sum of items maximum possible score �×100 figure 1. ske score calculation intervention total motion release® can be implemented using a set of standardized movements, or by testing and treating with any movement of choice. the standardized procedures of tmr® consist of repetitively recording a patient-rated numeric scale of dysfunction between zero (e.g., no pain, tightness, or impaired function) and 100 (e.g., extensive pain, tightness, or impaired function) during active movement through the tmr® screening which includes six primary exercises known as the fab 6.17 the fab 6 movements, developed by the tmr® originator tom dalonzobaker, include arm raise, arm press, trunk twist, leg raise, sit to stand, and bent knee toe reach (figure 2). 17 the patient performs each exercise bilaterally and assigns a score to each movement for each side. the motion with the greatest bilateral discrepancy as perceived by the patient is treated first. treatment consists of sets of repetitions and/or end-range holds of the fab 6 movements performed to the good side. scores are re-evaluated after every two to three sets, until a patient-reported score of 5 or below is achieved. the fab 6 is then repeated and rescored, and the next most discrepant movement is treated until balance is achieved across all movements.21,23,27,28 modifications of the fab 6 or additional movements can be incorporated to accommodate a patient’s limitations or needs. during the first week, which included the inflammatory phase of healing, the patient was instructed to use crutches to assist with weight bearing as tolerated. the patient was permitted to ice for pain but did not engage in any other forms of treatment or pain medication for the first week. intervention commenced one week after surgery and the patient began attending rehabilitation sessions three times per week, and did so for the next four weeks. the patient began each session with a 15-minute ice massage of the quadriceps to produce a hypoalgesic effect,29 while simultaneously isometrically contracting then relaxing the quadriceps of the affected limb with the knee in full extension (figure 3). figure 2: fab 6 evaluation movements.30 total motion release® for restoring normal knee function after acl reconstruction: a case study 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 figure 3. ice massage over the quadriceps of the affected leg while simultaneously contracting and relaxing for 15 minutes. immediately following the ice massage, tmr® was used with straight leg raises (figure 4). progression was indicated when the patient’s score decreased to 25 or less. as the patient progressed, knee hyperextensions (figure 5) and the fab 6 “sit to stand” movement were incorporated (figure 6). the patient completed the movements on the injured side reporting a score between 0 (i.e., no symptoms and full function) and 100 (i.e., very symptomatic and no function). because the patient reported the injured limb to have lower function, she performed the tmr treatment exercises on the uninjured side. the treatments consisted of either 3 sets of 10 repetitions and/or 5 holds for 30 seconds and were determined based on the ease to the patient. after each series, the patient completed the exercise on the injured side and reported a new score. during session one, the patient ended by performing self-paced half revolutions for 5 minutes on a stationary bike enabling the knee to flex and extend to 90° (table 1). the patient progressed appropriately and by the eighth session was capable of 20 minutes of full rotations on the stationary bike. she progressed from the bike to the treadmill and at the end of the four week time frame, the patient was jogging at a 5 mph pace at a 0° incline for 10 minutes on the treadmill (table 1). in addition to her treatment sessions, the patient was instructed to perform the entire treatment series of tmr® each day at home. outcomes at the end of 12 tmr® sessions, the straight leg raise had improved from an initial patientreported score of 70 to a final score of 0. the knee hyperextensions and sit to stand had improve to a score of 5 from an initial score of 60 and 80, respectively (table 2). the patient achieved 99.0% of pre-surgery extension and 96.4% of pre-surgery flexion. the patient had achieved 98.3% of their initial ske score. at the one-month after the tmr® rehabilitation protocol, the patient’s knee flexion was at 100% (140°) and extension increased 1° (-2°) from presurgical scores. the ske scores improved 36% figure 4. the starting (left) and ending (right) positions for the straight leg raise figure 5. the starting (left) and ending (right) positions for the leg extension. figure 6. the starting (left) and ending (right) positions for the sit to stand. total motion release® for restoring normal knee function after acl reconstruction: a case study 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 from the initial intake prior to surgery. at the six month follow-up, knee flexion and knee extension were also measured at 140° and -2° respectively (table 3). during week three, the patient reported an incident in which she was struck in the knee resulting in a minor regression. discussion the purpose of this study was to explore the effects of a rehabilitation protocol that included tmr® on knee range of motion after acl reconstruction. researchers have indicated an acl reconstruction patient should achieve greater than 110° of flexion and full knee extension by the table 1. comparison of tmr® to a traditional rehabilitation protocol for 12 sessions over four weeks after surgery. traditional tmr® sessions exercises sessions exercises 1-3 arm ergometer for cardiovascular fitness† 1-12 15 minutes ice massage with quadriceps contractions 1-3 wall slides‡ 1-4 straight leg raises for a maximum of 6 series* 1-3 patellar mobilization 30 to 50 times per day 2-12 knee extensions for a maximum of 6 series** 1-3 gait training† 5-12 sit to stand for a maximum of 6 series* 1-3 bike for rom† 1-2 5 minutes half revolutions on the stationary bike 1-3 quadriceps long-arc (90°-45°)‡ 3-11 20 minutes full revolutions on the stationary bike 1-3 straight leg raises‡ 12 10 minutes treadmill at 5mph at 0° incline 1-3 step-ups in pain-free range‡ 1-3 proprioceptive/balance training‡ 4-6 portal/incision mobilization as needed‡ 4-6 stairmaster† 4-6 wall squats† 4-6 wall sits† 4-6 prone hangs‡ 4-6 patellar mobilization in flexion‡ 4-6 stationary biking† 7-12 tibiofemoral mobilizations‡ 7-12 continue balance and proprioceptive activities‡ 7-12 increase intensity of stationary bike† 7-12 may add treadmill walking and/or elliptical† 7-12 advance intensity of pool program as tolerated * series: 3 sets of 10 repetitions on the unaffected side followed by one set of 10 repetitions on the affected side. ** series: 5 repetitions holding each for 30 seconds on the unaffected side followed by one repetition at a 30 second hold on the affected side. † 10 to 30 minutes ‡ 3 sets of 10 repetitions (3 times per day) adams, biggs, rosenberg, saka, shaw, shelbourne, van grinsven total motion release® for restoring normal knee function after acl reconstruction: a case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 table 3. patient's knee range of motion and subjective progress timeframe flexion extension ske score 1 week pre-op 140° -1° 69.0 1 day post-op 40° 20° 21.8 1 week post-op 50° 22° 24.1 2 week post-op 110° 13° 34.5 3 week post-op 130° 10° 44.8 4 week post-op 135° 0° 67.8 1 month follow up 140° -2° 94.3 6 month follow up 140° -2° 96.6 fourth week of rehabilitation following acl reconstruction surgery. 2,4-7,9,13 in this case study, the patient achieved greater than 110° of flexion and full knee extension by the end of the four weeks of tmr®. one month following tmr® the patient added an additional 5° of flexion and 2° of extension which was maintained at the sixmonth follow-up (table 3). a direct comparison of the time to completion for traditional rehabilitation elements and the protocol including tmr® is provided in table 1. rehabilitation exercises were included if they have been established in the literature and are widely used in patient practice for rehabilitation to increase rom following acl reconstruction.1,47,9,15 the tmr® protocol for the patient in this study was an effective method as compared to traditional rehabilitation, but was less timeconsuming and required less exercises.1,4-7,9,15 traditional rehabilitation averaged over 90 minutes per session three to five times per week for four weeks,1,4-7,9,15 and can include home exercises performed 3 times per day. in contrast, tmr® averaged less than 45 minutes per clinical session three times per week for four weeks, as well as daily at home, and generated the same patient outcomes as a traditional protocol. table 2. patient's tmr® pre and post session scores straight leg raises knee hyperextension sit to stand week session pre post pre post pre post 1 1 70 55 na na na na 2 55 15 60 55 na na 3 15 10 70 55 na na 2 4 10 0 40 25 na na 5 na na 25 20 80 50 6 na na 10 5 50 40 3 7* na na 50 45 35 30 8 na na 45 40 45 30 9 na na 30 20 15 10 4 10 na na 10 5 15 10 11 na na 10 5 10 5 12 na na 5 5 5 5 * patient experienced a minor hindrance when a person ran into her knee. total motion release® for restoring normal knee function after acl reconstruction: a case study 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 cryotherapy was incorporated for yielding therapeutic effects associated with the decrease of motor nerve conduction. the amount of the multiple action potential denotes the amount of nerve fibers that responds to an appropriate stimulus.29 therefore, the diminution of this parameter after the cold application could infer an escalation in the activation threshold of some nerve fibers, as well as the blocking of the fibers more sensitive to cooling.29 although the results were successful, some limitations exist. goniometric measurements were not blinded and could have decreased outcome validity.27 to determine the greatest effects of the protocol used in this case study, additional research is necessary using a larger number of participants randomized into tmr® and traditional rehabilitation groups. future researchers should blind the individuals measuring outcomes to the group assignments. clinical bottom line total motion release®17,20-23,28 was an effective treatment to restore knee rom following acl reconstruction surgery that took less time per treatment session than traditional rom techniques.1,4-7,9,15 ice massage while simultaneously contracting and relaxing the quadriceps may have contributed to stimulating the muscle fibers.30 the stationary bike also assisted with the patient’s rom.1,4-7,9,15 tmr® can be a practical, less time-consuming alternative for clinicians attempting to improve a patient’s rom after acl reconstruction. references 1. biggs a, jenkins wl, urch se, shelbourne kd. rehabilitation for patients following acl reconstruction: a knee symmetry model. n am j sports phys ther. 2009; 4(1):2-12. 2. kruse lm, gray b, wright rw. rehabilitation after anterior cruciate ligament reconstruction. j bone joint surg am. 2012; 94a(19), 17371748. https://doi.org/10.2106/jbjs.k.012 46. 3. lobb r, tumilty s, claydon ls. a review of systematic reviews on anterior cruciate ligament reconstruction rehabilitation. phys ther sport. 2012; 13(4), 270-278. https://doi.org/10.1016/j.ptsp.2012.05.00 1. 4. rosenberg cooley metcalf orthopedic clinic at park city. anterior cruciate ligament (acl) reconstruction post-operative protocol. https://rcmclinic.com/patientinformation/knee-information/knee-post-opcare-rehab/acl-reconstruction-post-op/. published 2007. accessed april 14, 2017. 5. saka t. principles of postoperative anterior cruciate ligament rehabilitation. world j orthop. 2014; 5(4), 450-459. https://doi.org/10.5312/wjo.v5.i4.450. 6. shelbourne kd, nitz p. accelerated rehabilitation after anterior cruciate ligament reconstruction. am j sports med. 1990; 18(3), 292-299. https://doi.org/10.1177/0363546590018 00313. 7. van grinsven s, van cingel re, holla cj, & van loon cj. evidence-based rehabilitation following anterior cruciate ligament reconstruction. knee surg sports traumatol arthrosc. 2010; 18(8), 1128-1144. https://doi.org/10.1007/s00167-0091027-2. 8. wright rw, preston e, fleming bc, amendola a, andrish jt, bergfeld ja, dunn wr, kaeding, kuhn je, marx rg, mccarty, parker rc, spindler kp, wolcott m, wolf br, williams gn. acl reconstruction rehabilitation: a systematic review part i. j knee surg. 2008; 21(3), 217-224. https://doi.org/10.1055/s-0030-1247822. 9. adams d, logerstedt d, hunter-giordano a, axe mj, snyder-mackler l. current concepts for anterior 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rehabilitation: how much and what type. phys ther sport. 2004; 5(3), 125-145. https://doi.org/10.1016/j.ptsp.2004.02.00 3. 13. shaw t, chipchase ls, williams mt. (2004). a users guide to outcome measurement following acl reconstruction. physical therapy in sport. 2004; 5, 57–67. https://doi.org/10.1016/j.ptsp.2003.11.00 7. 14. wright rw, preston e, fleming bc, amendola a, andrish jt, bergfeld ja, dunn wr, kaeding, kuhn je, marx rg, mccarty, parker rc, spindler kp, wolcott m, wolf br, williams gn. acl reconstruction rehabilitation: a systematic review part ii. j knee surg. 2008; 21(3), 225-234. https://doi.org/10.1055/s-0030-1247823. 15. shaw t. accelerated rehabilitation following anterior cruciate ligament reconstruction. phys ther sport. 2002; 3(1), 19-26. https://doi.org/10.1054/ptsp.2001.0089. 16. carroll tj, herbert rd, munn j, lee m, gandevia sc. contralateral effects of unilateral strength training: evidence and possible mechanisms. j appl physiol. 2006; 101(5), 1514–1522. https://doi.org/10.1152/japplphysiol.0053 1.2006. 17. dalonzo-baker, tom. total motion release. https://totalmotionrelease.com/tmrhome. n.d. accessed july 30, 2015. 18. chen cs, ingber de. tensegrity and mechanoregulation: from skeleton to cytoskeleton. osteoarthr cartil. 1999; (1), 81–94. https://doi.org/10.1053/joca.1998.0164. 19. wainner rs, whitman jm, cleland ja, flynn tw. regional interdependence: a musculoskeletal examination model whose time has come. j orthop sports phys ther. 2007; 37(11): 658–660. https://doi.org/10.2519/jospt.2007.0110. 20. gamma sc, baker rt, iorio s, nasypany a, seegmiller jg. a total motion release warmup improves dominant arm shoulder internal and external rotation in baseball players. int j sports phys ther. 2014; 9(4), 509–517. 21. drake r, rhinehart a, smith-goodwin e, tecklenburg l. can total motion release increase shoulder range of motion in collegiate swimmers? jsmahs. 2016; 2(1), 13. https://doi.org/10.25035/jsmahs.02.01.19. 22. gamma sc, baker rt, may j, seegmiller jg. nasypany a, iorio s. comparing the immediate effects of a total motion release warm-up and dynamic warm-up protocol on the dominant shoulder in baseball athletes. j strength cond res. 2018; 00(00), 1–7. https://doi.org/10.1519/jsc.0000000000 002229. 23. fermin s, larkins l, beene s, wetzel d. the effect of contralateral exercise on patient pain and range of motion. j sport rehabil. 2018; 27(2), 185–188. https://doi.org/10.1123/jsr.2016-0181. 24. collins nj, misra d, felson dt, crossley km, roosem. measures of knee function: international knee documentation committee (ske) subjective knee evaluation form, knee injury and osteoarthritis outcome score (koos), knee injury and osteoarthritis outcome score physical function short form (koos-ps), knee outcome survey activities of daily living scale (kos-adl), lysholm knee scoring scale, oxford knee score (oks), western ontario and mcmaster universities osteoarthritis index (womac), activity rating scale (ars), and tegner activity score (tas). arthritis care res (hoboken). 2011; 63(11), s208-s228. https://doi.org/10.1002/acr.20632. 25. rodriguez-merchan ec. knee instruments and rating scales designed to measure outcomes. j orthop traumatol, 2012; 13(1), 1-6. https://doi.org/10.1007/s10195-0110177-4. 26. brosseau l, balmer s, tousignant m, o'sullivan jp, goudreault c, goudreault m, gringras s. intraand intertester reliability and criterion validity of the parallelogram and universal goniometers for measuring maximum active knee flexion and extension of patients with https://doi.org/10.1177/0363546510384798 https://doi.org/10.1177/0363546510384798 https://doi.org/10.2519/jospt.2006.2222 https://doi.org/10.1016/j.ptsp.2004.02.003 https://doi.org/10.1016/j.ptsp.2004.02.003 https://doi.org/10.1016/j.ptsp.2003.11.007 https://doi.org/10.1016/j.ptsp.2003.11.007 https://doi.org/10.1055/s-0030-1247823 https://doi.org/10.1054/ptsp.2001.0089 https://doi.org/10.1152/japplphysiol.00531.2006 https://doi.org/10.1152/japplphysiol.00531.2006 https://totalmotionrelease.com/tmrhome https://doi.org/10.1053/joca.1998.0164 https://doi.org/10.2519/jospt.2007.0110 https://doi.org/10.25035/jsmahs.02.01.19 https://doi.org/10.1519/jsc.0000000000002229 https://doi.org/10.1519/jsc.0000000000002229 https://doi.org/10.1123/jsr.2016-0181 https://doi.org/10.1002/acr.20632 https://doi.org/10.1007/s10195-011-0177-4 https://doi.org/10.1007/s10195-011-0177-4 total motion release® for restoring normal knee function after acl reconstruction: a case study 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 3 – issue 3 – november 2020 knee restrictions. arch phys med rehabil. 2001; 82(3), 396-402. https://doi.org/10.1053/apmr.2001.19250 . 27. total motion release. research & evidence 2015. https://tmrseminars.com/researchevidence. accessed november 19, 2015. 28. rohman e, steubs jt, tompkins m. changes in involved and uninvolved limb function during rehabilitation after anterior cruciate ligament reconstruction. am j sports med. 2015; 46(6), 1391-1398. https://doi.org/10.1177/0363546515576 127. 29. herrera e, sandoval mc, carmago dm, ferris dp. motor and sensory nerve conduction are affected differently by ice pack, ice massage, and cold water immersion. phys ther. https://doi.org/10.2522/ptj.20090131. 30. total motion physical therapy, inc. pics of fab 6. copyright© 2013 https://www.tmrseminars.com/pics-of-fab6/. https://doi.org/10.1053/apmr.2001.19250 https://doi.org/10.1053/apmr.2001.19250 https://tmrseminars.com/research-evidence https://tmrseminars.com/research-evidence https://doi.org/10.1177/0363546515576127 https://doi.org/10.1177/0363546515576127 https://doi.org/10.2522/ptj.20090131 https://www.tmrseminars.com/pics-of-fab-6/ https://www.tmrseminars.com/pics-of-fab-6/ manuscript type evidence-to-practice review 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review madison m. hauge, scat, atc; kathryn c. downs, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract according to the centers for disease control and prevention, 100 people die of drug overdose in the united states every day. this frighteningly high mortality rate has created the need for community-based opioid overdose prevention programs (oopps). currently, there are more than 188 community-run programs operating in the united states. these programs teach individuals how to distribute naloxone and respond properly to a drug overdose situation. this guiding systematic review depicts the current literature available on oopps and their effectiveness. the authors performed an article search to discover the most relevant and recent articles, which were graded using a quality assessment score. the search uncovered 19 articles deemed appropriate to investigate the effectiveness of oopps. out of the 19 articles, 14 of these articles were cohort studies with large sample sizes that did a baseline and follow-up survey at two different time periods. almost 50% of participants in this review stated they personally experienced an opioid overdose in their life. furthermore, there was 79.2% of participants (across the 8 studies that report this data) to witness a drug overdose. nonmedical bystanders is defined as individuals who could properly reverse an opioid overdose when oopp training was completed. eleven studies detected a 100% survival rate post-naloxone administration with the remaining 8 studies not far behind with a survival rate range of 83-96%. the current evidence available suggests that oopps are successful in teaching their participants how to properly treat an opioid overdose with the administration of naloxone. key phrases drug overdose/drug therapy, program evaluation, opioid-related disorders/drug therapy, naloxone/therapeutic use correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation hauge mm, downs kc, winkelmann zk. community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review. clin pract athl train. 2021;4(2): 33-39. https://doi.org/10.31622/2021/0004.2.5. submitted: april 20, 2020 accepted: november 16, 2021. original reference clark ak, wilder cm, winstanley el. a systematic review of community opioid overdose prevention and naloxone distribution programs. j addict med. 2014;8(3):153-163. summary clinical problem and question according to the world health organization, the three main symptoms for an opioid overdose (generally termed “opioid overdose triad”) are pinpoint pupils, unconsciousness, and respiratory depression.1 this fatal combination can ultimately result in death. in fact, 128 people die every day in the united states from opioid overdose.2,3 according to the centers for disease control and prevention, opioid overdose is a rising issue in the united states with a 9.6% increase in the ageadjusted rate in overdose deaths from 2016 to 2017.4 in 2017, there were a total of 70,237 drug overdose deaths.2 to combat this public health emergency, opioid overdose prevention programs (oopps) were created to educate the public about how to recognize and manage an opioid overdose with treatment training using naloxone.2,5 naloxone, which is commonly referred to by its brand name narcan, is an opioid antagonist used to temporarily reverse a drug overdoses in an emergency situation. however, the drug is relatively new, and the opioid issue has continued to grow. in addition, oopps cover the risk factors of opioid overdose, as well as, the procedure of how to properly respond to an overdose with or without naloxone.1,2,4 opioid overdose prevention mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.2.5 community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 programs are essential since they advocate for prevention efforts such as encouraging people (e.g., people at risk, the family members of people considered ‘at risk’, and healthcare providers) to learn how to manage a drug overdose. opioid overdose prevention programs have been utilized in the united states for 24 years; though, there is very limited research on the programs’ impact and outcomes of the training.5-7 this evidence-to-practice review summarizes a systematic review to analyze the impact of oopps by evaluating if naloxone distribution reduces the instances of overdose among their participants.3 this review also compared the united states oopps effectiveness on increasing bystander knowledge on prevention, risk factors, and detection of and response to an opioid overdose.3 lastly, it appraises how oopps participants respond to opioid overdose. overall, this systematic review organizes the available current literature on opioid overdose to observe the general impact of oopps. summary of literature the guiding systematic review searched databases including pubmed, medline, and psychinfo, using the boolean search query: (opioid or opiate) and overdose and prevention. the search was limited to english language, which returned 360 different citations. the citations were sorted and included only original, peerreviewed articles examining community oopps that detected a training impact. this consisted of reports of overdose reversal rates, overdose fatalities, or any measure of overdose rate among program participants. exclusion criteria included oopps that did not incorporate training on the use or distribute naloxone, data that was unable to separate into program-specific information, and program evaluations that focused more on health care personnel training. thirty-eight articles were identified for full-text review; however, 19 articles fit the exact inclusion conditions and were included in this review. the remaining 17 were excluded because these articles did not assess a community oopp (11), did not report a training outcome (2), did not have naloxone training (1), or were based on grouped or clumped data (2). a quality appraisal was completed on the articles involved in this systematic review. the quality score had a possible range of 4 – 8 and this set of studies used in the review had a mean of 6.1, median of 6.5, and a mode of 7. although majority of these studies scored a 0 for randomization and low rates for follow-up, 18/19 of these studies got a maximum score for sample size and outcomes. overall, the studies were graded as fair based off descriptive quality. summary of intervention the intervention investigated in the systematic review were oopps. the systematic review focused on the effectiveness of the oopps and their outcomes within the respective communities. the oopp intervention ranged in duration from 10-60 minutes. the laws for prescribing naloxone varied by state, as well as, the physician involvement with the oopps. because of this, the qualifications of the personnel instructing the interventions differed between programs and in most studies the qualifications of the instructors were not specified. naloxone prescription is variable between states so involvement with physicians in oopps ranged from notification of program completion to meeting with a physician in order to receive a naloxone kit.8-10 a majority of the programs include a curricula based on five components including: 1) recognizing overdose (78.9%), 2) preventing overdose (73%), 3) risk factors of overdose (63%), 4) appropriate response to overdose (84%) and, 5) administration of naloxone (100%) with some variation and deviations in the material provided. the response to overdose, such as community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 rescue breathing, cardiopulmonary resuscitation (cpr), and the recovery position (figure 1), were addressed in the majority of oopps. in addition, administering naloxone in a variety of ways and at varying levels of practice was a part of the curricula in each of the intervention programs. fifteen of the articles provided training with needle-based administration, however, some programs provided training practice by injecting into an orange and while other programs used nasal naloxone. 11-13 summary of outcomes the guiding systematic review analyzed outcomes of the oopps. the first analysis was for the outcomes associated with the reduction of fatal and nonfatal overdose rates for those who participated in an oopp intervention. naloxone was used successfully 1,949 times by those who attended oopps. this review identified heroin as the most frequently reported overdosed drug, despite the national vital statistics system indicating opioid analgesics as the highest drug used. the studies reported that the survival postnaloxone administration rate ranged from 83%100% with 11 of the studies reporting a 100% survival rate. two of the articles that reported lower survival rates attribute the findings to unknown overdose outcomes.10,14 in addition, two studies found that areas with higher oopp enrollment demonstrated decreased opioid overdose mortality at a population level. 13,15 with the majority of studies demonstrating 100% survival after administration of naloxone by those who attended oopps, we conclude that oopps have the ability to reduce fatal and nonfatal overdoses among participants. next, the review analyzed the outcomes on the effectiveness of oopps to increase nonmedical bystander knowledge of prevention, risk factors and recognition of opioid overdose and correct response. just under half of the studies in the review reported preand post-training measures figure 1. demonstration of the recovery position in drug overdose management regarding the knowledge surrounding opioid overdose. the consensus among these studies is that those who participated in oopps had an increase in their knowledge of prevention, risk factors, and recognition of opioid overdose. 16-21 community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 in terms of response, participants in oopps displayed a behavior change with an increase in appropriate responses like rescue breathing, administering naloxone, initiating recovery position, and performing a sternal rub.10,14, 17, 22 however, in two studies there were reports of nonrecommended responses, such as using ice and cold water to revive patients.21, 22 these results display that the curriculum in studies that utilized preand post-training measures increased the knowledge of nonmedical bystanders.. this finding can be interpreted to show that nonmedical personnel have the ability to learn prevention, risk factors, and recognition of opioid overdose and therefore expand the population of those who can respond to opioid overdoses. when considering the following outcomes associated with the reduction of fatal and nonfatal overdose rates for those who participated in an oopp intervention and effectiveness of oopps to increase nonmedical bystander knowledge of prevention, risk factors and recognition of opioid overdose and correct response the literature shows that oopps may have the ability to create meaningful change within communities. oopps can reduce fatal and non-fatal overdoses. the data suggests the ability for non-medical bystanders to learn about and properly respond to opioid overdoses. however, due to the nature of the studies and the way they have been conducted these, conclusions are limited due to the lack of randomization. findings and clinical implications due to the lack of randomization and systematic measures, it is difficult to create generalizable statements and conclusions of the effectiveness of the programs when the specific content is not documented. although the evidence is not concrete, we can deduce that oopps have the potential to reduce opioid overdose morbidity and mortality. clinically, to reproduce similar outcomes within our communities, athletic trainers and non-medical bystanders need to be educated on the five components of oopps: recognizing overdose, preventing overdose, risk factors for overdose, appropriate response to overdose, and administration of naloxone. we know that a 100% survival rate can be achieved by attending oopps, and communities should focus on administration of naloxone as responses to overdose such as rescue breathing and cpr. naloxone education and administration should be integrated into standards and practices of all first responder and healthcare providers. standard 70 in the 2020 commission on accreditation of athletic training education (caate) standards describe that professional athletic training programs must teach how to evaluate and manage patients with acute conditions, including triaging conditions that are life threatening or otherwise emergent including drug overdose.23 this includes the administration of naloxone. however, the goal should be to ensure that all ats that completed formal education before this standard was implemented are also comfortable with the skill. this goal can also be achieved by incorporating elements of oopps into continuing education. by introducing oopp education and training into athletic training continuing education we ensure athletic trainers can carry out the skills themselves as well as teach the skills in their communities. by educating athletic trainers we can use them as a bridge to educate their respective communities. athletic trainers serve unique roles that allow for them to be very involved within their surrounding communities, especially those in the secondary school settings. communities should take advantage of this role that athletic trainers hold and use them as a liaison to instruct oopps in the communities they serve. studies show that non-medical bystanders have been deemed efficient and successful in administering naloxone to those who have overdosed.16-21 this means that athletic trainers can teach anyone the oopp curriculum and they have the potential to be successful in carrying out those skills. athletic community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 trainers can be extremely valuable by encouraging the high-risk populations that they know and interact with to attend oopps and help to cultivate better outcomes within the community. moving forward, the development of a standardized oopp could be used to effectively educate groups across the country about opioid overdose and naloxone administration. before a standardized oopp is created, there is an opportunity for an oopp assessment tool to be used to validate current programs. this tool would work towards deeming oopps efficient in education covering the five components; recognizing overdose, preventing overdose, risk factors for overdose, appropriate response to overdose, and administration of naloxone. oopp could be designed like first aid or cpr (cardiopulmonary resuscitation) certification programs that require vetted instructors to educate the participants on standardized information. no matter who teaches the course or where one takes the course, each participant will walk away with the same knowledge and abilities regarding opioid overdoses and naloxone administration. again, this is where athletic trainers can come in and use the information and skills they have gained in their continuing education course to teach and carry out the oopps. the systematic review highlights a need for oopps. it explains that opioid overdose is common, and naloxone is efficient and safe in reversing opioid overdoses. although these data are not methodologically sound, this guiding systematic review identifies a trend towards oopps having the potential to decrease morbidity and mortality with an opioid overdose. clinical bottom line opioid overdose prevention programs have worked towards reversing opioid overdoses, but research has reported mixed findings for its overall effectiveness in reducing the number of opioid incidences. this current systematic review was not able to determine this general effectiveness because of the lack of consistent measures and methodological limitations; however, the chief finding presented throughout the articles was that oopps were effective, specifically in the treatment of an opioid overdose and the administration of naloxone. evidence in this review detected that heroin was the most frequently reported drug before an overdose; however, the leading cause cited was opioids.24 this fact is essential to health care providers, since many injuries are prescribed with opioid analgesics to reduce injury pain. because of this athletes are an at risk population for the misuse of these prescription opioids. athletic trainers are suggested to monitor post-operative patients, or any patient given opioids, and checkin on their pain levels. the patient should not be reliant on opioids long term, so there should be a plan of action and timeline for gradually waning the patient off prescription pain relievers. the literature also did confirm that the majority of oopp participants used non-recommended strategies, such as not call emergency medical services for an overdose. this is a factor that athletic trainers should emphasize in educating their patients, whether they believe medical assistance is needed or not, because there could be medical complications from the restricted respiration occurring in an overdose.23,24 the fear of police was indicated as the main reason for not preparing; however, the studies displayed more positive interactions than negative.16,17 athletic trainers should direct attention to the prolonged medical issues an overdosed individual could have and attempt to ease the fear of utilizing ems personnel. 21,22 it is key that athletic trainers, much like the oopp, are able to prevent, recognize, and respond to opioid overdose using pharmacological and nonpharmacological interventions. we suggest that athletic trainers consider taking an oopp, or a formal opioid overdose training course, if community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 unfamiliar with the management techniques described in this review. additionally, athletic trainers can play a role in preventive efforts by spreading opioid overdose information to their population, including signs and symptoms of overdose, red flags to look out for, how to recognize an overdose, and how to respond if they are the non-medical bystander in an overdose situation. if opioid overdose education was accessible, or even mandatory prior to sport participation, for athletes and parents, then such education could improve the awareness and discourage opioid abuse. with the knowledge on how to deal with an opioid overdose, athletes can offer life-saving assistance in responding to a family member’s or roommates’ overdose situation. an athletic trainer should distinguish how to respond with or without a naloxone kit present, so individuals are prepared for both scenarios. overall, there is evidence that supports oopps may benefit how to effectively handle an overdose situation. however, research is needed on this subject with more of a standard instrument for measuring how well these programs assist their participants in managing a drug overdose. references 1. information sheet on opioid overdose. (2018, august 21). retrieved april 1, 2020, from https://www.who.int/substance_abuse/infor mation-sheet/en/. 2. hedegaard h, miniño am, warner m. drug overdose deaths in the united states, 1999– 2017. nchs data brief, no 329. hyattsville, md: national center for health statistics. 2018. 3. wheeler e, jones ts, gilbert mk, davidson pj. opioid overdose prevention programs providing naloxone to laypersons united states, 2014. mmwr morb mortal wkly rep. 2015;64(23):631-635. 4. centers for disease control and prevention. vital signs: overdoses of prescription opioid pain relievers—united states, 1999–2008. morb mortal wkly rep 2011;60:1487– 1492. 5. scholl l, seth p, kariisa m, wilson n, baldwin g. drug and opioid-involved overdose deaths united states, 2013-2017. mmwr morb mortal wkly rep.2018;67(5152):1419-1427. doi: 10.15585/mmwr.mm675152e1 6. sporer ka, kral ah. prescription naloxone: a novel approach to heroin overdose prevention. ann emerg med. 2007;49(2):172-177. https://doi.org/10.1016/j.annemergmed.20 06.05.025. 7. nida. opioid overdose crisis. national institute on drug abuse website. https://www.drugabuse.gov/drugsabuse/opioids/opioid-overdose-crisis. february 20, 2020. accessed april 1, 2020. 8. yokell ma, green tc, bowman s, et al. opioid overdose prevention and naloxone distribution in rhode island. med health rhode island. 2011;94:240–242. 9. galea s, worthington n, markham piper t, et al. provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in new york city. addict behav 2006;31:907–912. https://doi.org/10.1016/j.addbeh.2005.07 .020. 10. markham piper t, stancliff s, rudenstine s, et al. evaluation of a naloxone distribution and administration program in new york city. subst use misuse 2008;43:858–870. https://doi.org/10.1080/1082608070180 1261. 11. bennett t, holloway k. the impact of takehome naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the thn project in wales. drugs educ prev policy 2012;19:320–328. https://doi.org/10.3109/09687637.2012. 658104. 12. doe-simkins m, walley ay, epstein a, et al. saved by the nose: bystander-administered https://www.who.int/substance_abuse/information-sheet/en/ https://www.who.int/substance_abuse/information-sheet/en/ https://www.who.int/substance_abuse/information-sheet/en/ https://doi.org/10.1016/j.annemergmed.2006.05.025 https://doi.org/10.1016/j.annemergmed.2006.05.025 https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis https://doi.org/10.1016/j.addbeh.2005.07.020 https://doi.org/10.1016/j.addbeh.2005.07.020 https://doi.org/10.1080/10826080701801261 https://doi.org/10.1080/10826080701801261 https://doi.org/10.3109/09687637.2012.658104 https://doi.org/10.3109/09687637.2012.658104 community opioid overdose prevention and naloxone distribution programs: an evidence-to-practice review 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 intranasal naloxone hydrochloride for opioid overdose. am j public health 2009;99:788– 791. https://dx.doi.org/10.2105%2fajph.2008. 146647. 13. walley ay, xuan z, hackman hh, et al. opioid overdose rates and implementation of overdose education and nasal naloxone distribution in massachusetts: interrupted time series analysis. bmj 2013b;346:f174. https://doi.org/10.1136/bmj.f174. 14. enteen l, bauer j, mclean r, et al. overdose prevention and naloxone prescription for opioid users in san francisco. j urban health 2010;87:931– 941. https://doi.org/10.1007/s11524-0109495-8. 15. maxwell s, bigg d, stanczykiewicz k, et al. prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. j addict dis 2006;25:89– 96. https://doi.org/10.1300/j069v25n03_11. 16. bennett t, holloway k. the impact of takehome naloxone distribution and training on opiate overdose knowledge and response: an evaluation of the thn project in wales. drugs educ prev policy 2012;19:320–328. https://doi.org/10.3109/09687637.2012. 658104. 17. tobin ke, sherman sg, beilenson p, et al. evaluation of the staying alive programme: training injection drug users to properly administer naloxone and save lives. int j drug policy 2009;20:131–136. https://doi.org/10.1016/j.drugpo.2008.03. 002. 18. strang j, manning v, mayet s, et al. overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. addiction 2008a;103:1648–1657. https://doi.org/10.1111/j.13600443.2008.02314.x. 19. lopez gaston r, best d, manning v, et al. can we prevent drug related deaths by training opioid users to recognise and manage overdoses? harm reduct j 2009;6:26. https://doi.org/10.1186/14777517-6-26. 20. mcauley a, lindsey g, woods m, et al. responsible management and use of a personal take-home naloxone supply: a pilot project. drugs educ prev policy 2010;17:388–399. https://doi.org/10.3109/0968763080253 0712. 21. sherman sg, gann ds, scott g, et al. a qualitative study of overdose responses among chicago idus. harm reduct j 2008;5:2. https://doi.org/10.1186/14777517-5-2. 22. lankenau se, wagner kd, silva k, et al. injection drug users trained by overdose prevention programs: responses to witnessed overdoses. j community health. 2013;38(1):133-141. https://doi.org/10.1007/s10900-0129591-7. 23. standards for the commission on accreditation of athletic training education web site. https://caate.occutrain.net/wpcontent/uploads/2014/01/2012professional-standards.pdf. accessed march 25, 2020. 24. paulozzi lj. prescription drug overdoses: a review. j saf res 2012;43:283– 289. https://doi.org/10.1016/j.jsr.2012.08.009. https://dx.doi.org/10.2105%2fajph.2008.146647 https://dx.doi.org/10.2105%2fajph.2008.146647 https://doi.org/10.1136/bmj.f174 https://doi.org/10.1007/s11524-010-9495-8 https://doi.org/10.1007/s11524-010-9495-8 https://doi.org/10.1300/j069v25n03_11 https://doi.org/10.3109/09687637.2012.658104 https://doi.org/10.3109/09687637.2012.658104 https://doi.org/10.1016/j.drugpo.2008.03.002 https://doi.org/10.1016/j.drugpo.2008.03.002 https://doi.org/10.1111/j.1360-0443.2008.02314.x https://doi.org/10.1111/j.1360-0443.2008.02314.x https://doi.org/10.1186/1477-7517-6-26 https://doi.org/10.1186/1477-7517-6-26 https://doi.org/10.3109/09687630802530712 https://doi.org/10.3109/09687630802530712 https://doi.org/10.1186/1477-7517-5-2 https://doi.org/10.1186/1477-7517-5-2 https://doi.org/10.1007/s10900-012-9591-7 https://doi.org/10.1007/s10900-012-9591-7 https://caate.occutrain.net/wp-content/uploads/2014/01/2012-professional-standards.pdf https://caate.occutrain.net/wp-content/uploads/2014/01/2012-professional-standards.pdf https://caate.occutrain.net/wp-content/uploads/2014/01/2012-professional-standards.pdf https://doi.org/10.1016/j.jsr.2012.08.009 abstract manuscript type evidence-to-practice review 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 validity of selective tissue tests for knee pathologies: an evidenceto-practice review stephanie p. ulshafer, ms, atc; samara d. johnson, ms, atc; kevin n. schoell, ms, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract the knee is the most commonly injured joint in sport, inherently meaning the knee is also the joint most frequently evaluated by healthcare providers. clinicians evaluate and treat the knee as efficiently as possible to prevent long-term disability of the patient. clinicians rely on physical examination tests such as mcmurray’s test, apley’s test, joint line tenderness, lachman test, anterior drawer, pivot shift test, and the ottawa knee rules for initial diagnosis and initiation of care. these physical examination tests have varying levels of diagnostic accuracy and validity. clinicians should know how definite they can be about a diagnosis from physical examination alone based on the tests’ validity and reliability. the purpose of this evidence to practice review was to evaluate the validity of the individual and combinations of two or more selective tissue tests for the knee. the authors included systematic reviews and meta-analyses that reported on the diagnostic properties of one or more physical tests for one or more knee disorders. the 17 articles used were screened independently by two reviewers. each article was appraised using the assessment of the methodological quality of systematic reviews (amstar) ranking system. articles with the highest amstar ranking for each injury and evaluated the sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio were used to make recommendations for validity. physical examination tests of the knee included in the review were found to be most accurate when performed in combination with each other, as they had only low to moderate diagnostic properties. physical examination tests for the meniscus, acl, pcl, patellofemoral pain, and knee osteoarthritis are not valid to be used as individual diagnostic tests. the only exemption to this finding is the lachman test; with a sensitivity of 85%, the lachman test is suitable to rule out an acl tear as a stand-alone test. correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation ulshafer sp, johnson sd, schoell kn, winkelmann zk. validity of selective tissue tests for knee pathologies: an evidence-topractice review. clin pract athl train. 2022;5(2): 18-23. https://doi.org/10.31622/2022/0005.02.4. submitted: december 7, 2020, accepted: march 3, 2021. original reference décary s, ouellet p, vendittoli pa, roy js, desmeules f. diagnostic validity of physical examination tests for common knee disorders: an overview of systematic reviews and meta-analysis. phys ther sport. 2017;23:143-155. https://doi.org/10.1016/j.ptsp.2016.08.002 summary clinical problem and question the knee is the most commonly injured joint in sport, and thus the joint most typically evaluated by clinicians.1 it is important to address and intervene with injuries to the knee as soon as possible to prevent secondary injury and chronic damage to the joint, as knee disorders often cause a decrease in quality of life from loss of optimal function and development of osteoarthritis.2 healthcare providers will intervene by performing a myriad of physical examination tests to rule in or out pathologies for the patient. the physical examination is relied upon in many instances due to the significant costs incurred from clinical imaging and the time delay patients may experience while waiting for results and subsequent diagnosis.3,4 however, while physical mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.02.4 https://doi.org/10.1016/j.ptsp.2016.08.002 validity of selective tissue tests for knee pathologies: an evidence-to-practice review 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 examination tests are supposed to give patients and clinicians a firm diagnosis, most of these tests have both low sensitivity and low specificity.4 the clinician should be familiar with the validity (degree to which a test measures what it is intended to measure) and shortcoming of each selective tissue test they perform, and the shortcomings of certain diagnostic tests.5 because of the inconsistent results with many diagnostic physical evaluation tests, the purpose of the guiding systematic review was to evaluate the validity of individual and combinations of selective tissue tests for the knee.5 summary of literature the guiding systematic review’s authors conducted a literature search using five databases: pubmed, medline, cinahl, embase, and the cochrane database of systematic reviews. the authors used relevant, and mesh based keywords for articles published any time before january 2016 on all five databases to determine which systematic reviews and meta-analyses to include. to determine whether a study would be included in the guiding systematic review, the article, title, and abstract were all screened independently by two reviewers. systematic reviews and meta-analyses that were included in the guiding systematic review had to meet the following inclusion criteria: (1) be a systematic review or meta-analysis, (2) report on the diagnostic properties of one or more physical tests for one or more knee disorders, and (3) be written in english or french. following the search using the criteria listed above, 17 systematic reviews and meta-analyses of the original 6,750 systematic reviews and meta-analyses initially identified were included. of these 17 studies, 11 were meta-analyses while the other 6 were systematic reviews that did not include a meta-analysis. overall, the systematic reviews and meta-analyses explored selective tissue tests for meniscus injuries (n=8), anterior cruciate ligament (acl) injury (n=6), the combination of tests from acl/pcl/meniscus injuries and cartilage defects (n=2), while other systematic reviews and meta-analyses explored a clinical prediction rule for knee fractures (n=2) and knee osteoarthritis (n=2). each systematic review and meta-analyses were appraised using assessment of the methodological quality of systematic reviews (amstar) ranking system. the amstar is a reliable tool that is used to assess the overall quality of the systematic reviews and metaanalyses. each systematic review and meta-analyses were given an amstar score out of 11 to assess the strength of evidence. a score of an 8 or higher is considered a high-quality systematic review/meta-analysis. a score between 5 and 7 is a moderate quality and a score less than 5 was considered low quality. the amstar ranking for each study was averaged out and inter-rater agreement on each term was accounted for. from the 17 systematic reviews and meta-analyses, seven of them reached an amstar score of 7 or higher. summary of outcomes the authors of this guiding systematic review extracted sensitivity (ability of a test to rule a diagnosis out), specificity (ability of a test to rule a diagnosis in), positive likelihood ratio (the odds of detecting an injury in a patient who has that injury), negative likelihood ratio (the odds of detecting an injury in a patient who does not have that injury) and provided diagnostic odds ratio (the measure of effectiveness of a diagnostic test) in each of the 17 articles.4-6 the authors then assessed the data for each of the following selective tissue tests from the studies: mcmurray’s, apley’s, joint line tenderness, lachman, anterior drawer, pivot shift, and the ottawa knee rules. the authors of the guiding systematic review used the highest quality systematic reviews and meta-analyses for each selective tissue test of the knee, based on the respective amstar scores, to assess the sensitivity, specificity, and diagnostic odds ratios of each diagnostic selective tissue test. the validity of selective tissue tests for knee pathologies: an evidence-to-practice review 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 authors also reviewed the likelihood ratios to make recommendations on the validity of the selective tissue test, with ratio of 5 or higher indicating a positive likelihood ratio and 0.2 or lower indicating a negative likelihood ratio. if an injury is present, the test would prove to be positive, and if the injury is not present, the test will prove to be negative. findings and clinical implications the authors of the guiding systematic review grouped their findings into six different knee pathologies through nine physical tests and one clinical diagnostic rule with two scenarios that can be found in table 1. the first pathology was meniscus injuries, with eight systematic reviews and meta-analyses providing data on the selective tissue tests for this pathology. the amstar assessment of the systematic reviews for the clinical tests had ratings between a 2 to an 8. the tests with the highest validity were the mcmurray’s test, which had a sensitivity of 70.5% (95% ci: 67.4-73.4) and joint line tenderness test had a specificity of 77.4% (95% ci: 75.6-79.1%).7 when determining likelihood ratios, the joint line tenderness test provided the highest positive likelihood ratio (4.0; 95% ci: 2.1-7.5) and the lowest negative likelihood ratio (0.23; 95% ci: 0.12-0.44). tests for meniscal injuries of the knee should not be performed individually due to their low diagnostic validity.7 six systematic reviews and meta-analyses provided data on the diagnosis of an acl injury, with amstar scores ranging from 2 to 8. the selective tissue test with the highest sensitivity was the lachman test with a sensitivity of 85% (95% ci: 83.0-87.0%).8 the lachman test also provided the highest positive likelihood ratio (10.2; 95% ci: 4.6-22.7) and the lowest negative likelihood ratio (0.20; 95% ci: 0.10-0.30) out of all other selective tissue tests performed in the systematic reviews and meta-analyses. the pivot shift test had the highest specificity with a score of 98% (95% ci: 96.0-99.0%).8 for acl injuries, the lachman test has a high diagnostic value to help rule in and rule out the pathology and the pivot shift test is best suited to complement the lachman test when needing to rule in the condition. two systematic reviews, one that included a meta-analysis, were evaluated to look at patellofemoral pain with amstar scores of 6 and 7, respectively.9,10 the active instability test, pain using stairs, clarke’s sign, pain during prolonged sitting, and the patella tilt test were all assessed. when looking at likelihood ratios, no test has a significant clinical value to help include or exclude patellofemoral pain. it can be concluded that there are no individual tests recommended to diagnose patellofemoral pain and performing a combination of tests did not improve the positive likelihood ratio. only one systematic review was used to look at posterior cruciate ligament (pcl) injuries. the systematic review was given an amstar score of a 7.11 in the systematic review, 11 studies determined the posterior drawer test to be the most frequent test used to determine a pcl pathology. based on poor likelihood ratios for the posterior drawer test and despite a high specificity ranging from 96% to 100% for the quadriceps active test, there was no sufficient evidence to help include or exclude a pcl injury with any selective tissue test.11 for knee fractures, the ottawa knee rules was examined in two systematic reviews. the ottawa knee rules are used to rule in knee fractures and to avoid unnecessary radiographs.12 the two systematic reviews received amstar scores of 2 and 7. for the higher scoring systematic review, the sensitivity for the ottawa knee rules was 98.5% (95% ci: 93.2-100%), with a specificity of 48.6% (95% ci: 43.6-51.0%), and a negative likelihood ratio of 0.5 (95% ci: 0.02-0.23).12 the overall findings provide that the ottawa knee rule can be used to help understand if a referral for radiographic imaging should be ordered or not. if one validity of selective tissue tests for knee pathologies: an evidence-to-practice review 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 criterion from the ottawa knee rules is deemed positive, then the clinician should not rule out a fracture and referral for radiographic imaging is warranted. finally, knee osteoarthritis was examined in two systematic reviews. each systematic review received a 1 and a 2 for an amstar score.4,13 the criteria of the american college of rheumatology to diagnose knee osteoarthritis was examined in the systematic reviews. the criteria included age above 50 years, stiffness for more than 30 minutes, crepitus, bony tenderness, bony enlargement, and no palpable warmth. during an examination, if at least three criteria points are met, the sensitivity and specificity are 95.0% and 69.0%, respectively. when the fourth criteria point is found, the sensitivity and specificity are 84.0% and 89.0%, respectively.13 based on the results, it was concluded that the american college of rheumatology criteria can be used to determine knee osteoarthritis, but magnetic resonance imaging is also necessary to confirm the diagnosis as the amstar scores for the systematic reviews included were low. table 1. summary of diagnostic validity of selective tissue tests for the knee pathology selective tissue test number of studies sensitivity specificity diagnostic odds ratio meniscus mcmurray’s 14 71% 71% 4.5 apley’s 7 61% 70% 3.4 joint line tenderness 14 63% 77% 4.5 acl lachman’s 21 85% 94% 70 anterior drawer 20 55% 92% 21 pivot shift 15 24% 98% 12 knee fracture ottawa knee rules 6 99% 49% .05 (-lr) patellofemoral pain syndrome clarke’s sign 4 39% 76% n/a pcl posterior drawer 8 69% n/a n/a knee osteoarthritis american college of rheumatology criteria (3 criteria points) 2 95% 69% n/a american college of rheumatology criteria (4 criteria points) 2 84% 89% n/a items in bold are considered to have good diagnostic perform with a sensitivity or specificity above 90%. validity of selective tissue tests for knee pathologies: an evidence-to-practice review 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 clinical bottom line athletic trainers learn about and implement numerous selective tissue tests of the knee during their evaluation and assessment of patients experiencing orthopedic pain or limitations. the purpose of the selective tissue tests is to provide criteria to the athletic trainer to diagnose the patient. unfortunately, the guiding systematic review sheds light on the fact that some of the common selective tissue tests used and deployed in patient care do not yield the information we believe they do. it is becoming clearer that the physical aspect of the evaluation process is not as valid when used as a singular test. the findings support the use of lachman test as a valid selective tissue test for diagnosing or excluding an acl tear, whether used individually or in conjunction with other tests. in addition, the findings support the use of some clinical prediction rules14 such as the ottawa knee rules to rule out a knee fracture and the american college of rheumatology and european league against rheumatism (eular) rules to diagnose knee osteoarthritis. however, there are no valid selective tissue tests to diagnose a meniscal injury. the guiding systematic review suggests that clinicians are often using a combination of many physical tests, as well as a thorough history, to complete a full evaluation of the patient. while not specifically mentioned in the guiding systematic review, there is a clinical prediction rule for meniscal pathology which includes: 1) history of “locking” or “catching”, 2) pain with forced hyperextension, 3) pain with maximum flexion, 4) positive result from mcmurray’s, and 5) joint line tenderness to palpation.15 we suggest that athletic trainers utilize this clinical prediction rule which has between a 90-99% specificity when 3 or more of the 5 criteria are present in the patient.15 the high specificity takes the findings of the poor diagnostic validity for meniscal injuries and combines it with actionable items to implement when a one selective tissue test alone cannot diagnose the pathology. the guiding systematic review states that aside from the lachman test, ottawa knee rules, and eular rules, clinicians should not base their clinical diagnosis from a singular selective tissue test. in terms of acl injuries, while the pivot shift test and the anterior drawer test had good diagnostic performance, the tests were still not as accurate as the lachman test (see table 1). this guiding systematic review assessed many recent systematic reviews and meta-analyses about the validity of physical examination tests for the knee and found that the amstar rating for these was typically moderate. due to the limited and low-quality research on the validity of knee physical tests on their own, it is best to combine a physical exam with a thorough history or use a combination of data known as clinical prediction rules. for example, a clinician should consider the subjective history such as asking if the patient felt a pop or if their knee feels unstable or like it is going to give way. it is also important to determine what type of pain the patient is feeling; sharp pain refers to skeletal injury, aching pain can indicate muscular trauma or tendinopathy, and throbbing pain can mean a ligamentous injury or inflammation in the joint. overall, the clinical bottom line from the guiding systematic review is to consider using clinical decision-making tools, such as a clinical prediction rule, to diagnose musculoskeletal pathologies. these clinical prediction rules incorporate history, physical examination, and selective tissue tests to improve the diagnostic accuracy rather than a singular diagnostic test. references 1. bollen s. epidemiology of knee injuries: diagnosis and triage. br j sports med. 2000;34(3):227228. https://doi.org/10.1136%2fbjsm.34.3.227-a https://doi.org/10.1136%2fbjsm.34.3.227-a validity of selective tissue tests for knee pathologies: an evidence-to-practice review 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 2. filbay sr, culvenor ag, ackerman in, russell tg, crossley km. quality of life in anterior cruciate ligament-deficient individuals: a systematic review and meta-analysis. br j sports med. 2015;49(16):1033-1041. https://doi.org/10.1136/bjsports-2015-094864 3. stein la. making the best use of radiological resources in canada. healthc pap. 2005;6(1):18-23. https://doi.org/10.12927/hcpap..17719 4. jackson jl, o'malley pg, kroenke k. evaluation of acute knee pain in primary care. ann intern med. 2003;139(7):575-588. https://doi.org/10.7326/0003-4819-139-7-200310070-00010 5. décary s, ouellet p, vendittoli pa, roy js, desmeules f. diagnostic validity of physical examination tests for common knee disorders: an overview of systematic reviews and metaanalysis. phys ther sport. 2017;23:143-155. https://doi.org/10.1016/j.ptsp.2016.08.002 6. glas as, lijmer jg, prins mh, bonsel gj, bossuyt pm. the diagnostic odds ratio: a single indicator of test performance. j clin epidemiol. 2003;56(11):1129-1135. https://doi.org/10.1016/s08954356(03)00177-x 7. hegedus ej, cook c, hasselblad v, goode a, mccrory dc. physical examination tests for assessing a torn meniscus in the knee: a systematic review with meta-analysis. j orthop sports phys ther. 2007;37(9):541-550. https://doi.org/10.2519/jospt.2007.2560 8. benjaminse a, gokeler a, van der schans cp. clinical diagnosis of an anterior cruciate ligament rupture: a meta-analysis. j orthop sports phys ther. 2006;36(5):267-288. https://doi.org/10.2519/jospt.2006.2011 9. cook c, mabry l, reiman mp, hegedus ej. best tests/clinical findings for screening and diagnosis of patellofemoral pain syndrome: a systematic review. physiotherapy. 2012;98(2):93-100. https://doi.org/10.1016/j.physio.2011.09.001 10. nunes gs, stapait el, kirsten mh, de noronha m, santos gm. clinical test for diagnosis of patellofemoral pain syndrome: systematic review with meta-analysis. phys ther sport. 2013;14(1):54-59. https://doi.org/10.1016/j.ptsp.2012.11.003 11. kopkow c, freiberg a, kirschner s, seidler a, schmitt j. physical examination tests for the diagnosis of posterior cruciate ligament rupture: a systematic review. j orthop sports phys ther. 2013;43(11):804-813. https://doi.org/10.2519/jospt.2013.4906 12. bachmann lm, haberzeth s, steurer j, ter riet g. the accuracy of the ottawa knee rule to rule out knee fractures: a systematic review. ann intern med. 2004;140(2):121-124. https://doi.org/10.7326/0003-4819-140-5-200403020-00013 13. zhang w, doherty m, peat g, et al. eular evidence-based recommendations for the diagnosis of knee osteoarthritis. annals of the rheumatic diseases. 2010;69(3):483-489. https://doi.org/10.1136/ard.2009.113100 14. laupacis a, sekar n, stiell lg. clinical prediction rules: a review and suggested modifications of methodological standards. jama. 1997;277(6):488-494. https://doi:10.1001/jama.1997.03540300056034 15. lowery dj, farley td, wing dw, sterett wi, steadman jr. a clinical composite score accurately detects meniscal pathology. arthroscopy. 2006;22(11):1174-1179. https://doi.org/10.1016/j.arthro.2006.06.014 https://doi.org/10.1136/bjsports-2015-094864 https://doi.org/10.12927/hcpap..17719 https://doi.org/10.7326/0003-4819-139-7-200310070-00010 https://doi.org/10.1016/j.ptsp.2016.08.002 https://doi.org/10.1016/s0895-4356(03)00177-x https://doi.org/10.1016/s0895-4356(03)00177-x https://doi.org/10.2519/jospt.2007.2560 https://doi.org/10.2519/jospt.2006.2011 https://doi.org/10.1016/j.physio.2011.09.001 https://doi.org/10.1016/j.ptsp.2012.11.003 https://doi.org/10.2519/jospt.2013.4906 https://doi.org/10.7326/0003-4819-140-5-200403020-00013 https://doi.org/10.1136/ard.2009.113100 https://doi:10.1001/jama.1997.03540300056034 https://doi.org/10.1016/j.arthro.2006.06.014 abstract manuscript type evidence-to-practice review 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review amber m. kingsley, scat, atc; aysha b. reyes, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract avulsion fractures of the fifth metatarsal bone occur when a portion of the bone is broken or pulled off the rest of the bone. these fractures are often seen in athletes, especially those of a young age. avulsion fractures of the fifth metatarsal bone are commonly treated non-surgically with immobilization of the foot. there are several different options for immobilization of the foot with no clear result as to which immobilization method is the most effective. the purpose of this evidence-to-practice review was to summarize a systematic review on comparative outcomes of immobilization interventions on avulsion fractures of the fifth metatarsal. the authors included five studies in this review that compared two intervention methods including short leg casting and removable splinting of the foot. the authors reviewed foot function scores and non-union rates of the foot. it was found that both foot function scores and nonunion rates of the fifth metatarsal bone were better in the removable splinting intervention group. from the results of this evidence-to-practice review, we recommend the use of a removable splint for avulsion fractures of the fifth metatarsal bone. key phrases patient education, healthcare information technology, preceptor training and development correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation kingsley am, reyes ab, winkelmann zk. casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review. clin pract athl train. 2022;5(7): 53-57. https://doi.org/10.31622/2022/0005.01.8. submitted: december 3, 2020 accepted: september 3, 2021. original reference pituckanotai k, arirachakaran a, piyapittayanun p, tuchinda h, peradhammanon e, kongtharvonskul j. comparative outcomes of cast and removable support in fracture fifth metatarsal bone: systematic review and meta-analysis. j foot ankle surg. 2018;57(5):982-986. doi: 10.1053/j.jfas.2018.03.018 summary clinical problem and question fractures of the metatarsals are the most common fractures of the foot. specifically, fractures of the fifth metatarsal account for approximately 50% of all metatarsal fractures,1 and a large majority of these occur in young, active individuals.2 a jones fracture is defined as a transverse fracture of the proximal end of the fifth metatarsal bone in the foot,2 whereas a pseudo-jones fracture is an avulsion fracture of the base of the fifth metatarsal.3 a pseudo-jones fracture is also referred to as a zone 1 fracture, and occurs when a portion of the bone is pulled off from the remaining bone.2 the typical treatment for a fifth metatarsal fracture, including an avulsion fracture, is a non-surgical, conservative approach.4 immobilization of avulsion fractures has been determined to ensure union and proper healing of the bones occurs, which is a common concern with this injury.2 for athletes that sustain pseudo-jones fractures, effective immobilization is essential, as it can dramatically affect return to play. the method of immobilization for an avulsion fracture of the fifth metatarsal has been compared in several different studies,5-7 including use of a short leg cast versus a removable device such as a splint. the effect of each of these methods has been debated with no clear results as to the effectiveness of a short leg cast as compared to a removable support for the patient.5-7 as the best method of non-operative care for a pseudo-jones fracture is debated, there is a need to review and compare the functional outcomes of treatment between a short leg cast and removable splint for avulsion fractures of the fifth metatarsal. mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.01.8 casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 summary of literature the authors of the guiding systematic review performed a structured search of medline and scopus databases to locate published clinical trials of treatment options for fractures of the fifth metatarsal bone published between database inceptions to october 29, 2016. the authors established 4 criteria for published studies to be included in the guiding systematic review. the criteria included: (1) patients diagnosed with pseudo-jones avulsion fractures, (2) studies that utilized a comparison of outcomes between short leg cast and removable splint for treatment, (3) use of foot functional outcome scales or the visual analog scale (vas) for pain as outcome measures, (4) studies that were written in english.8 the database search of medline and scopus identified 127 total studies, and 104 studies were reviewed after 17 duplicate studies were removed. a quality assessment was conducted for risk of bias using the preferred reporting items for systematic reviews and metaanalysis guidelines for randomized control trials and the modified newcastle-ottawa scale for cohort studies. the search yielded five studies that were included in the guiding systematic review and meta-analysis as they matched all inclusion criteria listed above. the eliminated studies included: 86 that were non-comparative, 13 studies with other interventions and 2 that were non-english. all five included studies utilized a foot functional outcome measure, four studies assessed patients with non-union fractures, two studies were randomized control trials, and three studies were cohort studies. four of the studies included a follow-up assessment after 12 months, while the fifth study had a follow-up after 24 months.8 summary of interventions the guiding systematic review compared the short leg cast and the removable splint as treatment options for pseudo-jones fractures. the 5 studies used in the systematic review all used the short leg casting. a short leg cast is defined as a foot cast that immobilizes one joint above and below the fracture.8 additionally, in the guiding systematic review, there were 3 types of removable splints that were discussed. a removable splint, for the purpose of the guiding systematic review, included devices such as an elastic bandage, a jones’ bandage, and a boot splint. three of the studies used a bandage as their removable splint,7,9,10 one study used a boot splint,6 and the final study used a jones’ bandage.5 summary of outcomes the five studies in the guiding systematic review all used the american orthopaedic foot and ankle society (aofas) score for the anklehindfoot and the vas for foot and ankle pain. four of these studies also checked for the fracture nonunion. from the 5 studies included in the systematic review, three studies assessed mean function within 1 month of the fracture. the last follow-up to assess mean function was at 12 months in four of the studies and 24 months in the fifth study. findings and clinical implications the guiding systematic review utilized the aofas and vas for foot and ankle scores in the 5 studies. the short cast intervention reported lower scores for function compared to the removable splint intervention. by utilizing these patient-rated outcome measures, the authors were able to objectively measure the patients’ functions. the lower function scores were observed in the 1 month and the last follow-up visits in the respective studies. table 1 illustrates the last follow-up scores and non-union rates for the short leg cast group compared to the removable splint group. all five studies reported mean function scores at the last follow-up with patients, which was 12 months for four of the studies and 24 months for the casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 remaining study. once again, it was found that the foot function scores were lower for the short leg casting intervention group. four of the studies reported non-union rates of the fifth metatarsal bone and found that there was a lower risk for fracture non-union with the splinting intervention group. between better foot function scores and a lower risk of fracture non-union rates, the removable splint is the better intervention. there are other studies that have explored the outcomes from other interventions such as a controlled motion ankle boot, a hard-sole shoe, and a foot cast. for the foot cast, the methods were to immobilize above (tarsometatarsal joint) and below (metatarsophalangeal joint) the fifth metatarsal. the investigation of the foot cast and the short leg cast also utilized the aofas and the vas for pain, where they took the patients’ responses at 6-weeks and 8-weeks. the authors were able to determine with both the aofas and the vas scales that there were no significant differences in pain level.11 a different study that explored the controlled ankle motion (cam) boot, and the hard-sole shoe for non-casting options of treatment for a zone 1 avulsion fracture of the proximal fifth metatarsal also utilized the vas for pain, aofas score, and return to activity timeline to investigate patients’ clinical outcomes. the study found that at 8 weeks, both the hard-sole shoe and the cam boot had the same score output for both the vas for pain and the aofas. similarly, there was no significant difference between the two groups for the vas for pain and the aofas at 12 weeks. the study also identified that both groups had similar timeframes when participants were returning to their activities and sports.12 patients who utilized the removable splint for avulsion fractures of the fifth metatarsal had better function scores and non-union rates and had a faster return to activity, making the removable splint the ideal intervention for this injury. clinical bottom line patients that experience avulsion fractures of the fifth metatarsal will want the most effective treatment with the best outcomes. the patients may include athletes, and it is important that the immobilization method allows them to return to activity at the same level prior to injury. increased foot function and non-union rates are both essential when determining the course of treatment for an avulsion fracture. in the pursuit of providing better care for patients, as clinicians we need to know and explore what options are available. in the literature that we have reviewed and provided, there are several nonsurgical treatment options for immobilization of the foot and ankle for patients with fractures of the fifth metatarsal. short leg casting and splinting were two of the most common methods of immobilization for pseudo-jones fractures. foot table 1. comparison of outcomes of interest for intervention of fifth metatarsal fracture study aofas foot functional score (mean ± sd) nonunion of fifth metatarsal short leg cast removable splint short leg cast removable splint zenios et al.9 80 ± 11.6 89.5 ± 13.6 yes: 3 no: 22 yes: 0 no: 25 gray et al.6 87.5 ± 5.8 90.5 ± 5.2 yes: 0 no: 17 yes: 1 no: 19 shahid et al.7 93 ± 7 96 ± 7 n/a n/a akimau et al.10 93 ± 19.8 93 ± 23.7 yes: 0 no: 24 yes: 0 no: 36 wiener et al.5 86 ± 16 92 ± 16 yes: 0 no: 30 yes: 0 no: 30 casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 function scores and nonunion rates both had better results with a removable splint as an intervention. ultimately, the patient should be included in the shared decision making relevant to their care plan and make an informed choice based off their goals and potential to adhere to the plan. as the healthcare provider, the athletic trainer should use this review to educate the patient on the best option for non-surgical treatment of fifth metatarsal avulsion fractures. for those fractures that do not require surgery, utilizing a removable splint has better results for overall patient outcome and function, which is ideal for athletes returning to play after an injury. references 1. hasselman ct, vogt mt, stone kl, cauley ja, conti sf. foot and ankle fractures in elderly white women. incidence and risk factors. j bone joint surg am. 2003;85(5):820-824. https://doi.org/10.2106/00004623200305000-00008. 2. rhim b, hunt jc. lisfranc injury and jones fracture in sports. clin podiatr med surg. 2011;28(1):69-86. https://doi.org/10.1016/j.cpm.2010.09.00 3. 3. quill ge, jr. fractures of the proximal fifth metatarsal. orthop clin north am. 1995;26(2):353-361. 4. bigsby e, halliday r, middleton rg, case r, harries w. functional outcome of fifth metatarsal fractures. injury. 2014;45(12):2009-2012. https://doi.org/10.1016/j.injury.2014.06.0 10. 5. wiener bd, linder jf, giattini jfg. treatment of fractures of the fifth metatarsal: a prospective study. foot ankle int. 1997;18(5):267-269. https://doi.org/10.1177/1071100797018 00504. 6. gray ac, rooney bp, ingram r. a prospective comparison of two treatment options for tuberosity fractures of the proximal fifth metatarsal. foot (edinb). 2008;18(3):156158. https://doi.org/10.1016/j.foot.2008.02.00 2. 7. shahid mk, punwar s, boulind c, bannister g. aircast walking boot and below-knee walking cast for avulsion fractures of the base of the fifth metatarsal:a comparative cohort study. foot ankle int. 2013;34(1):7579. https://doi.org/10.1177/1071100712460 197. 8. pituckanotai k, arirachakaran a, piyapittayanun p, tuchinda h, peradhammanon e, kongtharvonskul j. comparative outcomes of cast and removable support in fracture fifth metatarsal bone: systematic review and meta-analysis. j foot ankle surg. 2018;57(5):982-986. https://doi.org/10.1053/j.jfas.2018.03.018 . 9. zenios m, kim wy, sampath j, muddu bn. functional treatment of acute metatarsal fractures: a prospective randomised comparison of management in a cast versus elasticated support bandage. injury. 2005;36(7):832-835. https://doi.org/10.1016/j.injury.2004.12.0 01. 10. akimau pi, cawthron kl, dakin wm, chadwick c, blundell cm, davies mb. symptomatic treatment or cast immobilisation for avulsion fractures of the base of the fifth metatarsal: a prospective, randomised, single-blinded non-inferiority controlled trial. bone joint j. 2016;98-b(6):806-811. https://doi.org/10.1302/0301620x.98b6.36329. 11. piyapittayanun p, mutthakalin k, arirachakaran a, kongtharvonskul j. comparative outcomes of foot cast and short https://doi.org/10.2106/00004623-200305000-00008 https://doi.org/10.2106/00004623-200305000-00008 https://doi.org/10.1016/j.cpm.2010.09.003 https://doi.org/10.1016/j.cpm.2010.09.003 https://doi.org/10.1016/j.injury.2014.06.010 https://doi.org/10.1016/j.injury.2014.06.010 https://doi.org/10.1177/107110079701800504 https://doi.org/10.1177/107110079701800504 https://doi.org/10.1016/j.foot.2008.02.002 https://doi.org/10.1016/j.foot.2008.02.002 https://doi.org/10.1177/1071100712460197 https://doi.org/10.1177/1071100712460197 https://doi.org/10.1053/j.jfas.2018.03.018 https://doi.org/10.1053/j.jfas.2018.03.018 https://doi.org/10.1016/j.injury.2004.12.001 https://doi.org/10.1016/j.injury.2004.12.001 https://doi.org/10.1302/0301-620x.98b6.36329 https://doi.org/10.1302/0301-620x.98b6.36329 casting and splinting options for pseudo-jones avulsion fractures: an evidence-to-practice review 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 leg cast in pseudo-jones avulsion fracture: a single blinded randomized controlled trial. j foot ankle res. 2019;12:47. https://doi.org/10.1186/s13047-0190359-5. 12. bishop ja, braun hj, hunt kj. operative versus nonoperative treatment of jones fractures: a decision analysis model. am j orthop (belle mead nj). 2016;45(3):e69-76. https://doi.org/10.1186/s13047-019-0359-5 https://doi.org/10.1186/s13047-019-0359-5 abstract manuscript type disablement model case study 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 university football player with hoffa’s fat pad syndrome: a disablement model case study kaitlyn jones, ms, atc, nrem*; kristy dao, ms, atc‡; zachary k. winkelmann, phd, scat, atc, chse† *north greenville university, tigerville, sc; ‡allen university, columbia, sc; †university of south carolina, columbia, sc abstract a 23-year-old university football player presented with acute onset anterior knee pain with no distinct mechanism of injury. the pain began soon after the start of fall football camp and prevented the patient from participating in team activities, including weights and practices. along with pain, the patient experienced edema, decreased knee flexion range of motion, and an antalgic gait. the findings of the evaluation of this patient were consistent with hoffa’s fat pad syndrome, an inflammatory and impingement condition of the infrapatellar fat pad that is often a rare diagnosis of exclusion. conservative treatment was used for this patient, which included rest, therapeutic rehabilitation exercises, cold modalities, and manual therapies. the patient adhered well to the treatment plan and was attentive and committed to his progress. within two weeks, the patient was partially participating in team weights, and after a month, the patient was fully participating in practice again. hoffa’s fat pad syndrome is frequently overlooked and not treated properly, although this case and other research have shown that it responds well to conservative treatment. understanding the role and involvement of the infrapatellar fat pad in anterior knee pain and knee biomechanics can be beneficial in recognizing conditions that affect the fat pad and implementing proper intervention programs that yield positive patient outcomes. hoffa’s fat pad syndrome is a manageable and treatable pathology that should be considered more in differential diagnoses of anterior knee pain. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation jones k, dao k, winkelmann zk. university football participation with hoffa’s fat pad syndrome: a disablement model case study. clin pract athl train. 2023;6(2): 50-57. https://doi.org/10.31622/2023/0006.02.8. introduction hoffa’s fat pad syndrome, a condition of the infrapatellar fat pad of the knee, is a rare diagnosis of anterior knee pain but a rather common occurrence.1,2 this pathology is often misdiagnosed and is more often used as a diagnosis of exclusion.1 the infrapatellar fat pad (ifp) is highly vascularized and innervated, contributing to its likelihood of being a source of anterior knee pain, although not often recognized in clinical examination.3,4 branches of the femoral, common peroneal, and saphenous nerves supply the ifp. hoffa’s fat pad is an intracapsular structure that fills the anterior compartment of the knee and is bordered by the patella, patellar tendon, proximal tibia, and knee joint synovium.3,4 the exact function and role of the ifp are unknown and poorly understood. still, studies suggest that it plays a role in knee biomechanics and reduces friction between the patella, patellar tendon, and deep structures.1,3,4 injury to hoffa’s fat pad, leading to fat pad syndrome, can occur through direct or indirect traumas and chronic microtrauma from repetitive stressors.3 these mechanisms can lead to inflammation or enlargement of the infrapatellar fat pad and cause impingement in the patellofemoral joint.2 patients with an ifp pathology often present with burning or aching infrapatellar anterior knee pain aggravated by physical activity and lessened with rest.3,4 through inspection, the fat pad may appear enlarged or have a firm consistency upon palpation.1,2 conservative treatment is recommended in the acute stages of hoffa’s fat pad syndrome, commonly rehabilitation-based care.2-4 other conservative treatments include taping or bracing, local corticosteroid injections, or avoiding the aggravating sport or activity.2-4 mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.02.8 university football participation with hoffa’s fat pad syndrome: a disablement model case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 patient information patient the patient is a 23-year-old african american male, an in-state student-athlete from a southeastern united states town. he participates on a ncaa division ii university football team as a defensive end. the patient consistently engaged in practices and team weights during fall football camp when he reported to the athletic training facility with insidious onset anterior knee pain, tenderness, and swelling along the front of his left knee. before attending the university, the patient underwent left anterior cruciate ligament (acl) reconstruction and meniscus tear surgery. in addition, he has had imaging done for his heart, which resulted in a heart murmur diagnosis, but he has no cardiovascular complications in his family history. the patient has no history of sickle cell trait. the injury occurred on august 11th, 2021, two weeks after beginning football camp. the patient returned to weights about a week after beginning treatment and returned to full sport participation about a month after treatment. differential diagnosis and evaluation examination of the patient showed obvious swelling along the anterior knee, no bony abnormalities, and palpable tenderness along the patellar tendon. functionally, the patient experienced a decreased active range of motion with knee flexion due to pain but no changes in knee extension. when compared bilaterally, internal rotation, external rotation, flexion, extension, adduction, and hip abduction were all within normal limits. similarly, the patient had decreased passive range of motion with knee flexion due to pain, no change in knee extension, and internal rotation, external rotation, adduction, abduction, and hip extension were all within normal limits when compared bilaterally. for the resistive range of motion, the patient had some discomfort with knee flexion, and hip external rotation caused some discomfort. hip internal rotation, adduction, abduction, extension, and knee extension were all within normal limits when compared bilaterally. manual muscle tests for the patient were rated 5/5 for flexion, extension, internal rotation, external rotation, adduction, and abduction. selective tissue tests done included thessaly’s, mcmurray’s, lachman’s, anterior drawer, posterior drawer, valgus stress, varus stress, lellis, apley’s compression and distraction, bouncehome, dial, slocum, bump, compression, ballotable, and hoffa’s test. only ballotable and hoffa’s tests yielded a positive result, with mcmurray’s causing some discomfort on the medial meniscus and valgus stress causing some pain along the patellar tendon. differential diagnoses for this patient were hoffa’s fat pad syndrome, medial meniscus injury, patellar tendonitis (jumper’s knee), and potential chondromalacia of patellar cartilage. the plan was to refer for mri/imaging if the pain persisted and begin conservative treatment. body structure and function this case involves moderate impairment of the musculoskeletal system, specifically of the left lower extremity or left knee. the patient reported no acute injury mechanism, just sudden pain, extreme tenderness, and swelling along the front of his left knee. the patient said there was some numbness along his patellar tendon scar and tingling along the surface but said that it has been going on since he was one month cleared postsurgical for his acl and meniscus tears. the patient explained that before this happened, he got scraping, an ace wrap, ice, and took ibuprofen for it, and it helped, but now it is not working. the patient reported his pain at a 7/10 on the numeric pain rating scale at the onset of pain and a 2/10 at rest for evaluation. the patient score from the 2000 ikdc subjective knee evaluation form patient-reported outcome was 15, indicating a low knee functionality. the ikdc subjective knee evaluation was designed to assess symptoms and function in activities of daily living for individuals with various knee pathologies.5 university football participation with hoffa’s fat pad syndrome: a disablement model case study 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 activity and participation the symptoms of the patient’s injury impacted his participation in team activities and social activities in different ways. the patient described activity limitations when he said he could not bend his left knee as much. he also said he walks with a limp due to pain, tried to rest it, and did no activity for the day. the patient exemplified participation restrictions when he could not participate in team weights or practice due to the injury. however, while injured, the patient could still go to work and complete his job as a forklift driver. he was also able to participate in school and greek life events. the patient reported no other hindrances besides sport-related activity and participation. however, patient responses on the short form36 (sf-36) patient-reported outcome indicated a physical functioning score of 25%, emotional well-being at 36%, social functioning at 50%, and general health at 50%. the short form-36 is a multi-item questionnaire designed to assess eight concepts of overall health for patients. these include limitations in physical activity, social activity, normal daily roles, general mental health, bodily pain, vitality, and general health perceptions.6 environmental and personal factors the patient was most concerned about his football participation and ability to remain on the team. coaches were threatening to cut athletes while the athlete was injured. this made it difficult for him to follow the treatment and rehabilitation plan because it required him to be removed from practices and weights. still, he understood that he would return faster and better if he followed the clinician’s protocol instead of trying to push through the disability. the patient has a strong family background, familial support, and good health insurance and transportation, so he could attend all treatment and rehabilitation sessions and was willing to be sent to the physician’s office for imaging if conservative treatment proved unsuccessful. the area of life most affected by the patient’s disability was sport and team participation. this was crucial to the patient because of the coaches’ cutting players from the team and the fear that his attendance in the athletic training facility would be seen as a weakness and avoidance of the team. this contributed to the low emotional wellbeing score and the low social functioning score on the sf-36. interventions the patient was removed from all activity until pain decreased and he could transition back into weights. the patient received compression with a neoprene style knee sleeve, compression, ice and ultrasound modalities, and performed rehabilitation exercises daily for his knee to increase strength and stability. therapeutic exercises included progressive quadriceps and hip-focused exercises for stability and appropriate vastus medialis oblique activation. examples include heel slides, quad sets, 4-way hips, singleleg balance, mini squats, lunges, single-leg russian deadlifts, and star excursions. referral was to be done if the patient showed no signs of improvement with treatment or the condition worsened. the patient responded well to conservative treatment, and a referral was unnecessary. outcomes body structure and function the patient came in for a follow-up evaluation after returning to weights with little to no impairment. the patient reported no pain with knee flexion. the patient also had a full range of motion, with knee flexion within normal limits when compared bilaterally. the patient still reported some tenderness with palpation along the patellar tendon and tibial tuberosity. upon re-evaluation, valgus stress, bouncehome, mcmurray’s for medial meniscus, and patellar mobilizations yielded positive test results. varus stress, ballotable, and university football participation with hoffa’s fat pad syndrome: a disablement model case study 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 clark’s sign yielded negative test results. the patient’s score on the 2000 ikdc subjective knee evaluation patient-reported outcome increased to 88, indicating greater knee functionality after treatment interventions. activity and participation the patient could resume participation in weights after one full week of rehab and treatment. he performed modified lower extremity movements and progressed to no modification and full participation in team weights. the patient then began a graduated return to play football, beginning with non-contact drills at practice. the patient continued work as a forklift driver without issues and was fully participating in class, school, and greek life extracurricular activities. percentages on the short form-36 patient-reported outcome increased to 100% for physical functioning, 92% for emotional well-being, 100% for social functioning, and 95% for general health, suggesting that increasing team participation and cohesion was incredibly beneficial for the patient’s overall sense of well-being. comparisons of pre-to-post objective findings for function and quality of life are presented in table 1. table 1. pre-to-post objective findings physical functioning, emotional well-being, social functioning, and general health were measured in sf-36 and presented in percentages (0-100%). knee function was measured using the ikdc subjective knee evaluation and presented as a score of function with 0=low function to 100=high function. environmental and personal factors the patient was consistent with treatment, coming in each day for either therapeutic exercises or treatment. the patient progressed well through rehabilitation and tolerated all prescribed treatments well. the patient did experience some anxiety and pressure from the coaches while rehabilitating his knee because the coaches were making cuts during this part of the season, and the patient’s position on the team was at risk. although the sports medicine clinicians assured the coaches that the patient was adhering well to rehabilitation, putting in good work, and progressing, the patient was still concerned that he would be let 0 20 40 60 80 100 120 physical functioning emotional wellbeing social functioning general health knee function pre post university football participation with hoffa’s fat pad syndrome: a disablement model case study 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 go. figure 1 below outlines the factors involved in this case that affected the patient and their outcomes based on the icf disablement model.7 discussion this case study is unique because it involves a rarely diagnosed but often occurring pathology. often a diagnosis of exclusion, hoffa’s fat pad syndrome is frequently overlooked and not treated correctly. individuals who experience patellar maltracking are predisposed to hoffa’s fat pad syndrome. however, there has been research done about the role and effect of the infrapatellar fat pad in knee function and anterior knee pain. one such study, which is of particular interest to this case study, examined the volume of the infrapatellar fat pad 6 to 12 months post anterior cruciate ligament reconstruction surgery. results described an increase in the volume of the infrapatellar fat pad between 6 and 12 months in the reconstructed limb, but the volume remained less than that of the fat pad in the uninjured limb at 12 months. additionally, greater increases in infrapatellar fat pad volume between 6 and 12 months post-reconstruction were related to better knee function at six months as measured by the ikdc.8 considering the limb-specific medical history of the patient in this case study, he may have been experiencing poor knee function, anterior knee pain, and hoffa’s fat pad syndrome due to post-surgical effects on his infrapatellar fat pad. hoffa’s fat pad syndrome was diagnosed by the clinicians in this case study due to the activity limitations and body functions affected in the patient. a study examining the effect of infrapatellar fat pad edema on knee biomechanics and kinematics and its relation to anterior knee pain reported findings of increased infrapatellar fat pad pressure, with the highest increase in pressure occurring around 113 degrees of flexion.9 these findings are consistent with hoffa’s syndrome and anterior knee pain that decreases flexion due to pain and is exacerbated by chronic mechanical impingement of the fat pad in knee flexion and extension. this case study presented with strengths and limitations. for example, the conservative treatment chosen to treat the diagnosis of hoffa’s fat pad syndrome proved successful and provided quick results for the patient. this was a strength in the approach to this specific case. another benefit of this treatment approach was that it could be beneficial but, most importantly, would not be harmful to any of the differential diagnoses presented in the case. therefore, the patient was not physically at risk by participating in the treatment and rehabilitation protocol designed by the clinicians. the patient was also committed to his rehabilitation and had the necessary means to attend treatment sessions and any appointments that may have been arranged. the patient was easily educated about his condition and communicated well with the clinicians, which encouraged favorable outcomes in this case. on the other hand, the lack of imaging provided in the case because the referral was not initially indicated could be considered a limitation when examining the diagnosis made in this case. the diagnosis was made primarily based on clinical findings and physical evaluation, as well as subjective reported symptoms. although hoffa’s fat pad syndrome does not present significant findings with common imaging techniques and is usually considered when nothing else remarkable is present on radiographic images, mris will occasionally reveal structural abnormalities of the infrapatellar fat pad. however, these findings are commonly benign or do not relate to a present pathology. this makes diagnosis by imaging difficult. in this specific case study, it may have been beneficial if there were abnormalities present in the infrapatellar fat pad of the post-surgical knee compared to the uninjured limb, which could then be compared to the evaluation findings and activity limitations. another limitation of this study was that the previous acl and meniscus tear, reconstruction surgery, and post-surgical rehabilitation were completed prior to the patient matriculating to the university. thus, it was difficult for the clinicians to reflect on the previous maintenance, treatment, and rehabilitation of the patient’s knee in the diagnosis or treatment of his new pathology. university football participation with hoffa’s fat pad syndrome: a disablement model case study 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 figure 1: icf disablement model for case study patient7 further research with the ability to follow patients longitudinally after an acl tear or reconstruction could offer more insight into uncommonly diagnosed complications experienced after surgery. additionally, future research examining the change in the size and quality of the infrapatellar fat pad over time in sporting populations could be beneficial to better understanding and managing this uncommon diagnosis. the patient returned to partial participation within two weeks and full participation within a month; however, he continued to face the threat of being cut from the team. the clinicians chose an aggressive conservative treatment approach because of this threat, so the patient would not have to wait for appointments, imaging arrangements, and follow-ups before re-engaging in team activity. since the patient showed promise during the initial stages of rehabilitation, the clinicians for this case decided not to refer the patient for imaging and potentially slow his progress. the patient’s goal was to return to activity as soon as possible so he could patient is a 23-year-old football defensive tight end, african american, in-state student athlete from greenville, sc who attends a ncaa division ii historically black college and university. environmental factors personal factors participation activity body structures/functions health condition hoffa’s fat pad syndrome unable to participate in weight training or practice unable to engage in pick-up basketball in the gym able to go to work, school, and participate in greek life extracurricular activities impairment of musculoskeletal system sudden pain extreme tenderness swelling decreased knee flexion inability to bend knee walks with limp due to pain inability to weight train for lower extremity inability to perform practice drills coaches making first round of cuts for the season athlete position on team in jeopardy good insurance and available transportation if needed good adherence to treatment and rehabilitation plan good trust in clinicians open minded; willing to try anything university football participation with hoffa’s fat pad syndrome: a disablement model case study 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 continue to fight for his spot on the university football team. the clinician’s goal was to ensure the patient returned to sport safely and was supported physically, mentally, and emotionally throughout the process. clinical bottom line hoffa’s fat pad syndrome is a commonly missed diagnosis but a manageable and treatable pathology by athletic trainers. it should be considered more often in cases of anterior knee pain and especially in cases of patients who have a history of acl reconstruction. because anterior knee pain can be present in many different conditions, it is important for clinicians to have a good understanding of the activity limitations and specific movements that are restricted for the patient. this can help narrow differential diagnoses and focus treatment plans appropriately. additionally, conservative treatment for this condition demonstrates favorable patient outcomes and is not harmful to differential diagnoses of anterior knee pain. therefore, conservative treatment can be implemented in similar cases to achieve good clinical outcomes. it is important that the management of hoffa’s fat pad syndrome is accompanied by good patient education about maintenance rehabilitation and understanding the chronic or traumatic stressors that may exacerbate the infrapatellar fat pad in the future. patient perspective when reviewing the case with the patient, he said that he “felt like my knee was the problem limiting my skills” on the football team. he detailed that he believed his injury was “more hurting the team than helping it” or that if his “knee doesn’t get better, i might get cut from the team.” this led to feelings of anxiety, frustration, and fear. he confided in the sports medicine staff that “even though i am trying everything, i am still failing” and that “i am letting people down and not doing what i said i would do for my teammates and coaches.” however, instead of allowing his diminishing mental state to discourage his recovery, the patient said it “encouraged me to stay focused on treatments and try different things” and to “go harder on sets and do more sets a day.” the patient shared that his overall goal was “to stop having knee pain when doing rigorous activity in any sense,” including pick-up basketball in the university gym. he claimed that he felt the most change and recovery from the rehabilitation exercises and the cold/compression modality treatment. the patient said, “after a week or two, i could feel the difference” from the intervention. the patient shared that he had great support from the athletic trainers, who were like a “family away from home,” and that he could comfortably confide in the sports medicine staff, which helped his adherence to the intervention program. once the patient was able to reintegrate into activity, beginning with team weights, he revealed that “i was very happy and able to focus on something other than my knee injury. i felt like part of the team again and was able to start getting stronger and build my knee up.” overall, the patient was pleased with the evaluation, intervention program, and outcomes, as he was able to play the rest of the season as a defensive tight end on the university football team. references 1. mace j bw, anand s. infrapatellar fat pad syndrome: a review of anatomy, function, treatment, and dynamics. acta orthop belg. 2016;82(1):94-101. 2. gerbino p. adolescent anterior knee pain. oper tech sports med. 2006;14:203–211. http://dx.doi.org/10.1053/j.otsm.2006.04.003. 3. draghi f, ferrozzi g, urciuoli l, bortolotto c, bianchi s. hoffa’s fat pad abnormalities, knee pain and magnetic resonance imaging in daily practice. insights imaging. 2016;7(3):373-383. https://doi.org/10.1007/s13244-016-0483-8. http://dx.doi.org/10.1053/j.otsm.2006.04.003 https://doi.org/10.1007/s13244-016-0483-8 university football participation with hoffa’s fat pad syndrome: a disablement model case study 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 4. dragoo jl, johnson c, mcconnell j. evaluation and treatment of disorders of the infrapatellar fat pad. sports med. 2012;42(1):51-67. https://doi.org/10.2165/11595680-000000000-00000. 5. higgins ld, taylor mk, park d, et al. reliability and validity of the international knee documentation committee (ikdc) subjective knee form. joint bone spine. 2007;74(6):594-9. https://doi.org/10.1016/j.jbspin.2007.01.036. 6. ware je, jr., sherbourne cd. the mos 36-item short-form health survey (sf-36). i. conceptual framework and item selection. med care. 1992;30(6):473-83. 7. icf model: a framework for athletic training practice. nata.org. march 17, 2016. https://www.nata.org/blog/beth-sitzler/icf-model-framework-athletic-training-practice. 8. wallace kg, pfeiffer sj, pietrosimone ls, et al. changes in infrapatellar fat pad volume 6 to 12 months after anterior cruciate ligament reconstruction and associations with patient-reported knee function. j athl train. 2021;56(11):1173-1179. https://doi.org/10.4085/1062-6050-0458.20. 9. bohnsack m, klages p, hurschler c, et al. influence of infrapatellar fat pad edema on patellofemoral biomechanics and knee kinematics: a possible relation to the anterior knee pain syndrome. arch orthop trauma surg. 2009;129(8):1025-1030. https://doi.org/10.1007/s00402-006-0237-z. https://doi.org/10.2165/11595680-000000000-00000 https://doi.org/10.1016/j.jbspin.2007.01.036 https://doi.org/10.4085/1062-6050-0458.20 https://doi.org/10.1007/s00402-006-0237-z abstract manuscript type disablement model case study 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study sara a. zilvetti, lat, atc; amanda y. young, pt, dpt; jeff stein, pt, dpt, lat atc; scott e. lawrance, dhsc, lat, atc, mspt, cscs *purdue university, west lafayette, in abstract this case examines a 19-year-old male college student with a left anterior cruciate ligament reconstruction (aclr) secondary to a motor vehicle accident (mva). the accident caused numerous severe injuries to both lower limbs including untreatable right lower leg injuries, leading to a right below knee amputation, and a left acl tear. before the accident, the patient was a varsity cross country and track athlete expecting to continue in college. six weeks following surgical reconstruction, the patient reported to the rehabilitation clinic for standard aclr rehabilitation practices including lower leg and proximal hip strengthening, attaining full knee rom, and balance exercises. gait training was essential due to an antalgic gait and complicated by the presence of the right leg prosthesis. he progressed as expected with balance and strengthening exercises; but progress was inhibited by many factors including global left knee swelling, his inability to achieve or maintain full left knee extension rom, intense end-range pain with left knee extension, and a leg length discrepancy (lld) between his remaining limb and daily prosthesis. psychological factors from rehabilitation fatigue may have hindered progress and contributed to higher pain sensations and frustration levels. four months after surgery, the patient was showing improvement in pain reduction and extension rom, but care was discontinued secondary to the covid-19 global pandemic when the patient declined to continue formal rehabilitation in an online format. one year post aclr the patient achieved normative scores for the lefs and ikdc. this case exhibits the impact of a prosthetic limb on the overall healing time of a patient and highlights how factors that can be easily overlooked such as llds, psychological stressors, and kinetic chain disruptions can greatly impact a patient's rehabilitation. by looking holistically at our patients, we can make connections to improve the patient’s rehabilitation and healing. content focus: health care competency correspondence dr. scott lawrance, 800 west stadium avenue, west lafayette, in 47907. email: lawrance@purdue.edu twitter: @selawrance full citation zilvetti sa, young ay, stein j, lawrance se. anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study. clin pract athl train. 2023;6(1): 21-28. https://doi.org/10.31622/2023/0006.01.4. introduction a male, collegiate, sophomore student presented to the clinic six weeks following a left anterior cruciate ligament reconstruction (aclr) secondary to a motor vehicle accident (mva) that occurred two years prior. the mva caused numerous gross injuries to his lower limbs including a tear to the left acl, but also a belowknee amputation (bka) of his right leg. throughout the rehabilitation process, the patient struggled with intense pain with knee extension, psychological fatigue from years of rehabilitation, and irritation of the right lower extremity stump, each contributing to a challenging rehabilitation progress. additionally, the patient’s daily use prosthesis presented a leg length discrepancy (lld) making gait training difficult. use of the running prosthetic diminished the lld and the patient was able to ambulate without pain, with full knee extension, and less pronounced drop foot. the patient was then referred to his prosthetist who confirmed our suspicions of a lld related to the prosthetic. the patient completed roughly four months of formal therapy before stopping due to the covid-19 pandemic. while following up with the patient about a year later, he scored within published normative values for both the lower extremity functional scale (lefs) and international knee documentation committee (ikdc) subjective evaluation forms. he also reported being able to complete most activities that he previously enjoyed with more limitations caused by his prosthetic limb than his aclr. mailto:lawrance@purdue.edu https://doi.org/10.31622/2023/0006.01.4 anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 patient information the patient was a caucasian, 19-year-old male college student presenting with a left knee aclr with a quadriceps tendon autograph. three years prior, the patient and his family stopped on the side of the road to assist another motorist when a passing vehicle lost control striking the patient head-on. he sustained a multitude of injuries including untreatable right lower leg trauma, left femur fracture, left knee acl and mcl tear, left ankle deltoid ligament tear, left hip greater trochanteric bursitis and heterotopic ossification, and left arm triangular fibrocartilage complex (tfcc) tear. immediately after the mva, an emergency right bka was performed with a left ankle deltoid ligament repair and left femur open reduction internal fixation (orif). as part of his initial bka recovery, the patient was fit for a prosthetic leg and performed intensive rehabilitation to regain independent ambulation and restore normal activities of daily living (adls). a little over a year later, he underwent a left tfcc repair with loose body removal. approximately three years following the mva, after the resolution of other more severe injuries, the patient underwent a left knee aclr with a quadriceps autograft. the patient decided to pursue the reconstruction based on a desire to continue his active lifestyle and fear of knee instability in the future with activities such as recreational basketball. the patient and surgeon’s fear of potential knee instability increased due to the presence of the contralateral bka. both felt the aclr gave him the highest chance of returning to future recreational activities. the patient was given a prescription for pain control medication (oxycodone and acetaminophen, 10mg/325mg) to be used during rehabilitation as needed. he had no diagnosed psychiatric history, but fatigue from years of therapy was evident clinically and may have contributed to increased frustration, higher pain sensations, and a longer recovery time. differential diagnosis and evaluation due to the high impact mechanism of the mva, the patient was rushed to the hospital where several emergent diagnostic images were obtained including radiographs, a head computed tomography (ct) scan, and a full-body mri. these scans were reviewed, and he was diagnosed with a left femur fracture, left knee acl and mcl tear, left ankle deltoid ligament tear, and left wrist tfcc tear. he also had untreatable traumatic right lower extremity injuries, which resulted in a bka. the differential diagnosis for his left knee included: pcl tear, meniscal tear, patella dislocation/subluxation, osteochondral fracture, and lcl sprain. body structure and function the patient initially presented to the clinic six weeks post-operative from aclr. the patient noted a sharp pain in his posterior left knee specifically during active knee extension. mild left knee swelling and significant scarring on the global left tibial region from the mva were observed. he had a bent-knee gait on the left lower extremity (lle), drop foot, most likely caused by peroneal nerve damage from the accident, and gait alterations due to his prosthetic limb. the patient wore a hinged knee brace for support while walking. the brace allowed for a controlled range of motion (rom) during ambulation, medial and lateral knee stability, and provided proprioceptive feedback to the patient. without the brace he was guarded and cautious with his movement for fear of his knee giving way. right knee active range of motion (arom) was noted to grossly be within normal limits for both flexion and extension in the right side, with left knee flexion of 127° with no pain and knee extension 0° with pain. strength testing of knee flexion and extension was 4+/5 on the right leg and 4/5 on the left. hip abduction was 4/5 bilaterally. a 6-inch step test was performed, and the patient used his prosthetic to perform this test. pain was present in the left leg when stepping onto the box, and the patient showed weakness with descending control for the right leg. this may have been due to not having proprioception between his prosthetic limb and the ground. anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 his quad set was fair. he was able to perform a good contraction but was unable to add movement to the hip without losing control. when asked to perform a straight leg raise he had a 5 to 10° quadriceps lag. the patient experienced numbness on the anterior left shin where he had significant scarring, but no tingling or radiating pain. activity and participation prior to the accident, the patient was a high school varsity track and cross-country runner with the expectation of continuing in college. he also lifted weights, played basketball, and swam recreationally after his accident, but before his aclr. the aclr procedure impacted his ability to perform all ambulatory activities including walking and going up and down stairs, participate in most of his extracurricular activities, and drive. he reported having disturbed sleep, and that he was taking melatonin supplements which helped. the patient reported his worst pain reached 8/10 on a 0 to 10 grading scale and occurred during active knee extension. he also completed the lower extremity functional scale (lefs) on initial evaluation with a score of 36/80. environmental and personal factors the patient expressed his rehabilitation goals were to return to playing recreational basketball, running, and weightlifting without restriction. since the patient had spent the previous three years in rehabilitation, mental fatigue was evident upon the initial visit. the stressors of being a college student were also noted as a possible limitation to his rehabilitation progress as was his right bka. interventions treatment for the patient was structured around standard post aclr rehabilitation practices including decreasing swelling, increasing rom, strengthening of the hamstrings, quadriceps, gluteals, and calves, and improving balance. gait training was also incorporated due to the presence of an antalgic gait on initial evaluation. the patient attended rehabilitation two days a week and was instructed to complete a home exercise program (hep) daily (table 1). every week, the patient progressed as expected with balance and strengthening of the hamstrings, gluteals, and calves. the patient struggled continuously with global knee swelling for the first few months of rehabilitation. swelling increased every week his activities of daily living (adls) included significant walking around campus or long car trips where his knee was held in a flexed position for hours at a time. table 1. home exercise program distributed to patient during initial evaluation sets repetitions side stepping with resistance band 3 15 sitting knee extension with resistance band 3 15 glute bridge with arms at sides and feet on swiss ball 3 10 long sitting calf stretch with strap 2 5 (10-second hold) lateral step down 3 10 *each exercise was to be completed once per day, 7 times per week. the patient struggled to maintain extension rom throughout the treatment period due to swelling and intense pain. he responded well to passive stretching but increases of motion achieved in each session were often not sustained between sessions. due to the severe level of posterior knee pain with knee extension, the anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 patient’s surgeon was contacted who confirmed there was no remaining structural damage. the pain was present regardless of his knee extension rom. to protect himself from the pain experienced during knee extension, he walked with a bent-knee gait likely contributing to the inability to maintain full knee extension. this limited knee extension from the quadriceps muscles but required overuse of his hamstrings. to walk functionally, he needed to compensate for his quadriceps weakness by also increasing the use of his glutes and calf musculature. the over-recruitment of the posterior chain muscles in the lower extremity dominated movement and contributed to his antalgic gait. these compensations led to slow strength progress of the quadriceps throughout the rehabilitation period. step-down exercises continually demonstrated poor motor control and limited endurance of the quadriceps. six weeks into treatment and three months following the surgery, the patient attempted exercises on the agility ladder. on the first visit he attempted to climb the agility ladder, he did not have the correct sleeve for his running prosthesis. he was very excited to progress to the agility ladder so he attempted the exercise with his daily prosthesis. he was able to complete this exercise with good tolerance in the left knee, and no increased pain, discomfort, or feelings of weakness were reported. unfortunately, the activity had to be discontinued early due to friction between his daily prosthesis and his right stump. two weeks later, the patient presented with increased knee rom, 2° of hyperextension and 138° of flexion, and decreased posterior knee pain. the patient reported he began committing time to his hep and passive stretching. this likely contributed to his rapid progress as he had neglected his hep previously. the agility ladder was attempted again during this time with his running prosthesis. the patient was able to complete the activity with greater ease than his first attempt and had good stability, speed, agility, and motor control of both legs. the patient used vasopneumatic compression after most sessions to help minimize swelling and decrease pain with good results. the patient was last seen by the medical team one week prior to the university shut down due to the covid19 pandemic. he was struggling with pain due to ingrown hairs on his right extremity residual stump, causing him to be stationary or in his wheelchair for a week because wearing his prosthetic was too painful. he had improved extension rom of his left leg after reportedly spending an increased amount of time every day stretching. quadriceps weakness was still present. once the patient returned home, he declined to continue with formal rehabilitation in an online format. he also had decreased compliance with his hep because he had normal ambulation and did not think continuing rehabilitation was needed. he continued doing cardiovascular exercises such as playing basketball recreationally, but neglected strength training. this further impacted his progress and lengthened his recovery time. about a year later, his knee began bothering him again, specifically when he was active, so he began strength training on his own. table 2 highlights objective measurements of the patient throughout the rehabilitation process. table 2. objective measurements throughout rehabilitation initial evaluation 4-month progress 1 year follow-up knee flexion arom r leg: wnl l leg: 127° r leg: wnl l leg: 135° r leg: wnl l leg: wnl knee extension arom r leg: wnl l leg: 0° (with pain) r leg: wnl l leg: -2° (no pain) r leg: wnl l leg: wnl pain level with active knee extension (0-10) 8 7* 0** disturbed sleep yes no no * pain occurred at end-range only ** no pain occurred with active knee extension, but pain was still present post activity anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 outcomes one year after stopping treatment, the medical team followed up with the patient. he reported that he was playing “a lot” of basketball which was one of his initial treatment goals. he reported no problems while playing, but stated afterward his left aclr knee hurt. he used ice consistently to limit pain and swelling after playing. he completed a lefs again and scored a 63/80 compared to 36/80 on the initial examination and a 55/80 on his last visit before campus closure (table 3). this value matches the reported discharge outcomes of those undergoing aclr and rehabilitation at four months.1 however, it should be noted the patient population observed by alcock and colleagues1 did not have a lower extremity amputation on the contralateral limb, nor the extensive injuries and rehabilitation process the patient in this case did. the patient here also completed an ikdc subjective evaluation form and scored 67.8 for this left knee. the ikdc is a valid and reliable form that is used to assess function, symptoms, and sports activity in patients with a variety of knee conditions. normative values have been reported for the ikdc previously and are based on gender, age, and if the patient was injured on the right, left, or both knees.2 those who had undergone surgery in their right knee only reported their ikdc score to be 56.6 ± 23.3, in the left knee only to be 58.3 ± 25.6.2 those reporting surgery in both knees, as was the case with this patient, reported their right knee ikdc score as 56.6 ± 25.3 and left knee as 51.4 ± 26.9.2 males in the study, aged 18-24 years, without a history of knee injuries or surgery reported a mean score of 89.1 ± 17.5.2 the patient here still struggled with the fit of his prosthetic one year after discharge from rehabilitation, which has continued to limit his function. he was still unable to jump because of his prosthetic and reported that he felt that it was more limiting for him than his left knee. table 3. patient-reported outcome measure scores initial evaluation 4-month progress 1 year follow-up lefs score (out of 80) 36 55 63 ikdc score (out of 100) --67.8 he had also followed up with his prosthetist and had the height of his prosthetic readjusted. unfortunately, he then had problems with the socket requiring a new prosthetic. since he attended school out of state, obtaining a new prosthetic was difficult. discussion the patient’s complex musculoskeletal medical history limited multiple aspects of rehabilitation and contributed to his antalgic gait. while wearing his running prosthesis, he was able to achieve full knee extension on his right leg and his left leg drop foot was less pronounced than while using his daily prosthesis. the research team hypothesized a limb length discrepancy could be the root of these issues; so, he was referred back to his prosthetist who confirmed our theory. according to a study done by friberg, only 15% of subjects had a prosthesis with equal leg length to their intact limb and shortening of the prosthetic between 5 and 10 millimeters was shown to lead to problems including knee or hip pain in the intact limb.3 both of these occurred in our patient. the patient’s bka also provided challenges with rehabilitation including pinching sensations from his prosthesis with certain exercises, and painful ingrown hairs that limited walking. according to a study done by dillingham and colleagues on long-term (defined as those who have used a prosthetic for at least one year) prosthetic users who suffered lower-limb amputations due to trauma, only 43% reported satisfaction with prosthetic comfort. skin wounds and sores caused by the prosthetic as with our patient were reported by 24% of the patients and general residual limb pain was reported in 17%. while not present in our case, dillingham and colleagues noted phantom pain affected about 24% of the anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 patients. furthermore, patients reported problems with their contralateral limb including problems with circulation (10%), joint pain (17%), muscle cramps (8.5%), sores or wounds (7%), and numbness or weakness (8.5%).4 when working with patients with prosthetic limbs, it is crucial to understand these confounding conditions and how they can inhibit rehabilitation to other areas that are seemingly unaffected. another factor that lengthened recovery time was the patient’s complaint of extreme pain with full knee extension and the inability to maintain knee extension between sessions. typically, most patients no longer have extreme pain with extension four months after surgery and should visibly improve extension every few weeks. with full passive knee extension, this patient was able to identify two separate, distinguishable pains. one pain was a mild discomfort “stretching sensation” of the posterior knee which was felt during light passive stretching. the second pain was deep, sharp, and intense. this pain was elicited at the end range of knee extension and limited all aspects of rehab, most notably the patient’s ability to achieve full knee extension. due to the severity of the pain, the medical team contacted the patient’s surgeon to confirm there was no remaining structural damage or mechanical limitation to impair motion. according to the surgeon’s physician assistant, there was no structural damage to the knee, and she believed that there may have been a psychosomatic component as well as a central nervous system hypersensitivity contributing to the pain. she recommended continuing rehabilitation, and for the patient to use his prescribed medication as needed. following the mva, the patient had an oxycodone and acetaminophen (10mg/325mg) prescription to take as needed for pain. however, since he was a full-time student, he rarely took them because he felt that they interfered with his studies and his daily life. continued knee pain also contributed to quadriceps weakness, thus limiting the patient’s ability to regain knee extension rom and strength.5 limitation in full knee extension increased the dominance in the patient’s posterior chain and further impacted his gait pattern. regardless of the possibility of a leg length discrepancy, instead of equally distributing weight to both limbs, individuals with a bka tend to put more weight and increase the stance time on their intact limb during ambulation.6 furthermore, a majority of them alter their gait to limit the forces on their prosthetic limb which has been shown to increase the forces acting on the joints of the intact limb.6 with this in mind, our patient may have unconsciously put extra stress on his left leg while it was attempting to heal. the increase in pressure on his knee in combination with the amount of walking he did every day around campus may have contributed to our patient’s struggle with global knee swelling and intense posterior knee pain. the patient also struggled with psychological stressors slowing his overall rehabilitation and treatment. since his mva three years prior, he had been continuously in and out of rehabilitation following surgeries to his right leg, left ankle, and right wrist. injuries overall have been shown to influence mental health and in turn the rehabilitation process.7 heijne and colleagues showed that all patients studied experienced frustration with the length of rehabilitation after an aclr. this frustration negatively influenced their self-esteem and lead to decreased confidence in their rehabilitation process.8 looking at our patient, who had been in rehabilitation for over three years prior to his aclr, he likely entered his aclr rehabilitation with a similar frustration to those identified in the study by heijne et al., the patient’s mental fatigue with rehabilitation was evident early in the rehabilitation process. for a majority of the four months, he neglected his hep, and would periodically cancel last minute or forget to come entirely. the medical team did not perform a formal screening of psychological wellness during the treatment period. issuing a patient reported outcome measure, such as the athletic coping skills inventory-28 (acsi)-28, early in rehabilitation or after the team noticed mental fatigue could have raised early awareness of this patient’s psychological state. it may have also served as rationale for a referral for professional psychological counseling. the acsi-28 form has been shown to significantly correlate with recovery time following an aclr in an adolescent population.9 without anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 this outcome measure, the medical team found that changing his exercises consistently engaged the patient and he completed his rehabilitation with greater enthusiasm. clinical bottom line this case highlights how the presence of a prosthetic limb can complicate the rehabilitation plan and increase the recovery time of a patient with an injury otherwise unrelated to their amputation. in the case of this patient, while he was in rehabilitation for a left aclr, his right bka caused him to ambulate with increased pressure on his left leg. this imbalance of weight and increased pressure in the knee joint likely contributed to his struggle with global knee swelling and increased pain. when working with a patient with an amputated limb, it is crucial to routinely monitor the stump for any superficial injuries that could lead to infection. even with continuous monitoring of the stump, problems arose in the patient such as friction in the prosthetic, wornout sleeves causing pain, and ingrown hairs. these occasionally required the patient’s aclr rehabilitation to be modified or canceled for the day depending on the type of issues and the ability to work around them. when working with a patient with a bka, athletic trainers must be aware of how the patient’s prosthetic impacts the injured body part, how it can interfere with the overall healing time of the patient, and must be flexible with their rehabilitation plan if complications with the patient’s residual limb occur. this case also highlights the relationship between the healing of an injury and factors that may otherwise be overlooked. the patient’s overall healing time and rehabilitation progress were impacted by kinetic chain disruptions, a lld, and psychological stressors. in the case of this patient, the kinetic chain disruptions and lld were due to an improper prosthetic fit, but these problems occur in patients without an amputation too. these types of complications can exacerbate symptoms that would otherwise be minimal or be the root cause of symptoms altogether. in this patient, his antalgic gait and posterior chain dominance were caused by his lld. when using his running prosthesis, his lld was less pronounced, and his gait became less antalgic as he was able to fully extend his left knee. since his antalgic gait contributed to a posterior chain dominance, by correcting it we were able to see great improvement in overall function and pain sensations. in general, it is crucial for athletic trainers to practice patient-centered care and to look holistically at the patient, not just the injured body part, as there may be confounding conditions that can lead to a longer recovery time or inhibit recovery altogether. references 1. alcock gk, werstine ms, robbins sm, stratford pw. longitudinal changes in the lower extremity functional scale after anterior cruciate ligament reconstructive surgery. clin j sport med. 2012; 22(3): 234-239. https://doi.org/10.1097/jsm.0b013e31824cb53d. 2. anderson af, irrgang jj, kocher ms, mann bj, harrast jj. the international knee documentation committee subjective knee evaluation form: normative data. amer j sports med. 2006; 34(1): 128135. https://doi.org/10.1177/0363546505280214/ 3. friberg o. biomechanical significance of the correct length of lower limb prostheses: a clinical and radiological study. prosthet orthot int. 1984;8(3):124-129. https://doi.org/10.3109/03093648409146072. 4. dillingham tr, pezzin le, mackenzie ej, burgess ar. use and satisfaction with prosthetic devices among persons with trauma-related amputations: a long-term outcome study. am j phys med rehabil. 2001;80(8):563-571. https://doi.org/10.1097/00002060-200108000-00003. 5. flaxman te, shourijeh ms, alkjær t, et al. experimental muscle pain of the vastus medialis reduces knee joint extensor torque and alters quadriceps muscle contributions as revealed through musculoskeletal modeling. clin biomech (bristol, avon). 2019;67:27-33. https://doi.org/10.1016/j.clinbiomech.2019.04.005. https://doi.org/10.1097/jsm.0b013e31824cb53d https://doi.org/10.1177/0363546505280214/ https://doi.org/10.3109/03093648409146072 https://doi.org/10.1097/00002060-200108000-00003 https://doi.org/10.1016/j.clinbiomech.2019.04.005 anterior cruciate ligament reconstruction of a college student with a prosthetic limb: a disablement model case study 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 6. gailey r, allen k, castles j, kucharik j, roeder m. review of secondary physical conditions associated with lower-limb amputation and long-term prosthesis use. j rehabil res dev. 2008;45(1):15-29. https://doi.org/10.1682/jrrd.2006.11.0147. 7. te wierike sc, van der sluis a, van den akker-scheek i, elferink-gemser mt, visscher c. psychosocial factors influencing the recovery of athletes with anterior cruciate ligament injury: a systematic review. scand j med sci sports. 2013;23(5):527-540. https://doi.org/10.1111/sms.12010. 8. heijne a, axelsson k, werner s, biguet g. rehabilitation and recovery after anterior cruciate ligament reconstruction: patients' experiences. scand j med sci sports. 2008;18(3):325-335. https://doi.org/10.1111/j.1600-0838.2007.00700. 9. ellis hb, sabatino m, nwelue e, wagner kj, force e, wilson p. the use of psychological patient reported outcome measures to identify adolescent athletes at risk for prolonged recovery following an acl reconstruction. j pediatr orthop. 2020 oct;40(9):e844-e852. https://doi.org/10.1097/bpo.0000000000001624. https://doi.org/10.1682/jrrd.2006.11.0147 https://doi.org/10.1111/sms.12010 https://doi.org/10.1111/j.1600-0838.2007.00700 https://doi.org/10.1097/bpo.0000000000001624 abstract manuscript type patient-centered care commentary 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care rebecca m. lopez, phd, atc, cscs*; samar long, msed, at, atc†; dani m. moffit, phd, lat, atc‡; and ashley k. crossway, dat, atc** *university of south florida, tampa bay; †ohio state university, columbus; ‡idaho state university, pocatell; **state university of new york college, cortland key phrases cultural competence; intersectionality; healthcare disparities correspondence dr. rebecca m. lopez, university of south florida, 13220 usf laurel dr. mdc 106, tampa, fl 33612. e-mail: rml@usf.edu twitter: @rlopez1010 full citation lopez rm, long s, moffit dm, crossway ak. intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care. clin pract athl train. 2021;4(1):8-16. https://doi.org/10.31622/2021/0004.1.2. submitted: september 25, 2020 accepted: january 22, 2020. supplemental infographic: https://create.piktochart.com/output/48611749-my-visual introduction one of the key components of evidence-based medicine is incorporating the patient’s values and characteristics into the plan of care. as healthcare providers, athletic trainers should understand the importance of patient values and providing patient-centered care. however, this process of incorporating the patient’s values into the care provided requires learning more about the patient as a whole, rather than solely obtaining information regarding the reason they sought care. this process of patient-centered care provides focus beyond the simple characteristics seen on the outside. historically, patients who are of racial or ethnic minorities, such as those that are black or indigenous persons of color (bipoc) experience unconscious biases in medical care that lead to healthcare inequities.1 it has been documented in black women that the intersection of gender and race can lead to further discrimination.1,2 similarly, individuals of sexual and gender minorities have been marginalized and experience significant healthcare disparities.3 individuals that identify as lesbian, gay, bisexual, transgender, queer, intersex, or other gender or sexual minority (lgbtq+) experience healthcare disparities due to inadequate treatment, as well as avoidance of seeking care due to discrimination and stigmatization by healthcare providers. similarly, patients who are of racial or ethnic minorities, such as primarily those that are bipoc, have also experienced unconscious biases in medical care that lead to healthcare inequities.1 studies on athletic trainers’ perceptions of lesbian, gay, and bisexual (lgb) patients4 and lgbtq+ patients5 have shown that respondents overall had positive attitudes toward lgbtq+ patients, however, this was largely dependent on clinicians being female and/or having a close friend or relative that identified as lbg or lgbtq+.4,5 to our knowledge, there are no published studies specific to the healthcare provided to bipoc patients by athletic trainers. however, it is important not to compartmentalize our patients as belonging to one group or via a single-axis framework. this is highlighted by crenshaw’s work describing how the intersection of race and sex often results in the multidimensionality of the discrimination some individuals face.2 the intersection of race and sexual orientation and gender demonstrates that these factors are not mutually exclusive.2 individuals that belong to more than one marginalized group (i.e. race, sexual orientation, and gender identity) may have negative experiences (i.e. discrimination, mailto:rml@usf.edu https://doi.org/10.31622/2021/0004.1.2 https://nam02.safelinks.protection.outlook.com/?url=https%3a%2f%2fcreate.piktochart.com%2foutput%2f48611749-my-visual&data=04%7c01%7cmatthew.rivera%40indstate.edu%7c3689d417f57c4f519bff08d8d8d09dad%7c3eeabe396b1c4f95ae682fab18085f8d%7c0%7c0%7c637497737890222623%7cunknown%7ctwfpbgzsb3d8eyjwijoimc4wljawmdailcjqijoiv2lumziilcjbtii6ik1hawwilcjxvci6mn0%3d%7c1000&sdata=peskmik406dkncbawzuriy3az74cysfnjncz536z2ay%3d&reserved=0 intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 inadequate care) in healthcare due to belonging to a “dual minority”.1 implicit biases, prejudices, and stigmatization faced by marginalized groups often negatively impact mental health; this is referred to as minority stress.6 the lgbtq+ community, and other minority groups, find these experiences further lead to healthcare and health disparities. understanding these various aspects of intersectionality as it relates to ethnic minorities, sexual minorities, and other marginalized groups is essential in providing culturally competent care. therefore, the purpose of this commentary is to describe culturally competent care for lgbtq+ patients impacted by intersectionality and healthcare disparities. intersectionality people who have multiple marginalized identities often experience additional barriers to equitable healthcare when compared to those with singular marginalized identities; this cumulative effect is attributed to the theory of intersectionality.2 intersectionality is a theoretical framework that considers multiple social categories (i.e. race, ethnicity, gender, sexual orientation, socioeconomic status) intersecting at the micro level of individual experience to reflect multiple interlocking systems of privilege and oppression at the macro, social-structural level (i.e., racism, sexism, heterosexism).7 the phrase “women and minorities,” often used together, implies these two identifiers are mutually exclusive, when in fact, these two categories often intersect.7 additionally, minority has many different definitions. it can reference populations such as individuals in the lgbtq+ community; people with mental and/or physical disabilities; or, when living in other countries, white people.7 for example, the multiple layers of intersecting categories can lead one to a low-income black bisexual man with a physical disability. when considering the social determinants of health (i.e., socioeconomic status, gender, race, ethnicity, community), it is critical to consider how intersectionality can create complexity in treating patients. inequities and/or unfair gaps are widened when a person falls into more than one category. historically, white males with financial security receive the best medical care.7 consider the latino gay male who is not financially secure. the care he receives could change simply because of several distinct characteristics, in that he is gay, is a member of an ethnic minority, and is not financially secure. social justice in healthcare is relevant, but those who tend to be most harmed by social inequalities are those who have multiple forms of discriminatory characteristics in their being.8 part of the role of any healthcare provider is to know their patient; lack of understanding on potential barriers to care and discriminatory experiences by an athletic trainer can negatively affect the patient-provider relationship and lead to future health concerns of the patient. for example, athletic trainers should be concerned with their patients’ health across the lifespan; if a patient has a negative experience with one healthcare provider, this can be a deterrent and prevent this patient from seeking care from another provider in the future. therefore, understanding healthcare experiences may be moderated for patients who fall into more than one specific category and how this can impact their treatment and recovery. further, this understanding becomes imperative for any athletic trainer to better understand the needs of the patient. minority stress health disparity research often focuses on an individual cultural group, often race or sexual orientation, as opposed to considering the whole person which exists at the center of multiple identities.1 for persons with multiple social disadvantages, both health and well-being are influenced in a variety of ways.1 both intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 intersectionality and minority stress theories are helpful frameworks for understanding how compounding experiences of racism and homophobia cause barriers to seeking care and mistrust in the patient-provider relationship.1 for example, an individual that is part of an ethnic minority and is also part of the lgbtq+ community may experience adverse treatment that is commonly noted in each community, such as refusal of care or having expressed needs ignored or dismissed. often, having a very negative experience while seeking care from a healthcare provider is unique in that the patient’s hardships experienced in vastly differently communities converge. the minority stress model evolved from dr. ilan myers original work in 1995 to build the concept of a unique stress that sexual minority people (i.e., individuals in the lgbtq+ community) experience as a result of stigma, prejudice, and discrimination due to their sexual identity.6 lived experiences marked by hostile and stressful social environments contribute to higher incidences of mental health disorders and other health concerns. minority stress specifically addresses the excessive stress experienced by individuals from stigmatized social categories as a result of their marginalized social identities (i.e., race, religion, sexual orientation, gender identity), which deviate from societal norms and influence intergroup relations.6 viewing minority stress through the lens of the model of multiple dimensions of identity highlights how different identity dimensions are present in each individual but vary in degree of saliency based on context. common moderators of salience are family background, sociocultural conditions, and current life experiences.9 the minority stress processes include the experience of prejudice, expectations of being rejected, hiding and concealing, internalized homophobia, and various coping processes.6 since identity is both externally defined and internally experienced, instances of discrimination or expectations imposed from outside sources heavily impacts how a person makes meaning of their life experiences.9 the cumulative effect of holding a minority position in society further exacerbates the unyielding cycle of stress. in an attempt to cope, african-american lgbtq+ persons may compartmentalize their sexuality or attempt to diminish or hide their sexuality so they are seen embodying only one marginalized identity. hiding this aspect of their identity may help to lessen the anticipated effects of minority stress but will likely worsen their health outcomes.1 although taxing, the process of hiding an invisible, marginalized identity and engaging in performativity of gender occurs in the hope of receiving more equitable care. as noted earlier, a negative experience with a healthcare provider may result in a lack of trust in healthcare providers and lead an individual to not seek care. one way to alleviate the stress placed upon vulnerable patients is to create a safe space and engage in shared decision-making, which may facilitate better patient-provider communication and treatment compliance. a safe space can be anywhere that individuals feel included and comfortable being themselves. for example, in an inclusive athletic training clinic, a patient that identifies as transgender can ask the athletic trainer and others to refer to them by the pronouns with which they identify without negative consequence. an inclusive healthcare facility uses inclusive intake forms that allow patients to share their identity and guide patient care. a safe space allows patients to share relevant medical information freely, without judgement, as part of the shared decision-making process1 in addition to creating a safe space, clinicians must maintain awareness of the disadvantages among patients of marginalized identities within the healthcare system and across social class while providing patient-centered care for all.1 a lack of a safe space by a healthcare provider can lead to disadvantages experienced by minoritized intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 groups; these may include barriers to access, erasure of identity (gender identity, sexual orientation), healthcare stereotype threat, and refusal to treat, which lead to healthcare disparities. healthcare disparities in addition to the minority stress experienced by individuals in marginalized groups, these individuals often experience health disparities, or a diminished quality of health and healthcare across racial, ethnic, and socioeconomic groups.1,5 healthcare disparities often occur as a result of explicit or implicit biases from their healthcare provider, often affecting both mental and physical health. for example, an athletic trainer may have negative biases toward individuals that are transgender; as a result, the clinician may not provide adequate care to a transgender patient that is injured. these implicit biases by clinicians toward sexual and gender minorities, as well as other marginalized groups, have been shown to negatively impact patient perception of care, clinical decisions, and patient-clinician interactions.3,10 these disparities have been noted in various settings, including the pediatric population. lgbtq+ youth are at greater risk of healthcare disparities compared to their heterosexual, cisgender counterparts.11 these inequities may be due to stigmatization, family rejection, victimization, and lack of adequate training in healthcare providers.11 the disadvantages faced in lgbtq+ youth often continue into adulthood and can lead to increased substance abuse, depression, anxiety, and suicide.11 research on healthcare disparities often focuses on single social groups, and not on the intersection of various identifiers or groups an individual may belong to.1 the intersection of gender and sexual minorities with race and ethnicity may result in greater healthcare disparities for individuals that may be subjected to discrimination due to belonging to multiple marginalized groups. this is especially true for bipoc that identify as being part of the lgbtq+ community. although recent studies suggest athletic trainers are knowledgeable about the importance of patient-centered care and being culturally competent, it is unclear how clinicians can best implement this knowledge into clinical practice. athletic trainers and other healthcare providers should strive to continue to learn more about cultural competency and how to incorporate this information into their history taking, physical exams, management of injuries, and other aspects of their clinical practice. some examples of how athletic trainers can learn more and be more inclusive include seeking out continuing education opportunities regarding the lgbtq+ population and healthcare as well as reading the latest research regarding this patient population. athletic trainers and other clinicians can utilize this information to create a more inclusive environment in their setting. creating an inclusive athletic training environment can include the use of appropriate terminology and representation of inclusion and diversity, creating culturally competent forms for documentation, and ensuring all policies and procedures are reviewed to ensure they are inclusive (figure 1).12 it is also important to assess environmental and social factors that may be impacting the patient’s physical and mental health.1 whether or not an lgbtq+ individual is accepted by their family, friends and teammates, for example, can impact an individual’s physical and mental health status. if a young high school athlete has been kicked out of his home and does not have access to basic needs or medical insurance, this can have a devastating impact on their health and wellbeing. incorporating this information into the care provided would be a prime example of how minority stress and the negative impacts that discrimination and negative experiences can have intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 on someone’s physical and mental health can impact the care rendered by the athletic trainer. clinical application there are several action steps providers can take to ensure that they are providing patient-centered care to all patients, particularly those that are bipoc, of sexual or gender minorities or other marginalized groups. patient-centered care is a philosophy of care that encourages shared decision-making, focusing on the patient as a whole, and treats patients as partners in care. by understanding the role intersectionality plays in the lives of some of our patients, athletic trainers will enhance the patient-provider relationship. assessing one’s own biases will provide insight of how care may need to be adjusted to meet a patient’s needs. research has demonstrated disparities in shared decision-making and communication among sexual and gender minorities as well as bipoc and other racial/ethnic disparities. therefore, it is imperative for healthcare providers to ensure they are utilizing shared decision-making and patientcentered care. through shared decision-making, the clinician and patient can work together to have open communication, discuss treatment options, and develop a plan that will meet the needs of the patient.1 in addition to a selfassessment and the individual initiatives of each clinician, there are several system-based actions that should be taken to improve the clinic environment. the clinic should publicly display their non-discrimination policy, provide diverse educational materials, use inclusive intake forms, and train the entire staff (i.e., receptionist, insurance coordinators, etc.) not just the clinicians. furthermore, the facility should perform regular audits to ensure that the patients’ experience match the intended outcomes of the clinic. conclusion most lgbtq+ and bipoc individuals have experienced some form of discrimination in their lives. individuals that identify both as lgbtq+ and bipoc likely experience more discrimination due to the intersection of their race and sexual orientation or gender identity. unfortunately, some of these instances of discrimination have occurred with healthcare providers. as athletic trainers, it is important for us to increase our knowledge of the impact of intersectionality and minority stress on healthcare, examine our own biases, create an inclusive athletic training setting, and ensure that we are providing quality patientcentered care to all patients. references 1. peek me, lopez fy, williams hs, et al. development of a conceptual framework for understanding shared decision making among african-american lgbt patients and their clinicians. j gen intern med. 2016;31:677687. https://doi.org/10.1007/s11606-0163616-3. 2. crenshaw k. demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. u chi legal f. 1989:139-168. 3. arnold e, dhingra n. health care inequities of sexual and gender minority patients. dermatol clin. 2020;38:185-190. https://doi.org/10.1016/j.det.2019.10.002 . 4. ensign ka, yiamouyiannis a, white km, ridpath bd. athletic trainers' attitudes toward lesbian, gay, and bisexual national collegiate athletic association studentathletes. j athl train. 2011;46: 69-75. https://doi.org/10.4085/1062-6050-26017. 5. nye ea, crossway a, rogers sm, games ke, eberman le. lesbian, gay, bisexual, transgender, and queer patients: collegiate athletic trainers' perceptions. j athl train. 2019;54:334-344. https://doi.org/10.1007/s11606-016-3616-3 https://doi.org/10.1007/s11606-016-3616-3 https://doi.org/10.1016/j.det.2019.10.002 https://doi.org/10.1016/j.det.2019.10.002 https://doi.org/10.4085/1062-6050-260-17 https://doi.org/10.4085/1062-6050-260-17 intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 https://doi.org/10.4085/1062-6050-26017. 6. meyer ih. prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. psychol bull. 2003;129:674-697. https://dx.doi.org/10.1037%2f00332909.129.5.674. 7. bowleg l. the problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health. am j public health. 2012;102:1267-1273. https://doi.org/10.2105/ajph.2012.30075 0. 8. hankivsky o. women's health, men's health, and gender and health: implications of intersectionality. soc sci med. 2012;74:17121720. https://doi.org/10.1016/j.socscimed.2011.1 1.029. 9. jones sr, mcewen mk. a conceptual model of multiple dimensions of identity. j coll stud dev. 2000;41:405-414. 10. mcdowell mj, goldhammer h, potter je, keuroghlian as. strategies to mitigate clinician implicit bias against sexual and gender minority patients. psychosomatics. 2020; 61(6): 655-661. https://doi.org/10.1016/j.psym.2020.04.0 21. 11. hafeez h, zeshan m, tahir ma, jahan n, naveed s. health care disparities among lesbian, gay, bisexual, and transgender youth: a literature review. cureus. 2017;9:e1184. https://doi.org/10.7759/cureus.1184. 12. harriell k. teaching, learning cultural competency: respecting patient values, preferences vital to patient-centered care. in: nata news. vol. april 2020: 18-19. https://doi.org/10.4085/1062-6050-260-17 https://doi.org/10.4085/1062-6050-260-17 https://dx.doi.org/10.1037%2f0033-2909.129.5.674 https://dx.doi.org/10.1037%2f0033-2909.129.5.674 https://doi.org/10.2105/ajph.2012.300750 https://doi.org/10.2105/ajph.2012.300750 https://doi.org/10.1016/j.socscimed.2011.11.029 https://doi.org/10.1016/j.socscimed.2011.11.029 https://doi.org/10.1016/j.psym.2020.04.021 https://doi.org/10.1016/j.psym.2020.04.021 https://doi.org/10.7759/cureus.1184 intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 figure 1: supplemental infographic intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 intersectionality: the role of the athletic trainer in providing culturally competent patient-centered care 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 manuscript type evidence-to-practice review 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review laura m. kehr, ms, atc*; dylan c. rowe, ms, atc*; rylee m. learn, ms, atc*; allison b. smith, phd, scat, atc†; zachary k. winkelmann, phd, scat, atc* *university of south carolina, columbia, sc; †university of louisiana at lafayette, lafayette, la abstract while musculoskeletal (msk) pain conditions are some of the most common health issues faced internationally, the quality of patient care with msk pain is lacking. problems with msk care include the overuse of imaging, surgery, opioids, and failure to educate patients. improving the quality of care for msk conditions is considered a priority for all involved healthcare clinicians. the 2019 guiding systematic review addressed the concerns of msk management by identifying common recommendations for high-quality care through appraisals of clinical practice guidelines (cpgs). data was extracted from four databases and included articles examining the most common sites of msk pain in adults. selected articles were appraised using the agree ii instrument that provided scores to indicate the level of quality. researchers in the guiding systematic review then classified the cpgs to determine consistent recommendations. the results from the guiding manuscript identified eleven common and consistent recommendations for msk pain management that focused on a comprehensive approach to address the overall well-being of the individual to ensure patientcentered care. the recommendations should be incorporated into healthcare and clinical practices to give healthcare professionals patient-centered outcomes for msk pain management and improve the quality of care. correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation kehr lm, rowe dc, learn rm, smith ab, winkelmann zk. recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review. clin pract athl train;5(2): 24-31. https://doi.org/10.31622/2022/0005.02.5. submitted: december 2, 2020 accepted: august 24, 2021. original reference lin i, wiles l, waller r, et al. what does best practice care for musculoskeletal pain look like? eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. br j sports med. 2020;54(2):79-86. doi:10.1136/bjsports-2018-099878. summary clinical problem and question some of the leading causes of disability worldwide are musculoskeletal pain (msk) conditions.1 a lack of quality healthcare and a lack of universally agreed-upon treatment plans for these msk conditions, are two primary reasons for the msk related disability. a lack of quality healthcare results in the overuse of imaging,2,3 unnecessary surgeries,4,5 use of opioids.6,7 and a failure to properly educate and advise patients about their conditions.8 in order to combat quality of care issues and improve healthcare, clinicians can utilize clinical practice guidelines (cpgs), which are ‘statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options’.9 patient care that follows cpg recommendations typically results in improved patient outcomes and lower costs to the consumer, especially with the management of low back pain (lbp).10,11 these cpgs can also help ease transitions between different healthcare in terms of treatment options and care plans. unfortunately, there are also many shortcomings with cpgs, creating discourse and criticism in the literature. criticisms include the use of various guidelines for the same conditions having mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2022/0005.02.5 recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 inconsistent terminology, having too much or too little representation of certain conditions, and a lack of instruction for implementation into practice.12 despite criticisms, high quality cpgs may be effective methods for shaping how msk conditions are treated in the healthcare system. msk pain conditions in different body areas may share similarities in regard to mechanisms and clinical courses.13,14 however, there is inconsistent evidence that cpgs share similarities for how best to treat msk pain or that the recommendations can be applied across levels of healthcare. therefore, the purpose of the reviewed study was to establish recommendations to better assess and manage msk pain conditions based on available cpgs. summary of literature the authors of the guiding systematic review conducted a literature search of four databases that included medline, cinahl, embase, physiotherapy evidence database, and four unnamed guideline repositories to evaluate msk pain cpgs. the search terms and methods used in this study are the same as a previously published study.12 for a cpg to be included in the systematic review, it had to meet certain criteria including: 1) published no earlier than 2011, 2) focused on adults, 3) described pain development processes, and 4) had to be written in english. the guidelines that only focused on traumatic msk pain, single modalities, specific disease processes, and those that required payment were excluded from the systematic review. the authors’ initial search resulted in 6,232 cpgs, and after screening those results using their inclusion criteria, 44 guidelines were remaining for further appraisal. appraisal was completed by three independent investigators using the appraisal of guidelines for research and evaluation ii (agree-ii) instrument, which resulted in eleven cpgs that were considered high quality. the agree-ii instrument was utilized as it is the most widely used tool to obtain overall rating scores and identify high-quality cpgs.15,16 of the eleven cpgs that were high-quality and used in the systematic review, four of them evaluated low back pain, four investigated osteoarthritis pain, two evaluated neck pain, and one evaluated shoulder pain. after the appraisal, the cpgs were synthesized in four steps: extracting the cpg recommendations, classifying these recommendations, creating a narrative summary, and identifying common recommendations among msk conditions when possible. the authors were able to use the information from their extensive search and evaluation to produce the following outcomes and results. summary of outcomes the cpgs were classified according to “should do,” “could do,” “do not do,” and “uncertain” guidelines to help identify consistent recommendations which are defined in table 1. the guidelines that were assigned either “should do'' or “do not do” classifications and did not have conflicting evidence were considered consistent recommendations. following the appraisal and classification process, only 44 cpgs of the 6232 identified records met the inclusion criteria. the 44 included cpgs applied to various msk conditions which are specified in figure 1. from the 44 cpgs, 11 common and consistent recommendations were chosen to be applied across msk pain conditions. the guiding systematic review suggested that these recommendations could guide healthcare providers with a clear and simple consensus of current msk pain priorities and, as a result, may help address the variations in the quality-of-care patients receive.2,17,8 one intervention not listed in the systematic review was a consensus for cpgs related to opioid prescription. this is due to conflicting recommendations and the potential for harm; however, the only consistent view was to urge caution and discouraged the use of opioids. figure 1. number of appraised cpgs and their specific musculoskeletal conditions. recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 table 1. classification system the guiding systematic review used to determine consistent recommendations from relevant cpgs. classification definition should do recommendations that could be applied in all circumstances of musculoskeletal pain unless contraindications are present. these ‘should do’ recommendations are based on strong evidence such as having high-quality evidence of positive clinical effects or that the benefits of following the recommendations outweigh the risks. could do recommendations that could be applied in individual circumstances depending on the patient. these ‘could do’ recommendations are based on lesser quality studies with consistent evidence and where the benefits outweigh the harms. do not do recommendations with strong evidence of no benefits and/or the harms outweigh the benefits. uncertain ‘uncertain’ classification was applied because of incomplete or inconsistent findings and could not give a recommendation for or against a clinical practice. 0 2 4 6 8 10 12 14 16 other neck conditions shoulder conditions osteoarthritis low back pain number of identified cpgs recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 findings and clinical implications the appraisal and classification process in the guiding systematic review revealed 11 consistent recommendations for health care providers to incorporate into their practice. recommendations are summarized in table 2. the 11 recommendations may be used in a variety of ways to improve patient care. the reviewed article provided three examples of improvement. first, the recommendations may assist patients in making more informed decisions about their healthcare and help them recognize that some care they are receiving may be suboptimal. second, the recommendations can guide clinicians in their decision making for the best course of action for their patients. clinicians may also use them to identify areas where continued professional development is needed to improve their patient care. third, with continued development of the recommendations, a set of indicators could be used as a benchmark of quality care or as minimum standards. limitations of the article were also addressed. the agree ii instrument that scored the cpgs reflects processes and reporting of guidelines, not necessarily the quality of that content; therefore, high quality trials could have been excluded. also, the investigators created their own criteria for appraising cpgs based on the agree ii instrument which has the potential for bias. the study only reviewed cpgs in english, leaving out other relevant guidelines; however, the article is confident that, through their appraisal process, all relevant cpgs were included. clinical bottom line msk pain can greatly impact the quality of life for affected individuals. furthermore, variation in healthcare makes receiving care difficult for patients, as there are no common recommendations for the treatment of msk conditions. the assessment and management of msk conditions is the most effective way to improve the overall well-being of patients, and the lack in quality of care from the healthcare system is the largest problem faced by patients. the cpg recommendations were developed to address the shortcomings of the assessment and management of msk pain conditions, and implementation of the recommendations may begin to fix this problem. after reviewing this article, all members of the healthcare team should utilize the recommendations put forth by the guiding systematic review to provide measurable, impactful care. athletic trainers are included in the healthcare team and are no exception when it comes to following the guidelines presented by the reviewed article. athletic trainers have primary roles involving prevention, emergency care, assessment, and therapeutic interventions for illnesses and injuries, specifically with orthopedic and musculoskeletal care.18 athletic trainers also work with a variety of patients in various settings that can affect msk health. one of the eleven recommendations suggests completing an inclusive exam which may include neurological screenings and mobility and strength testing, which all athletic trainers are already trained to do during patient evaluations. athletic trainers already incorporate some of the cpg recommendations into practice by providing mobility, strength, and flexibility exercises and conservative management into rehabilitation therapy for their patients. however, even though this approach is already practiced, athletic trainers are still not perfect in their care. a study from 2016 indicated athletic trainers have knowledge about using evidence-based care, such as the cpg recommendations, in clinical settings, but less than 30% actually implemented evidence-based healthcare into practice.19 constant awareness, intentional implementation, and daily practice of the 11 recommendations is necessary to improve patient care in patients with msk pain conditions. recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 table 2. recommendations and examples to improve patient care recommendation examples classification of recommendations care should be patient centered • viewing the patient holistically • viewing each patient as an individual • allowing the patient to be involved with the decision-making process • using effective communication • base context on patient’s preferences categorized as “should do” for osteoarthritis (4/4), low back pain (4/4), neck pain (2/2), and shoulder pain (1/1) practitioners should screen patients for serious pathological conditions • suspected infections, malignancy, fracture, inflammatory causes of pain, or neurological deficits • serious conditions that present as msk pain but are not (aortic aneurysm) • gout • other arthritis or malignancy (bone pain) categorized as “should do” for osteoarthritis (1/1), low back pain (3/3), neck pain (2/2), and shoulder pain (1/1) assess psychosocial factors which can be affected by their injuries/illnesses • emotions/moods such as depression and anxiety • fear/kinesiophobia (irrational fear of physical movement due to injury or reinjury) categorized as “should do” for osteoarthritis (2/2), low back pain (4/4), neck pain (2/2), and shoulder pain (1/1) only use radiological imaging in specific situations • suspecting serious pathology • conservative care is not working • unexplained progression of signs and symptoms occurs • imaging is likely to change management categorized as “do not do” routine use of radiological imaging for osteoarthritis (1/1), low back pain (4/4), and shoulder pain (1/1) assessments should be complete and all inclusive • physical exams • neurological screening • mobility • muscle strength testing categorized as “should do” for osteoarthritis (2/2), low back pain (3/3), neck pain (1/1), and shoulder pain (1/1) use validated patientoriented outcome measures to evaluate patient progress • patient self-rated recovery questions • pain intensity measures • functional capacity or activities of daily living • quality of life questionnaires categorized as “should do” for osteoarthritis (2/2), low back pain (1/1), neck pain (1/1), and shoulder pain (1/1) educate patients about their conditions and the management options • to encourage self-management of their conditions • inform and reassure patients categorized as “should do” for osteoarthritis (3/3), low back pain (4/4), neck pain (2/2), and shoulder pain (1/1) recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 management options should address physical activity and exercise • strengthening • flexibility • mobility exercises (range of motion and stretching) • water-based exercises • neuromuscular education categorized as “should do” for osteoarthritis (4/4), low back pain (2/4), neck pain (2/2), and shoulder pain (1/1) categorized as “could do” for low back pain (2/4) use manual therapy only in combination with other evidence-based treatments • used with other management strategies like: o exercise o psychological therapy o information/education o activity advice categorized as “should do” with other modalities for osteoarthritis (1/1), low back pain (4/4), and shoulder pain (1/1) offer non-surgical treatments before considering surgery unless “red flag” conditions are present • conservative treatment yields no progress or makes the conditions worse categorized as “should do” for osteoarthritis (1/1), low back pain (2/2), and shoulder pain (1/1) facilitate continuation or resumption of work after msk injury • avoid inactivity • gradually increase normal daily activity levels • return to work and while continuing rehabilitation services • communication between workers, employers, and health providers categorized as “should do” for osteoarthritis (1/1), low back pain (2/3), neck pain (1/1), and shoulder pain (1/1) categorized as “could do” for low back pain (1/3) numbers provided in the classification of recommendation column refer back to the 11 cpgs (osteoarthritis=4, low back pain=4, neck pain=2, shoulder pain=1) athletic trainers also have a unique role in the healthcare team, as they practice in collaboration with other healthcare professionals, such as physicians, physical therapists, nurses, dietitians and pharmacists.18 if all of the healthcare professionals follow the recommendations of the guiding systematic review, the transfer of patient care will be seamless, the overall quality of care will increase, and better outcomes can occur for the patient in the event of a patient transfer between collaborating healthcare professionals. this holds true for athletic trainers when they perform an initial evaluation but must refer the patient to a physician for further testing or a physical therapist for a more focused rehabilitation plan. following the guidelines will allow for referrals to be smooth and will benefit the patient in the end. healthcare services can also use the cpg recommendations as benchmarks or minimum standards for documentation, reporting, or clinical audit purposes. for example, athletic trainers may base performance evaluation criteria on the cpg recommendations to evaluate the staff’s clinical performances and ensure patient-centered care is being practiced. in conclusion, msk pain conditions are common issues in various populations. unfortunately, the treatment and management of msk conditions can be inconsistent and suboptimal. treatment options and plan of care for patients can be lost during the transition between different healthcare providers and professions. improving recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 patient-oriented quality of care for msk conditions also poses a challenge in healthcare; fortunately, the cpg recommendations provide simple and direct guidelines to implement into practice. the eleven recommendations can serve as an educational tool and reference for all healthcare professionals who provide care for msk pain conditions, as well as a benchmark for comparing the quality of care between health services and minimum standards during reporting or clinical audits. the healthcare team, including athletic trainers, should be able to implement the eleven recommendations with ease which would in turn improve care for msk patients. the recommendations can be applied with minimal or no resources as several of the recommendations require the clinician to be patient-centered in their exam and delivery of information. examples of implementation without resources including assessing psychosocial factors, using validated outcome measures, and providing clear patient education. references 1. buchbinder r, van tulder m, öberg b, et al. low back pain: a call for action. the lancet. 2018;391(10137):2384-2388. https://doi.org/10.1016/s0140-6736(18)30488-4. 2. runciman wb, hunt td, hannaford na, et al. caretrack: assessing the appropriateness of health care delivery in australia. med j aust. 2012;197(2):100-105. https://doi.org/10.5694/mja12.10510. 3. ivanova ji, birnbaum hg, schiller m, kantor e, johnstone bm, swindle rw. real-world practice patterns, health-care utilization, and costs in patients with low back pain: the long road to guidelineconcordant care. spine j. 2011;11(7):622-632. https://doi.org/10.1016/j.spinee.2011.03.017. 4. adelani ma, harris ahs, bowe tr, giori nj. arthroscopy for knee osteoarthritis has not decreased after a clinical trial. clinl orthop relat res. 2016;474(2):489-494. . https://doi.org/10.1007/s11999-015-4514-4. 5. ketola s, lehtinen jt, arnala i. arthroscopic decompression not recommended in the treatment of rotator cuff tendinopathy: a final review of a randomized controlled trial at a minimum follow-up of ten years. bone joint j. 2017;99(6):799-805. https://doi.org/10.1302/0301-620x.99b6.bjj-20160569.r1. 6. dowell d, haegerich tm, chou r. cdc guideline for prescribing opioids for chronic pain—united states, 2016. jama. 2016;315(15):1624. https://doi.org/10.1001/jama.2016.1464. 7. sullivan md, howe cq. opioid therapy for chronic pain in the united states: promises and perils. pain. 2013;154:s94-s100. https://doi.org/10.1016/j.pain.2013.09.009. 8. williams cm. low back pain and best practice care. arch intern med. 2010;170(3):271. https://doi.org/10.1001/archinternmed.2009.507. 9. institute of medicine committee on standards for developing trustworthy clinical practice g. in: graham r, mancher m, miller wolman d, greenfield s, steinberg e, eds. clinical practice guidelines we can trust. washington (dc): national academies press (us). copyright 2011 by the national academy of sciences. all rights reserved.; 2011. https://doi.org/10.17226/13058. 10. childs jd, fritz jm, wu ss, et al. implications of early and guideline adherent physical therapy for low back pain on utilization and costs. bmc health serv res. 2015;15(1). doi:10.1186/s12913-0150830-3 https://doi.org/10.1186/s12913-015-0830-3. 11. rutten gm, degen s, hendriks ej, braspenning jc, harting j, oostendorp ra. adherence to clinical practice guidelines for low back pain in physical therapy: do patients benefit? phys ther. 2010;90(8):1111-1122. https://doi.org/10.2522/ptj.20090173. 12. lin i, wiles lk, waller r, et al. poor overall quality of clinical practice guidelines for musculoskeletal pain: a systematic review. br j sports med. 2018;52(5):337-343. https://doi.org/10.1136/bjsports2017-098375. 13. babatunde oo, jordan jl, van der windt da, hill jc, foster ne, protheroe j. effective treatment options for musculoskeletal pain in primary care: a systematic overview of current evidence. plos one. 2017;12(6):e0178621. https://doi.org/10.1371/journal.pone.0178621. https://doi.org/10.1016/s0140-6736(18)30488-4 https://doi.org/10.5694/mja12.10510 https://doi.org/10.1016/j.spinee.2011.03.017 https://doi.org/10.1007/s11999-015-4514-4 https://doi.org/10.1302/0301-620x.99b6.bjj-2016-0569.r1 https://doi.org/10.1302/0301-620x.99b6.bjj-2016-0569.r1 https://doi.org/10.1001/jama.2016.1464 https://doi.org/10.1016/j.pain.2013.09.009 https://doi.org/10.1001/archinternmed.2009.507 https://doi.org/10.17226/13058 https://doi.org/10.1186/s12913-015-0830-3 https://doi.org/10.2522/ptj.20090173 https://doi.org/10.1136/bjsports-2017-098375 https://doi.org/10.1136/bjsports-2017-098375 https://doi.org/10.1371/journal.pone.0178621 recommendation for best practices in the management of musculoskeletal pain: an evidence-to-practice review 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 14. henschke n, ostelo rw, terwee cb, van der windt da. identifying generic predictors of outcome in patients presenting to primary care with non-spinal musculoskeletal pain. arthritis care res. 2012:n/an/a. https://doi.org/10.1002/acr.21665. 15. brouwers mc, kho me, browman gp, et al. development of the agree ii, part 2: assessment of validity of items and tools to support application. can med assoc j. 2010;182(10):e472-e478. https://doi.org/10.1503/cmaj.091716. 16. brouwers mc, kho me, browman gp, et al. development of the agree ii, part 1: performance, usefulness and areas for improvement. can med assoc j. 2010;182(10):1045-1052. https://doi.org/10.1503/cmaj.091714. 17. buchbinder r, staples mp, shanahan em, roos jf. general practitioner management of shoulder pain in comparison with rheumatologist expectation of care and best evidence: an australian national survey. plos one. 2013;8(4):e61243. https://doi.org/10.1371/journal.pone.0061243. 18. rizzo cs, breitbach ap, richardson r. athletic trainers have a place in interprofessional education and practice. j interprof care. 2015;29(3):256-257. https://doi.org/10.3109/13561820.2014.942778. 19. keeley k., walker se, hankemeier da, martin m, cappaert ta. athletic trainers' beliefs about and implementation of evidence-based practice. j athl train. 2016;51(1):35-46. https://doi.org/10.4085/1062-6050-51.2.11. https://doi.org/10.1002/acr.21665 https://doi.org/10.1503/cmaj.091716 https://doi.org/10.1503/cmaj.091714 https://doi.org/10.1371/journal.pone.0061243 https://doi.org/10.3109/13561820.2014.942778 https://doi.org/10.4085/1062-6050-51.2.11 abstract manuscript type evidence-to-practice review 61 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review leona j. keller, ms, atc*; sooji m. berthiaume, ms, atc†; karis j. landry ms, atc‡; alyssa l. bolno, ms, atc§; zachary k. winkelmann, phd, atc? *vanderbilt university, nashville, tn; †west creek high school, clarksville, tn; ‡landrum high school and middle school, campobello, sc; §the walker school, marietta, ga ;?university of south carolina, columbia, sc abstract concussions can have lasting symptoms in children such as depression, anxiety, hyperactivity, or failure to control anger. if diminished mental health outcomes are not monitored and do not improve after concussion, children may need additional treatment as a result of sequela. the purpose of the guiding systematic review was to determine if there are increased mental health symptoms in pediatric patients who sustained a concussion as compared to pediatric patients who have not sustained a concussion. the guiding systematic review and meta-analysis authors used seven different databases for articles published from 1980 to 2020. selected articles had mental health outcomes classified as internalizing, externalizing, or total mental health difficulties. mental health was assessed by new psychiatric findings post-injury, as well as total problem subscales. twenty-nine articles identified mental health complications following a pediatric concussion. children with pre-injury mental health (50% to 60%) were more likely than children without preinjury mental health symptoms to have decreased mental health outcomes following concussion. in acute (less than 3 months postinjury), persistent (between 3and 12-months post-injury), and chronic (over 12 months post-injury) timelines, the concussion group demonstrated significant, moderate effects in mental health for internalizing and externalizing. this topic is clinically relevant for athletic trainers as they may work with adolescent populations with a previous medical history of concussion or who may experience a concussion in the future. mental health training sessions, such as online continuing education courses, for athletic trainers will build the skills to treat patients who may be experiencing diminished mental health outcomes following concussion. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation keller lj, berthiaume sm, landry kj, bolno al, winkelmann zk. childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review. clin pract athl train. 2023;6(1): 61-66. https://doi.org/10.31622/2023/0006.01.9. original reference gornall a, takagi m, morawakage t, liu x, anderson v. mental health after paediatric concussion: a systematic review and meta-analysis. br j sports med. 2021;55: 1048-1058. summary clinical problem and question sports related concussions are estimated to affect between 1.1-1.9 million children under the age of 18 per year.1 concussion is a form of mild traumatic brain injury (mtbi) as defined by the international concussion in sports group (cisg) as “a traumatic brain injury induced by direct or indirect biomechanical forces to the head, neck or body”.2 concussions can have lasting difficulties such as cognitive, behavioral, physical, somatic, and emotional symptoms and often coincide with mental health symptoms.2 specifically, in children aged 0-18 years, symptoms may present as internalizing which are focused inward or externalizing features which are focused outward. internalizing features may be anxiety or depressive symptoms, and externalizing features may be aggression, hyperactivity, or disruptive conduct. this topic is clinically relevant because athletic trainers often work with adolescent populations who have or will experience a concussion, as well as mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.01.9 childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 work with patients who have been diagnosed with a mental health condition by a psychiatrist. the lasting impact of concussions can be hard to determine which makes assessments and interventions critical. poor increased mental health symptoms typically decrease after concussion, but occasionally children have lasting mental health symptoms that require additional treatment. utilizing mental health outcomes and mental health questionnaires could help concussion management regarding mental health difficulties faced postconcussion.3 the purpose of the guiding systematic review was to determine if there are increased mental health symptoms in pediatric patients with concussions as compared to pediatric patients without concussion. summary of literature the guiding systematic review used medline, embase, psycinfo, cinahl, sportdiscus, scopus and pubmed in their search for articles published from 1980 to june 2020. article inclusion criteria was 1) peerreviewed articles reporting prospective mental health outcomes following concussion in pediatric populations (ages 0-18 years at time of injury), 2) quantitative studies included observational designs, prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies, 3) qualitative studies included phenomenology, grounded theory, ethnography and action research, 4) mixed-methods studies were considered if data from the quantitative or qualitative components could be extracted, 5) the concussion definition was consistent with the berlin cisgcriteria, regardless of whether or not these criteria were explicitly cited, 6) presence of a control group, and 7) completion of mental health measures (scat5, voms, symptom evaluation, etc.). the classifications of mental health symptoms were internalizing (symptoms focused inwardly), externalizing (symptoms focused outwardly) and overall mental health difficulties measured by novel psychiatric diagnoses post-injury.4 internalizing classifications were disorders such as anxiety, depressive, and somatic symptoms.4 externalizing classifications were disorders such as prominent impulsive, disruptive conduct, aggression, and substance use symptoms.5 mental health was assessed by new psychiatric findings post-injury as well as total problem subscales of confirmed behavioral and emotional inventories. the study included a broader range of time since injury to capture the context of recovery, the time points were defined as: 1) acute, 2) persisting, and 3) chronic. the downs and black quality appraisal criteria (dbc) and the oxford centre for evidence-based medicine 2011 levels of evidence was used to assess the quality and strength of the eligible studies.6,7 the studies that were included were rated as excellent or good quality on the dbc. forty-three studies recruited participants using consecutive admissions or inception cohort design, indicating low risk of selection bias. risk of selection bias was suggested in 22 studies in the meta-analysis because they recruited controls from the same setting as the concussion sample. the search of databases discovered 69 articles that met the eligibility criteria and 60 were included in the systematic review. out of the 69 articles, 29 were excluded from the meta-analysis because of the absence of a control group, or because the meta-analysis did not complete the mental health measures, resulting in 40 articles. summary of outcomes the data was collected from the characteristics of 89,114 children (60.9% males) with concussions. the three main mechanisms of injury were from falls (42.3%), sporting injuries (29.5%), and motor vehicle accidents (15.5%).8 the mental health outcomes were defined by validated questionnaire measures (n=60), interviews of the children (n=2), a formal psychiatric diagnosis (n=3), or engagement with mental health services (n=3). the most commonly used outcome measures to detect mental health outcomes were the child behavior checklist, the behavior assessment system for children, and the personality inventory for children. the child behavior checklist (n=19, 27.5%) is a self-administered test given to a parent, teacher, and the child. this childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 test is part of the achenbach system of empirically based assessment to test for behavioral and emotional problems in children.9 the behavior assessment system for children (n=7, 10.1%) was used to assess the behavioral and emotional functions from taking the results of a questionnaire given to the child, parent, and a teacher.9,10 the personality inventory for children (n=7, 10.1%) was also used to measure mental health outcomes. internalizing features (n=43), overall mental health (n=32), and externalizing features (n=29) were assessed (table 1). twenty-eight of the studies assessed the premorbid mental health status. this included the preinjury behavior (n=19) or psychiatric diagnoses (n=9) using the international classification of disease criteria-10 (icd-10). findings and clinical implications the present systematic review showed significant, moderate effect sizes of internalizing features with comparing the acute, persisting and chronic outcomes (table 1). the acute outcome was measured over less than three months, the persisting difficulties was from 3 to 12 months and the chronic difficulties were any case over 12 months. there were significant, moderate effect sizes observed in the externalizing features comparing the acute persisting, and chronic outcomes. for total features, the results showed that mental health in children generally improves over a span of 12 months with the acute cases experiencing the most effects. several of the articles addressed the frequency of decreased mental health after a pediatric concussion. these studies suggest a minority of the children experienced clinically significant levels of internalizing, externalizing, and total mental health difficulties following their concussions.11 the factors that predicted mental health challenges following pediatric concussion included pre-injury mental health, age from 2.5 to 18 years old (the younger kids from age 2.5 to11 showed more externalizing features), and sex (females have a greater risk of developing new mental health symptoms).8,12,13 males with psychiatric history were at a greater risk for further complications. overall, age and sex were inconsistent predictors of mental health difficulties but some studies showed females to be more vulnerable to internalizing mental health features post-concussion.11 familial factors such as the family functioning, anxiety, characteristics (e.g., figure 1. systematic review flow chart childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review 64 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 parent education, family socioeconomic status, living arrangements of the child), as well as parent mental health, and distress played a role in the mental health of the children studied.14 mental health and postconcussion syndrome was examined in 11 studies. internalizing symptoms significantly predicted the acute and post-acute post-concussion syndrome recovery.15 mental health remains consistent over time post-injury with the mental health issues developing within the first-year post-concussion.11 it took 3 to 6 months to see significant improvements post-concussion with infants and toddlers experiencing social and emotional behavior issues (oppositional defiance, attention-deficit/hyperactivity, substance use and mood disorder symptoms seen around ages 14 to 16).16 additional studies are needed on the impact of age and sex due to the lack of age-specific and sex-specific data acquired. table 1. mental health difficulties following pediatric concussions as compared to controls acute timeline persistent timeline chronic timeline internalizing externalizing internalizing externalizing internalizing externalizing mean size difference likelihood ratio 95% ci p 5.12 0.45 0.17-0.74 0.01 5.77 0.37 0.09-0.65 0.03 4.26 0.42 0.20-0.63 0.001 4.94 0.46 0.25-0.66 <0.001 2.88 0.41 0.10-0.72 0.01 3.46 0.25 0.09-0.41 0.005 t=mean size difference between two groups; g=likelihood ratio that the test would be positive in the target population; 95% ci=confidence interval means that there is a 95% chance the real value is in the interval; p=means that there is the p-value chance that the observed differences occurred by chance clinical bottom line clinicians who work with patients who participate in sports are likely to have experiences with mild traumatic brain injuries (mtbi) and mental health conditions. it is especially important for pediatric patients that the sports medicine team remains aware of the patient’s mental health as a factor in their concussion recovery. athletic trainers can greatly improve the concussion recovery by including a mental health screen with the baseline concussion test before the onset of the sport/activity. for mental health concerns to be detected early, a psychiatric screening should be conducted in accordance with a yearly concussion baseline test as part of ppe. these additions can be implemented into the established policies and procedures manuals. as the national athletic trainers’ association position statement on concussion management does not adequately address mental health screenings, the translating research into injury prevention practice (tripp) framework would be necessary to start those changes. the previous recommendation would be a part of stages 5 and 6 of the tripp frameworks which would help explore how to implement changes and then if those changes would be effective. after typical concussion symptoms have decreased, it is recommended that the same psychiatric screening used prior to the injury is utilized again. this will allow providers to assess if there is a change in the patients baseline mental health and the mental health concerns they may still be facing. after sustaining a concussion, the patient’s “symptoms check” should include physical and cognitive symptoms, as well as mental healthrelated items such as nervousness, anxiety, sadness, depression, and/or increased irritability.3 in children, externalizing features are prominent such as hyperactivity, failure to control anger, or disordered conduct.8 childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review 65 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 it is key to remember that children that have been diagnosed with a concussion will experience overall mental health problems what will express internally and externally. as athletic trainers, we must be able to recognize and refer based off these symptoms. internalizing symptoms would include anxious/overwhelmed (e.g., restlessness, uneasiness, panic), somatic concerns (e.g., excessive thoughts or feelings related to body symptoms such as pain or aches), and withdrawal (e.g., social isolation, introverted personality). a patient presenting with aggressive behaviors, intrusive thoughts, and risky behaviors are experiencing more externalizing symptoms. athletic trainers should consider using screening instruments, like the brief symptom inventory 18 (bsi-18) in conjunction with a psychological care team, to measure psychological distress prior to and following a pediatric concussion. individuals with an existing history of mental health challenges appear to be at a greater risk for persistent symptoms prior to their concussion diagnosis.17 athletic trainers should be mindful of assessing persistent postconcussion symptoms and recognize the possible overlap of mental health symptoms. athletic trainers should work with other health care providers when there are persistent mental health concerns. an interprofessional team consisting of an athletic trainer, physician, counselor, or psychologist is recommended with prolonged mental health concerns.18 if the site does not have an athletic trainer, the physician who is responsible for clearing the athlete for participation after their concussion should screen the athlete for any mental health concerns and if found, there should be a follow-up appointment with that physician, or a referral made to a counselor or psychologist to. previous management recommendations included prolonged rest, but studies have identified this to be associated with poor mental health outcomes.19 participation in early physical activity is associated with shorter symptom recovery times and fewer overall symptoms such as dizziness, nausea, headache, or visual problems..20 athletic trainers have an important duty to educate and increase awareness for the pediatric patients and their families regarding the effects of mental health-related symptoms associated with concussions. an educational pamphlet can be incorporated with the initial ppe form including information on post-concussion management as well as potential mental health consequences for the parents or guardians since they play a vital role in the patient’s care. the physical, cognitive, and mental health-related symptoms of concussion occur at different rates and last for various periods of time. this represents an important diagnostic criterion of post-concussion syndrome for both icd-10 and diagnostic and statistical manual of mental disorders (dsm-5).3 references 1. bryan ma, rowhani-rahbar a, comstock rd, rivara f. sportsand recreation-related concussions in us youth. pediatrics. 2016;138(1). https://doi.org/10.1542/peds.2015-4635. 2. mccrory p, meeuwisse w, dvořák j, et al. consensus statement on concussion in sport-the 5(th) international conference on concussion in sport held in berlin, october 2016. br j sports med. 2017;51(11):838-847. http://dx.doi.org/10.1136/bjsports-2017-097699. 3. topolovec-vranic j, zhang s, wong h, et al. recognizing the symptoms of mental illness following concussions in the sports community: a need for improvement. plos one. 2015;10(11):e0141699. https://doi.org/10.1371%2fjournal.pone.0141699. 4. association ap. diagnostic and statistical manual of mental disorders (5th ed.). 2013. 5. reynolds c, kamphaus r. behavior assessment system for children–third edition (basc-3). bloomington, mn: pearson. 2015. https://doi.org/10.1542/peds.2015-4635 http://dx.doi.org/10.1136/bjsports-2017-097699 https://doi.org/10.1371%2fjournal.pone.0141699 childhood mental health outcomes following mild traumatic brain injury: an evidence-to-practice review 66 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 6. downs sh, black n. the feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. j epidemiol community health. 1998;52(6):377-384. https://doi.org/10.1089/neu.2018.6235. 7. howick j, chalmers i, glasziou p, et al. the oxford levels of evidence 2. 2011. 8. gornall a, takagi m, clarke c, et al. behavioral and emotional difficulties after pediatric concussion. j neurotrauma. 2020;37(1):163-169. https://doi.org/10.1089/neu.2018.6235. 9. rescorla la. assessment of young children using the achenbach system of empirically based assessment (aseba). ment retard dev disabil res rev. 2005;11(3):226-237. https://doi.org/10.1002/mrdd.20071. 10. biedermann f, fleischhacker ww. psychotic disorders in dsm-5 and icd-11. cns spectr. 2016;21(4):349-354. https://doi.org/10.1017/s1092852916000316. 11. massagli tl, fann jr, burington be, jaffe km, katon wj, thompson rs. psychiatric illness after mild traumatic brain injury in children. arch phys med rehabil. 2004;85(9):1428-1434. https://doi.org/10.1016/j.apmr.2003.12.036. 12. brooks bl, plourde v, beauchamp mh, et al. predicting psychological distress after pediatric concussion. j neurotrauma. 2019;36(5):679-685. https://doi.org/10.1089/neu.2018.5792. 13. keenan ht, clark ae, holubkov r, cox cs, ewing-cobbs l. psychosocial and executive function recovery trajectories one year after pediatric traumatic brain injury: the influence of age and injury severity. j neurotrauma. 2018;35(2):286-296. https://doi.org/10.1089/neu.2017.5265. 14. antshel km, malhotra a, seigers d. attributions of behavior in the pediatric mild closed head injury (chi) population. psychol health med. 2007;12(1):48-63. https://doi.org/10.1080/13548500500535654. 15. anderson v, davis ga, takagi m, et al. trajectories and predictors of clinician-determined recovery after child concussion. j neurotrauma. 2020;37(12):1392-1400. https://doi.org/10.1089/neu.2019.6683. 16. mckinlay a, grace r, horwood j, fergusson d, macfarlane m. adolescent psychiatric symptoms following preschool childhood mild traumatic brain injury: evidence from a birth cohort. j head trauma rehabil. 2009;24(3):221-227. https://doi.org/10.1097/htr.0b013e3181a40590. 17. iverson gl, gardner aj, terry dp, et al. predictors of clinical recovery from concussion: a systematic review. br j sports med. 2017;51(12):941-948. https://doi.org/10.1136/bjsports-2017-097729. 18. silverberg nd, iaccarino ma, panenka wj, et al. management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. arch phys med rehabil. 2020;101(2):382-393. https://doi.org/10.1016/j.apmr.2019.10.179. 19. difazio m, silverberg nd, kirkwood mw, bernier r, iverson gl. prolonged activity restriction after concussion: are we worsening outcomes? clin pediatr (phila). 2016;55(5):443-451. https://doi.org/10.1177/0009922815589914. 20. wilson jc, kirkwood mw, potter mn, wilson pe, provance aj, howell dr. early physical activity and clinical outcomes following pediatric sport-related concussion. j clin transl res. 2020;5(4):161-168. https://doi.org/10.1089/neu.2018.6235 https://doi.org/10.1089/neu.2018.6235 https://doi.org/10.1002/mrdd.20071 https://doi.org/10.1017/s1092852916000316 https://doi.org/10.1016/j.apmr.2003.12.036 https://doi.org/10.1089/neu.2018.5792 https://doi.org/10.1089/neu.2017.5265 https://doi.org/10.1080/13548500500535654 https://doi.org/10.1089/neu.2019.6683 https://doi.org/10.1097/htr.0b013e3181a40590 https://doi.org/10.1136/bjsports-2017-097729 https://doi.org/10.1016/j.apmr.2019.10.179 https://doi.org/10.1177/0009922815589914 abstract editorial 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association meredith decker, phd, lat, atc* & shaketha pierce, ms, lat, atc† *university of texas at arlington, arlington, tx; †newman smith high school, carrollton, tx moderator: s. andrew cage, med, lat, atc key phrases patient-centered care; lgbtqia full citation decker m, pierce s. the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association. clin pract athl train. 2021;4(3): 5-9. https://doi.org/10.31622/2021/0004.3.2. editorial the southwest athletic trainers’ association (swata) is excited to begin this new partnership with clinical practice in athletic training. as part of this partnership, the swata free communications and research committee provides double-blinded peer review abstracts from credentialed athletic trainers who presented their works in the free communications program at the annual swata symposium. out of an abundance of caution, the 2021 symposium was held virtually, and those free communications presentations were disseminated via social media. the swata mission statement states that the purpose of the organization is to enhance the quality of healthcare for the physically active; to promote and advance the athletic training profession; to promote a better working relationship among those who work toward care and prevention of athletic injuries; enhance the healthcare of persons served by the membership; safeguard and advance the membership; and to promote the free exchange of information with swata. to this end, the swata free communications and research committee has entered into collaborative efforts with the district’s lesbian, gay, bisexual, transgender, and queer (lgbtq+) advisory committee and the ethnic diversity advisory committee. through these efforts, the hope is to promote a community of athletic trainers who embrace their collective roles as clinicians, educators, and scholars, working toward a common goal of enhancing the holistic health of physically active individuals from all populations. at the 2021 swata virtual symposium, the district expressed the explicit need for continuing professional development and programming to improve diversity, equity, inclusion, and social justice in athletic training. to this end, the swata free communications committee interviewed our district lgbtq+ advisory committee chair, meredith decker, and ethnic diversity advisory committee chair, shaketha pierce. the swata free communications and research committee chair, andrew cage, gained insight into the committees’ current initiatives. cage: please tell the readers the roles and responsibilities of these committees within swata, and the athletic training profession as a whole. pierce: the great thing about the ethnic diversity advisory committee is that our role is that we get to bring awareness to ethnically diverse situations for patients and athletic trainers. we get to serve as advocates for information and research relating to healthcare issues and conditions that affect the health of physically active ethnic minority patients. we identify and address issues related to cultural distinctions in healthcare delivery. we advocate for recruitment and retention of athletic trainers from ethnic minorities, and bring attention to healthcare disparities affecting ethnic minority patients. https://doi.org/10.31622/2021/0004.3.2 the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 decker: the role of the lgbtq+ advisory committee is to serve as an advisory committee our main goal as a committee is to facilitate inclusive athletic training practices. we specifically do so by providing resources on the wide range of lgtbq+ topics. whether that is creating and disseminating articles or infographics, putting together research, or just sharing the most relevant resources tied to lgbtq+ issues in the community. cage: what are some of the challenges the patient populations you serve encounter in healthcare? pierce: the challenges that the populations that i serve encounter tend to be health disparities. when these patients have been sent to physician, the physician is not always aware of the cultural conditions that these patients are faced with. the patients may not receive the best care possible due to different biases healthcare providers have. there are also language barriers patients may encounter. some patients do not have insurance or have other financial issues leading to them being turned away. along with that, we also have to make sure that we send our patients to healthcare providers who we know will give them the best care. we also have to make sure that our patients are getting the best patient-centered care from us and other healthcare providers. decker: for the lgbtq+ patient population, this is a really broad category of individuals. there are a lot of different challenges that the community as a whole faces. it relates to the identities within the lgbtq+ community. whether it is an identity related to gender or sexual orientation within the community. it depends on those factors what challenges those people will face. overall, the lgbtq+ community is still looking to gain equality in this country. i think that spans into healthcare as well. we can see that nowadays with the various anti-transgender and anti-lgbtq+ legislation that is occurring within our country. specific to that, there are a lot of issues related to access to healthcare. a lot of people in the lgbtq+ community have trouble finding inclusive healthcare providers that are willing to treat their individualized patient needs. it really boils down to providers not truly understanding those patient needs and getting to know the patient on that individual level and providing patient centered care. another big issue is that patients and patients may not feel like they are in a safe and inclusive environment. they may not feel like they can be themselves or disclose their identities for fear of repercussions from an acceptance standpoint and access to healthcare standpoint. cage: what are some of the challenges the clinician populations you serve encounter in their clinical practice? pierce: a lot of challenges ethnically diverse clinician populations face come down to the first challenge that usually comes up, microaggressions. it could have to do with the clinician’s hair, how they speak, how they express themselves. a clinician may talk with their hands or elevate their voice, which can be perceived as aggressive by those who do not understand how the clinician expresses themselves. that does not mean the clinician has attitude, which is just how they express themselves. it is often misperceived. decker: a lot of lgbtq+ athletic trainers may feel that there are negative repercussions if they are their authentic selves in their patient care settings. that may limit them from being out or sharing their authentic selves. they may be out in their personal lives, but not in their work lives for fear of acceptance or their job security. it is an unfortunate reality that people can still be fired for being lgbtq+ in their work environment. also, not being fully understood in the identities that we all share in the lgbtq+ community. this impacts us as an individual person, and we want our coworkers and others to take that into account. i would say the biggest challenge is the feeling that the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 there is not a safe space to be clinicians, similar to our patients. cage: how does someone who is unfamiliar gain a better understanding of what athletic trainers and patients from ethnic minorities and the lgbtq+ community deal with while trying to do their jobs or participate in sports? pierce: i would say for ethnic minorities the biggest thing is, last year the national athletic trainers’ association (nata) came out with the listen first initiative. that would be the first thing, listen first. if a patient comes in and is trying to tell you that they feel a certain way about care they have received or someone they have encountered, the biggest thing is to listen and try not discredit what they are telling you. try not to say “i didn’t see that”. you may not have, because it did not happen to you. while you are listening, work to be an active listener. make sure you are listening to understand, not to try to counter what you are being told. also, work to be able to have uncomfortable conversations. with ethnically diverse populations, we are used to being the only ones in the room. we are used to being uncomfortable. often times, when others we speak with are uncomfortable it makes them feel a certain way, and they are not use to that. so work to get used to having uncomfortable conversations and having those encounters where you can ask questions in that safe space that meredith mentioned earlier. next, make sure to remove personal opinions and beliefs. make sure that whenever you go into your clinic or facility, whatever person beliefs that you have do not keep you from treating your patients the way they should be treated. even if there is something you do not agree with, your patient should never know that. decker: i am going to echo the first point that shaketha made about listening and understanding. i think that is the first step regardless of which community or patient we are talking about. it is really the ability to try to understand people on an individual level that makes us patient centered clinicians. also, become educated more about the lgbtq+ community as a whole; dive into understanding different populations. this may just start with some of the basics of understanding the difference between gender identity and sexual orientation. try to understand the specifics, but also the community as a whole and the challenges that they face. the part about education that i really want to emphasize is that it has to be self-driven to fully understand the lgbtq+ population. we cannot fully rely on those within the lgbtq+ community to share their experiences and to direct our learning for us. we have to be a self-directed learner where you seek out that information on your own and then can come back to the patients and providers that you are working with and show that you have gained and are using that understanding. cage: what specific knowledge and skills do you think athletic trainers need in order to best serve a patient population that includes members of ethnic minorities and the lgbtq+ community? pierce: i would say one of the skills would be interpersonal skills, to be able to have conversations with patients and colleagues and be able to ask about families, life, and to get beyond the typical patient information. another skill is cultural competence, a lot of times we shy away from it and go back to the mindset of “i am just doing what i have always done.” the beauty of athletic training is that we are always learning. we are never at a standstill, we are lifelong learners. also, having an inclusive mindset. maybe one of your patient populations is not being well served, so having awareness is a crucial skill. next, basically provide grace. understand that your patients may not understand what you are saying. they may not understand what athletic trainers do because they have not been around them. they may come in and they are very independent, and we are trying to educate them the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association 8 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 and do not understand why they do not understand. so, we have to provide grace but also ask for grace in this case. the last skill i would say is patience. understand that this is a process that is new for a lot of athletic trainers. have patience with your colleague, but ask for patience in return as well. decker: i agree with shaketha. i also think the biggest factor is going to be soft skills. it is not going to be the tangible skills you learn in your athletic training program. it is going to be soft skills that you have and you continue to develop as a professional. those are the most important factors to serving patients in the lgbtq+ community. it goes back to what we have talked about regarding providing patient-centered care. there are no two patients within the lgbtq+ community are the same. you may be treating two gay men that may identify similarly from a sexual orientation standpoint, they are going to have individual needs. it is critical to understand those needs and factors about our patients and their individual preferences throughout all of their care. we also need to move away from “treating all patients the same” regardless of their individual factors and differences. i think people have good intentions when they say that, but the reality is you are not being patient centered when you are treating every patient the same. when we take those individual factors into account, we are truly being patient centered and we can understand the unique aspects of the patient’s needs. cage: what advice do you have for your fellow athletic trainers as we moved forward as a profession and try to uphold our responsibilities as healthcare providers to provide quality healthcare to all of our patients regardless of their demographic? pierce: do not make assumptions. do not assume every patient and their situation are the same. do not assume that two patients’ households are run the same just because they come from the same cultural background. everyone is different. make sure you ask questions. try not to be offensive. if you have a question you need to ask but are worried it might be offensive, it might help to pose it as “may i ask this question, this is something i would like to know to better serve you.” next, do not pass judgement on the athlete. whatever their situation is, do not judge them. meet them where they are and try to make sure that you are providing patient centered care. make sure we uphold the role as liaison for our patients. we are there to treat, we are there to serve as a liaison between our patients and our clinics. make sure we do not feed into a bias we know may be held against the patient we are serving. decker: i think the first thing that we all have to do, regardless of our experiences, is to constantly self-reflect on the nata code of ethics and the board of certification standards of professional practice. those are our guidelines to being the best, most inclusive, and competent healthcare providers that we can be. instead of just assuming that we are doing those things, we should always go back to those and do an audit of ourselves to truly identify if we are upholding those guidelines to the best of our ability. beyond that, it really starts with understanding and addressing our own biases. we have a responsibility to be inclusive healthcare providers. we are not only responsible for ourselves, but we are responsible for those around us as well. i think it is important that within that understanding and audit that we are doing, that we are continually committing to ourselves and our profession that we are going to hold others accountable as well as ourselves. cage: what are some ways members of swata and other districts can get involved to help your committees and committees like them? pierce: definitely support our committee efforts. the biggest thing with ethnic diversity advisory committee is that every year we aim to have an education event and a community service or project. with that, when there is a sign up form for our projects, do not be afraid to sign up and the need for diversity, equity, inclusion, and social justice in the southwest athletic trainers’ association 9 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 participate. do not assume that the project is only for ethnically diverse athletic trainers. the committee aims to serve ethnically diverse populations, but our committee projects are a representation of every athletic trainer in swata. next, attend education sessions. do not assume that just because you see title, that it does not include you. do not assume from the title of a presentation that you cannot learn anything from it just because you feel you are already culturally competent and inclusive. there is always something new to learn. too often people assume that a presentation with the topic of diversity or inclusion is not for them. we need everyone to be there. make sure that you want to include yourself on what there is to learn. also, sign up to be a volunteer on the volunteer list. even if you are not on our committee, you may still be able to serve in other ways. when you see us in the exhibit hall, come over and see how you can be involved. in the month of march we usually highlight athletic trainers. when we send out those forms, some people are still in the mindset of “well, i am not ethnically diverse; this is not for me.” you do not have to be ethnically diverse to participate, march is national athletic training month. we want to make sure that we highlight everyone. when we try to provide unity and break down those walls, we want to remove as many obstacles as possible. decker: the first two steps to take are attending lectures, workshops, and events and consistently staying up to date with the committee and the committee’s efforts. a lot of this information is changing rapidly. make sure that you are constantly attending those events. also, sign up to volunteer. you do not have to serve as a committee member. there are so many ways to get involved. reach out to the committee and see if there are side volunteer opportunities. lastly, i think beyond just the committee or the scope of the athletic training profession i would encourage people to get involve at your school or organization. i had a colleague who completed safe space training and then reached out to me and said “our athletic department is not as inclusive. i am worried i am not going to be able to make as big of an impact as i had hoped.” my advice to her was to explore her campus environment and determine if she could make an impact outside of just the athletic department. this also goes into your community. if you can volunteer in your community, that is indirectly helping the initiatives of the committee to try to make our profession more inclusive. if we have a community that is safer and inclusive, people in the lgbtq+ community can feel safer being their true and authentic selves. cage: what is one step athletic trainers could take today to make their clinics more inclusive? pierce: work to understand the demographic characteristics of the patients you are serving. in my clinic, i serve a lot of hispanic and latinx patients. one thing i did was making sure i have physical forms in english and spanish. this provides a more inclusive environment right from the start. this helps the patient come into the room and not feel that the room is not inclusive of them, and it creates a safe space. decker: have something visible that shows that you run an inclusive facility. i do not think this is the most important step to take, but i do think seeing those visible images makes people feel safer. maybe it is a safe space sticker or a pride sticker, but it might help people let their guard down. that is a very superficial step, so i think there needs to be more to that. i think you have to actually act on those images and show people that you are inclusive beyond just showing them. other additions could be displaying a non-discrimination policy, and having a zero tolerance policy to anything other than inclusivity in your facility from everyone who walks in the door. manuscript type disablement model case study 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study bridget l. davidson, bs richelle m. williams, phd, lat, atc, sean m. rogers, dat, lat, atc drake university, des moines, ia abstract this clinical case study involves a 36-year-old male patient who injured his right lower leg while working in the kitchen at a county correctional institution. the mechanism of injury involved the patient getting his foot caught under a wooden pallet, losing his balance, and then catching himself on his right leg in a twisting motion. the injury led to the patient seeking care in the emergency department and was diagnosed with a nonspecific strain of the right triceps surae muscle group. upon discharge, the patient was referred to outpatient athletic training services within the hospital system. follow-up care provided by athletic trainers and athletic training students consisted of an injury evaluation, plan of care discussions, and therapeutic interventions, including moist heat packs, low-level laser therapy, desensitization massage, fluidotherapy, and electrical stimulation implemented over six weeks. during the six weeks of therapeutic intervention, the patient sustained an additional injury resulting in a right ankle sprain with a possible ankle avulsion fracture. following six weeks of intervention, this patient demonstrated no symptom improvement. due to the complexity of this patient case, an intentional effort was made to approach care using the international classification of functioning, disability, and health (icf) disablement model to better inform the involved clinicians on areas of social determinants of health (sdoh), chronic disease, and acute rehabilitation. in this case, the sdoh and environmental factors contributed to poor patient outcomes, resulting in this patient continuing to seek care from other healthcare disciplines. overall, this case demonstrates the effects of social and environmental factors on the rehabilitation process of a lower extremity workplace injury. content focus: health care competency correspondence dr. sean rogers, drake university department of athletic training, 2507 university ave, des moines, ia 50311. email: sean.rogers@drake.edu twitter: @datsearog full citation davidson bl, williams rm, rogers sm. effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study. clin pract athl train. 2023;6(2): 43-49. https://doi.org/10.31622/2023/0006.02.7. introduction social determinants of health (sdoh) are the conditions in which people are born, grow, live, work, and age.1-2 characteristics of sdoh are responsible for most health inequities and disparities among u.s. citizens, resulting in adverse patient health outcomes each year.2 sdoh conditions may include education, job, and transportation, all of which impact a patient’s ability to receive care. athletic trainers (ats) need to recognize sdoh characteristics to actively work to reduce adverse patient outcomes associated with such characteristics. while sdoh plays a role in all care ats deliver, this case is a unique combination of social factors not typically seen in the athletic population but includes care ats provide. this patient case presents the complexities of sdoh and its impact on acute injury rehabilitation within a 36-year-old patient with a workplace injury. this case also demonstrates the impact of uncontrolled type 1 diabetes mellitus (t1dm) on injury rehabilitation. this case study will provide ats with ideas on approaching unique and complex patient cases related to sdoh and the international classification of functioning, disability, and health (icf) disablement model. patient information patient this patient case involves a 36-year-old white male who works in the kitchen at a county correctional institution. this patient’s injury occurred in late august while at work, reporting an incident involving his right mailto:sean.rogers@drake.edu https://doi.org/10.31622/2023/0006.02.7 effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 foot getting stuck under a pallet, causing him to lose his balance and catch himself on his right leg with a twisting motion. the patient was initially seen in the emergency department (ed) and was diagnosed with a nonspecific right calf strain. the patient was seen by an occupational medicine doctor after the ed visit and was given a prescription for outpatient athletic training services. the patient presented to athletic training services approximately one week after sustaining his injury at work with a chief complaint of pain and reduced function of the right lower extremity. this patient was seen and treated over approximately six weeks, with one visit taking place about every other week due to the patient’s work and transportation limitations. the initial injury took place in late august, the initial at evaluation was in early september, and treatment lasted through mid-october. this patient has a medical history of a right ankle fracture as a teenager, bilateral carpal tunnel for which he is a surgical candidate, seven self-reported concussions, and type 1 diabetes myelitis (t1dm). personal factors relevant to this patient’s health condition include a diagnosis of t1dm at the age of 21 and uncontrolled blood glucose levels, including a hemoglobin a1c of 11 as recently as the previous july. differential diagnosis and evaluation following the initial work injury and ed visit in august, in which radiographs of the right knee were unremarkable, this patient was diagnosed with a nonspecific right calf strain. the patient reported pain at rest to be a 7-8/10 on a 0–10-point numeric pain rating scale (nprs) and described the pain as radiating with numbness and burning from the anterior and posterior right hip down the entirety of the right leg to the bottom of right foot (dermatomes l2-l5 and s1-s2). the patient was hypersensitive to light touch along the right lower leg and posterior thigh and demonstrated no observable deformities, discoloration, or edema. it was evident after evaluation that this patient’s symptoms were more complex than an isolated musculoskeletal injury and were impacted by his extensive history of comorbidities and health disparities. many of this patient’s post-injury symptoms were similar to those seen in cases of chronically uncontrolled diabetes, as the most common complication of diabetes is neuropathy.4 diabetic neuropathy is characterized by loss of sensory function and pain distally, most commonly in the toes.4 no definitive diagnosis was made after evaluating this patient’s initial work injury; however, differential diagnoses included calf strain, hamstring strain, neuralgia, and diabetic neuropathy. three weeks following the initial injury, in mid-september, this patient sustained a secondary injury from falling down his stairs while using a unilateral crutch due to his first injury. the patient landed on his right leg and immediately experienced pain in his right ankle. he was seen in the ed for this injury on the same day, and radiographic imaging was performed. radiographs of the right ankle showed deep vein grooves, atherosclerotic changes inconsistent with the patient’s age, and ossicles along the lateral and medial malleolar regions. radiographic imaging did not indicate whether ossicle formations were pre-existing or due to acute avulsion injury. the patient’s secondary ankle injury was ultimately diagnosed in the ed as a nonspecific right ankle sprain with a possible avulsion fracture. after the diagnosis was determined and initial treatment was deemed ineffective, an effort was made to re-evaluate this case study using the icf disablement model for guidance. body structure and function upon initial evaluation of a right lower extremity work injury with athletic training services in early september, the patient demonstrated increased tone along the right gastrocnemius, with visible and palpable spasms along the right gastrocnemius and hamstring. the patient could not tolerate range of motion (rom) assessment and special testing due to pain and discomfort. right ankle manual muscle testing (mmt) effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 performed demonstrated results of dorsiflexion (df): 5-/5, plantarflexion (pf): 5-/5, inversion (inv): 4/5, and eversion (ev): 4/5. mmt of the left ankle was within normal limits. the patient had a reduced right patellar tendon reflex when compared bilaterally. upon evaluation of the patient’s secondary injury to his right ankle in mid-september, the patient reported right ankle pain at rest to be an 8-10/10 on a 0-10point nprs. the patient continued to experience pain and hypersensitivity of the entire right leg; however, he reported that the right ankle pain was more intense than the right leg pain. findings of the evaluations conducted by athletic training services of both the initial and secondary injuries did not support the diagnoses of an acute non-specific calf strain or ankle sprain, which the ed provided due to the patient’s intense symptoms that were inconsistent with these musculoskeletal injuries. during the evaluation of this patient’s secondary ankle injury, right ankle active rom was performed, demonstrating limitations in all directions due to pain, with measurements of df: 0 degrees, pf: 30-35 degrees, inv: 20 degrees, and ev: 5 degrees. right ankle mmt measurements conducted included df: 4/5, pf: 4-/5, inv: 4-/5, and ev: 4-/5. the patient demonstrated limited ability to provide consistent resistance in all directions of ankle mobility with slight manual resistance. all mmts also reproduced the patient’s ankle pain. ankle special tests were performed with the following findings: anterior drawer test: negative on the right and left; talar tilt inversion and eversion: negative on the left, laxity noted for both inversion and eversion on the right; squeeze test: positive for pain in the right calf, but no severe pain down the tibial shaft. the patient demonstrated apprehension and muscle guarding during all special tests, which likely impaired testing accuracy. using a floor scale, the patient could put 50 pounds of weight through his right leg. activity and participation the patient demonstrated severe functional limitations due to pain, including an inability to ambulate without crutch assistance. the patient reported alternating between single and bilateral crutch assistance due to discomfort with bilateral crutch use caused by pre-existing bilateral carpal tunnel. the patient demonstrated severe activity limitations, including discomfort during sleep resulting in lack of sleep; functional limitations with all activities of daily living (adls) such as ascending/descending stairs, as well as prolonged sitting and standing tolerance; requirement of crutch assistance for ambulation; and inability to tolerate everyday work tasks. the patient continued to work after the injury; however, he was restricted to sitting jobs and tasks only, demonstrating significant limitations to his role as a correctional institution kitchen staff member. environmental and personal factors environmental factors related to this patient include the injury taking place at work and, therefore, having to go through workers' compensation for injury evaluation and management. this means the patient is restricted to healthcare services his employer covers. this patient also has an undisclosed criminal history, low economic stability, and lacks access to reliable transportation due to not having a driver's license. therefore, these factors contribute to the challenges faced by the management of this patient. personal factors for this patient include being a parent to a five-year-old child, a high school diploma as the highest level of education, a personal career goal of becoming a correctional officer, and no established primary care provider (pcp). this patient, therefore, uses the ed as his primary access to healthcare. his electronic medical records demonstrated at least one ed visit per month for the previous six months. effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 interventions this patient attended therapy appointments for outpatient athletic training services for approximately six weeks, averaging one visit every other week due to work and transportation limitations. at the initial evaluation appointment in early september, the first therapeutic intervention attempted was low-level laser therapy (lllt). the lllt intervention was used with the patient in a prone position along eight spots from the distal right calf to the mid-posterior thigh at 5.0 j/cm2. the patient reported no immediate change in symptoms after this intervention, although he did report a mild numbing effect in the posterior right leg for a short period following the appointment. at following therapy appointments, other therapeutic interventions such as moist heat packs, desensitization massage, fluidotherapy, and electrical stimulation (80-150 hz, 2.03.8 v, 18 min.) were used with the goals of decreasing hypersensitivity of the entire right leg, decreasing muscle spasm and tone, and increasing overall comfort and functional ability of the patient. at the next visit in mid-september, two moist heating packs were applied to the right posterior thigh and calf for 14 minutes. then, a desensitization massage technique of the right posterior thigh and calf was performed with no change in the patient’s hypersensitivity nor tenderness to palpation. fluidotherapy was attempted for the right lower extremity in the range of 100-110 degrees fahrenheit; however, the patient did not tolerate this intervention due to reported pain in the right achilles and posterior calcaneus region within the first few minutes of treatment. the validity of the fluidotherapy intervention could not be determined since treatment was discontinued after approximately three minutes due to the patient’s discomfort. at the subsequent therapy visit in early october, no therapeutic interventions were attempted due to increased discomfort reported by the patient that day. this visit consisted primarily of discussing the patient’s plan of care, including upcoming therapy appointments and goals, appointments with the orthopedic department, and appointments with the patient’s nurse practitioner for t1dm management. there was also a lengthy discussion of t1dm homecare and management. at the following therapy appointment in mid-october, electrical stimulation was used with the patient in a prone position on the mid to distal right hamstring, using pre-modulated, continuous cycle settings at 80-150 hz and 2.0-3.8 v for 18 minutes. simultaneously, electrical stimulation was also used on the proximal to distal right calf, using the pre-modulated, continuous cycle settings at 80-150 hz and 2.2-3.5 v for 18 minutes. lllt was then used with the patient in a prone position along ten spots from the distal right calf to the mid-posterior thigh at 5.0 j/cm2. the patient reported that his right leg felt stiff and numb immediately following these therapeutic interventions, but no immediate change in pain or sensitivity. outcomes body structure and function the rehabilitation of this patient was interrupted for six weeks due to the patient leaving town for correctional officer academy training. at the time of the last therapy appointment, the patient demonstrated no improvements in pain, hypersensitivity, rom, and ability to perform adls. the plan of care for this patient includes the continuation of therapy to decrease pain, decrease hypersensitivity, increase rom, and increase functional abilities. activity and participation effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 at the last therapy appointment, the patient demonstrated no improvement in activity tolerance and participation. the patient continued to use crutch assistance for ambulation and demonstrated functional limitations with all adls. the patient also continued to demonstrate severe discomfort during sleep, thus resulting in a prolonged lack of sleep. due to these limitations, the patient could not tolerate work tasks and was still restricted to sitting jobs and tasks only. environmental and personal factors this case study's environmental and personal factors significantly impacted the therapeutic intervention adherence and tolerability for this patient. scheduling therapy appointments for this patient was challenging due to limitations by this patient’s work schedule and his lack of access to reliable transportation. an unexpected challenge within this case was the patient ceasing therapy appointments to leave town for correctional officer academy training. at the time the patient left town for the academy, he had been attending therapy appointments inconsistently for six weeks and had shown no improvement. the patient informed the athletic training staff that his academy training would be six weeks long and was unsure of his ability to attend future appointments. after the patient attended six weeks of correctional officer academy training, he was seen for a follow-up appointment with the orthopedic department. the orthopedic physician told the athletic training staff and students that there was still no symptom improvement. ultimately, this patient chose not to pursue further therapy treatment after returning from the academy. discussion the case study demonstrated many unique characteristics uncommon for ats to manage regularly. due to the non-specific nature of the diagnosis provided by the ed, athletic training services decided to approach treatment from the disablement model perspective to address impairments and barriers associated with sdoh. one unique component of this case includes the lack of symptom improvement following extensive treatment and the continued decline in this patient’s health status following six weeks of therapeutic intervention. after taking six weeks off from therapy treatment due to attending a correctional officer training academy, this patient demonstrated no symptom improvement at a follow-up appointment with the orthopedic department. after returning from the academy, this patient did not resume outpatient therapy, likely due to personal and environmental barriers. this case study uniquely presents the complex interrelationships between sdoh, chronic disease, and acute rehabilitation. this patient had an apparent acute injury; however, the presentation of that injury was very different than typical injuries seen by ats. the findings of this case study demonstrate how health disparities and underlying chronic conditions can impact patient health outcomes. this patient’s lack of a driver’s license limited his access to reliable transportation to work, therapy appointments, and appointments related to his t1dm care, resulting in poor appointment attendance. socioeconomic status, ability to pay, and access to transportation also presented a challenge for this patient when attending healthcare appointments, as he could not afford to miss work. this patient’s socioeconomic status also made it more challenging to manage his t1dm successfully, such as accessing healthy food options, affording prescription medications, and seeking assistance from healthcare professionals. research has shown that damage and failure of many organs and body systems result from diabetes and chronic hyperglycemia.3-6 this case is an unusual presentation of the effects of chronically uncontrolled t1dm that were likely systemically triggered by acute injury stress. this is demonstrated by this patient’s prolonged nerve-related symptoms and pain patterns and the lack of symptom improvement despite therapeutic effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 intervention. overall, this patient’s history of uncontrolled t1dm is also rooted in his barriers related to sdoh. this case study also uniquely demonstrates the importance of understanding sdoh while emphasizing the importance of providing patient-centered healthcare. ats need to be able to recognize various health disparities within their patients so they can reduce adverse health outcomes associated with sdoh.2,7 throughout the treatment of this patient, it was observed that he had barriers related to all five key areas of sdoh: 1) healthcare access and quality, 2) education access and quality, 3) social and community context, 4) economic stability, and 5) neighborhood and built environment. the combination of social barriers identified in this case is not typically seen within patient populations treated by ats; however, ats work with patients every day that sdoh impact. potential interventions to address the underlying causes of observed social barriers in this patient case could include medical rideshare programs, social worker or counselor referrals, diabetes support groups, dietitian referrals, and state or federal financial support programs. clinical bottom line this unique patient case involving an initial workplace injury, a secondary musculoskeletal injury, chronic t1dm, and other systemic health issues demonstrates the importance of utilizing an approach based on the icf disablement model, as it allows for ats to recognize sdoh characteristics and identify social barriers affecting their patients. this case also demonstrates the need for ats to understand the impact of sdoh and chronic disease on various patient populations and their health outcomes. ats must understand the importance of managing chronic diseases such as t1dm, as they can adversely affect healing processes when not properly managed. additionally, ats must consider health disparities and their underlying causes within every patient case to provide the best quality patient-centered healthcare. overall, this case emphasizes how applying the disablement model to patient cases allows for the identification of sdoh characteristics related to personal factors, environmental factors, activity, functional limitations, and participation status. this identification then facilitates better quality patient-centered care based on a deeper understanding of underlying causes and how they can complicate and prolong typical rehabilitation processes. the education of ats surrounding recognition and identification of sdoh factors is ongoing and is something the profession is continually striving to improve. ats play an essential role in the healthcare system; this education can make a meaningful difference in patient outcomes. references 1. social determinants of health: know what affects health. cdc.gov. reviewed march 10, 2021. accessed 10 jan 2022. https://www.cdc.gov/socialdeterminants/about.html. 2. daniel h, bornstein ss, kane gc, et al. we are addressing social determinants to improve patient care and promote health equity: an american college of physicians position paper. ann intern med. 2018;168(8):577-578. https://doi.org/10.7326/m17-2441. 3. schuster dp, duvuuri v. diabetes mellitus. clin podiatr med surg. 2002;19(1):79-107. https://doi.org/10.1016/s0891-8422(03)00082-x. 4. feldman el, callaghan bc, pop-busui r, et al. diabetic neuropathy. nat rev dis primers. 2019;5(1):42. published 2019 jun 13. https://doi.org/10.1038/s41572-019-0097-9. 5. kollias an, ulbig mw. diabetic retinopathy: early diagnosis and effective treatment. dtsch arztebl int. 2010;107(5):75-84. https://doi.org/10.3238/arztebl.2010.0075. 6. khateeb j, fuchs e, khamaisi m. diabetes and lung disease: a neglected relationship. rev diabet stud. 2019; 15:1-15. published 2019 feb 25. https://doi.org/10.1900/rds.2019.15.1. https://www.cdc.gov/socialdeterminants/about.html https://doi.org/10.7326/m17-2441 https://doi.org/10.1016/s0891-8422(03)00082-x https://doi.org/10.1038/s41572-019-0097-9 https://doi.org/10.3238/arztebl.2010.0075 https://doi.org/10.1900/rds.2019.15.1 effects of social determinants of health and diabetes on a lower extremity workplace injury: a disablement model case study 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 7. picha kj, welch bacon ce, normore c, snyder valier ar. social determinants of health: considerations for athletic health care. j athl train. 2022;57(6):521-531. https://doi.org/10.4085/1062-60500010.21. 8. icf disablement model. nata. accessed 17 jan 2022. https://www.nata.org/icf-disablement-model. https://doi.org/10.4085/1062-6050-0010.21 https://doi.org/10.4085/1062-6050-0010.21 https://www.nata.org/icf-disablement-model abstract manuscript type evidence-to-practice review 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 opioid medication use and education following sports medicine procedures: an evidence-to-practice review caitlin s. o’mara, scat, atc; michael g. ward, scat, atc; zachary k. winkelmann, phd, scat, atc university of south carolina, columbia, sc abstract according to the centers for disease control (cdc), illicit and prescription drug overdoses are responsible for 128 deaths every day in the united states. in 2018, 70% of all overdose related deaths involved opioids. efforts to minimize the opioid epidemic focus on community education, research, partnership, and healthcare support. under the cdc guidelines, current practices include monitoring trends of drug use and drug related deaths, conducting research to recognize areas in need of improvement and to analyze effectiveness of current treatments, partner with community organizations and healthcare systems that deal firsthand with opioid users, and educate the public on drug use, misuse, and overdoses. people are commonly uneducated on the proper use and disposal of their prescription opioids. consistent and appropriate communication among surgeons and their patients can decrease this risk associated with prescription drugs. the purpose of this evidence-to-practice review was to summarize a systematic review on the current data and findings related to postoperative opioid prescribing and consumption behaviors after a common sports medicine operation. the guiding systematic review explored several ways to reduce the risk of patients developing opioid dependence and abuse due to physicians overprescribing opioids. first, educating each patient about pain management during preand postoperative phases, how to store opioids safely, and how to dispose of opioids properly need to be created to help reduce the risk of the patient abusing opioids. secondly, having the prescribing provider create an extensive history that reveals any red flags for opioid abuse for each patient. thirdly, the prescribing provider should prescribe the lowest dose and shortest regimen to limit the number of opioids left over. these protocols may help slow the current opioid epidemic. key phrases drug overdose/drug therapy, program evaluation, opioid-related disorders/drug therapy, naloxone/therapeutic use correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation o’mara cs, ward mg,winkelmann zk. opioid medication use and education following sports medicine procedures: an evidence-to-practice review. clin pract athl train. 2021;4(2): 40-44. https://doi.org/10.31622/2021/0004.2.6. submitted: december 15, 2020 accepted: march 3, 2021. original reference sheth u, mehta m, huyke f, terry ma, tjong vk. opioid use after common sports medicine procedures: a systematic review. sports health. 2020;12(3):225-233. https://doi.org/10.1177/1941738120913 293. summary clinical problem and question in the united states, orthopedic surgeons are responsible for 7.7% of all prescribed opioids.1 when investigating the effects of these practices, two main factors that are studied are mean prescription and consumption values, and appropriate disposal procedures. the guiding systematic review examines these factors following three common procedures: knee, shoulder, and hip arthroscopies. with the increase in the level of skill and competition in athletics, there comes an increased need in medical and surgical knowledge. studies have shown that there are close to 2 million knee arthroscopic surgeries performed every single year in the united states.2 the incidence for the other common injuries (hip and shoulder) are increasing dramatically as well. the drastic increase of these injuries has directly impacted the prescribing patterns of orthopedic surgeons in the united states. patients and surgeons often assume the use and duration of opioid treatment, that the decision to determine the extent to which the patient needs an opioid prescription, is often overlooked. regardless of how common the surgery is, or how many times the specific surgeon has performed the surgery, postoperative opioids should be prescribed mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.2.6 https://doi.org/10.1177/1941738120913293 https://doi.org/10.1177/1941738120913293 opioid medication use and education following sports medicine procedures: an evidence-to-practice review 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 based on the individual patient and with prior research in mind. supporting research has shown that large percentages of prescribed postoperative opioids are not consumed and/or disposed of properly.3,4 in addition to less individualized prescribing patterns, education on proper disposal medication was not always provided.6 a lack of awareness of proper disposal can often lead to the patient stockpiling their unused medications. the act of collecting pills poses a great risk for future drug abuse or suicidal means. these subsequent behaviors threatened the health and wellbeing of patients, their support systems, and adds to the burden of the current drug epidemic in the united states. therefore, the purpose of this evidence to practice review was to summarize a systematic review on the current data and findings related to postoperative opioid prescribing and consumption behaviors following three common sports medicine procedures. summary of literature a systematic search was conducted using embase, medline, and pubmed databases. the keywords searched included arthroscopy, sports medicine, opioids, and other related wording. inclusion criteria consisted of studies containing patients experiencing an arthroscopic procedure of the knee, hip, or shoulder. other significant inclusion criteria included evaluation of postoperative opioid prescribing behaviors and evaluated opioid consumption rates.2 studies also needed more than 10 participants and had reports of patient-specific data to be accepted. quality of the studies was determined using the methodological index for non-randomized studies. for these studies; the highest possible score is a 16. all studies had a score of 10 or higher, assigning them high quality. the initial search identified 119 studies. after screening, 8 studies meet the inclusion criteria and were deemed eligible. summary of outcomes five variables were examined in the various studies including opioid prescribing practices, postoperative opioid consumption, duration of opioid use, opioid disposal, and refill rate. during statistical analysis, the guiding review’s authors referred to the accepted conversion table from the centers for medicare and medicaid services.5 with the oral morphine milligram equivalent conversion factors, the quantity of opioids prescribed, used, and leftover were converted to milligram morphine equivalents (mmes) for standardized reporting.6 in the studies converting opioid prescribing patterns, mmes are identified for arthroscopic procedures of the shoulder, hip, and knee. findings and clinical implications among 195 patients (3 studies) undergoing the shoulder procedure, there was a mean of 610 mmes prescribed and 418 mmes consumed. for 451 patients (4 studies) undergoing the knee procedure, there was a mean of 197 mmes prescribed and 131 mmes consumed. for 96 patients (2 studies) undergoing hip procedure, there was a mean of 613 mmes prescribed and 223 mmes consumed.2 to summarize these findings, the percentage of prescribed opioids going unused are: 31% for shoulder procedures, 34% for knee procedures, and 64% for hip procedures. out of the three surgical procedures, 30mg tablets of oral codeine were prescribed most frequently. the other most frequently prescribed opioids were a 5mg tablet of oral hydrocodone and a 5mg tablet of oxycodone.6 two additional studies (277 patients) focused on how frequently post-op patients refill their prescription. the studies concluded that 26% of these patients asked for a prescription refill following their procedure. this review found overwhelming evidence that opioids are overprescribed for patients that have undergone shoulder, knee, and hip arthroscopic surgery opioid medication use and education following sports medicine procedures: an evidence-to-practice review 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 despite that evidence has shown that more than one third of opioids prescriptions went used and more than half of the patients do not take the opioids after 3 days following their surgery. five studies (348 patients) looked at opioid disposal methods or if the patient had any prior education on how to properly dispose of the excess prescription. out of those 348 patients, only 36% of patients were given instruction on how to dispose of their medications when they no longer needed them for pain management.1 after finding that only 36% of patients were given instruction on how to properly dispose of their unused medications, there is an increased emphasis on developing strategies to better inform guidelines for both the doctors and the patients.1 an increased focus on better prescribing patterns for doctors along with a more consistent patient education program are two critical components needed to evoke change. one strategy that has been suggested is for surgeons to prescribe the lowest dosage for the shortest duration period.7 several studies have made dosage recommendations on these three specific procedures as well as alternate strategies for controlling postoperative pain. the authors of the guiding systematic review discussed the growing risk of the over prescribing patterns of opioids and demonstrated that sports medicine procedures are no exception. the opioid use concerns are not just limited to providers prescribing more than needed, but also to the lack of education given to their patients. overprescribing and improper disposal methods leads to more opioid medications in the hands of people they don’t belong, in turn becoming a contributing factor to the opioid epidemic. this heightens the need for athletic trainers and other healthcare providers to be aware of signs and symptoms of opioid abuse. if the problem can be identified early on, there is more time for an appropriate intervention or referral to be made. this additional time can be the difference between a healthy post-operative experience and one with long term complications. the guiding systematic review found overwhelming evidence that opioids were overprescribed to patients that have undergone shoulder, knee, and hip arthroscopic surgery. even with doctors overprescribing opioids, only 36% of the surgical patients were educated on how to dispose of the medication(s) when they were no longer needed for pain management.1 these statistics are not unique to these three surgeries. over prescription is also seen in foot, ankle, and even upper extremity surgical literature.8 clinical bottom line due to the ongoing battle with the opioid epidemic, which includes misuse and abuse of opioids, focus has been shifted on creating safer prescription practices. an initial in-depth preoperative medical history can aid the clinician with a more appropriate pain management consideration. each patient would be assessed for not only past opioid use but other drug dependencies as well.1 in addition, each patient would be educated using handouts about the expectations of pain throughout the preoperative and postoperative phases as well as storing and disposing of the medication. according to one systematic review, 5% of the patients were educated on how to dispose of medication properly, 3 out of 4 patients stored the medication in an unlocked location, and less than 30% planned to or disposed of any unused opioids. of that, less than 10% disposed of the opioids by returning to the pharmacy or flushing down the toilet.8,9 the best option for disposing of unused medications is to return them to an official take back location. take back locations can include pharmacies, police stations, or other approved sites. the drug enforcement agency website allows individuals to enter their zip code and find locations within their area that allow medication take backs. the dea website also has a “flush list” of what medications are safe to be opioid medication use and education following sports medicine procedures: an evidence-to-practice review 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 flushed down the toilet. if the medication is not listed on the flush list, the only disposal method is to return to a take back location. take back locations are the safest option because it minimizes the risk that someone within the home will get a hold of the medication. it also eliminates the risk of a drug contaminating the water if it is flushed down the toilet. if the medication is not on the flush list and there are no take back locations in the area, medications can be disposed of in the trash. the fda suggests mixing the medication with a substance like cat litter, dirt, or food waste in a sealed plastic bag before placing it in the garbage.10 all personal information should be scratched off or removed from the prescription bottles as well before disposal.10 another review suggested method to limit over prescription is for providers to administer other analgesics via different intake methods. several studies within the review have shown decreased opioid use after surgery on patients treated with multiple analgesics during the perioperative phase.7,11 the guiding systematic review determined there was evidence of a correlation of risk factors that correlates with long-term opioid use such as suicide, other drug dependency, mood disorders, and chronic pain. despite not having control of postoperative prescriptions, athletic trainers can be a valuable resource for patients to help them understand their procedure and prescriptions. athletic trainers can be an advocate for patients to help facilitate proper use and ensure clarity of use through discussions with the prescribing provider and members of the sports medicine team. ensuring that their patient is aware of proper consumption and disposal is an easy task that can prevent addiction or abuse in the future. the providing prescribers can implement this into practice by establishing communication with a patient throughout the entirety of their surgical process. early and consistent communication among the orthopedic surgeon, athletic trainer, and the patient can mitigate the risk of opioid addiction. athletic trainers are in a unique position to help educate patients on how to properly consume, store, and dispose of their opioids. athletic trainers can also work with their collaborating physician to develop a plan to avoid postoperative opioid abuse and misuse. references 1. sheth u, mehta m, huyke f, terry ma, tjong vk. opioid use after common sports medicine procedures: a systematic review. sports health. 2020;12(3):225-233. https://doi.org/10.1177/1941738120913 293. 2. siemieniuk rac, harris ia, agoritsas t, et al. arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. bmj. 2017;357:j1982. https://doi.org/10.1136/bmj.j1982. 3. ellis ta, 2nd, hammoud h, dela merced p, et al. multimodal clinical pathway with adductor canal block decreases hospital length of stay, improves pain control, and reduces opioid consumption in total knee arthroplasty patients: a retrospective review. j arthroplasty. 2018;33(8):2440-2448. https://doi.org/10.1016/j.arth.2018.03.05 3. 4. sabatino mj, kunkel st, ramkumar db, keeney bj, jevsevar ds. excess opioid medication and variation in prescribing patterns following common orthopaedic procedures. j bone joint surg am. 2018;100(3):180-188. https://doi.org/10.2106/jbjs.17.00672. 5. centers for disease control and prevention. analyzing opioid prescription data and oral morphine milligram equivalents (mme). https://www.cdc.gov/drugoverdose/resourc es/data.html. published october 9, 2020. 6. centers for disease control and prevention. understanding the epidemic. https://www.cdc.gov/drugoverdose/epidem ic/index.html. published 2020, march 19. accessed. 7. labrum jt, ilyas am. the opioid epidemic: postoperative pain management strategies in orthopaedics. jbjs rev. 2017;5(8):e14. https://doi.org/10.2106/jbjs.rvw.16.00124. https://doi.org/10.1177/1941738120913293 https://doi.org/10.1177/1941738120913293 https://doi.org/10.1136/bmj.j1982 https://doi.org/10.1016/j.arth.2018.03.053 https://doi.org/10.1016/j.arth.2018.03.053 https://doi.org/10.2106/jbjs.17.00672 https://www.cdc.gov/drugoverdose/resources/data.html https://www.cdc.gov/drugoverdose/resources/data.html https://www.cdc.gov/drugoverdose/epidemic/index.html https://www.cdc.gov/drugoverdose/epidemic/index.html https://doi.org/10.2106/jbjs.rvw.16.00124 opioid medication use and education following sports medicine procedures: an evidence-to-practice review 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 8. merrill hm, dean dm, mottla jl, neufeld sk, cuttica dj, buchanan mm. opioid consumption following foot and ankle surgery. foot ankle int. 2018;39(6):649656. https://doi.org/10.1177/1071100718757 527. 9. bicket mc, long jj, pronovost pj, alexander gc, wu cl. prescription opioid analgesics commonly unused after surgery: a systematic review. jama surg. 2017;152(11):1066-1071. https://doi.org/10.1001/jamasurg.2017.08 31. 10. u.s. food and drug administration. how to safely dispose of unused or expired medicine. https://www.fda.gov/drugs/safe-disposalmedicines/disposal-unused-medicines-whatyou-should-know. published september 25, 2020. 11. elkassabany nm, wang a, ochroch j, mattera m, liu j, kuntz a. improved quality of recovery from ambulatory shoulder surgery after implementation of a multimodal perioperative pain management protocol. pain med. 2019;20(5):1012-1019. https://doi.org/10.1093/pm/pny152. https://doi.org/10.1177/1071100718757527 https://doi.org/10.1177/1071100718757527 https://doi.org/10.1001/jamasurg.2017.0831 https://doi.org/10.1001/jamasurg.2017.0831 https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-you-should-know https://doi.org/10.1093/pm/pny152 abstract manuscript type evidence-to-practice review 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 racial and ethnic disparities in pain management nicolette a. harris, dat, lat, atc, cscs*; samar long, msed, at, atc† *at still university, mesa, az; †ohio state university, columbus, oh abstract pain is subjective, which makes its management a complicated task. the challenge of medical decisionmaking associated with pain often requires health care providers to rely heavily on their individual discretion and experience. this often creates an avenue for biases to play a role in the selection of the best available and most appropriate pain management interventions. therefore, the overall purpose of this review is to summarize the current literature related to racial and ethnic disparities in pain management. electronic searches of four databases revealed 2,112 articles; however, only six studies met criteria for inclusion in this review. even when the source of pain is the same, research indicates management may differ between racial or ethnic groups. while the treatment of objectively painful conditions remains relatively constant among races and ethnicities, inequities in pain management become more apparent in the treatment of conditions characterized by only subjective pain indicators. further disparities were identified in the dosage, dosage reduction, and oversight of opioid analgesics between groups. inequities in prescribing patterns widen existing healthcare disparities by contributing to undertreatment of pain in ethnic minorities and overtreatment of pain and subsequent risk of opioid abuse in whites. health care providers must use a patient-centered and evidence-based approach to combat the ambiguity of clinical decisionmaking regarding pain. when knowledgeable of appropriate standard of care for pain management, athletic trainers can identify when a patient’s pain needs are unmet or when substance abuse interventions may be necessary. key phrases public health, clinician-rated outcomes, patientrated outcomes, professional standards correspondence dr. nicolette a harris, at still university, 5850 e still circle mesa, az 58206 email: nicolletteharris@atsu.edu twitter: @youngprof_at full citation harris na, long s. racial and ethnic disparities in pain management. clin pract athl train. 2021;4(1): 43-56. https://doi.org/10.31622/2021/0004.1.6. editor’s note: this paper is an invited paper by the authors for this special issue submitted: july 30, 2020 accepted: february 22, 2021. clinical problem and question according to healthy people 2020, healthcare disparities adversely affect people who encounter substantial systemic obstacles to health based on their racial or ethnic group.1 healthcare disparities have been reported across the continuum of care including in the treatment and management of pain.2 for example, scholars have noted black patients receive inadequate treatment for pain conditions as compared to white patients.2-6 primary care physicians were reported as being twice as likely to underestimate pain in black patients as compared to all other ethnicities combined.4 analgesic medications are often a principal component of pain management, and to no surprise, disparities have also been suggested to affect the prescribing patterns of these medications. black patients have been prescribed pain medications at a lower frequency and a lower dosage than non-black patients.2, 4, 5 a study of analgesic administration by nursing staff in the emergency department (ed) found african americans received analgesics in 57% of instances and non-hispanic whites in 74% of cases, with no significant differences in the amount of pain reported to medical personnel.5 discrepancies exist in the use of analgesic medication to manage pain between racial and ethnic groups; however, the source of inequality in pain management practices cannot be limited to a single cause. racial disparities in pain management have been attributed to several theoretical approaches of discriminatory practices among health care providers.7 first, the application of bias, clinical uncertainty, inaccurate beliefs, or stereotypes contributing to health care behaviors may result in inequitable treatment.7 mailto:nicolletteharris@atsu.edu https://doi.org/10.31622/2021/0004.1.6 racial and ethnic disparities in pain management 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 for instance, providers may make assumptions that a black patient will be noncompliant and therefore fail to prescribe medications that align with the standard of care.2, 3 second, based on stereotypes, physicians may invalidate the experience of pain allowing racial bias to contribute to the undertreatment of pain.4, 8, 9 investigators have determined perceptions of hardship, internalized as strength or toughness, influence perceptions of pain and contribute to racial bias in pain perception.10 lastly, many stereotypes of substance use and abuse in ethnic minority groups have been developed secondary to the united states (us) illegal drug epidemic of the 1990s.11 a perceived potential for abuse in non-white minority groups may bias providers not to prescribe analgesic pain relievers to individuals of minoritized groups, despite the fact that nonmedical use of prescription opioids is two times greater in the whites.11 these results further highlight how dominant narratives of the experiences of people of color are built on racial stereotypes and can influence the care patients in marginalized communities receive. while provider bias may have good intention to protect minoritized communities from the use and abuse of opioid analgesics, in addition to causing undertreatment non-white patients, these prescribing patterns may in turn also contribute to higher opioid-related overdose and death rates in white patients11 racial inequities are not limited to health care or any specific medical setting, but it is important for athletic trainers to understand the types of experiences their patients have after being referred for further care. we echo the institute of medicine’s call for all health care providers to actively eradicate contributions to racial and ethnic biases in health care.7 as health care providers, the goal of athletic trainers is to provide the best possible care to every patient. we must uphold the first principle of the national athletic trainers’ association (nata) code of ethics by practicing with compassion and respecting the rights, well-being, and dignity of others.12 pain is expressed differently based on personal experiences and context; therefore, providing appropriate care in those moments is central to ensuring the primacy of patient care. advocating for patient needs can begin when athletic trainers develop a better understanding of the experience patients of color may have when seeking pain management. research suggests that in recent years, the practices of medical professionals regarding pain management are not applied equitably among racial and ethnic groups due to personally held beliefs.13 in fact, the standard of care a patient receives is often influenced by their race or ethnicity.2, 3, 4, 5 the subjective nature of pain raises the concern of whether race or ethnicity can affect a clinician’s approach to managing pain. to our knowledge, there is no published literature discussing the influence of race and ethnicity on pain management in athletic training. therefore, this review aims to address the following research question: in patients with pain of subjective or objective origin, does race or ethnicity affect the prescription of analgesic medication? search of the literature data sources and searches a wide-ranging, electronic search of four individual databases (sportdiscus, ebscohost, pubmed, psycinfo) was performed. boolean terms and phrases included the following: racial bias and pain perception and athletes, ethnicity and pain sensitivity and athletes, ethnicity and pain tolerance and athletes, ethnicity and pain perception and athlete, social determinants and pain perception and athletes, minority and pain perception and athlete, pain perception and cultural competence (table 1). additionally, reference lists were searched by hand for relevant articles. study selection evidence-to-practice review 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 table 1. search terms, databases, and number of articles retrieved search terms sportdiscus ebscohost pubmed psycinfo total racial bias and pain perception and athletes 1 113 1 1 116 ethnicity and pain sensitivity and athlete 286 8 4 0 298 ethnicity and pain tolerance and athletes 710 5 4 0 719 ethnicity and pain perception and athlete 323 19 4 0 346 social determinants and pain perception and athletes 1 239 15 0 255 minority and pain perception and athlete 192 4 4 0 200 pain perception and cultural competence 2 167 7 2 178 total 1515 555 39 3 2112 articles were included in this review if they were peer-reviewed and published in english, between 2010 and 2020, and explored pain management in ethnically diverse patients. in attempts to synthesize evidence of high methodological quality, authors aimed to include meta-analyses, systematic reviews, randomized control trials, cohort and cross-sectional studies with satisfactory design, validity, and applicability to patient care. editorials, commentaries, and studies of nonscientific origin were excluded. additionally, articles including patients with health conditions outside of those commonly seen in athletic training practice were also omitted.14 furthermore, research studies that did not address the question of interest were also excluded in this review. succeeding the removal of duplicate articles, both authors completed a dual-step process to classify articles for inclusion. initially, each author (nah, sl) screened the title and abstract of each identified article, after which, a meeting was held between both authors to ensure consensus on inclusion criteria. next, a full-text review of articles was performed by both authors (nah, sl) followed by a meeting resulting in agreement to further constrain inclusion criteria to pain management articles included within this study. articles were excluded if consensus on the inclusion criteria was not reached at any point during the selection process. assessment of methodological quality the methodological quality of each study was assessed using the national institutes of health (nih) quality assessment tool for observational cohort and cross-sectional studies or the nih quality assessment of systematic reviews and meta-analyses. the nih quality assessment tool for observational cohort and cross-sectional studies contains 14 items, 12 of which were applicable to included studies.15 two checklist items, participation rate, and loss to follow-up, were not relevant to the retrospective nature of studies included within this manuscript. each of the 12 items were eligible to receive a yes, no, not applicable, not reported, or cannot determine rating. items that fulfilled ‘yes’ criteria were assigned a score of 1 point, while items that fulfilled ‘no’ criteria or that were not reported received 0 points toward a total quality score of 12.15 items not applicable to the included study were not counted negatively toward the overall methodological quality score. likewise, the nih quality assessment of systematic reviews and meta-analyses is a checklist of 8 items.15 each item meeting the quality standard was scored 1 point while those that did not meet the item standard or did not report sufficient information to evaluate item criterion were assigned a score of 0.15 cohort or cross-sectional studies were eligible to achieve a maximum score of 12 and systematic reviews or meta-analyses a maximum of 8.15 for purposes of racial and ethnic disparities in pain management 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 comparison, quality assessment scores were weighted by dividing raw scores by the number of applicable items and multiplying by 10. each study was scored using the nih quality assessment tools by both authors. disagreement in scores between authors were resolved through discussion. weighted scores of 6 or higher were deemed high-quality studies, while weighted scores under 6 were considered low-quality. a rating of good-quality translates into a low risk of bias. grade of recommendation recommendations resulting from the conclusions of this manuscript were graded using the strength of recommendation taxonomy (sort). the sort was first used to classify the level evidence provided to each individual study.16 level 1 evidence is demarcated by good-quality studies such as meta-analyses and systematic reviews which are patient-oriented, while level 2 evidence is patient-oriented but lacks quality or consistency in findings.16 level 3 is used to categorize diseaseoriented evidence or evidence derived from case series and studies.16 after a level of evidence was assigned to each individual study, we used the sort to provide a weighted grade for the collective strength of evidence supporting each conclusion. grades of a were reserved for conclusions constructed from level 1 evidence with consistent results across studies.16 a grade of b was given to conclusions resulting from studies of level 2 evidence.16 conclusions formulated from level 3 evidence were given a grade of c. grade b and c recommendations should be incorporated into clinical practice on an individualized and case-by-case basis.16 data extraction, analysis, and synthesis the study design, participants, sources of pain, outcome measures, interventions, results and conclusions were extracted from all included studies (table 2). data were analyzed by authors using the nih quality assessment tools15 and sort16 based on study content and context relevant to the research question. data synthesis was expressed using a qualitative synthesis of the context of findings relevant to the research question. synthesis of medication administration based on patient demographics was grouped by treatment setting and prescribing patterns of analgesic drugs. summary of findings search results and study inclusion our preliminary search resulted in a total of 2,112 articles for potential inclusion in this review. of these articles, there were 1,496 that were identified as duplicates and subsequently excluded. the remaining 561 were screened by title after which 518 were excluded for being irrelevant for the subject of this paper. the abstracts of the remaining for 43 articles were screened by authors for inclusion. after appraising abstracts, an additional 8 articles were excluded for study designs that failed to assess the use of analgesic medication for the management of pain. therefore, 35 articles persisted to full-text evaluation and data extraction (figure 1). an additional 29 articles were excluded during the data extraction process: 7 studies featured experimental pain; 5 studies did not adequately answer the research question; 5 studies investigated only the assessment of pain; 3 studies focused on linguistic barriers; 2 studies did not report the source of pain; 2 studies did not address pain as an outcome; 2 articles did not report race or ethnicity; 1 article did not provide age range data; 1 article had pain outside the professional scope of athletic training; and 1 study looked at incidence or prevalence/trends. a total of six articles remained from which data was extracted and summarized into findings.17-22 general characteristics of included studies this review included one meta-analysis,18 two studies presenting with cross-sectional designs,21,22 racial and ethnic disparities in pain management 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 and three studies categorized as retrospective cohorts17, 19-20 (table 2). all study participants were adults, age 18 or older, presenting to the ed or an outpatient clinic for pain-related conditions. a majority of the studies were conducted with white, non-hispanic, black/african american, and hispanic latinos. demographic variables including age, gender, and race/ethnicity were collected from participants across all studies in addition to the source of pain. pain sources included non-definitive conditions such as toothache, back pain, and abdominal pain, as well as definitive conditions such as long bone fracture, kidney stones, appendicitis, or gallbladder disease. furthermore, a range of outcomes were reported within the included studies regarding the prescription and receipt of analgesic drugs. outcome measures focused on the prescription, administration, and dose reduction of opioid and non-opioid analgesic medications. opioid medications included, but were not limited to, fentanyl, morphine, oxycodone, hydrocodone, methadone, tramadol with or without acetaminophen, aspirin, and ibuprofen combinations. likewise, non-opioids involved nonsteroidal anti-inflammatory drugs, salicylates, analgesics combinations, anti-migraine agents, and cox-2 inhibitors. additional outcomes included total dosage of analgesic medication, type of insurance, wait time to see a provider, length of visit in the ed, concurrent benzodiazepine prescription, and total medications overall. a single study17 investigated the outcome of dose reduction of opioid pain relievers within a two-year follow-up period. data synthesis summary in regard to non-opioid medications, no racial or ethnic differences in the prescription of analgesics were found in the ed or ambulatory settings.18 specifically, when the use of opioids for the management of pain-related complaints in the ed was investigated, no racial or ethnic disparities were found to exist in prescription or administration for definitive and objectively painful conditions such as toothaches and kidney stones.19 additionally, no statistically significant interactions were discovered between race or ethnicity and opioid administration for individuals presenting to the ed with definitive pain confirmed sportdiscus 2010-2020 1515 citations ebscohost 2010-2020 555 citations pubmed 2010-2020 39 citations psycinfo 2010-2020 2 citations 561 nonduplicate citations screened inclusion & exclusion criteria applied 8 articles excluded after abstract screen 35 articles retrieved inclusion & exclusion criteria applied 29 articles excluded after full-text screen and data 6 articles included 518 articles excluded after title screen figure 1. study selection process evidence-to-practice review 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 table 2. summary of included studies (n=6) source study design participants source of pain outcome measures interventions results key conclusions meghani, byun, and gallagher meta-analysis n/a traumatic/surgical (bone fracture, postoperative); nontraumatic, non-surgical (migraine, back pain, abdominal pain, osteoarthritis); cancer pain; and mixed pain. prescription of any analgesic, opioid analgesic, and non-opioid analgesic medications. opioid and non-opioid analgesic medications no disparities were found in prescription of any analgesia for hispanics/latinos, but hispanics/latinos were 22% less likely than whites to receive opioids treatment. blacks/african americans were 22% less likely than whites to receive any analgesia and 29% less likely than whites to receive opioid treatment for similar painful conditions. no disparities were found in prescription of opioids to hispanics/latinos for traumatic/surgical pain, but strong differences were found in prescription of opioids for nontraumatic/nonsurgical pain types for which hispanics were 30% less likely than whites to receive opioids. blacks/african americans were 34% less likely to be prescribed opioid medication for nontraumatic/nonsurgical pain. opioid treatment disparities are present between hispanic/latinos and black/african americans which present health care safety and quality concerns. rasu and knell cross sectional adults (n=690,205,290) aged 18 or older treated for chronic problemroutine or chronic problem-flare up visits in us outpatient settings. non-malignant chronic pain (nmcp) of neuropathic, inflammatory, muscle, mechanical/compressive, or general chronic pain origin. opioid prescribing; age, gender, ethnicity, pain diagnosis, number of total medications, region of prescribing, payment type, physician opioids including morphine, codeine, fentanyl, hydrocodone, hydromorphone, levorphanol, meperidine, methadone, oxycodone, propoxyphene, and tramadol with or without acetaminophen, aspirin, and ibuprofen. hispanics and patients with private insurance were less likely to receive opioids for chronic pain management. differences exist between those prescribed and not prescribed opioids. further research is needed on prescription and monitoring of opioids to diminish racial and ethnic disparities in pain management 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 specialty, and patient relationship with provider. treatment disparities. singhal, tien, and hsia retrospective cohort adults (n=16,428) age 18-65 with nondefinitive or definitive pain conditions non-definitive conditions including toothache, back pain and abdominal pain as well as definitive conditions involving long-bone fractures and kidney stones. numerical pain score (0-10); race/ethnicity (non-hispanic white, nonhispanic black, hispanic and non-hispanic other); age, sex, type of insurance, location of the ed. point of care: opioid prescribed at emergency department (ed) discharge, administered in the ed, or both. opioids including narcotic analgesics or narcotic analgesic combinations. non-opioids included nonsteroidal antiinflammatory agents, salicylates, analgesic combinations, antimigraine agents, and cox-2 inhibitors. non-hispanic blacks were less likely to received opioid prescription at ed discharge for back pain and abdominal pain, but not for toothache, fractures, and kidney stones as compared to non-hispanic whites. racial/ethnic disparities in opioid prescription and administration exist for most nondefinitive conditions but not for definitive conditions. differential prescription of opioids by race/ethnicity may lead to widening of existing health disparities and the burden of opioid abuse among nonhispanic whites. buonora et. al. retrospective cohort adults (n=1,097) aged 18 or older prescribed with 3 or more opioid pain relief prescriptions at least 21 days apart with stable dosage. non-cancer related pain opioid pain relievers (opr) dose reduction within two years following the end of each patient’s baseline period. reduction was defined as a reduction in daily opr dose of at least 30% in any 6-month follow-up period relative opioid dose or concurrent benzodiazepine use. black race and female gender were associated with greater odds of opioid dose reduction. clinical decisionmaking regarding opr dose reduction may be influenced more by social factors such as race and gender rather than clinical factors such as dosage and concurrent drug use which may indicate actual risk. racial and ethnic disparities in pain management 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 to baseline. clinical variables included baseline daily opr dose and concurrent benzodiazepine prescription and race/ethnicity and gender. rosenbloom et al. retrospective cohort patients (n=553) aged 12-55 visiting emergency department (ed) appendicitis or gallbladder disease race/ethnicity; sex; receipt of opioid analgesic medication; receipt of nonopioid medications anti-emetic medications, wait time to see a provider (in minutes) and length of visit in the ed (in minutes). opioids included fentanyl, morphine, hydromorphone/dilaudid, oxycodone, hydrocodone, hydrocodoneacetaminophen/vicodin, tramadol, and oxycodoneacetaminophen/percocet. non-opioids included acetaminophen/tylenol, ibuprofen/motrin, and ketorolac/toradol. antiemetics included ondansetron/zofran, famotidine/pepcid, and metoclopramide/reglan. no interaction was identified between sex and race/ethnicity on the odds of receiving opioids. no significant difference in opioid administration was found between noncaucasians as compared to caucasians. noncaucasians did not different from caucasians on receipt of non-opioid analgesics or antiemetics. wait time to see provider nor length of hospital also did not differ between ethnicity. no statistically significant interaction between race/ethnicity and sex for administration of opioid analgesia to patients presenting to ed for appendicitis or gallbladder disease. romanelli et al. cross sectional patients (n=11,576) aged 18 or older with emergency department (ed) discharge diagnosis of long bone fracture. long bone fracture on a single limb prescription for an opioid analgesic at ed discharged; total morphine milligram equivalent (mme) units or oral medications. opioids including oral hydrocodone, parenteral hydromorphone, parenteral morphine. rates of opioid prescribing were no different by race/ethnicity however among patients with an opioid prescription, total mme units prescribed were less for hispanics, blacks, and asians relative to nonhispanic whites. racial and ethnic minorities received similar frequencies of opioid prescribing for cases of long bone fracture, but small potency differences exist. more research is needed on why potency differences exist. evidence-to-practice review 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 to originate from the appendix or gallbladder.20 moreover, two studies confirmed the frequency of opioids prescribed at discharge was similar between racial and ethnic groups for patients presenting to the ed for long bone fracture.19, 21 in contrast, racial and ethnic disparities were established for non-definitive and more subjectively painful conditions such as back and abdominal pain where a distinct source of pain was not always clearly identifiable.19 chronic pain conditions are associated with drug-seeking behavior; therefore, it is worth investigating how this knowledge may affect providers decisions on drug administration. previous research has found that non-hispanic whites have a higher frequency of opioid addiction.17,19 however, despite this fact, both hispanics/latinos and black/african american patients remain at significant risk of under-prescribing. hispanics/latinos were less likely receive opioids for the treatment of nondefinitive pain conditions when visiting ambulatory care facilities.18, 22 likewise, nonhispanic blacks were less likely to receive a prescription for opioid pain medication at discharge despite lower opioid abuse and addiction rates as compared to non-hispanic whites.19 specifically, black/african americans were 22% less likely to receive any analgesic and 29% less likely to receive opioid analgesics as compared to white counterparts with similar pain conditions.18 similarly, with respect to patient reported sex, black and female patients had greater odds of dose reduction of opioid pain relievers as compared to white and male patients within the same urban academic health system.17 these findings are in line with previous research indicating that black patients received tighter oversight as compared to whites undergoing treatment with opioid medications.23 this is suggestive of a reverse disparity in the strategies used to monitor opioid use between racial and ethnic groups.23 methodological quality results five of the six included studies were rated as highquality (table 3). the mean quality score for the six included studies was 7.92, indicating overall good methodological quality. one study19 failed to clearly state the research question. likewise, one study22 failed to clearly define independent variables. two studies20,21 failed to assess exposure(s) more than once over time and examine different levels of exposure as related to the outcome. one study21 did not adjust for key confounding variables, while all studies failed to blind the exposure status of the participants.17-22 table 3. methodological quality source quality assessment score quality rating meghani, byun, and gallagher 10 high rasu and knell 5.83 low singhal, tien, and hsia 8.33 high buonora et. al. 9.16 high rosenbloom et al. 7.5 high romanelli et al. 6.67 high table 4. level of evidence source level of evidence rating meghani, byun, and gallagher 1 rasu and knell 2 singhal, tien, and hsia 1 buonora et. al. 1 rosenbloom et al. 2 romanelli et al. 2 grade of recommendation conclusions regarding racial and ethnic disparities in pain management were graded using the sort (table 5). conclusions have been allocated into 5 primary areas: non-opioid analgesic treatments, opioid analgesics for the treatment of objective sources of pain, opioid analgesics for the treatment of subjective sources of pain, opioid racial and ethnic disparities in pain management 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 tapering or dose reduction, and risk of opioid abuse or overdose death. non-opioid analgesic medications 1. racial/ethnic inequalities appear to exist in the prescription of non-opioid analgesic medications. black/african americans are less likely to receive prescription of any analgesic medication as compared to white counterparts with similar subjectively painful, non-specific conditions.18 (grade = a) opioid analgesics for treatment of objective sources of pain 2. there is no apparent racial or ethnic disparity in opioid prescription nor administration for treatment of objectively painful conditions. the frequency of opioid prescription is similar between races/ethnicities for conditions resulting from verified pain sources such as toothaches, kidney stones or gallstones, long bone fractures, and appendicitis. 19, 20, 21, 22 (grade = b) opioid analgesics for treatment of subjective sources of pain 3. disparities seem to exist between races/ethnicities for the prescription of opioids for the treatment of conditions in which the source of pain may not be readily verifiable. both blacks/african americans and latinos/hispanics are significantly less likely to receive an opioid medication for the treatment of non-traumatic or non-surgical pain conditions such as non-specific back or abdominal pain.18, 19 (grade =a) opioid abuse risk 4. racial/ethnic inequalities may occur in the tapering and reduction of opioid doses. black/african american have greater odds of opioid dose reduction as compared to non-hispanic whites.17 (grade = a) 5. there are evident racial/ethnic disparities in the risk of opioid abuse and opioid overdose death. non-hispanic whites have a higher risk of opioid abuse and opioid related overdose death.17, 19 (grade = a) discussion and clinical implications findings of this review suggest racial and ethnic minorities are at significant risk for the undertreatment of pain conditions. this is evident by the fact that disparities exist in the prescribing of analgesic pain medication. while inequalities were less stark for hispanic/latino patients, black/african american patients were significantly less likely to receive prescription of any analgesic medication to treat their pain at discharge from the ed.18 however, when pain type was considered, these disparities were eliminated for conditions with objective sources of pain such as surgery or trauma; yet disparities persisted for subjectively painful conditions in which a source of pain could not be clearly identified.18 these findings extended to the prescription and administration of opioid pain relievers. we concluded, with good confidence, that there are no apparent racial or ethnic disparities in the administration of opioid pain relievers in the ed or at ambulatory discharge for patients with definitive conditions such as toothaches and kidney stones19, long bone fracture19, 21, or from the appendix or gallbladder.20 all of the previously mentioned conditions have a clear diagnostic process that can be confirmed with objective data, which could also influence why disparities were unfounded. to the contrary, racial and ethnic disparities emerge in the prescription of opioid analgesic medications for racial and ethnic disparities in pain management 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 subjectively painful conditions.18, 19 both hispanic/latino and black/african american patients were less likely to be prescribed an opioid medication for the treatment of back pain, abdominal pain, or migraine headache.18 in instances where the provider was required to extend trust to the patient regarding conditions reliant on subjective confirmation racial disparities were apparent. racial and ethnic differences in the management of pain using opioid pain appraise the severity of the patient’s pain as well as judge their risk of misuse or abuse by their sociocultural characteristics.17 over and above the fact that black/african american patients obtained fewer opioid prescriptions, we also concluded that this population received lower doses of medication plus tighter oversight when compared to nonhispanic whites with equivalent diagnoses.17, 21 specifically, the odds of dose reduction were 82% higher in black/african american patients when compared to white patients within the same time interval.17 inconsistencies in the prescription and administration of these drugs between ethnicities may suggest implicit biases on part of the health care provider. again, evidence suggests racial and ethnic inequalities in pain management may be reflective of a health care provider’s ability to appraise the severity of pain in latino/hispanic and black/african american patients.17 failure in appraisal may lead providers to underestimate the severity of symptoms and be conservative in the prescription of opioid medications to non-white patients in medically ambiguous situations.19 this unconscious bias leads to a pattern of discrimination which denies vulnerable patient populations access to pain relief. 18 undertreatment of pain has the potential to accelerate existing health disparities and further promote poor health outcomes in racial and ethnically diverse communities that already experience greater barriers to obtaining appropriate health care.17, 19 inequity in pain management does not only affect ethnic minorities. in the case of opioid monitoring, it appears that non-whites actually receive care that is more in-line with that of expert recommendations, while whites experience inappropriate laxity in the monitoring of their opioid treatment and the implementation of risk reduction strategies.23 the use of opioids for pain management presents high potential for addiction and abuse of these medications in non-hispanic whites.19 the fact that these individuals are much table 5. grades of recommendation conclusion source(s) grade racial/ethnic inequalities appear to exist in the prescription of non-opioid analgesic medications. meghani et al. a no apparent racial/ethnic disparities exist in opioid prescription or administration for treatment of objectively painful conditions. singhal et al; rosenbloom et al; romanelli et al. a racial/ethnic disparities are present in the prescription of opioid analgesics for subjectively painful conditions. singhal et al; meghani et al. a racial/ethnic inequalities may occur in the tapering and reducing of opioid doses. buonora et. al. b there are evident racial/ethnic disparities in the risk of opioid abuse and opioid overdose death. buonara et al. a racial and ethnic disparities in pain management 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 more likely to be administered and prescribed high-dose opioid medications for long-term duration is a potential contributing factor to why whites have an age-adjusted death rate that is more than three times that of non-hispanic blacks.19 ethnic disparities in prescribing practices may contribute not only to undertreatment of pain in non-hispanic blacks, but also promote the misuse, abuse, and potential opioid overdose death in non-hispanic whites.19 these findings suggest the assessment of a patient’s treatment risks may rely on the clinician’s interpretation of the patient’s self-reported pain and the clinician’s judgement about the patient’s potential misuse of opioids.19 the highly subjective nature of these decisions and the influence of implicit bias leave room for assumption and unchallenged misconceptions to play a role in the selection of pain management interventions. to combat this, we advocate for a universal approach to the prescription of opioid analgesics medications as well as in the management and risk-reduction for patients with definitive and non-definitive pain conditions.23 the treatment of pain is complicated by its inherently subjective nature, but identification and acknowledgement of implicit racial or ethnic biases, as well as use of an evidence-based approach, may assist health care providers in clinical decision-making during times of medical ambiguity. individual patient factors such as cultural traditions, religious beliefs, and previous lived experiences need to be valued by clinicians for their potential to affect the pain experience in patients from various racial and ethnic backgrounds.24 likewise, all providers within the interdisciplinary health care team should be knowledgeable regarding current and appropriate standards of care. when properly educated on the standard of care and health inequities, athletic trainers can serve as vital patient advocates.25 furthermore, we can evaluate and document the effectiveness of these analgesic medications to determine when a patient’s pain needs are not being met or when intervention for substance misuse or abuse may be warranted.26 clinical bottom line clinicians have a responsibility to act in their patients’ best interest and provide high-quality patient care. therefore, they need to remain aware of the role implicit bias may play in treatment decisions. analgesic medications are often a principal component of pain management. findings of this review concluded equity exists in the prescription of analgesics for definitive injuries such as long bone fractures, yet disparities are present in the prescription of analgesic drugs for more subjective conditions like back or abdominal pain between racial and ethnic groups.18, 19, 20, 21 furthermore, evidence suggests that ethnic minorities may suffer from lower medication dosing and stricter opioid oversight from prescribing providers.17, 21 racial and ethnic disparities in prescribing of these drugs may contribute not only to the inadequate management of pain for non-white communities but contribute to the high rates of abuse and overdose-related death characteristic of the opioid epidemic within the non-hispanic white population.17 respect for the patient’s values, preferences and subjective reports of pain are important factors for all clinicians to consistently consider during clinical decision-making. it is particularly important that athletic trainers be aware of the current standards of care for managing pain through the use of analgesic medications. furthermore, we should be knowledgeable and actionable regarding the signs of opioid misuse, abuse, and addiction. this will require acknowledging pain in patients, detecting the source of pain, evaluating pain at routine intervals, and developing an interdisciplinary plan with physicians and other health care professionals for successful pain management.26 because athletic trainers regularly work with racial and ethnic disparities in pain management 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 patients recovering from surgery and other painful conditions in which analgesics are prescribed, future research directions should specifically investigate racial and ethnic disparities in the prescription, administration, and abuse of these medications in the athletic population. references 1. u.s. department of health and human services. the secretary’s advisory committee on national health promotion and disease prevention objectives for 2020. phase i report: recommendations for the framework and format of healthy people 2020. section iv: advisory 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(2012). time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the united states. pain med. 2012;13(2):150–174. https://doi.org/10.1111/j.15264637.2011.01310.x. 19. singhal a, tien yy, hsia ry. racial-ethnic disparities in opioid prescriptions at emergency department visits for conditions commonly associated with prescription drug abuse. plos one. 2016;11(8):e0159224. https://doi.org/10.1371/journal.pone.0159 224. 20. rosenbloom jm, burns sm, kim e, august da, ortiz ve, houle tt. race/ethnicity and sex and opioid administration in the emergency room. anesthesia & analg. 2019:128(5):1005-1012. https://doi.org/10.1213/ane.0000000000 003517. 21. romanelli rj, shen z, szwerinski n, scott a, lockhart s, pressman ar. racial and ethnic disparities in opioid prescribing for long bone fractures at discharge from the emergency department: a cross-sectional analysis of 22 centers from a health care delivery system in northern california. ann emerg 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https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://caate.net/wp-content/uploads/2018/09/2020-standards-for-professional-programs-copyedited-clean.pdf https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools https://www.nhlbi.nih.gov/health-topics/study-quality-assessment-tools https://doi.org/10.4085/1062-6050-240-19 https://doi.org/10.4085/1062-6050-240-19 https://doi.org/10.1093/pm/pny137 https://doi.org/10.1111/j.1526-4637.2011.01310.x https://doi.org/10.1111/j.1526-4637.2011.01310.x https://doi.org/10.1371/journal.pone.0159224 https://doi.org/10.1371/journal.pone.0159224 https://doi.org/10.1213/ane.0000000000003517 https://doi.org/10.1213/ane.0000000000003517 https://doi.org/10.1016/j.annemergmed.2019.05.018 https://doi.org/10.1016/j.annemergmed.2019.05.018 https://doi.org/10.1093/pm/pnx025 https://doi.org/10.1370/afm.1242 https://doi.org/10.2217/pmt.12.7 abstract manuscript type disablement model case study 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 exertional heat stroke in a male high school runner with disordered eating: a disablement model case study brittni g. hoover, ms, lat, atc*; rebecca m. hirschhorn, phd, atc, nraemt†; allison b. smith, phd, lat, atc‡; amy f. hand, phd, scat, atc** *university of north carolina at charlotte, charlotte, nc; †louisiana state university, baton rouge, la; ‡university of louisiana at lafayette, lafayette, la; ** university of south carolina, columbia, sc abstract a 16-year-old male high school cross country athlete collapsed at the end of an afternoon 5k cross country meet. the patient was unable to stand, and after outwardly displaying confusion and agitation, his coaches sought assistance from the athletic trainers (ats). the patient consumed one cup of water and a granola bar on the day of the meet. the ambient air temperature was 90°f with 69% humidity. differential diagnoses included exertional heat stroke (ehs), exertional heat exhaustion, exertional collapse associated with sickle cell trait, heat syncope, dehydration, malnutrition, and hypoglycemia. approximately 20 minutes passed between activation of the emergency action plan (eap), initial collapse, and cold-water immersion. assessment of rectal temperature did not occur until after submersion due to waiting for parental consent. the patient was removed from the water after 12 minutes with a rectal temperature of 100.5°f. he was transported to the hospital, received 2 liters of intravenous normal saline among multiple other tests, with no significant findings, and was released approximately 9 hours later. it was later learned that the athlete dealt with disordered eating. the patient was asked to complete a seven-day food and drink log and was provided nutrition guidance by the ats. this patient’s disordered eating habits could have contributed to the development of ehs. the ats were unaware of his eating patterns until after the ehs event. athletes need to be educated on how to properly fuel themselves for athletic competition in anticipation of adverse environmental conditions. if a patient is already prone to disordered eating, this individual will not have the proper intake of nutrients to sustain athletic competition, nor to sustain everyday living. athletic trainers should be aware of all potential medical concerns in their patients, including those not often discussed, to accurately diagnose conditions and avoid any potential sequelae. correspondence brittni g. hoover, 1300 wheat street, columbia, sc 29208. e-mail: bghoover@email.sc.edu twitter: @britthoover2 full citation hoover bg, hirschhorn rm, smith ab, hand af. exertional heat stroke in a male high school runner with disordered eating: a disablement model case study. clin pract athl train. 2022;5(2): 45-51. https://doi.org/10.31622/2022/0005.02.8. submitted: may 4, 2021 accepted: july 26, 2021. introduction exertional heat stroke (ehs) is the most severe exertional heat illness (ehi) characterized by a core body temperature exceeding 105°f, the presence of central nervous system (cns) dysfunction, and multiple organ system failure.1-5 when the metabolic heat produced by muscle during activity outpaces body heat transfer to the surroundings, the core temperature rises to levels that disrupt organ function, unless correctly recognized and treated in a timely manner.2,5 care should begin within 30 minutes of initial collapse to include cooling from the neck down.6 relevant to this case study, high school boys’ cross country has been found to have an ehi incidence rate at 0.52 per 10,000 athlete-exposures per cross country season, during competition, and 0.50 per 10,000 athlete-exposures in practice, the second-highest ehi rate following boys’ american football.8 exertional heat stroke is one of the leading causes of sudden death during activity.1,2 risk factors for ehs include lack of heat acclimatization, cardiovascular dysfunction, fever, illness, dehydration, and hypokalemia, among others.2 some of these factors can also be directly associated with eating disorders.5 eating disorders can be determined by using questionnaires such as the eating disorder examination (ede). this questionnaire includes questions related to eating disorder (ed) risk. these questions are specific to sport and are related to being diagnosed.6 if an individual is not consuming enough nutrients, it can result in low energy availability, health risks, and ultimately affects bone mineral density.5 disordered http://bghoover@email.sc.edu https://doi.org/10.31622/2022/0005.02.8 exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 eating behaviors are similar to eating disorders, but they do not meet the criteria for diagnosis.7 relevant risk factors pertaining to this case include that the patient struggled with disordered eating (de).7 if not addressed appropriately or in a timely manner, de can result in physiological and psychological effects. some of these include inadequate energy availability, decreased bone mineral density, and for females specifically, menstrual disorders and the female athlete triad.6 in athletes who completed the ede-12 questionnaire, body dissatisfaction, drive for thinness, and body mass index were found to contribute to their de habits.8 in males specifically, body dissatisfaction has been found to be linked to muscularity and weight concerns.6 in this case, the patient’s family was previously aware of his nutritional habits; however, the ats at his school were not. patient information the patient in this case study is a 16-year-old male high school cross country athlete that collapsed at the conclusion of an afternoon 5k cross country meet. at the time of the incident, the patient was in the 11th grade and had been participating on the cross-country team since middle school. there was no documented family history of heart disease, diabetes, ed, or mental health disorders. he had no previous history of ed, injury, or other illness. on the day of the meet, which started at 4 pm, the patient had only consumed one cup of water and one granola bar. at the time of the collapse, the ambient air temperature was 90°f with 69% humidity, which is in the dangerous percentile and increases the risk of ehi.9 these measures were not determined until after the collapse occurred. differential diagnosis and evaluation the differential diagnoses were ehs, exertional heat exhaustion, exertional collapse associated with sickle cell trait, heat syncope, dehydration, malnutrition, and hypoglycemia.2 when the patient first collapsed at the finish line, the ats decided for the patient to drink water and sit down since he was conscious, alert, and oriented. due to the patient’s fatigue, he was assisted to the team tent by his coaches and teammates. the patient’s presentation drastically changed after arrival at the team tent, which is when the coaches called the ats for assistance. the most notable changes included signs of cns dysfunction (confusion, inability to form speech, unaware of date, place, time, personality change/aggression), feeling of extreme overheating of the body that could not be cooled with water, and extreme fatigue (inability to walk or stand). the patient was transported from the team tent to the athletic training facility where cold water immersion and a rectal thermometer were available. at this time, emergency medical services were called. since the patient was a minor, the at’s policy was to get parental consent prior to the use of rectal thermometry and immediately initiated cold water immersion. the patient’s parents were not at the race and were called to receive permission to utilize the device. after the patient was immersed for 12 minutes and showed obvious signs of improved cns function, the ats removed him from the cold-water immersion tub and assessed his rectal temperature after receiving parental consent. at this time, his rectal temperature was 100.5°f, and it was determined that the patient was now able to be safely transported. emergency medical services then transported him to the hospital, where he received further evaluation and care. body structure and function the body function most affected was his cns, as shown through his delirium. when talking to the patient after the event, he recalls that he felt an out-of-body experience. the patient expressed that he knew something was wrong, but he did not know what was going on. the best practice, or gold standard, of immediate treatment for ehs is the assessment of rectal temperature and cold-water immersion.1,3 exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 activity and participation at nine months since the event, there are no documented long-term negative effects on the patient’s health as a result of his ehs event. the incident made the ats aware of the patient’s de behaviors. additionally, the patient expressed that it made him realize the drastic effects that his de can have on his body, and he began to change his eating habits. this event shows clinicians that de presents in males as well as females. he has worked with his parents to improve his de. the patient took time off from running to help his body heal. it is important to note that de is not an overnight fix and takes months and sometimes years to get to a healthy place. environmental and personal factors the patient expressed that the nature of the sport of cross country and associated physical appearance standards, the overwhelming media push to “look skinny,” and the myth shared throughout his high school that you should not eat too much as an athlete, were all factors that led up to his de. he shared that his teammates’ support had a huge hand in the difference between him having a successful and unsuccessful recovery. parental involvement was a key factor in his recovery process, as well, due to their constant support without judgment. this patient, in particular, expressed that the encouragement that he received from his teammates and family is what helped him face his de and get on a path to recovery and healing. interventions due to the patient’s personality changes and aggressive behavior, indicative of cns dysfunction, the ats initiated the emergency action plan, which was to call emergency medical services and immerse the patient in cold water. the cold tub was not located at the cross-country course, and the patient had to be transported to the athletic training facility for cold-water immersion, resulting in approximately 20 minutes passing between initial collapse and cold-water immersion. the patient had partial consciousness and was unaware of the events happening during the cold-water immersion. after 12 minutes of cold-water immersion, the patient’s cognitive function improved, so he was removed from the water, and his rectal temperature was assessed. at that time, his core temperature (100.5°f) was determined to be safe for transportation by emergency medical services, who arrived shortly after his immersion. at the hospital, he received two liters of intravenous normal saline and was administered multiple tests, including an electrocardiogram and blood panel, with no significant findings. he was released approximately 9 hours after arriving at the emergency department following the resolution of symptoms. the patient followed up with his at the following day, who had since been informed of possible de by a concerned peer. the patient was asked to complete a 7-day food and drink log and was provided nutrition guidance where he logged everything he ate and drank each day. in the mornings, he reported to the athletic training facility prior to school to review what he ate prior to practice the night before and to report his breakfast intake prior to school for the day. he also reported to the athletic training facility at the end of each day, where the log was reviewed. if he did not consume adequate calories based on the recommended daily intake values, he was not permitted to practice.10,11 on the days that he was not in school, he contacted the head at to report his documented intake electronically. outcomes the only quantitative data, or validated outcome measures that were taken, were taken during the initial incidence. based upon conversation, his body has returned to normal function, and he is now able to exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 participate in full activity. in addition to completing the 7-day food log and daily check-ins with the at, the patient’s return to play included an evaluation of the nutrients that he took in every day and if that fulfilled his requirements to participate in sport. if he did not meet this threshold, he was not allowed to practice that day. his running mileage was also greatly lowered. he began his return to play with biking and walking in the athletic training facility, to progressing to walking with a friend and a mile of light running. after 7 days, he had built up enough nutrient intake as well as mileage increase to return to full practice. due to concerns over the patient running alone, it was decided to have a friend run with the patient during his return-to-play in case another situation occurred while they were out on the course. the patient has continued to address his de behavior, but the family has kept the continued process personal. discussion certain aspects of this case that are important to note, such as the delay in assessing rectal temperature to confirm an ehs diagnosis, wet-bulb globe temperature (wbgt), which had not been used prior to or during the event, and the lack of immediate on-site access to cold water immersion. rectal thermometry is the gold standard of care to assess core body temperature during a heat illness event.9,11-14 methods such as oral or temporal temperature assessment are inaccurate.15 however, recent literature still demonstrates that most secondary school ats do not assess a rectal temperature during suspected cases of ehs.9,11-14 less than half of surveyed ats reported that they were comfortable using a rectal thermometer to assess for ehs.15 in this situation, the ats wanted to protect themselves in case the parents did not give consent. however, rectal thermometry is the standard of care for athletic training for heat-related illness emergencies, as stated by the nata,2 and therefore, it is the required practice of care, regardless of parental consent or the patient being a minor.1,2 barriers to implementing the use of rectal thermometers have been found to be lack of training with equipment, misunderstandings of use and cost, and the possibility of legal issues.16 there are also extrinsic factors that negatively impact ats use of rectal thermometry. for example, in some cases, school administrators may express concerns with the use of rectal thermometry on minors. this has especially been noted by ats that work in private school settings.4 recommendations to overcome these barriers include proper education of these devices explaining the importance of understanding the efficacy of the temperature measurement compared to other tools.17 ultimately, it is the at’s responsibility to ensure meetings with administrators are held prior to such events so that all individuals are on the same page when it comes to emergency action plans and protocols. in this case, the ats had not gotten prior permission from the parents to utilize this standard of care. this should be explained to parents prior to sport participation, and a form signed that gives the ats the right to care for their student-athletes using rectal temperature if the parents are not present at the time of the incident.2 there is a heat stroke treatment authorization form that is created by the nata that clearly lists out the proper evidence and the definitions of the at’s scope of practice that parents and guardians can sign at the beginning of every season.18 the day of the patient’s ehs event was one of the hottest days within the first few weeks of the cross-country season. the team was only a few weeks into regulated practices and had not gone through a low to high increase in practice mileage/intensity or regulated acclimatization period during those weeks, nor did they have any regulated summer practices. this day, in particular, was too hot for participation in sports (90°f and 69% humidity) based on the ambient temperature and relative humidity.3 according to the heat stress risk temperature and humidity graph,19 if the relative humidity is between 50-60% ambient temperature should not exceed 86-90°f for safe sport participation.16 however, there were no modifications to the competition based on the extreme environmental conditions. ideally, a wbgt device should have been utilized, and the event delayed or postponed until the conditions were more favorable; however, a wbgt reading was not utilized prior to that day’s events.3 wbgt is preferred to ambient temperature and radiant exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 heat alone due to differences in weather effects within various regions of the country.2 wbgt is calculated by completing a mathematical equation including wet-bulb temperature, black-globe temperature, and drybulb temperature.2 lastly, the facilities where the cold tub was located, were a 5 to 8-minute walk from the finish line and team tents. precious time was lost during the commute from the team’s tents to the place where the cold tub was utilized. since the patient was being carried, this also added to the time that he could have been in the cold tub. rectal thermometry and cold-water immersion were utilized within the 30-minute recommendation after the start of treatment, supported by the nata position statement for standard of care for ehs.2,19 clinical bottom line it is important for ats to ensure they are up to date on the standard of care that is expected of the profession. emergency action plans for situations like this should be implemented and practiced prior to an event occurring. ats should be in contact with emergency personnel to make sure that the standard of care is continued during and after transportation to a hospital. ehs can be avoided if prevention and recognition are practiced correctly. individuals presenting with ehs must be cared for within a short amount of time to prevent serious injury or death. it is the at’s responsibility to ensure all important personnel are trained and ready for any emergencies that may occur.2 with the proper training, pre-participation examinations, and weather precautions in place, ehs can be avoided and potentially completely prevented. this case is important due to the rise of ehs in both the high school and college athlete populations.10 rectal thermometry has been the gold standard of practice since 2002, yet many ats still do not feel comfortable performing it if they did not learn this in their schooling.1,12 since this information was published 18 years ago, this standard of care should be fully accepted and administered across the athletic training world. athletic trainers are responsible for learning and implementing new athletic training competencies into their practice, even after obtaining their initial certification.20 state, regional, and national conferences should provide opportunities for ats to learn and practice these skills to help facilitate implementation to practice. ats should be aware of other factors that could affect and increase risk of ehs. in this scenario, disordered eating was a factor that led to the patient's ehs. other factors of this ehs event included lack of supplies, at preparation, and difficulty accessing emergency equipment. it is important for athletes to have a basic understanding of proper nutrition guidelines for their sport participation and how environmental conditions may further compound.8,21 outdoor sport athletes need to be especially careful due to potential exposure to adverse environmental conditions.4 it is suspected that the patient’s de had a key effect on his dehydration and lack of nutrients to be able to successfully compete in his race. the authors recommend three important take-a-ways from the experience. one of the most important things that an at can do with their staff is to review and practice their eaps, annually.2,4,5,16,19 this plan includes instructions on what to do in case of an emergency, and more specifically, a heat related illness event. rectal thermometry should be available to all ats at every level, even including secondary schools. 1,2,4,16,17 there are certain forms and parameters that can be navigated to gain permission from parents in regard to minors. ats should consider screening athletes for nutritional concerns prior to sport participation through preparticipation exams (ppes) and throughout the season utilizing validated risk assessments, such as the ede-q and ede-12 questionnaires.6,8 ats should be aware of all potential medical concerns in their patients, identified through ppes, to properly refer to physicians or specialists and diagnose conditions to avoid any potential sequelae. if ats adopt the regular use of eaps, rectal temperature, and ppes in their practice, exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 50 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 incident rates of fatal heat related illnesses should drastically decrease due to the awareness gained through these three avenues. references 1. miller kc, hughes le, long bc, adams wm, casa dj. validity of core temperature measurements at 3 rectal depths during rest, exercise, cold-water immersion, and recovery. j athl train. 2017;52(4):332338. https://doi.org/10.4085/1062-6050-52.2.10. 2. casa dj, demartini jk, bergeron mf et al. national athletic trainers' association position statement: exertional heat illnesses. j athl train. 2015;50(9):986–1000. https://doi.org/10.4085/1062-605050-9-07. 3. casa dj, armstrong le, kenny gp, o’connor fg, huggins ra. exertional heat stroke. curr sports med rep. 2012;11(3):115-123. https://doi.org/10.1249/jsr.0b013e31825615cc. 4. adams wm, hosokawa y, belval ln. factors involved in the onsite management and care of exertional heat stroke in secondary school athletics. athl train sports health care. 2019;11(5):206209. https://doi.org/10.3928/19425864-20181010-01. 5. armstrong le, casa dj, millard-stafford m, moran ds, pyne sw, roberts wo. exertional heat illness during training and competition. med sci sports exerc. 2007;39(3):556-572. https://doi.org/10.1249/mss.0b013e31802fa199. 6. martinsen m, bahr r, børresen r, holme i, pensgaard am, sundgot-borgen j. preventing eating disorders among young elite athletes. med sci sports exerc. 2014;46(3):435-447. https://doi.org/10.1249/mss.0b013e3182a702fc. 7. first mb. diagnostic and statistical manual of mental disorders, 5th edition, and clinical utility. j nerv ment dis. 2013;201(9):727-729. https://doi.org/10.1097/nmd.0b013e3182a2168a. 8. raevuori a, keski-rahkonen a, hoek hw. a review of eating disorders in males. curr opin psychiatry. 2014;27(6):426-430. https://doi.org/10.1097/yco.0000000000000113. 9. ganio ms, brown cm, casa dj et al. validity and reliability of devices that assess body temperature during indoor exercise in the heat. j athl train. 2009;44(2):124-135. https://doi.org/10.4085/1062-6050-44.2.124. 10. kerr zy, yeargin sw, hosokawa y, hirschhorn rm, pierpoint la, casa dj. the epidemiology and management of exertional heat illnesses in high school sports during the 2012/2013–2016/2017 academic years. j sport rehabil. 2020;29(3):332-338. https://doi.org/10.1123/jsr.2018-0364. 11. nedimyer ak, chandran a, hirschhorn rm et al. exertional heat-stroke management practices and intentions among secondary school football athletic trainers. j athl train. 2020;55(10):1081-1088. https://doi.org/10.4085/1062-6050-474-19. 12. casa dj, becker sm, ganio ms et al. validity of devices that assess body temperature during outdoor exercise in the heat. j athl train. 2007;42(3):333-42. 13. miller kc, casa dj, adams wm et al. roundtable on preseason heat safety in secondary school athletics: prehospital care of patients with exertional heat stroke. j athl train. 2021;56(4):372–382. https://doi.org/10.4085/1062-6050-0173.20. 14. mazerolle sm, scruggs ic, casa dj et al. current knowledge, attitudes, and practices of certified athletic trainers regarding recognition and treatment of exertional heat stroke. j athl train. 2010;45(2):170-180. https://doi.org/10.4085/1062-6050-45.2.170. 15. mclean dr, scarneo-miller se, lopez rm. perceptions of secondary school athletic trainers in the diagnosis of exertional heat stroke. j athl train. 2020;55(10):1070-1080. https://doi.org/10.4085/1062-6050-0247.19. 16. casa dj, anderson s. nata’s heat-illness consensus statement. athl ther today. 2003;8(5):35. https://doi.org/10.1123/att.8.5.35. 17. mazerolle sm, ganio ms, casa dj, vingren j, klau j. is oral temperature an accurate measurement of deep body temperature? a systematic review. j athl train. 2011;46(5):566-573. https://doi.org/10.4085/1062-6050-46.5.566. https://doi.org/10.4085/1062-6050-52.2.10 https://doi.org/10.4085/1062-6050-50-9-07 https://doi.org/10.4085/1062-6050-50-9-07 https://doi.org/10.1249/jsr.0b013e31825615cc https://doi.org/10.3928/19425864-20181010-01 https://doi.org/10.1249/mss.0b013e31802fa199 https://doi.org/10.1249/mss.0b013e3182a702fc https://doi.org/10.1097/nmd.0b013e3182a2168a https://doi.org/10.1097/yco.0000000000000113 https://doi.org/10.4085/1062-6050-44.2.124 https://doi.org/10.1123/jsr.2018-0364 https://doi.org/10.4085/1062-6050-474-19 https://doi.org/10.4085/1062-6050-0173.20 https://doi.org/10.4085/1062-6050-45.2.170 https://doi.org/10.4085/1062-6050-0247.19 https://doi.org/10.1123/att.8.5.35 https://doi.org/10.4085/1062-6050-46.5.566 exertional heat stroke in a male high school runner with disordered eating: a disablement model case study 51 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 18. kerr zy, casa dj, marshall sw, comstock rd. epidemiology of exertional heat illness among u.s. high school athletes. am j prev med. 2013;44(1):8-14. https://doi.org/10.1016/j.amepre.2012.09.058. 19. casa dj. almquist j, anderson s. inter-association task force on exertional heat illnesses consensus statement. nata news. june;2003:24–29. 20. certification maintenance requirements for athletic trainers: reporting period ending december 31, 2021. accessed july 20, 2021. https://online.flowpaper.com/7f6907b2/202021certmaintenancerequirements/#page=1. 21. belval ln, casa dj, adams wm et al. consensus statementprehospital care of exertional heat stroke. prehosp emerg care. 2018;22(3):392-397. https://doi.org/10.1080/10903127.2017.1392666. https://doi.org/10.1016/j.amepre.2012.09.058 https://online.flowpaper.com/7f6907b2/202021certmaintenancerequirements/#page=1 https://doi.org/10.1080/10903127.2017.1392666 abstract manuscript type evidence-to-practice review 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review molly m. osborn, ms, lat, atc*; victoria a. williams, ms, scat atc‡; allison b. smith, phd. lat, atc†; zachary k. winkelmann, phd, scat, atc, chse§ *florida international university, miami, fl; ‡lexington high school, lexington, sc; †otterbein university, westerville, oh; §university of south carolina, columbia, sc abstract life as an athlete in the national collegiate athletic association (ncaa) can enrich and play an integral part in a young studentathlete's development. consequently, this lifestyle comes with its own stressors that affect one’s physical, spiritual, and psychosocial well-being. these issues can affect various aspects of a student-athlete’s life, including their performance in sports, school, and social settings. recent studies have begun connecting these domains directly to the health and well-being of ncaa student-athletes, leading to new evidence focused on the best intervention protocols for the biopsychosocial-spiritual (bpss) model of health. a systematic review was conducted using five electronic databases. twenty studies were included in this review, each assessing how effective existing interventions were at helping the health outcomes of bpss factors in ncaa student-athletes specifically. the most used interventions in the reviewed literature included cognitive behavioral therapy, cognitive dissonance, and mindfulness. results suggested that the interventions had positive bpss effects on student-athlete stressors. this data can be especially beneficial for healthcare providers, such as athletic trainers, who work directly with them daily. the overall health of ncaa student-athletes should be considered when creating treatment protocols and bpss-based programs should be incorporated due to their demonstrated positive effects. content focus: health information technology correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation osborn mm, williams va, smith ab, winkelmann zk. interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review. clin pract athl train. 2023;6(2): 15-20. https://doi.org/10.31622/2023/0006.02.2. original reference brown bj, jensen jf, hodgson jl, brown re, rappleyea dl, schoemann am. mind, body, spirit, and sport: a systematic review examining the effectiveness of interventions targeting the biopsychosocialspiritual health of ncaa student-athletes. j study sports athl educ. 2020;14(3):235-261. summary clinical problem and question the national collegiate athletic association (ncaa) has about 500,000 participants yearly.1 sports can be an experience that helps athletes grow in confidence, maturity, social skills, work ethic, problem-solving, acceptance, and much more.1 but for others, the addition of sports to college lives can prove to be too much when balancing social, spiritual, psychological, and biological stressors.2 in recent years, researchers have begun studying these stressors of ncaa student-athletes and their connection to risky behaviors, mental health problems, and spirituality.3 data gathered from the national college health assessment identified that half of male ncaa athletes and almost three out of four female ncaa athletes described experiencing overwhelming anxiety in the last year.4 furthermore, over 5% of student-athletes have experienced suicidal ideation, and 30% of sudden deaths have come from suicide and drug-related activities.4-6 it has been hypothesized that these behaviors are based on an inability to cope with the pressure from sports and school.7 with this type of data surfacing, the ncaa acknowledged mental health as being the top health mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.02.2 interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – september 2023 concern for student-athletes.8 athletic trainers in the collegiate setting work directly with this population daily; knowing what afflicts them physically is equally important as knowing what afflicts them mentally. the athletic trainer must aid in preventing, educating, and referring issues involving the patient’s mental, social, and spiritual health and well-being. therefore, this evidence-to-practice review aims to explore successful interventions managing the biopsychosocial-spiritual (bpss) health of ncaa student-athletes. summary of literature to identify studies that highlighted interventional effects on the bpss model, the authors of the guiding systematic review searched cinahl, psycinfo, pubmed, eric, and sportdiscus for articles. the search terms included many words related to “intercollegiate athletes,” “depression,” “stress,” “body image,” “treatment,” and “spirituality.” those search terms revealed 420 unique articles, which, after a review of titles and abstracts, yielded 75 studies for a full review. for the full text to be reviewed, the study had an intervention to affect the bpss model, be peer-reviewed, be published in english, and study ncaa studentathletes. if the reported outcome was biological, the study also had to report a psychological, social, or spiritual outcome. a double review system provided inter-rater consistency to the full-text review inclusions and exclusions. once studies were deemed relevant, researchers used the cochrane collaboration tools and the quality assessment tool for quantitative studies (qatsq) to assess bias, study design, methods, and other factors that affect the quality of the study. the scores from these quality assessments were used to rate the studies as either weak, moderate, or strong; the strong research was kept, and the weak and moderate articles were not included. of these reviews, eighteen articles remained and were included, and two additional articles were selected after hand-searching the reference lists of the chosen articles. summary of interventions these studies used various psychological, mindfulness, educational, and social interventions. most interventions were single administration education or intervention, 7 to 14 sessions of therapy or group intervention, or season-long interventions. four studies used forms of cognitive behavioral therapy (cbt) administered by a therapist or a sports psychologist, while another study used normative therapy techniques via interactive computer programs. six studies focused on mindfulness training related to performance measures, anxiety, stress, and heart rate. these techniques were either self-guided or conducted by a trained meditation instructor. the three studies aimed to investigate if cognitive dissonance and healthy weight education programs implemented by psychologists impacted body image and disordered eating habits. six studies had at least one group given an educational intervention focused on stress, substance abuse, or health. only one study looked at social support from the athletic training staff and its impact on the bpss model of health. several studies used more than one of the interventions mentioned earlier and a control group to compare 3 or 4 levels of an independent variable. summary of outcomes because the bpss model encompasses many aspects of a person, the outcomes needed to study it should be equally encompassing. these studies researched objective and subjective biological, psychological, social, and spiritual wellness measures. each study chose its unique biological measures, including body fat percentage, resting heart rate, illness/injury days, and several visits to a health center. psychological outcomes examined body dissatisfaction, thinness idealization, self-esteem, sports anxiety, bulimic pathology, and anxiety symptoms. to assess the social impacts of the interventions, they measured alcohol use, alcoholrelated consequences, levels of social cohesion, and team leadership skills. mindfulness scores and overall interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – september 2023 life satisfaction appraised improvements in spirituality. a few studies in the systematic review also viewed qualitative outcomes in addition to the quantitative measures collected. these included patients’ preferences of intervention types and their subjective beliefs of the effectiveness of the treatments. they collected coaches’ performance, leadership skills, and coping skills ratings of players who received the interventions compared to the control groups. in addition, studies qualitatively assessed how team group activities, like campouts and meetings, compared to more formal interventions in affecting the bpss outcomes. findings and clinical implications results from the guiding systematic review identified improvements in bpss health outcomes when interventions based on mindfulness and cognitive-behavioral approaches were implemented (table 1). mindfulness involves specific meditative actions (yoga, deep breathing exercises, etc.) that help to decrease a patient’s reactivity to stressful internal problems and help them develop skills to better self-reflect.9 cognitive-behavioral approaches involve treatments that help patients focus on maladaptive thoughts and behaviors to better understand and work through their emotions during high-stress situations.10 research from one study found that these intervention types showed significant decreases in the number of injured days, sick days, and visits to the health center,11 and another study showed improvements in sports performance, concentration, and anxiety.12 additional research revealed in-person programs focusing on cognitivebehavioral and motivational interviewing techniques positively affected student-athlete substance use and abuse.13 the participants had decreases in the frequency and amount of alcohol use and alcohol-related penalties, as well as increased protective behaviors. athletic trainers could incorporate mindfulness and/or cognitive-behavioral type activities by starting with guided awareness of their body in space, their breath, and their thoughts while in a relaxed state and leading into self-guided meditative control over these same factors when in stressful situations.14 table 1. definition of cognitive therapies intervention type definition cognitive behavioral therapy a treatment method that focuses on maladaptive behaviors and thoughts of individuals. it enhances the individual’s attentiveness and understanding of their emotions, heightens their cognitive flexibility, and increases their ability to work through anxious, negative, and avoidant behaviors and thoughts.10 mindfulness a treatment method that uses exercises such as yoga, seated meditation, and deep breathing to help an individual decrease their reactivity to negative internal issues and increase their ability to self-reflect by focusing on the orientation of their bodies in that present moment.9 cognitive dissonance a theory that states an individual’s preferences are modulated by the act of choosing between two alternatives. this can cause psychological tension and stress and can be reduced by reevaluating the alternatives post-decision-making.21 several studies showed positive outcomes related to body positivity and disordered eating. one study found that dissonance prevention and healthy weight education decreased restrictive eating habits, bulimic pathologies, weight concerns, and thinness ideals.15 another study showed that those interventions also decreased dietary restraint in those with dietary restraint issues.16 health education intervention focusing on positive health behaviors was also linked to decreased body dissatisfaction and thinness idealization.17 data interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – september 2023 from multiple studies determined that biopsychosocial-spiritual interventions also helped with depressive symptoms. one of these studies used a 10-week individual/group psychological training program focused on relaxation, positive self-talk, and the use of imagery, which demonstrated positive adjustments to selfconfidence.18 another study found that implementation of a 7-week stress management program decreased anxiety and increased psychological abilities, sports performance, and educational performance.13 implementing mindfulness and meditation programs showed increased awareness, mindfulness, and focus on the present and individual goals.19,20 in one study, it led to greater goal-directed energy.16 the results discussed can heavily influence clinical practice in the collegiate setting. for athletic trainers working with ncaa athletes, many of the patients they work with will experience some of the issues described above (substance abuse, loss of concentration, anxiety, low self-confidence, depression, etc.). athletic trainers must know how to recognize these concerns and which interventions to seek out for their patients. athletic trainers possessing the ability to help with matters outside of just sport-related issues can be critical in increasing their patients' overall quality of life. this review showed great support for cbt techniques. athletic trainers may not have the necessary training to employ this on their own; therefore, enlisting the help of a psychologist, social worker, or counselor trained in cbt may be beneficial. referring athletes to the appropriate mental health specialist when they are experiencing difficulties in rehab, school, and social situations may help their overall wellness and improve their sports performance. the research presented in this article has shown how interconnected the mind, body, and spirit are; if one aspect fails, it can adversely affect the others. conversely, addressing one of those aspects can result in healing the whole person. this can lead to safer behaviors, better health-related outcomes, and increased sports performance. having the capability to help a patient or seek help on behalf of a patient in all four of these areas should be the standard of care for every athletic trainer, especially in the collegiate setting. clinical bottom line being an ncaa student-athlete can have adverse effects on the bpss aspects of one’s daily life. those working directly with this population, especially athletic trainers, need to address and help manage these patients' specific social, spiritual, biological, and psychological issues. athletic trainers play a significant role in the physical health of a student-athlete, and by extension, they have considerable influence over mental health. recognition is one of the first skills athletic trainers need when dealing with bpss issues. to do this, proper training and education need to be available and tailored to athletic training on issues like anxiety, depression, and substance use/abuse. once recognized, the athletic trainer can implement the appropriate plan of care. regarding ncaa student-athletes, there is no set intervention that guarantees positive results for all facets of the patient’s bpss character. so, it is particularly important that athletic trainers continue to learn about various interventions that have proved successful in similar populations. these studies outline major ways athletic trainers can affect the bpss well-being of their athletes. the most prominent way is through educational interventions. athletic trainers can implement whole team or individual educational programs, which, as discussed previously, can be especially effective for disordered eating and substance abuse. pre-emptive educational programs could help those at risk for serious issues and improve the overall well-being of the team unit. the comprehensive health of ncaa student-athletes is constantly challenged by life and sports stressors, and this should be a priority for everyone involved in their healthcare team. interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – september 2023 another method to address the patient's well-being is by athletic trainers incorporating mindfulness techniques into the daily plan of care and rehabilitation programs. adding breathing techniques, stress management, visualization, and/or yoga into a patient’s rehabilitation plan could improve both their mental and physical health. successful interventions mentioned in this review include but are not limited to mindfulness meditations, motivational interviewing, life skills training, breathing techniques, individual and group sessions, substance use prevention programs, managing cognitive-behavioral stress techniques, and more. different sports have various obstacles that can negatively impact a student-athlete’s bpss model. athletic trainers benefit from researching what has worked well for common bpss issues in the sports in which they work. this article represents a great starting point to see what the data indicates are the most effective interventions for collegiate student-athletes in one sport compared to another. further research should be conducted on the bpss model and related intervention strategies. references 1. chen s, snyder s, magner m. the effects of sport participation on student-athletes and non-athlete students' social life and identity. j issues intercoll athl. 2010:176-193. 2. malinauskas r. the associations among social support, stress, and life satisfaction as perceived by injured college athletes. soc behav pers. 2010;38(6):741-752. http://dx.doi.org/10.2224/sbp.2010.38.6.741. 3. kimball a, freysinger vj. leisure, stress, and coping: the sport participation of collegiate studentathletes. leis sci. 2003;25(2/3):115. https://psycnet.apa.org/doi/10.1080/01490400306569. 4. american college health association. american college health association-national college health assessment ii: reference group executive summary spring 2019. silver spring, md: american college health association; 2019. 5. miller ke, hoffman jh. mental well-being and sport-related identities in college students. sociol sport j. 2009;26(2):335-356. https://doi.org/10.1123%2fssj.26.2.335. 6. maron bj, haas ts, murphy cj, ahluwalia a, rutten-ramos s. incidence and causes of sudden death in u.s. college athletes. j am coll cardiol. 2014;63(16):1636-1643. https://doi.org/10.1016/j.jacc.2014.01.041. 7. defreese jd, smith al. teammate social support, burnout, and self-determined motivation in collegiate athletes. psychol sport exerc. 2013;14(2):258-265. https://doi.org/10.1016/j.psychsport.2012.10.009. 8. burnsed b. nata, ncaa, and others announce mental health recommendations. 2013. published september 25th, 2013. 9. hofmann sg, gómez af. mindfulness-based interventions for anxiety and depression. psychiatr clin 2017;40(4):739-749. https://doi.org/10.1016%2fj.psc.2017.08.008. 10. oar el, johnco c, ollendick th. cognitive behavioral therapy for anxiety and depression in children and adolescents. psychiatr clin north am. 2017. https://doi.org/10.1016/j.psc.2017.08.002. 11. perna fm, antoni mh, baum a, gordon p, schneiderman n. cognitive behavioral stress management effects on injury and illness among competitive athletes: a randomized clinical trial. ann behav med. 2003;25(1):66-73. https://doi.org/10.1207/s15324796abm2501_09. 12. holm je, beckwith be, ehde dm, tinius tp. cognitive-behavioral interventions for improving performance in competitive athletes: a controlled treatment outcome study. int j sport psychol. 1996;27(4):463-475. 13. cimini md, monserrat jm, sokolowski kl, dewitt-parker jy, rivero em, mcelroy la. reducing high-risk drinking among student-athletes: the effects of a targeted athlete-specific brief intervention. j am coll health. 2015;63(6):343-352. https://doi.org/10.1080/07448481.2015.1031236. 14. parsons ce, crane c, parsons lj, fjorback lo, kuyken w. home practice in mindfulness-based cognitive therapy and mindfulness-based stress reduction: a systematic review and meta-analysis of participants' http://dx.doi.org/10.2224/sbp.2010.38.6.741 https://psycnet.apa.org/doi/10.1080/01490400306569 https://doi.org/10.1123%2fssj.26.2.335 https://doi.org/10.1016/j.jacc.2014.01.041 https://doi.org/10.1016/j.psychsport.2012.10.009 https://doi.org/10.1016%2fj.psc.2017.08.008 https://doi.org/10.1016/j.psc.2017.08.002 https://doi.org/10.1207/s15324796abm2501_09 https://doi.org/10.1080/07448481.2015.1031236 interventions for the mind, body, and spirit of ncaa student-athletes: an evidence to practice review 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – september 2023 mindfulness practice and its association with outcomes. behav res ther. 2017;95:29-41. https://doi.org/10.1016/j.brat.2017.05.004. 15. becker cb, mcdaniel l, bull s, powell m, mcintyre k. can we reduce eating disorder risk factors in female college athletes? a randomized exploratory investigation of two peer-led interventions. body image. 2012;9(1):31-42. https://doi.org/10.1016/j.bodyim.2011.09.005. 16. smith a, petrie t. reducing the risk of disordered eating among female athletes: a test of alternative interventions. j appl sport psychol. 2008;20(4):392-407. https://psycnet.apa.org/doi/10.1080/10413200802241832. 17. abood da, black dr. health education prevention for eating disorders among college female athletes. am j health behav. 2000;24(3):209-219. https://doi.org/10.5993/ajhb.24.3.6 18. savoy c, beitel p. the relative effect of a group and group/individualized program on state anxiety and state. j sport behav. 1997;20(3):364. 19. baltzell a, akhtar vl. mindfulness meditation training for sport (mmts) intervention: impact of mmts with division i female athletes. j happiness & well-being. 2014;2(2):160-173. 20. goodman fr, kashdan tb, mallard tt, schumann m. a brief mindfulness and yoga intervention with an entire ncaa division i athletic team: an initial investigation. psychol conscious. 2014;1(4):339. https://psycnet.apa.org/doi/10.1037/cns0000022. 21. colosio m, shestakova a, nikulin vv, blagovechtchenski e, klucharev v. neural mechanisms of cognitive dissonance (revised): an eeg study. j neurosci. 2017;37(20):5074-5083. https://doi.org/10.1523/jneurosci.3209-16.2017. https://doi.org/10.1016/j.brat.2017.05.004 https://doi.org/10.1016/j.bodyim.2011.09.005 https://psycnet.apa.org/doi/10.1080/10413200802241832 https://doi.org/10.5993/ajhb.24.3.6 https://psycnet.apa.org/doi/10.1037/cns0000022 https://doi.org/10.1523/jneurosci.3209-16.2017 abstract manuscript type evidence-to-practice review 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review victoria j. simpson, ms, atc*; zachary k. winkelmann, phd, scat, atc* *university of south carolina, columbia, sc abstract in the united states, sudden cardiac death (scd) is the leading cause of fatality in young athletes during exercise. allied healthcare professionals have used screening tools such as the 12-element american heart association recommendations, the european society of cardiology (esc) recommendations, and the international olympic committee guidelines to screen for cardiovascular abnormalities in athletes. although each of these protocols consist of personal and family history questions complemented with a physical examination, a uniform screening strategy to identify athletes at risk of scd does not exist. the purpose of this evidence to practice review is to summarize a systematic review regarding scd-related abnormalities in young middle eastern and african competitive athletes and to assess available cardiac preparticipation physical examination (ppe) screening tools. the authors examined literature that reported the prevalence of positive cardiac abnormalities detected with history and physical examination tools compared to noninvasive cardiac testing, such as electrocardiography. the review also highlights the significant number of false positives achieved through history and physical examination tools only, whereas electrocardiography interpretations indicated by the 2014 refined criteria are superior to the 2013 seattle criteria and the 2010 esc recommendations. the guiding systematic review indicates that electrocardiography is sensitive and specific to predicting scd-related abnormalities and should be a tool implemented in the ppe. key phrases public health, clinician-rated outcomes, patientrated outcomes, professional standards correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation simpson vj, winkelmann zk. implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review. clin pract athl train. 2021;4(1): 36-42. https://doi.org/10.31622/2021/0004.1.5. submitted: december 15, 2020 accepted: april 4, 2021. original reference hallak yo, battistin u, al-masaeed am. cardiac screening to mitigate the risk of sudden cardiac death in middle eastern and african competitive athletes. a systematic review. j saudi heart assoc. 2020; 32(2): 174-185. summary clinical problem and question prior to a competitive season, athletes undergo a preparticipation physical examination (ppe). the ppe includes vital screening tools utilized by allied healthcare professionals to determine readiness for a specific sport and identify any potential or correctable conditions that may impair athletic performance.1 the national athletic trainers’ association (nata) has compiled recommendations for items included in a ppe which includes personal and family medical history, current medical conditions, signs and symptoms during exercise, and system-based physical examinations (e.g., cardiovascular, central nervous system, pulmonary).2 currently, the nata position statement recommends “noninvasive cardiac testing (e.g., echocardiography, ecg, exercise stress testing) not be a routine aspect of ppe screening unless warranted by findings from personal and family history”.2 this position statement also indicated the need for continued research on cardiac screening methods to “improve the ability to identify at-risk individuals in a cost-effective manner” with an acceptable false-positive rate to be utilized as a screening method to reduce the rates of sudden cardiac death (scd).3 mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2021/0004.1.5 implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 in the united states between 2014-2018, 50% of sudden cardiac arrest cases occurred in caucasian competitive athletes with 55% (n=88/164) of those cases resulting in survival.4 however, the survival rates for african american athletes was only 25% (n=39/109) with an accompanied incidence rate for a male, african american, national collegiate athletic association (ncaa) division 1 basketball player at 1:2087.4 the rates in male, african american athletes are 2.4 times higher when compared to their caucasian counterparts.1 the ncaa also reports the incidence of scd as higher in black athletes (1:1700) and male basketball players (1:7000).5 reports in the united states have estimated an incidence of 110 scd cases each year in young athletes, which equates to 1 death every 3 days.5 additionally, the literature supports that african american/black athletes are 5 times more likely to develop hypertrophic cardiomyopathy (hcm), which is the leading cause of scd in young competitive athletes when compared to their arab counterparts.6 the scarcity of literature reporting the prevalence rates of scd in the middle east and africa highlight the lack of ethnic-specific cardiac ppe screenings in these regions. therefore, there is a need to exploring equitable screening and testing practices dependent upon race/ethnicity. the purpose of this evidence-to-practice review was to assess cardiac ppe screening methods and their ability to detect predisposing abnormalities correlated with scd in young middle eastern and african competitive athletes. summary of literature the guiding systematic review’s authors conducted a systematic search with pubmed (medline) and google scholar that examined the findings of middle eastern and african competitive athletes using any cardiac ppe screening method. the authors applied the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines to conduct their search. the studies included in the systematic review had to meet the following inclusion criteria: (1) original published studies in peer-reviewed journals, in english or arabic, involving ppe cardiac screening in arab or african competitive athletes, (2) study population not restricted to gender, or athletic level, but age restricted to less than 36 years of age, (3) involved no less than 100 participants as sample size, (4) included cardiac screening programs and african or middle eastern athletes, and (5) articles published between january 2009 and march 2019. the pubmed (medline) and google scholar database searches identified 17 articles that met the initial inclusion criteria. studies were eventually excluded due to their title, abstract screening, non-athletic populations, studies conducted outside of arab or african competitive athletes, or if they were a book, editorial, case report, or review. the number of papers were reduced to 6 prior to the authors conducting a full text screening for eligibility. overall, 4 studies were included in the qualitative synthesis of this systematic review. the inclusion of only 4 studies in this systematic review diminished the authors potential to generalize this data, yet this discrepancy depicts the gap in literature focused on ppe screening in athletes in this region of the world. the regions where these articles were conducted include 2 studies in qatar, 1 study in the united arab emirates, and 1 study in gabon. the authors noted that the main limitation of this study was the restricted access to only 2 databases, which may have decreased their yielded results. summary of outcomes the authors of the guiding systematic review gathered the sample characteristics, sample size and population, study setting and focus, screening tools, prevalence of cardiovascular abnormalities, and personal and family history from the implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 participants in the 4 studies. the authors designated the 2010 european society of cardiology (esc) as the guideline used to interpret ecg findings amongst the studies. the study conducted by alattar et al.7 (listed as maffulli n et al. in the guiding systematic review) incorporated the lausanne recommendations along with the esc for interpretation of united arab emirates national athletes. this method includes collection of personal and family history, a physical examination, and a 12-lead ecg.7 the abnormalities associated with scd that were examined in these studies included wolffparkinson-white syndrome (wpw), arrhythmogenic right ventricular cardiomyopathy (arvc), hcm, dilated cardiomyopathy, and long qt syndrome. findings and clinical implications the guiding systematic review assessed the reported prevalence of cardiac abnormalities with the efficacy of various cardiac screening methods for middle eastern and african athletes. the information from the 4 studies compiled to a total of 3,655 men, with ages ranging from 12 to 35 years, who participated in a variety of sports including: football, basketball, tennis, volleyball, and handball. all studies incorporated the esc recommendations to assess the results of cardiovascular screenings of participants. there were variations in results pertaining to the prevalence of these scd-related abnormalities, which ranged from 0.47%-4.29% across all studies. specifically, alattar et al.7 reported 5 arab athletes (2.17%) with scd-related abnormalities including 2 with wpw, 1 with atrial fibrillation, 1 with long qt syndrome, and 1 with arvc. riding et al.6 documented scd-related abnormalities in 10 (0.47%) athletes: 5 black and 2 arab athletes with hcm, and 3 arab athletes with wpw. wilson et al.8 recorded 7 (0.63%) athletes with an scd-associated abnormality: 1 arab and 1 african athlete had wpw, 2 arab and 1 african athlete had hcm, 1 african athlete had arvc, and 1 arab athlete had long qt syndrome. the final study by schmied et al.9 detailed those 9 (4.29%) african athletes had an scd-related abnormality: 5 with long qt syndrome, 3 with wpw, and 1 with hcm upon echocardiography. the prevalence of scd-related abnormalities in these arab athletes were 2.17% and produced false-positive rates at 20.4 %.7 the riding et al.6 study examined false-positive rates when using the esc, seattle criteria, and the 2014 refined criteria in arab and black athletes. the ecg interpretations by the 2014 refined criteria decreased false-positives to 3.6% in arab athletes (vs 19.1% using esc guidelines and 9.7 % using seattle criteria) and 10% in black athletes (vs 29.9% using esc guidelines and 16.6% using seattle criteria).6 the 2014 refined criteria was 100% sensitive in discovering scdrelated cardiac pathologies, while reducing falsepositives.6 alattar et al.7 indicated 2 arab athletes had a positive family history of scd, 6 (2.6%) arab athletes reported a history of syncope, and 8 (3.8%) experienced a form of chest discomfort. wilson et al.8 reported 17 west asian and 14 black athletes with a family history of scd and 8 (0.66%) athletes reporting cardiovascular symptoms during activity. finally, schmied at al.9 shared those 36 (17%) african athletes had a family history of scd with 19 (9%) indicating atypical chest discomfort. clinical bottom line the american heart association (aha) estimates the prevalence of scd-related abnormalities that predispose young athletes is 0.3%, whereas the incidence of potentially lethal scd consistently ranges between 0.2 to 0.7%.1 this correlate to 1 in 500 athletes with an undetected cardiac abnormality.1 the aha, the esc, and the international olympic committee recommend implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 cardiovascular screening for all athletes. nevertheless, these entities do not have a uniform protocol, nor do they all advocate for the inclusion of a resting 12-lead ecg in ppe.1 several differences exist when comparing the esc recommendations to the 12-element aha recommendations for cardiac pre-participation screening.10 based on the findings of the guiding systematic review and other supporting evidence, the sensitivity of preparticipation protocols that simply implement history questions and physical examinations do not significantly detect predisposing scd-related abnormalities in young athletes. in a previous systematic review comparing screening strategies, the most clinically sensitive method to rule out a cardiovascular condition was an ecg (94%) as compared to history (20%) or physical exam (9%).11 however, the specificity of each of these methods is similar (ecg: 93%, history: 94%, physical exam: 97%).11 in a report of 115 scd cases in young athletes, only 1 athlete (0.9%) was accurately diagnosed with an underlying cardiovascular issue when using the history and physical examination screening model.1 although there is a concern that ecgs produce a high number of false-positive results leading to unnecessary diagnostic testing, studies have shown that the adoption of modern, strict ecg criteria have lowered false-positive rates to 6% compared to history at 8% and physical examination at 10%.1,3 the studies in this review highlight that the rate of false-positives are greater with a history and physical examination model. another consideration is the cost component associated with the implementation of ecg to pre-participation screenings. the cost to perform the aha-recommended cardiovascular history and physical examination is estimated at $0 because it is done in conjunction with a ppe.12 however when an scd-related abnormality is detected, the athlete will undergo a cardiology consultation (average cost of $150), potential treadmill testing (average cost of $225), and 2d echocardiography (average cost of $350) for an average cost of $500 to evaluate an abnormality detected with the aha-recommended screening.12 conversely, the estimated cost to perform an ecg during mass ppe is $10 with an average cost of $365 to evaluate detected abnormalities.12 cardiac abnormalities that have gone undetected in traditional ppe screenings prior to physical activity have resulted in wrongful death lawsuits.13 in 2012, the family of ronald rouse, an 18-yearold former hartsville football player, were compensated $260,000 to dismiss the wrongful death of their son from an undiagnosed cardiac arrhythmia that resulted in cardiac arrest.13 similar instances of young athletes dying from cardiac arrest from detectable abnormalities include cases such as kleinknecht v. gettysburg college with the death of a lacrosse player and 15-year-old star ifeacho at dunbar high school.14,15 this upstream initiative to minimize fatalities related to scd through early detection could potentially save young lives at a low incremental cost of $10 and negate costly wrongful death lawsuits.12 the interpretation of the guiding systematic review and supporting literature suggests that the addition of the updated criteria for 12-lead ecg in ppe could potentially positively detect scd-related abnormalities when compared to history and physical examinations alone, especially in susceptible minority populations. conditions that predispose athletes to scd are preventable if effectively managed through activity modification and medical intervention. the guiding systematic review reported that the prevalence of scd occurred at higher rates in football and basketball as compared to soccer. we suggest that clinicians use this data to provide a comprehensive, patient-centered ppe exam that is reflective of the cultural and ethnic differences of the individuals we treat. while equal care would incorporate advanced cardiac testing for implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 all, the results of this guiding systematic review suggest, at minimum, equitable care be provided to the predisposed young individuals of african and middle eastern descent. however, equitable care extends beyond cardiac testing in minority populations. athletic trainers must be cognizant how social determinants of health based on a patient’s race and ethnicity may influence their health outcomes and risks. a prime example of this bias in care, involves how blacks and other minority populations in the united states have been systemically denied mortgages or approval for leased housing in neighborhoods at higher rates than caucasians for decades.16 this housing crisis cascaded to create an increasing educational gap where black students are inadequately prepared for academic success because they attend poorer, disadvantaged school systems.16 overall, this is just one example of how blacks and african americans have been impoverished and unhealthy because of an oppressive system established over 300 years ago that resulted in racialized institutions and further perpetuated white privilege.17 to provide patient-centered care, we must recognize how race and ethnicity, as well as other social determinants of health, may change the ppe process for some athletes as compared to others. barkley et al.16 discussed how diversity in athletic participation is continually increasing in the ncaa, but there is a need for sports medicine literature to address additional knowledge, skills, and abilities in cultural competency and to promote health equity.16 historically in this nation, minority populations, especially black people, have not been treated equitably in the healthcare system compared to their caucasian counterparts.16,17,18,19 evidence also suggests that health care professionals, such as athletic trainers and team physicians, have limited knowledge about effectively delivering culturally competent care.16 this variance in treatment in minority populations, especially in black communities, stems from the higher proportion of minorities living in “medical deserts” where communities lack health care resources.19 residential segregation and racial disparities are a fundamental cause for health disparities and have an association with infant mortality, adult mortality, poor health status, smoking during pregnancy, poor birth outcomes, tuberculosis and other infectious diseases, and exposure to cancer-causing air toxins.16 the discord in research that quantifies these statistics and the effort to combat these issues do not align. the majority-white decisionmakers include public health researchers, policymakers, medical educators, officials, hospital administrators, and insurance and pharmaceutical executives.17 caucasians make up three quarters of those practicing medicine, 77% of american medical association delegates, 85% of american medical association board members, 23 of 27 directors of the national institutes of health, 90% of national institutes of health branch and lab chiefs, and 83% of senior investigators.17 these healthcare providers write policies from a position of privilege, creating a white framework which normalizes discriminatory practices and reinforces institutionalized inequity in health care and health – a contributing factor in the delay to adopt cardiac screening by many leading sports organizations.17 public health efforts to reduce scd in black athletes is a crucial step; however, it is only a small aspect of the health disparity issue that needs to be addressed holistically for true equality to be achieved.18 further research is needed to understand the underlying persistent racial differences in scdrelated abnormalities to mitigate the risk of scd in black athletes.18 the profession of athletic training is continuously advancing its skillset to minimize patient risk of injury and illness. athletic trainers complete ppes annually to mitigate these risks. in the united states, the nata suggests the implementation of the 12-element aha recommendations for cardiovascular screening to detect potential underlying cardiac conditions in young athletes.2 implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 however, evidence indicates that questioning an athlete about their personal and family history paired with a physical examination does not accurately detect these fatal disorders.12 a parallel example of a lethal medical condition in the athletic setting is sickle cell trait, which athletic trainers now readily test for. the literature provides evidence that ecgs are highly sensitive in indicating scd-related abnormalities and should become common practice during ppes in both the collegiate and youth setting. these entities should strive to incorporate ecg testing into their policies and procedures as a means of best practice. the results from the manuscript suggest that additional research on the prevalence of abnormalities correlated to scd in young middle eastern and african competitive athletes should be conducted since scd disproportionately impacts athletes of color; especially young, african american males. references 1. asif im, toresdahl bg, drezner ja. chapter 3: prevention of sudden cardiac death in young athletes. in: casa dj, stearns rl. preventing sudden death. 2nd ed. jones & bartlett learning; 2017:3350. 2. conley km, bolin dj, carek pj, konin jg, neal tl, violette d. national athletic trainers’ association position statement: preparticipation physical examinations and disqualifying conditions. j athl train. 2014;49(1):102-120. https://doi.org//10.4085/1062-605048.6.05. 3. winkelmann zk, crossway ak. optimal screening methods to detect cardiac disorders in athletes: an evidence-based review. j athl train. 2017;52(12):11681170. https://doi.org/10.4085/10626050-52.11.24. 4. peterson df, kucera k, thomas lc, maleszewski j, siebert d, lopezanderson m, zigman m, schattenkerk j, harmon kg, drezner ja. aetiology and incidence of sudden cardiac arrest and death in young competitive athletes in the usa: a 4-year prospective study. bjsm. published online first: 12 november 2020. https://doi.org/10.1136/bjsports2020-102666. 5. casa dj, guskiewicz km, anderson sa, courson rw, heck jf, jimenez cc, mcdermott bp, miller mg, stearns rl, swartz ee, walsh km. national athletic trainers’ association position statement: preventing sudden death in sports. j athl train. 2012;47(1):96-118. https://doi.org/10.4085/1062-605047.1.96. 6. riding nr, sheikh n, adamuz c, watt v, farooq a, whyte gp, george kp, drenzer ja, sharma s, wilson mg. comparison of three current sets of electrocardiographic interpretation criteria for use in screening athletes. heart. 2015;101:384-390. https://doi.org/10.1136/heartjnl-2014306437. 7. alattar a, ghani s, mahdy n, hussain h, maffulli n. pre-participation musculoskeletal and cardiac screening of male athletes in the united arab emirates. transl med unisa. 2014;9:4349. pmid: 24809035. 8. wilson mg, chatard jc, carre f, hamilton b, whyte gp, sharma s, chalabi h. prevalence of electrocardiographic abnormalities in west-asian and african male athletes. br j sports med. 2012;46:341-347. https://doi.org/10.4085/1062-6050-48.6.05 https://doi.org/10.4085/1062-6050-48.6.05 https://doi.org/10.4085/1062-6050-52.11.24 https://doi.org/10.4085/1062-6050-52.11.24 https://doi.org/10.1136/bjsports-2020-102666 https://doi.org/10.1136/bjsports-2020-102666 https://doi.org/10.4085/1062-6050-47.1.96 https://doi.org/10.4085/1062-6050-47.1.96 https://doi.org/10.1136/heartjnl-2014-306437 https://doi.org/10.1136/heartjnl-2014-306437 implementing cardiac testing to mitigate the risk of sudden cardiac death: an evidence-to-practice review 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 https://doi.org/10.1136/bjsm.2010.08 2743. 9. schmied c, di paolo fm, zerguini ay, dvorak j, pelliccia a. screening athletes for cardiovascular disease in africa: a challenging experience. br j sports med. 2013;47(9):589-584. https://doi.org/10.1136/bjsports2012-091803. 10. lithwick dj, fordyce cb, morrison bn, nazzari h, krikler g, isserow s, heilbron b, taunton j. pre-participation screening in the young competitive athlete: international recommendations and a canadian perspective. b c med j. 2016;58(3):145-151. 11. harmon kg, zigman m, drezner ja. the effectiveness of screening history, physical exam, and ecg to detect potentially lethal cardiac disorders in athletes: a systematic review/metaanalysis. j electrocardiol. 2015;48(3):329-338. https://doi.org/10.1016/j.jelectrocard. 2015.02.001. 12. fuller cm. cost effectiveness analysis of screening of high school athletes for risk of sudden cardiac death. med sci sports exerc. 2000;32(5):887-890. 13. smith c. parents settle s.c. football wrongful death suit for $260,000. usa today. december 14, 2016. accessed april 2, 2021. https://usatodayhss.com/2016/parentssettle-outstanding-football-wrongfuldeath-suit-for-just-260000. 14. kleinknecht v. gettysburg, 786 f. supp. 449 (m.d. pa 1992). 15. mother of high school athlete who died after collapsing at school files lawsuit. wkyt. december 11, 2017. accessed april 2, 2021. https://www.wkyt.com/content/news/m other-of-high-school-athlete-who-diedafter-collapsing-at-school-files-lawsuit463411543.html. 16. barkley l, taliaferro la, baker k, garcia j. the holistic athletic healthcare model: addressing the developmental, social, and cultural needs of collegiate athletes. jheai. 2018;1(3):26-47. https://doi.org/10.15763/issn.23765267.2018.1.3.26-47. 17. feagin j, bennefield z. systemic racism and u.s. health care. soc sci med. 2014;103:7-14. https://doi.org/10.1016/j.socscimed.20 13.09.006. 18. deo r, safford mm, khodneva ya, jannat-khah dp, brown tm, judd se, mcclellan wm, rhodes jd, shlipak mg, soliman ez, albert cm. differences in risk of sudden cardiac death between blacks and whites. j am coll cardiol. 2018;72(20):2431-2439. https://doi.org/10.1016/j.jacc.2018.08 .2173. 19. gaskin dj, dinwiddie gy, chan ks, mccleary rr. residential segregation and the availability of primary care physicians. health serv res. 2012;47(6):2353-2376. https://doi.org/10.1111/j.14756773.2012.01417. https://doi.org/10.1136/bjsm.2010.082743 https://doi.org/10.1136/bjsm.2010.082743 https://doi.org/10.1136/bjsports-2012-091803 https://doi.org/10.1136/bjsports-2012-091803 https://doi.org/10.1016/j.jelectrocard.2015.02.001 https://doi.org/10.1016/j.jelectrocard.2015.02.001 https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000 https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000 https://usatodayhss.com/2016/parents-settle-outstanding-football-wrongful-death-suit-for-just-260000 https://www.wkyt.com/content/news/mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html https://www.wkyt.com/content/news/mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html https://www.wkyt.com/content/news/mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html https://www.wkyt.com/content/news/mother-of-high-school-athlete-who-died-after-collapsing-at-school-files-lawsuit-463411543.html https://doi.org/10.15763/issn.2376-5267.2018.1.3.26-47 https://doi.org/10.15763/issn.2376-5267.2018.1.3.26-47 https://doi.org/10.1016/j.socscimed.2013.09.006 https://doi.org/10.1016/j.socscimed.2013.09.006 https://doi.org/10.1016/j.jacc.2018.08.2173 https://doi.org/10.1016/j.jacc.2018.08.2173 https://doi.org/10.1111/j.1475-6773.2012.01417 https://doi.org/10.1111/j.1475-6773.2012.01417 abstract manuscript type quality imrpovement report 52 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans briana burgette, dat, atc; tamara c. valovich mcleod, phd, atc, fnata *a.t. still university, mesa, az abstract concussion is a significant health issue at all levels of sports participation. at saint luke’s health system (slhs) in kansas city, missouri, the sports medicine and concussion team discovered an issue with dissemination of patient education for concussion rehabilitation plans. a quality improvement project was launched in august 2019 to develop concussion educational rehabilitation plans, incorporating cluster symptoms into concussion profiles and improving communication during follow-up care. the project promoted improvement of patient understanding of individualized rehabilitation plans and effective communication for the treatment management team. three cycles of a plan-do-study-act (pdsa) quality improvement project were completed over 6 months. the physicians and athletic trainers reviewed literature and treatment plan recommendations for patients. comparison of pre-pdsa and post-pdsa adherence to charting standards was performed. before this project, patients had insufficient documentation of the education they were receiving. additional implementations included education, patient health questionnaire (phq-9) score, graded symptom scale (gss) score, and changes to the documentation template. eighty patients (46 male, 34 female) were included in the 6-month project. of pre-pdsa (control) concussion patients, 71% (n=29) were male football players. after the pdsa cycles were completed, only 18% (n=7) of patients were football players. the season had no effect between the number of patients included pre-pdsa or pdsa cycles 1-3. for pdsa cycle 1, the pre-pdsa goal was surpassed, and 100% of new concussion patients received concussion education during their initial visit. during the 3-month data collection period for that cycle, only 10.5% (2/19) of followup patients received a concussion information packet during their visit. after completion of pdsa cycle 2, 100% of patients received education pamphlets; initially, only 85% received pamphlets. finally, pdsa cycle 3 successfully implemented the use of the new concussion template system-wide and the addition of concussion symptom profiles for patient education and individualized treatment planning. correspondence dr. tamara c. valovich mcleod, athletic training programs and school of osteopathic medicine in arizona, a.t. still university, 5850 e. still circle, mesa, az 85206. e-mail: tmcleod@atsu.edu twitter: @tamaracvmcleod full citation burgette b, valovich mcleod tc. quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans. clin pract athl train. 2022;5(2): 52-60. https://doi.org/10.31622/2022/0005.02.9. submitted: september 17, 2021, accepted: january 12, 2022. current model the original process for concussion rehabilitation at slhs in kansas city, missouri, involved an initial clinical examination consisting of a physical examination, impact test, balance error scoring system test, and symptom score. patients were then provided with academic supports, concussion education, and a signed missouri state high school activities association or kansas state high school athletic association concussion form for the school, which allowed the patient to begin the return-to-play progression with the athletic trainer once free of symptoms. if there were referrals to other providers for therapy, patient education was limited. the main therapies considered were vestibular/oculomotor (after 7 days), manual therapy for the cervical spine (if the patient had cervical pain), and neuropsychological evaluation for patients with persistent symptoms that did not resolve using alternative treatment plans. the primary issue addressed in this quality improvement project was the lack of individualized concussion rehabilitation treatment plans and patient education for these plans. initially, the concussion rehabilitation treatment process at slhs was limited, referring patients for a few therapy techniques while neglecting others. typical treatment recommendations for patients were rest followed by a progression back to sport that gradually increased exertion.1 the primary method used to assess patient status was a self-reported mailto:tmcleod@atsu.edu https://doi.org/10.31622/2022/0005.02.9 quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 53 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 symptom questionnaire.2 the post-concussion symptom scale was used for tracking symptoms throughout the recovery phase and has been reported as a useful tool for assessing concussions;3,4 however, it was only used to determine when symptoms resolved rather than to direct therapy. as concussion treatment evidence continues to emerge, we felt we should be constantly innovating new ideas and processes throughout our sports medicine program. recent evidence has identified presentations of src that have been termed profiles5 or subtypes.6 various taxonomies have been developed that categorize symptoms in a somewhat different manner; but many include similar constructs, such as cognitive, emotional, vestibular, and ocular.7 furthermore, sleep and cervicogenic injury have been implicated as modifiers for any concussion profile.6 we identified a gap in patient care from the resting phase through return to sport beyond the progression of exertion. secondarily, there was limited communication with the patient and parents about the necessary steps required after initial evaluation. patients did not take home any written information about their current rehabilitation plan. if a patient needed a specific therapy, the specialized office would call to schedule the therapy. the physician educated the patient and the parents in the office; but once they left the clinic, it was assumed they understood the next steps of the rehabilitation plan. the majority of the time the patients would call and ask additional questions because they forgot when they should begin therapy or when they could start their return-to-play progression. therefore, the two primary aims of this quality improvement project were to (1) establish symptom profiles as part of each patient’s individualized treatment plan and (2) improve patient and parent education and understanding of concussion treatments and return to play. to identify changes that addressed the project aims, information from the comprehensive physical examination at the initial visit, adjunct assessments, and the symptom scale was used to assign a symptom profile to each patient. ideally, the symptom profile would result in an appropriate individualized approach to the concussion treatment and management plan. a second change required using the information from the symptom profile assignment to better educate patients and parents about the next steps in their care and expectations for the recovery process. measurable outcomes for this project included improving the percentage of patients assigned a concussion symptom profile and providing patient educational materials at the initial visit. plan-do-study-act (pdsa) cycles baseline evaluation pre-pdsa (baseline) data were analyzed from august-september 2019 and included data from every concussion patient seen by slhs sports medicine department during that period. an assessment of the treatment and rehabilitation plans that patients received was also performed. three pdsa cycles were then used to establish necessary changes for improvements to patients’ concussion education, communication of rehabilitation and treatment plans, and electronic medical record (emr) template changes for staff to ensure assignment of a concussion symptom profile. a summary of the sports patients participated in during the 6month project is presented in figure 1. to complete the three pdsa cycles during the project, there was a 6-week delay, where no data were collected. before the pdsa cycle 1 data collection period, 41 patients were identified as meeting inclusion criteria. however, 2 cases were excluded because the concussion was caused by a motor vehicle accident and the patient was not attending school. quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 54 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 figure 1. patient demographics per their sport. blue: pre pdsa1 aug-sept 2019 controlled data patients. orange: pdsa2 dec-feb 2020 patient’s data. in 15% (n=6/41) of pre-pdsa cases, it was unclear whether the patient received any concussion education material because that information was not documented in the emr. for the other 85% of cases, it was clearly documented that the patient received concussion education. pdsa cycle 1 the first pdsa cycle focused on improvements in the use of concussion symptom scores through the development of concussion symptom profiles and modifications to the emr. plan: to implement concussion symptom profiles based on concussion symptom scores and physical examination findings for each patient, the clinical athletic trainer was responsible for obtaining the physical findings and categorizing patients into profiles after each examination. after the profiles were established, the implementation process took less than 5 minutes. resources needed for pdsa cycle 1 included an up-todate concussion literature review, emr training, and instruction from the information technology team to change the templates. this cycle was expected to require a month to plan because of constraints related to scheduling with others. do: five concussion symptom profiles were established to drive treatment plans. the concussion symptom profiles were discussed among the entire sports medicine team and informed by the concussion symptom cluster of the gss. after the 5 symptom profiles were established, changes were made to the emr template (table 1) to create symptom profile groups within the documentation; the previous emr template included only a total symptom severity score. thus, pdsa cycle 1 resulted in changes to the entire healthcare emr system that were not limited to the sports medicine physicians. more specifically, the templates were changed 0 5 10 15 20 25 n um be r of p at ie nt s sport pre pdsa pdsa quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 so, the exact symptoms that patients were experiencing reflected their symptom profile. one unexpected finding was the placement of a symptom in the correct profile when the symptom could be categorized in multiple profiles. for example, headache could arise from lack of sleep but is still a physical symptom. study: following this emr change, we compared data from concussion patients evaluated during the current football season with those from the prior season (before individual plans were developed based on the symptom profile). act: based on the patient concussion symptom profiles, the sports medicine staff at slhs developed and delivered individualized concussion treatment and rehabilitation plans, and concussion education for at least 90% of all new concussion patients during a 3-month period. according to pdsa cycle 1 data, in 66% (n=14) of pre-pdsa cases, patients received recommendations for academic supports during their visit with the physician. however, 50% of patients who did not receive temporary academic adjustments were follow-up patients with a symptom score of 0 who were ready to be cleared for return to play. changes between the proposed process map to the post-pdsa cycle process are presented in figure 2. pdsa cycle 2 the second pdsa cycle was directed specifically toward staff communication and education training and how to effectively educate patients and parents about the individualized concussion rehabilitation and treatment plans. the addition of patient-reported outcomes (pros) facilitated communication among the staff and improved visualization of patients’ documented outcomes. plan: to build new concussion templates within the emr, the sports medicine staff met weekly before clinic. these weekly meetings were needed to discuss the new templates and answer any questions about them. saint luke’s medical liaisons were part of the implementation process to ensure all concussion specialist physicians had access to the templates. the concussion templates were available for use across the entire health system for any provider who wanted to use the template. in addition to educating the staff about concussion template changes, finalizing the patient education pamphlets was included in the weekly meetings. table 1. emr template changes incorporating concussion symptom profiles. review of symptoms (ros) physical symptoms headache (yes/no) neck pain (yes/no) radicular symptoms (yes/no) vision complaints (yes/no) sound complaints (yes/no) mood symptoms sad/depressed (yes/no) irritable/angry (yes/no) anxious/fearful? (yes/no) phq-9 modified for teens score (0-30) sleep symptoms hard to get sleep? (yes/no) sleeping more than usual? (yes/no) cognitive symptoms missing school/work (yes/no) confusion/memory problems (yes/no) distracted/attention problems (yes/no) feeling foggy/slowed down/groggy (yes/no) normal school grades vestibular dizziness (yes/no) balance issues (yes/no) car sickness (yes/no) nausea/vomiting (yes/no) physical education alert and oriented answers questions appropriately quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 do: communication and staff education were used to ensure everyone understood and used the templates the same way. the previous concussion template did not include symptom profiles and only included the patient’s graded symptom scale (gss) total score. improvements to the emr template may have affected an observed increase in the number of documented patient pros. an unexpected finding of this cycle was a lack of gss scores for follow-up patients, which had been previously recorded. staff were also unaware of how to document information in the emr because of lack of training before pdsa cycle 2. injury to head or neck resulting in concussion symptoms visit concussion team within 48-72 hours history and physical exam consistent with concussion (neurological exam, balance error scoring system, cervical spine exam, vestibular testing, phq-9, cnn symptom scale) refer to primary care or manage differential diagnosis initial period of brain rest, school supports, no sports, tylenol if needed vestibular therapy if dizziness, nausea, positive vestibular vision therapy, behavioral therapy, if needed physical therapy if cervicogenic headache, consider radiographs (listhesis) symptom free in 2-3 weeks, re-evaluate by physician, return to sport protocol, and release to full school consider imaging, neuropsychological testing, medications, behavioral psychology yes yes no no figure 2. changes between the proposed process map to the post-pdsa cycle process quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 study: notable changes were made to the emr templates and patient education pamphlet. a staff meeting that included all members of the sports medicine and orthopedics team was conducted for staff education and training purposes. topics discussed during the meeting included wording changes, where to find the new pros, how to interrupt the pro results, and the process for neurocognitive testing. the patient education pamphlet also included a change in patient instructions increasing the amount of time allowed for the brain to rest (48-72 hours) before beginning light exercise, the pros given to the patient (gss score, patient health questionnaire [phq-9], and the number of times the patient completed neurocognitive testing (baseline, after injury, before return to play, and after clearance for a new baseline). act: table 2 presents data for this cycle (december 2019-february 2020). improvements were made to the concussion education material the patient received and, subsequently, to the rehabilitation and treatment plans. new pro measures, including the phq-9, were also added. before pdsa cycle 2, 85% of patients received patient education; however, this number increased to 100% after the pdsa cycle 2. table 2. change in the percentage of patients with documented outcome measures prior to and following pdsa cycle 2. outcome variable pre-pdsa2 post-pdsa2 patient education 85 100 gss 86 95 phq-9 0 80 pdsa cycle 3 the third pdsa cycle was structured to implement all the concussion education changes in the updated pamphlet that the patients and parents received. plan: individualized plans were highlighted on the concussion education handout for each patient. the concussion symptom profiles were listed using the american medical society for sports medicine overlapping symptom profiles, which is an emerging concept to facilitate individualized management after sport-related concussion.5-7 study: marketing reviewed the size, color, and number of pages of the pamphlet before it was sent to production for printing. do: information was condensed in order to make the handout smaller. further, all pictures were removed from the original concussion education handout to limit the number of pages. act: results for pdsa cycle 3 indicated the pre-pdsa goal was surpassed and 100% of new concussion patients received concussion education during their initial visit. during the 3-month pdsa cycle 1 data collection period, only 10.5% (2/19) of follow-up patients received a concussion information packet during their follow-up visit. both of those follow-up patients were still experiencing symptoms. the new education handouts started being used after completion of pdsa cycle 3. quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 lessons and limitations while we successfully made improvements during this quality improvement project, several lessons were learned during the process, some of which were specific to our situation and some of which may benefit others interested in a quality improvement initiative at their institution. the first lesson learned was to extract data from the same season, same sport, and same time of year for better comparisons. because of time constraints on the project, we were limited in this ability. however, we were fortunate that the population of pre-pdsa concussion patients during football season was similar to the population of post-pdsa concussion patients during the winter sports season. the second lesson learned was to involve other hospital system departments, such as marketing, before making specific pamphlet changes to ensure all formatting requirements of the organization were followed appropriately. the revision of the education pamphlet in pdsa cycle 3 was completed by department clinicians without consulting the hospital system’s marketing department. in hindsight, the sports medicine department should have focused solely on updating the content and then working collaboratively with marketing to ensure compliance with hospital branding, thus decreasing the number of edits required before printing. there are plans to continue this quality improvement project with a fourth pdsa cycle to facilitate to improve the nationwide implementation of the new src symptom profile and individualized concussion rehabilitation and treatment plans throughout the emrs of this healthcare system. the emr template changes can be shared system-wide and could also be used by providers in other healthcare networks that use the same emr. further, using the same template may decrease documentation errors and result in better patient care. it may also decrease the amount of time it takes clinicians to review previous patient records before followup appointments. financial savings may be another benefit resulting from decreases in documentation errors and the amount of time spent on documentation. although this project focused solely on a single hospital department, the changes made and lessons learned can be applied to concussion protocols of other institutions. a similar concussion template could be used in other settings, such as industrial, performing arts, military, hospital, secondary school, or collegiate settings. the development of similar educational materials to improve patient understanding of other elements of concussion treatment and rehabilitation plans can also be replicated by other institutions. the evaluation and management of concussion has changed markedly in the past several years, and with our increased understanding of the effectiveness of active rehabilitation and treatment plans, we can expect these changes to continue. active and targeted rehabilitation strategies, such as vestibular and oculomotor rehabilitation and pharmacological interventions, have emerging evidence supporting their use.8 the use of quality improvement processes to evaluate the concussion protocols of an institution or individual clinician is an important way to ensure contemporary practice and the provision of evidence-informed patient care. further, continuously evaluating aspects of concussion management using pdsa cycles can help clinicians effect small changes over short periods to ease implementation burden. for this particular project, our focus was on simple changes to the educational materials provided to patients regarding their treatment plans; however, quality improvement strategies have also been used for the treatment of concussion to improve management of academic considerations9 and to ensure patients are provided education about driving.10 to evaluate potential gaps in protocols, clinicians should review their concussion protocols annually and when quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 updated consensus or position statements are published. a quality improvement process can then be initiated for implementation of those changes. conclusion from a team approach perspective, miscommunication and lack of documentation for a patients with concussion may be detrimental to patient care. since concussion patients are often treated by more than one healthcare professional, it is imperative that all healthcare professionals communicate with each other about the patient’s rehabilitation and treatment plan and, perhaps more importantly, that patients understand their follow-up care plans. this quality improvement project showed that modifications to the emr to capture symptom clusters and assign symptom profiles and that revision of patient educational materials were effective improvements for concussion care. utilizing a multidisciplinary approach and having effective communication among athletic trainers, coaches, and parents will ensure the patient’s concussion rehabilitation and treatment plans are implemented as prescribed. for athletic trainers in states that allow them to treat concussions on their own, symptom concussion profiles can be used to drive the treatment plans for each individual patient. further, the concussion symptom profiles, and individualized treatment approach allow the patient to visualize their plan and helps them create short-term goals for each therapy session. importantly, these goals can be shared and viewed by other healthcare professionals on the patient’s treatment team. using concussion symptom profiles as a part of the src treatment plan can also guide athletic trainers when deciding whether it is appropriate to refer patients to specialty providers. ultimately, a quality improvement approach is ideal because it allows clinicians to evaluate their protocols in relation to best practice documents and emerging evidence and to implement small changes for evaluation of outcomes in their specific setting. references: 1. schneider kj, leddy jj, guskiewicz km, et al. rest and treatment/rehabilitation following sportrelated concussion: a systematic review. br j sports med. 2017;51(12):930-934. http://dx.doi.org/10.1136/bjsports-2016-097475. 2. mccrory p, meeuwisse w, dvorak j, et al. consensus statement on concussion in sport-the 5th international conference on concussion in sport held in berlin, october 2016. br j sports med. 2018;51:838-847. http://dx.doi.org/10.1136/bjsports-2017-097699. 3. giza cc, kutcher js, ashwal s, et al. summary of evidence-based guideline update: evaluation and management of concussion in sports. report of the guideline development subcommittee of the american academy of neurology. neurology. 2013;80(24):2250-2257. https://doi.org/10.1212%2fwnl.0b013e31828d57dd. 4. iverson gl, gardner aj, terry dp, et al. predictors of clinical recovery from concussion: a systematic review. br j sports med. 2017;51(12):941-948. https://doi.org/10.1136/bjsports2017-097729. 5. kontos ap, elbin rj, trbovich a, et al. concussion clinical profiles screening (cp screen) tool: preliminary evidence to inform a multidisciplinary approach. neurosurgery. 2020;87(2):348-356. https://doi.org/10.1093/neuros/nyz545. 6. lumba-brown a, teramoto m, bloom oj, et al. concussion guidelines step 2: evidence for subtype classification. neurosurgery. 2020;86(1):2-13. https://doi.org/10.1093/neuros/nyz332. http://dx.doi.org/10.1136/bjsports-2016-097475 http://dx.doi.org/10.1136/bjsports-2017-097699 https://doi.org/10.1212%2fwnl.0b013e31828d57dd https://doi.org/10.1136/bjsports-2017-097729 https://doi.org/10.1136/bjsports-2017-097729 https://doi.org/10.1093/neuros/nyz545 https://doi.org/10.1093/neuros/nyz332 quality improvement: implementation of individualized concussion patient education and rehabilitation treatment plans 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 7. collins mw, kontos ap, okonkwo do, et al. statements of agreement from the targeted evaluation and active management (team) approaches to treating concussion meeting held in pittsburgh, october 15-16, 2015. neurosurgery. 2016;79(6):912-929. https://doi.org/10.1227/neu.0000000000001447. 8. langevin p, frémont p, fait p, dubé mo, bertrand-charette m, roy js. aerobic exercise for sportrelated concussion: a systematic review and meta-analysis. med sci sports exerc. 2020;52(12):2491-2499. https://doi.org/10.1249/mss.0000000000002402. 9. ranns d, valovich mcleod tc. optimizing return to learn following a sport-related concussion: a quality improvement project. clin pract athl train. 2019;2(3):1-15. https://doi.org/10.31622/2019/0003.1. 10. stuart ea, duerson dh, rodenberg re, ravindran r, macdonald jp. return to drive counseling after sports-related concussion: a quality improvement project. pediatr qual saf. 2016;1(2):e006. https://doi.org/10.1097%2fpq9.0000000000000006. https://doi.org/10.1227/neu.0000000000001447 https://doi.org/10.1249/mss.0000000000002402 https://doi.org/10.31622/2019/0003.1 https://doi.org/10.1097%2fpq9.0000000000000006 abstract manuscript type clinical outcomes research 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 intrinsic foot muscle training for medial tibial stress syndrome katherine newsham, phd, atc*; michelle boyd, ms, atc†; christine lauber, edd, lat, atc‡ *saint louis university, st. louis, mo; †truman state university, kirksville, mo; ‡community health network, indianapolis, in abstract medial tibial stress syndrome (mtss), a common condition in physically active individuals, is widely studied, yet effective and efficient intervention is elusive. we compared the effects of a 2-week neuromuscular-based intervention to the “usual treatment” in a nonrandomized trial involving intercollegiate athletes with complaints of mtss involving soft tissue. the neuromuscular-based intervention focused on relieving trigger points in the deep compartment and improving intrinsic foot muscle (ifm) function. the control group received “usual treatment” that did not include the study exercises, but did include rest, modalities, stretching, and/or strengthening exercises. preand post-intervention measures included pain at rest, during activities of daily living (adl), and during activity; pressure-pain threshold on soft tissue; the foot & ankle ability measure (faam); faam sports subscale; and exercise-induced leg pain questionnaire (eilpq). patients were followed for 3 months for recurring symptoms. the experimental group (nmtx) had significantly greater improvement in pain during activities of daily living (change -2.5 nmtx; -0.5 con; p=.03), pain during activity (change -4.5 nmtx; -0.33 con; p<.001), and pressure-pain threshold (change +2.41 nmtx; -0.03 con; p=.001). the nmtx group also reported greater improvement on the self-reported faam sport-subscale (change +40 nmtx; +6.5 con; p=.001) and had a higher global rating of change (4.71 nmtx; 3.5 con; p=.008). recurrence of symptoms within 3 months was reported by 7% of nmtx and 87% of con. this study demonstrates a neuromuscular-based intervention aimed at relieving soft tissue tenderness in the deep compartment and improving ifm function provides significant and sustained relief of leg pain. content focus health care competence correspondence dr. kitty newsham, saint louis university, 3437 caroline mall, st louis, mo 63104 e-mail: katherine.newsham@health.slu.edu full citation newsham k, boyd m, lauber c. intrinsic foot muscle training for medial tibial stress syndrome. clin pract athl train. 2023;6(1): 1-12. https://doi.org/10.31622/2023/0006.01.2. introduction exercise-induced leg pain (eilp), or exercised-related leg pain (erlp), is common among physically active individuals, accounting for 13-20% of all injuries among runners and up to 35% among military recruits.1,2 eilp/erlp is a vague descriptor encompassing many conditions associated with microtrauma, including exertional compartment syndrome, popliteal artery entrapment, nerve entrapments, tibial and fibular stress fractures, periosteal reactions, and various tendinopathies.3 medial tibial stress syndrome (mtss) localizes the pain to the posteromedial aspect of the tibia, but also describes a continuum of conditions including muscle strain, tendinopathy, and bone stress reaction.2,4 despite the prevalence of mtss, the pathophysiology of the condition is not well understood.3 recent investigations of mtss have identified alterations in bone as well as soft tissue, including the flexor digitorum longus, tibialis posterior, soleus, and crural fascia.5-8 a reliable mtss diagnosis can be made through history and physical exam.9 effective interventions are elusive, and interventions are poorly described in the literature. rest is a mainstay of treatment, yet it does not appear to be effective in the long term.4 stretching, strengthening, taping, orthotics, and various therapeutic modalities have been employed as interventions with mixed and limited results.10-13 extracorporeal shock-wave therapy (eswt) has demonstrated positive effects, particularly with recalcitrant cases; however, return to sport may take 2-15 months.12,13 ultimately, clinicians are left with few choices for effective and efficient treatments. mailto:katherine.newsham@health.slu.edu https://doi.org/10.31622/2023/0006.01.2 intrinsic foot muscle training for medial tibial stress syndrome 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 clearly, mtss is problematic as it interrupts training and adversely affects performance. further, the frequency of re-injury is concerning with up to 80% of individuals reporting recurrence of mtss.6,14 the combination of adverse impact on performance, duration of therapeutic interventions, and frequency of recurrence is likely discouraging to individuals with mtss. limited success in treating mtss may be attributed to failing to appropriately treat pain generating tissue and related dysfunction. myofascial trigger points in the deep compartment can be a source of pain in mtss and shortened extrinsic flexors can contribute to inhibition of intrinsic foot muscles.15,16 interventions addressing trigger points, and muscle inhibition specifically, are critical to alleviating pain and correcting somatic dysfunction.17,18 proprioceptive neuromuscular facilitation (pnf) techniques, using both reciprocal and autogenic inhibition, have been found to aid in deactivation of trigger points through analgesic effects, an increase in sarcomere extension, and an increase in stretch tolerance.19 the theoretical framework for this approach to managing mtss is sound, but has not been described in the literature. measuring effectiveness of interventions is as varied as interventions themselves. return to sport or occupation is a commonly reported outcome for intervention studies.11,12,20,21 some have reported numeric pain scale and patient-specific functional outcome, while others have criticized a lack of a condition specific patientreported outcome.11,12,22 still others have explored pressure-pain threshold as a means of quantifying pain from palpation.16,20 reports of persistence of the effect of interventions were lacking, though 2 studies required participants to be pain-free for 3 weeks to be classified as recovered.23,24 as with any evaluation, multiple measures provide a more robust assessment; dependence on a single dependent variable may not provide a complete picture. the purpose of this study was to explore the efficacy of a 2-week neuromuscular focused intervention for mtss involving soft tissue injury. the intervention utilized pnf techniques to relieve trigger points, inhibit tight and over-active muscles, and facilitate inhibited intrinsic foot muscles (ifm) before employing more familiar isotonic strengthening exercises. borrowing from deficiencies described in the literature, we proposed to measure efficacy through patient-oriented data that allowed participants to describe their perceptions of pain, pain related to activity, and impact of mtss on daily and sport activities utilizing standard patientreported outcome measures. a secondary purpose was to develop minimal clinically important differences specific to mtss for patient-reported outcomes and pain related measures. methods participants any intercollegiate athlete reporting to one of three university (ncaa division ii) athletic training clinics with complaint of exercise-related medial leg pain consistent with mtss (i.e., medial tibial tenderness extending >5cm, trigger points in the deep compartment, no neurologic or vascular symptoms) was invited to participate in this study.9 clinical diagnoses were established by athletic trainers (≥5 years clinical experience in collegiate setting). patients demonstrating neurologic or vascular symptoms or focal bony tenderness suggestive of stress fracture (<5cm) were not included in this study. each participant provided informed consent prior to participation in this irb approved study. institutions (universities) were designated as treatment or control sites rather than assigning individuals to intervention. this was done to limit potential contamination from participants observing other patients and mimicking their exercises. participants reported duration of symptoms and level of pain during sport activity, activities of daily living, and at rest. pain was quantified on an 11-point numeric rating scale; 0 indicated no pain and 10 indicated intrinsic foot muscle training for medial tibial stress syndrome 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 unbearable pain.25 trigger points in the deep compartment were identified through careful palpation;17,18 locations were mapped and recorded for accuracy in subsequent trigger point measures. with the participant seated, knees flexed to 60°, and the foot supported, the pressure-pain threshold was measured with an algometer (wagner instruments, greenwich ct, usa) by instructing the participant to notify the investigator when the pressure applied to a trigger point transitioned from pressure to pain.18 the pressure indicated on the algometer at that point was recorded. lower scores indicate greater trigger point sensitivity, while higher scores indicate greater load capacity.26 for participants with bilateral symptoms, pain related measures were obtained from the side with greater pain. the participant remained seated and the knee was flexed to 90° with the foot flat on a firm surface for ifm evaluation. ifm dysfunction was defined as the inability to extend the great toe while the lesser toes remained in a neutral position and/or the inability to extend the lesser toes while the great toe remained in a neutral position.15,16 the participant completed the foot and ankle ability measure (faam), the faam sports subscale, and the exercise-induced leg pain questionnaire (eilpq).27 in addition to rating difficulty performing certain tasks, the faam forms include self-reported level of function relative to “normal.” the eilpq is similar to faam, but is specific to leg pain. it has been found to be valid and reliable, though is not widely represented in the literature.27 a post-intervention data collection session was performed 14 days after initial testing (pain scale, pressure-pain threshold, faam, faam sports subscale, eilpq and global rating of change (groc)). the groc allowed participants to express overall improvement or worsening of symptoms after the intervention.28 patients were followed for 3 months to assess recurrence of mtss symptoms. intervention the neuromuscular intervention, provided by athletic trainers (all with ≥5 years clinical experience and trained in study procedures), utilized neuromuscular facilitation and inhibition techniques common to physical medicine and rehabilitation (table 1). phase 1 each session in week 1 began with pnf techniques (e.g., slow-reversal, hold-relax, contract-relax) to relieve trigger points in the deep compartment. the flexor hallucis longus and flexor digitorum longus were targeted with 4-5 repetitions of each technique for the great toe and then for the lesser toes (as a group). release techniques were followed by re-education, or facilitation, of the toe extensors and intrinsic foot muscles. participants were seated with the foot flat on the floor and instructed to extend the great toe without moving the lesser toes. visual and tactile stimulation, passive positioning, and isometric and eccentric contractions were employed to assist skill acquisition. when participants could extend the great toe without extraneous movement of the lesser toes, they alternated to extending the lesser toes without tensing or flexing the great toe and/or arch. participants in the nmtx group performed exercises daily (monday – friday) under the supervision of the treating athletic trainer and again a second time in the evening unsupervised. phase 2 in the second phase, pnf stretching techniques and toe extension exercises continued. manual resistance was added and, in some instances, light resistance facilitated extension. the participant was instructed in the short foot exercise (sfe), increasing ifm activity with a submaximal contraction. the participant intrinsic foot muscle training for medial tibial stress syndrome 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 table 1. intervention exercises exercise volume intensity relieve trigger points in deep compartment a slow-reversal 4-5 reps low to moderate contract -relax 4-5 reps low to moderate hold-relax 4-5 reps low to moderate activate inhibited muscles passive positioning, tactile stimulation, eccentric contraction; progress to concentric a 2 sets to fatigue minimal resistance; high mental focus manual resistance b 2-3 sets 5-15 reps low to moderate short-foot exercise seated b 2 sets 5-15 reps low stretch shortened structures: low-load long-duration (slant board) a 3-5 min low incorporate functional activity c short foot exercises standing, progress to staggered stance; 10 x 10s progress as tolerated low to moderate resisted inversion, eversion, dorsiflexion 2 x 8-15 reps low to moderate a phase 1 (days 1 and 2) b phase 2 initiate manual resistance and sfe; continue with phase 1 exercises (days 3-5) c phase 3 initiate functional activity and continue with slant board stretching (days 8-14) attempted to draw the heads of the metatarsals toward the calcaneus without toe activity. the sfe was introduced with the participant in a seated position with the foot on the floor. passive modeling was utilized to facilitate exercise. phase 3 in phase 3, pnf release techniques were discontinued; resisted toe extension exercises were continued. the sfe was advanced to the standing position, where the participant was instructed to assume the short foot position and hold it while in a weight bearing stance. resisted inversion, eversion, and dorsiflexion exercises for the extrinsic muscles of the foot were introduced. treatment sessions included 3-5 minutes of static stretching for the gastrocnemius-soleus complex after completing exercises. no taping, bracing, or orthoses were used to address mtss symptoms. further, no restrictions on training and exercise were imposed on the participants; normal athletic participation was encouraged. the con group did not receive the neuromuscular intervention (i.e., pnf techniques and ifm exercises); rather, they followed an individualized prescription from their providers. this treatment represented the “usual treatment” for this condition and included rest, various therapeutic modalities, stretching, and/or strengthening of the leg muscles. means and standard deviations were calculated for baseline and post-intervention measures. a one-way analysis of variance (anova) was performed to evaluate group differences at baseline and to evaluate differences in change scores. change scores were calculated by subtracting the baseline score from the post-intervention score. pain at rest was not included in the change score analysis as pre-test ratings were minimal at baseline (<1.5), limiting meaningful change. wilcoxon signed-rank tests were used to analyze results for ordinal data for level of function and groc. a minimal clinically important difference (mcid) was calculated using participant report of global improvement (groc) and change scores. effect sizes intrinsic foot muscle training for medial tibial stress syndrome 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 (omega squared) were calculated using an interpretation of small (0.01), medium (0.06), or large (0.14).29 statistical analyses were performed using spss version 27.0 (ibm, armonk, ny) and level of significance was set at p<.05. results twenty-seven athletes initially presented to one of the athletic training clinics with a chief complaint of exercise-related medial leg pain and trigger points in the soft tissue of the medial aspect of the leg. complaints were bilateral in 15 (55.5%) participants; 5 (18.5%) were left-sided and 7 (26%) right-sided; 81% (22/27) demonstrated ifm dysfunction (defined above). seven participants in the nmtx group withdrew from the study due to scheduling conflicts (n=4) or were withdrawn for a failure to complete >50% of physical rehabilitation sessions (n=3). twenty participants (mean 19.6, sd 1.43 years) provided complete, usable preand post-test data. the sport and sex distribution differed between the nmtx group (n=14; 35% female) and the con group (n=6; 100% female) (table 2). the nmtx group included football, soccer, swimming, baseball, and track & field athletes, while the con group included basketball, cross-country, and track & field. the con group reported a longer duration of symptoms (approximately 10 days longer) prior to treatment (p=.05) one hundred percent (100%) of the con group (6/6) and 65% of the nmtx group (9/14) demonstrated ifm dysfunction at baseline. there were no significant differences in pain or patient-reported outcome measures at baseline (table 3). change scores for pain related measures were significantly different between groups after the 2-week intervention. the nmtx group improved significantly on pain during adls, pain during activity, and pressure-pain threshold; no significant differences were observed in con (figure 1, table 4). nmtx also reported significant improvement in faam sports subscale; eilpq difference was not significant, though a large effect size is noted (figure 2, table 4). overall, medium (0.06) to large (0.14) effect sizes were noted for nmtx, indicating substantial change from baseline independent of sample size differences. a significant difference was found between groups on a 5-point groc. all participants in the nmtx group reported being “a little better” (n=4) or “a great deal better” (n=10); in the con group, 1 participant reported being “a great deal better,” 2 reported being “a little better,” 2 reported “no change,” and 1 reported being “a little worse” at 2 weeks (z = -2.66, p=.008). similarly, nmtx reported significant increase in self-reported level of function on the faam sports subscale compared to con (nmtx z= -2.92; p=.004; con z=1.00; p=.32) (figure3). in addition, none of the nmtx group (0/14) table 2. participant characteristics at baseline control baseline average (sd) nmtx baseline average (sd) 95% confidence interval p value age (years) 19.8 (1.47) 19.5 (1.45) -1.16, 1.82 .64 duration of symptoms (days)* 25.33 (5.1) 14.8 (11.5) 0.09, 21.00 .05 ifm dysfunction 100% (n=6) 64% (n=9) sex male female 0 6 9 5 sd, standard deviation; ifm, intrinsic foot muscle; *statistically significant difference intrinsic foot muscle training for medial tibial stress syndrome 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 demonstrated ifm dysfunction after the intervention period, though dysfunction persisted in the con group (6/6). recurrence of mtss symptoms during the 90-day follow-up was reported by 7% (n=1) of the nmtx group and 83% (n=5) of the con group. table 3. patient-reported outcomes baseline measures control baseline average (sd) experimental baseline average (sd) 95% confidence interval p value pain at rest 1.0 (1.26) 1.43 (1.22) -1.69, 0.84 .49 pain in adl (0-10) 2.5 (1.05) 3.1 (1.38) -1.90, 0.76 .38 pain act (0-10) 6.8 (1.27) 6.43 (1.46) -1.34, 2.15 .63 ppt (kg) 2.58 (0.64) 2.61 (1.45) -1.34, 1.29 .97 faam (%) 83.67 (9.80) 79.43 (13.90) -9.02, 17.49 .51 faam function (%) 90.33 (4.90) 88.29 (11.10) -8.96, 11.06 .83 faam sport (%) 59.33 (13.40) 47.86 (15.2) -3.64, 26.60 .13 faam sport function (%) 66.7 (15.30) 75.36 (9.10) -20.17, 2.79 .13 eilpq 62.83 (11.90) 56.11 (16.50) -9.03, 22.48 .38 abbreviations: sd, standard deviation; adl, activities of daily living; pain act, pain during activity; ppt, pressure-pain threshold; faam, foot and ankle ability measure; faam sport, sport sub-scale; eilpq, exercise-induced leg pain questionnaire. 0.00 20.00 40.00 60.00 80.00 100.00 120.00 faaam faamsport eilpq patient reported outcomes nmtx pre nmtx post con pre con post * * figure 2. patient reported outcomes mean scores pre post-intervention; bars represent standard deviation. abbreviations: faam, foot & ankle ability measure; faam sport, sub-scale; eilpq, exercise induced leg pain questionnaire. *statistically significant change (p=.001) 0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 padl pact ppt pain related measures nmtx pre nmtx post con pre con post * figure 1. pain related mean scores prepost-intervention; bars represent standard deviation. abbreviations: padl, pain activities of daily living; pact, pain during activity; ppt, pressure-pain threshold. *statistically significant change p≤.05 * * intrinsic foot muscle training for medial tibial stress syndrome 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 a significant difference was found between groups on a 5-point groc. all participants in the nmtx group reported being “a little better” (n=4) or “a great deal better” (n=10); in the con group, 1 participant reported being “a great deal better,” 2 reported being “a little better,” 2 reported “no change,” and 1 reported being “a little worse” at 2 weeks (z = -2.66, p=.008). similarly, nmtx reported significant increase in self-reported level of function on the faam sports subscale compared to con (nmtx z= -2.92; p=.004; con z=1.00; p=.32) (figure3). in addition, none of the nmtx group (0/14) demonstrated ifm dysfunction after the intervention period, though dysfunction persisted in the con group (6/6). recurrence of mtss symptoms during the 90-day follow-up was reported by 7% (n=1) of the nmtx group and 83% (n=5) of the con group. table 4. change in pain and patient-reported outcomes scores from baseline to 2-weeks control change average (sd) experimental change average (sd) p value effect size ω2 95% ci pain in adl (0-10) -0.50 (2.16) -2.50 (1.51)* .03 0.19 -0.05, 0.46 pain act (0-10) -0.33 (1.86) -4.50 (1.99)* <.001 0.48 0.10, 0.67 ppt (kg) -0.03 (0.70) 2.41 (1.36)* .001 0.44 0.07, 0.66 faam (%) 4.67 (12.96) 16.86 (12.88)* .06 0.12 -0.05, 0.39 faam function (%) -0.33 (7.12) 8.93 (10.01) .06 0.14 -0.05, 0.41 faam sport (%) 6.50 (15.42) 40 (18.93)* .001 0.40 0.04, 0.63 faam sport function (%) 10 (18.71) 16.57 (11.84) .35 -0.004 -0.05, 0.25 eilpq 12.50 (18.39)* 31.07 (20.11)* .07 0.12 -0.05, 0.39 abbreviations: sd, standard deviation; adl, activities of daily living; pain act, pain during activity; ppt, pressure-pain threshold; faam, foot and ankle ability measure; faam sport, sport sub-scale; eilpq, exercise-induced leg pain questionnaire *exceeds minimal clinically important difference for this measure figure 3. level of function. comparison of the frequency of patient-reported level of function preand post-intervention. wilcoxon signed-ranks con p=.32; nmtx p=.004 baseline post-treatment intrinsic foot muscle training for medial tibial stress syndrome 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the minimal clinically important difference (mcid) was calculated by comparing the difference in mean change scores for participants reporting they were at least “a little better” after the 2-week intervention.30 for pain during adls, mcid was 1.2; for pain during activity, it was 2.5; and for pressure-pain threshold, it was 2.0 kg. for patient-reported outcomes, mcid was 10 points for faam; 15 points for faam sports subscale, and 12 points for eilpq. nmtx exceeded mcid for each of these measures; con did not meet mcid for any measure other than eilpq (table 4). discussion this study describes outcomes after a 2-week neuromuscular-based intervention designed to alleviate mtss by relieving trigger points and improving ifm function among intercollegiate athletes. releasing trigger points in the deep compartment may be central to reducing pain in sport activity. however, this effect may have been limited without efforts to prevent recurrence of the development of trigger points. the toe extension exercises as described can induce reciprocal inhibition of the toe flexors to prevent recurrence of trigger points while also engaging the ifm.31 the sfe requires increased activation of the ifm and executing sfe in a standing position is a standard progression for increased load and ifm activation.31,32 while all participants reported some improvement after 2-weeks of treatment, those in the nmtx group demonstrated greater reduction in self-reported pain during activity and increased perceived sport function. they also rated their overall condition as being improved more than the con group at the end of two weeks and had minimal recurrence of mtss symptoms over the 90-day follow-up program. the groups were similar relative to pain and function at baseline, though the average duration of symptoms for the con group was approximately 10 days greater than the nmtx group. the clinical importance of this difference is not clear. intuitively, one might expect a longer duration of symptoms to lead to a longer recovery period. yet, multiple studies of mtss interventions have found no relationship between duration of symptoms and time to recovery, functional outcomes, or numeric pain scales.12,21,22 at the conclusion of a 2-week intervention, all participants in the nmtx group reported improvement (“a little” to “a great deal”) on the groc, while only half of the con group did. further, the nmtx group reported an 80% reduction in pain during adls and a 62% reduction in pain during sport activity after the 2-week neuromuscular intervention. the con group reported minimal reductions in pain during adls and sport activity (0.5% and 2%, respectively). an earlier study, also focused on restoring ifm function in patients with mtss, reported a 50% reduction in pain during sport activity after a 14-day intervention.16 in contrast, a study utilizing extrinsic muscle stretching and strengthening program resulted in only a 14% reduction in pain at 4 weeks and fewer than half of participants returning to preferred sport activity at 15 months.13 the nmtx group participants were never removed from activity and were encouraged to participate in activity as tolerated. this is contrary to traditional interventions that call for a 7-10-day rest period with a 50% reduction in physical training intensity in the sub-acute phase.4,33,34 in this study, no nmtx participants refrained from training or competitions. conversely, all con group participants reported a period of rest, though all had resumed sport activity to some degree before the end of the 2-week intervention. the potential for patients with mtss to realize a significant reduction in pain without being prohibited from training may result in better reporting and better compliance with the intervention. intrinsic foot muscle training for medial tibial stress syndrome 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 participant perception of function was captured with the faam, faam sports subscale, and eilpq. all participants perceived some limitation in adls (faam) and sport activity (faam sport and eilpq) secondary to leg pain. sport activity was, predictably, more limited than adls. the nmtx group realized a 40-point gain in faam sports subscale and a 32-point gain in eilpq after intervention. the faam sports subscale and eilpq have very similar questions with eilpq adding items regarding exercise of increasing duration, but omitting items related to activities outside of sport. scores increased on each patient-reported outcome between time points with increases well beyond mcid. the degree of recovery in the nmtx group observed at 2 weeks represents a substantially shorter recovery period than one might expect. prospective studies of novice runners have established recovery times of approximately 10 weeks, while military recruits demonstrated recovery at 8-11 weeks.22-24,35 studies of graduated running programs with or without eswt demonstrated recovery at 2-14 weeks.11,12,21 sharma et al, pointing to the burden of mtss, urged re-examination of current approaches to management of this condition.35 the current study describes a different approach that may result in shorter recovery time. ifm exercise may be an important addition to mtss rehabilitation. training the ifm may provide the dynamic support individuals with mtss are lacking.36,37 with 2 weeks of training, it is not likely that muscle hypertrophy has occurred; rather, we suggest a neuromuscular adaptation leading to improved muscle recruitment. ifm training has been found to decrease navicular drop and improve foot posture in uninjured subjects.36 we did not measure foot posture or navicular drop in this study; however, we observed ifm dysfunction in approximately 80% of patients with mtss. bandholm et al, reported increased navicular drop and medial longitudinal arch deformation during quiet standing and during gait in subjects with mtss compared to controls.38 this may be related to inversion strength deficits associated with mtss.39 given the role of inverters in providing dynamic support for the medial longitudinal arch, it is logical that extrinsic muscle strengthening would be beneficial for individuals with mtss; however, results of extrinsic strengthening are unimpressive.11-13,22,34 restoring ifm function can provide sensory and motor input that is integrated into dynamic control.40 the results of our study support a more comprehensive approach with resolving the trigger points in the deep compartment, restoring ifm function, and strengthening the extrinsic muscles. the persistence of the effect of this intervention suggests the intervention goes beyond temporary pain relief to realize resolution of ifm dysfunction and restoration of muscle balance. ifm exercises have not previously been reported as an intervention for mtss. limitations this study was limited by a small sample size and unequal groups. further, 7 participants (26%) did not complete the study. two contributing factors were an unexpected reduction in patients presenting with mtss during the 18-month study period and changes in professional healthcare staff, limiting the availability of personnel trained in the intervention and/or willing to adopt this approach to treatment. however, we feel the magnitude of improvement and persistence of effect allow these findings to contribute to clinical practice. the difference in duration of symptoms cannot be ignored, but it is difficult to know the accuracy of reporting and the effect a 10-day difference might have. an additional limitation was the representation of females in the nmtx (35%) and con (100%) groups. female sex has been identified as a risk factor in some studies and some literature has reported a longer recovery time for intrinsic foot muscle training for medial tibial stress syndrome 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 females.2,12,41,42 the small sample size limited gender comparisons in this study. it is possible that allowing a longer treatment period may have benefited female participants. clinical application the intervention used in this study provided significant improvement in pain and functional measures in athletes with mtss within 2 weeks that persisted for more than 90 days. these improvements were well beyond mcid with large effect sizes observed for measures associated with physical activity. the approach, focused on relieving trigger points in the deep compartment and improving ifm function, required no elaborate equipment, allowing application in a variety of settings. the persistence of effect is of consequence to clinicians and patients who can be frustrated by the recurrent nature of this condition. references 1. hamstra-wright kl, bliven kc, bay c. risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. b j sport med. 2015;49(6):362-9. https://doi.org/10.1136/bjsports-2014-093462. 2. yates b, white s. the incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. am j sport med. 2004;32(3):772-80. https://doi.org/10.1177/0095399703258776. 3. lohrer h, malliaropoulos n, korakakis v, padhiar n. exercise-induced leg pain in athletes: diagnostic, assessment, and management strategies. the physician and sportsmedicine. 2019;47(1):47-59. https://doi.org/10.1080/00913847.2018.1537861. 4. chambers hg. medial tibial stress syndrome: evaluation and management. operative tech sports med. 1995;3(4):274-277. 5. brown aa. medial tibial stress syndrome: muscles located at the site of pain. scientifica (cairo). 2016;7097489. https://doi.org/10.1155/2016/7097489. 6. ohya s, nakamura m, aoki t, et al. the effect of a running task on muscle shear elastic modulus of posterior lower leg. j foot ankle res. 2017;10:56. https://doi.org/10.1186/s13047-017-0238-x 7. saeki j, nakamura m, nakao s, fujita k, yanase k, ichihashi n. muscle stiffness of posterior lower leg in runners with a history of medial tibial stress syndrome. scand j med sci sports. 2018;28(1):246-251. https://doi.org/10.1111/sms.12862. 8. winters m, burr db, van der hoeven h, condon kw, bellemans j, moen mh. microcrackassociated bone remodeling is rarely observed in biopsies from athletes with medial tibial stress syndrome. j bone miner metab. 2019;37(3):496-502. https://doi.org/10.1007/s00774-0180945-9. 9. winters m, bakker ewp, moen mh, barten cc, teeuwen r, weir a. medial tibial stress syndrome can be diagnosed reliably using history and physical examination. b j sport med. 2018;52(19):1267-1272. https://doi.org/10.1136/bjsports-2016-097037. 10. craig d. advances in understanding medial tibial stress syndrome. sport med rehab j. 2016;1(1) 11. moen mh, holtslag l, bakker e, et al. the treatment of medial tibial stress syndrome in athletes; a randomized clinical trial. sports med arthrosc rehabil ther technol. 2012;4:12. https://doi.org/10.1186/1758-2555-4-12. https://doi.org/10.1136/bjsports-2014-093462 https://doi.org/10.1177/0095399703258776 https://doi.org/10.1080/00913847.2018.1537861 https://doi.org/10.1155/2016/7097489 https://doi.org/10.1186/s13047-017-0238-x https://doi.org/10.1111/sms.12862 https://doi.org/10.1007/s00774-018-0945-9 https://doi.org/10.1007/s00774-018-0945-9 https://doi.org/10.1136/bjsports-2016-097037 https://doi.org/10.1186/1758-2555-4-12 intrinsic foot muscle training for medial tibial stress syndrome 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 12. moen mh, rayer s, schipper m, et al. shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. b j sport med. 2012;46(4):253-7. https://doi.org/10.1136/bjsm.2010.081992. 13. rompe jd, cacchio a, furia jp, maffulli n. low-energy extracorporeal shock wave therapy as a treatment for medial tibial stress syndrome. am j sport med. 2010;38(1):125-32. https://doi.org/10.1177/0363546509343804. 14. hubbard tj, carpenter em, cordova ml. contributing factors to medial tibial stress syndrome: a prospective investigation. med sci sports exerc. 2009;41(3):490-6. https://doi.org/10.1249/mss.0b013e31818b98e6. 15. garth wp, jr., miller st. evaluation of claw toe deformity, weakness of the foot intrinsics, and posteromedial shin pain. am j sport med. 1989;17(6):821-7. https://doi.org/10.1177/036354658901700617. 16. newsham kr, beekley md, lauber ca. a neuromuscular intervention for exercise-related medial leg pain. j sport rehab. 2012;21:54-62. https://doi.org/10.1123/jsr.21.1.54. 17. mcpartland jm. travell trigger points--molecular and osteopathic perspectives. j am osteopath assoc. 2004;104(6):244-9. 18. shah jp, thaker n, heimur j, aredo jv, sikdar s, gerber l. myofascial trigger points then and now: a historical and scientific perspective. pm r. 2015;7(7):746-761. https://doi.org/10.1016/j.pmrj.2015.01.024. 19. trampas a, kitsios a, sykaras e, symeonidis s, lazarou l. clinical massage and modified proprioceptive neuromuscular facilitation stretching in males with latent myofascial trigger points. phys ther sport. 2010;11(3):91-8. https://doi.org/10.1016/j.ptsp.2010.02.003. 20. newman p, waddington g, adams r. shockwave treatment for medial tibial stress syndrome: a randomized double blind sham-controlled pilot trial. j sci med sport. 2017;20(3):220-224. https://doi.org/10.1016/j.jsams.2016.07.006. 21. moen mh, bongers t, bakker ew, et al. risk factors and prognostic indicators for medial tibial stress syndrome. scand j med sci sports. 2012;22(1):34-9. https://doi.org/10.1111/j.16000838.2010.01144.x. 22. meulekamp mz, sauter w, buitenhuis m, mert a, van der wurff p. short-term results of a rehabilitation program for service members with lower leg pain and the evaluation of patient characteristics. mil med. 2016;181(9):1081-7. https://doi.org/10.7205/milmed-d-15-00303. 23. mulvad b, nielsen ro, lind m, ramskov d. diagnoses and time to recovery among injured recreational runners in the run clever trial. plos one. 2018;13(10):e0204742. https://doi.org/10.1371/journal.pone.0204742. 24. nielsen ro, ronnow l, rasmussen s, lind m. a prospective study on time to recovery in 254 injured novice runners. plos one. 2014;9(6):e99877. https://doi.org/10.1371/journal.pone.0099877. 25. boonstra am, stewart re, koke aj, et al. cut-off points for mild, moderate, and severe pain on the numeric rating scale for pain in patients with chronic musculoskeletal pain: variability and influence of sex and catastrophizing. front psychol. 2016;7:1466. https://doi.org/10.3389/fpsyg.2016.01466. 26. reeves jl, jaeger b, graff-radford sb. reliability of the pressure algometer as a measure of myofascial trigger point sensitivity. pain. 1986;24(3):313-321. https://doi.org/10.1016/03043959(86)90117-x. 27. nauck t, lohrer h, padhiar n, king jb. development and validation of a questionnaire to measure the severity of functional limitations and reduction of sports ability in german-speaking patients https://doi.org/10.1136/bjsm.2010.081992 https://doi.org/10.1177/0363546509343804 https://doi.org/10.1249/mss.0b013e31818b98e6 https://doi.org/10.1177/036354658901700617 https://doi.org/10.1123/jsr.21.1.54 https://doi.org/10.1016/j.pmrj.2015.01.024 https://doi.org/10.1016/j.ptsp.2010.02.003 https://doi.org/10.1016/j.jsams.2016.07.006 https://doi.org/10.1111/j.1600-0838.2010.01144.x https://doi.org/10.1111/j.1600-0838.2010.01144.x https://doi.org/10.7205/milmed-d-15-00303 https://doi.org/10.1371/journal.pone.0204742 https://doi.org/10.1371/journal.pone.0099877 https://doi.org/10.3389/fpsyg.2016.01466 https://doi.org/10.1016/0304-3959(86)90117-x https://doi.org/10.1016/0304-3959(86)90117-x intrinsic foot muscle training for medial tibial stress syndrome 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 with exercise-induced leg pain. br j sports med. 2015:1-6. https://doi.org/10.1136/bjsports2012-091745. 28. kamper sj, maher cg, mackay g. global rating of change scales: a review of strengths and weaknesses and considerations for design. j man manip ther. 2009;17(3):163-70. https://doi.org/10.1179/jmt.2009.17.3.163. 29. field ap. discovering statistics using ibm spss statistics. 4th ed. sage; 2013:915. 30. mouelhi y, jouve e, castelli c, gentile s. how is the minimal clinically important difference established in health-related quality of life instruments? review of anchors and methods. health qual life outcomes. 2020;18(1):136. https://doi.org/10.1186/s12955-020-01344-w. 31. gooding tm, feger ma, hart jm, hertel j. intrinsic foot muscle activation during specific exercises: a t2 time magnetic resonance imaging study. j athl train. aug 2016;51(8):644-650. https://doi.org/10.4085/1062-6050-51.10.07. 32. kelly la, kuitunen s, racinais s, cresswell ag. recruitment of the plantar intrinsic foot muscles with increasing postural demand. clin biomech (bristol, avon). 2012;27(1):46-51. https://doi.org/10.1016/j.clinbiomech.2011.07.013. 33. burrus mt, werner bc, starman js, et al. chronic leg pain in athletes. am j sports med. jun 2015;43(6):1538-47. https://doi.org/10.1177/0363546514545859. 34. galbraith rm, lavallee me. medial tibial stress syndrome: conservative treatment options. curr rev musculoskelet med. 2009;2(3):127-33. https://doi.org/10.1007/s12178-009-9055-6. 35. sharma j, greeves jp, byers m, bennett an, spears ir. musculoskeletal injuries in british army recruits: a prospective study of diagnosis-specific incidence and rehabilitation times. bmc musculoskelet disord. 2015;16:106. https://doi.org/10.1186/s12891-015-0558-6. 36. mulligan ep, cook pg. effect of plantar intrinsic muscle training on medial longitudinal arch morphology and dynamic function. man ther. 2013;18(5):425-30. https://doi.org/10.1016/j.math.2013.02.007. 37. zhang x, schütte kh, vanwanseele b. foot muscle morphology is related to center of pressure sway and control mechanisms during single-leg standing. gait posture. 2017;57:52-56. https://doi.org/10.1016/j.gaitpost.2017.05.027. 38. bandholm t, boysen l, haugaard s, zebis mk, bencke j. foot medial longitudinal-arch deformation during quiet standing and gait in subjects with medial tibial stress syndrome. j foot ankle surg. 2008;47(2):89-95. https://doi.org/10.1053/j.jfas.2007.10.015. 39. yuksel o, ozgubuz o, ergun m, et al. inversion/eversion strength dysbalance in patients with medial tibial stress syndrome. j sports sci med. 2011;10:737-742. 40. mckeon po, fourchet f. freeing the foot: integrating the foot core system into rehabilitation for lower extremity injuries. clin sports med. 2015;34(2):347-61. https://doi.org/10.1016/j.csm.2014.12.002. 41. newman p, witchalls j, waddington g, adams r. risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. open access j sports med. 2013;4:229-41. https://doi.org/10.2147/oajsm.s39331. 42. reinking mf, austin tm, richter rr, krieger mm. medial tibial stress syndrome in active individuals: a systematic review and meta-analysis of risk factors. sports health. 2017;9(3):252-261. https://doi.org/10.1177/1941738116673299. https://doi.org/10.1136/bjsports-2012-091745 https://doi.org/10.1136/bjsports-2012-091745 https://doi.org/10.1179/jmt.2009.17.3.163 https://doi.org/10.1186/s12955-020-01344-w https://doi.org/10.4085/1062-6050-51.10.07 https://doi.org/10.1016/j.clinbiomech.2011.07.013 https://doi.org/10.1177/0363546514545859 https://doi.org/10.1007/s12178-009-9055-6 https://doi.org/10.1186/s12891-015-0558-6 https://doi.org/10.1016/j.math.2013.02.007 https://doi.org/10.1016/j.gaitpost.2017.05.027 https://doi.org/10.1053/j.jfas.2007.10.015 https://doi.org/10.1016/j.csm.2014.12.002 https://doi.org/10.2147/oajsm.s39331 https://doi.org/10.1177/1941738116673299 abstract editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 improving care for individuals in pain through a biopsychosocial view john kiesel, pt, dpt indiana state university, terre haute, in key phrases biopsychosocial, psychosocial factors, persistent pain, patient-centered care correspondence dr. john kiesel, indiana state university, 567 nth 5th street, terre haute, in 47809. e-mail: john.kiesel@indstate.edu full citation kiesel j. improving care for individuals in pain through a biopsychosocial view. clin pract athl train. 2021;4(2): 1-5. https://doi.org/10.31622/2021/0004.2.1. editorial everyone experiences pain to some degree during their life. it is a universal part of the human experience. pain can be a critical protective mechanism, as it warns us to change behaviors and move away from danger. it can serve to protect an injured tissue from further damage. pain can also be the source of suffering, and in cases of persistent pain, it can become the disease itself in the absence of other tissue involvement. the burden of pain on society is well documented and involves a significant economic impact.1 the individual impacts of suffering and distress are unmistakable, and the effects of pain on the individual do not reside there alone. interpersonal relationships are often strained and societal roles go unfulfilled. as healthcare providers, we have each personally seen the burden of pain shouldered by our patients and sometimes our friends, family, and co-workers. the individual and subjective, yet universal nature of pain are what make it particularly challenging to treat. it has been a decade since the institute of medicine released the report relieving pain in america: a blueprint for transforming prevention, care, education, and research.2 this report outlined the multiple challenges related to reducing the burden of pain in the united states. the challenges included rising rates of chronic pain, increased opioid use, and inadequate access to treatment for the most vulnerable patients.2 despite upward trends in the prevalence of pain, healthcare providers identified ongoing gaps in their education regarding the treatment of pain and a lack of confidence in their ability to care for individuals with more complex pain conditions. due to these findings, the report called for a cultural transformation in the way the public and clinicians view pain and its treatment. the transformation called for a more thorough understanding of pain in to improve the prevention, assessment, and treatment of pain.2 the public health burden of pain along with self-reports of inadequate preparedness by healthcare providers to treat pain motivated this recommendation. the institute of medicine’s report urged clinicians treating patients in pain to adopt a more complete view of the patient. this more complete view incorporates aspects of culture, beliefs, previous experiences, knowledge, expectations, and values.2 this perspective aligns with a biopsychosocial model of pain, and it integrates the traditional biomedical model with its tissue pathology focus into a much broader view of the patient that includes psychosocial factors.3 the biopsychosocial view emphasizes the role of psychological and social factors play combined with biological factors involved in the prevention, assessment, and treatment of pain. this is not a new perspective on how to be most effective at caring for people in pain, but it has been slow to be embraced into our biomedical culture. engel https://doi.org/10.31622/2021/0004.2.1 improving care for individuals in pain through a biopsychosocial view 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 2 – september 2021 made a case for the biomedical model being outdated and lacking validity in his 1960 paper stating, “[on outdated models,] a disease, then, has substantive qualities, and the patient can be cured if the diseased part is removed. that this often proves to be the case, as attested to by the successes of surgery, is actually not evidence for the validity of such a point of view.”4 traditional training for healthcare professionals has focused on a biomedical view of pain that would support the idea that a tissue-based pathology is the cause of pain and disability. prevention, assessment, and treatment of pain within this biomedical view center on identifying the pathological tissue and promoting healing of the involved tissue. limitations of the biomedical view include a poor ability to explain persistent pain and a lack of congruency with recent evidence highlighting the importance of psychosocial factors in pain and disability.5 the biomedical view has been increasingly challenged as imaging has advanced and tends to find pathological tissues in the majority of people. unhealthy tissues are present in people who have never had an injury or pain in the region of the findings. this biomedical view is at odds with more complex pain presentations and the majority of individuals with persistent pain. patients with persistent pain often present with minimal tissue based pathology or have long since healed from a tissue pathology but continue to experience pain and disability. much of the focus of the biopsychosocial view has been on applying it to patients with persistent pain. 6 while this is valid, it does ignore the reality that all chronic pain begins as acute pain. psychosocial factors that play a role in the persistence of pain are often present in acute pain presentations. adopting a view of acute pain that incorporates psychological and social factors along with tissue based factors is the way to accepting this view for chronic pain. many prognostic indicators for the progression of acute to chronic pain are psychological and social in nature.7 after a whiplash injury, for example, perceived injustice and pain catastrophizing are predictive factors for poor recovery.8 patient expectations of recovery after an injury also play an important role in prognosis. for individuals with acute injuries similar in nature, those with higher expectations of recovery are less likely to develop persistent pain.9 pain-related fear of movement, a common maladaptive pain behavior after acute injury, was the single strongest contributing factor to disability in a group of patients with foot and ankle pathology.10 we should not ignore that tissue pathologies more severe in nature take longer to heal, but the extent of injury alone is a poor predictor of who will transition to persistent pain and ongoing functional loss.11,12 only a more complete accounting of a patient’s culture, beliefs, previous experiences, knowledge, expectations, and values can begin to account for this transition from acute pain to persistent pain. so what does this biopsychosocial view of pain look like? it looks a lot like compassionate, patientcentered care. it involves a skilled interview that moves beyond the state of the tissue to understand contributing factors to the pain experience.13 it involves a thorough physical examination that by itself can reduce pain and improve the patient’s psychological orientation to treatment.14 it also involves using standardized patient self-report questionnaires to help you get a more complete understanding of the multidimensional factors that contribute to your patient’s pain experience.15 it may involve referral or collaboration of an interprofessional or intraprofessional nature. most of all it involves compassionate care and building a meaningful therapeutic alliance with your patient.16 these are within the skill set of many healthcare providers, but those of us in rehabilitation have some specific advantages. we see patients repeatedly over an episode of care, which allows us to build a working relationship while we consistently reevaluate the patient’s improving care for individuals in pain through a biopsychosocial view 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 2 – september 2021 status. we spend a significant amount of training on developing our physical examination skills, and we tend to have more time with our patients than our physician colleagues. the development of new imaging techniques, lessinvasive surgeries, and novel pharmaceuticals as ways to treat pain have not moved the needle on the burden of pain in society. in some cases, as is often true for advanced imaging, these tools have resulted in increased downstream costs and maladaptive pain beliefs that result in harm to patients.17 advanced imaging and many novel interventions cling to the biomedical view and are lacking when it comes to addressing the psychosocial issues related to persistent pain. effective treatment for persistent pain incorporates the biopsychosocial view through graded activity, addressing maladaptive behaviors, and educating patients with an emphasis on self-management and understanding the individual factors that influence their pain.18,19 embracing the biopsychosocial view is integral to enhancing the role athletic trainers and other healthcare providers play in reducing the burden of pain on society. i encourage you to take a moment and consider your view of pain. reflect on what you are doing to incorporate psychological and social factors into how you prevent, assess, and treat pain. if we are going to be more effective in our role treating pain, it has to occur one person at a time through a view that incorporates psychosocial aspects into our patient management. it must involve a change in culture that is long overdue. references 1. gbd 2016 disease and injury incidence and prevalence collaborators. global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the global burden of disease study 2016. lancet. 2017;390(10100):1211-1259. https://doi.org/10.1016/s01406736(17)32154-2. 2. institute of medicine (us) committee on advancing pain research, care, and education. relieving pain in america: a blueprint for transforming prevention, care, education, and research. washington (dc): national academies press (us); 2011. https://doi.org/10.17226/13172. 3. engel gl. the need for a new medical model: a challenge for biomedicine. science. 1977;196(4286):129-136. https://doi.org/10.1126/science.84746 0. 4. engel gl. a unified concept of health and disease. perspect biol med. 1960;3:459485. https://doi.org/10.1353/pbm.1960.00 20. 5. alhowimel a, alotaibi m, radford k, coulson n. psychosocial factors associated with change in pain and disability outcomes in chronic low back pain patients treated by physiotherapist: a systematic review. sage open med. 2018;6:2050312118757387. published 2018 feb 6. https://doi.org/10.1177/2050312118 757387. 6. gatchel rj, peng yb, peters ml, fuchs pn, turk dc. the biopsychosocial approach to chronic pain: scientific advances and future directions. psychological 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transition to chronicity after whiplash injury. spine (phila pa 1976). 2011;36(25 suppl):s244-s249. https://doi.org/10.1097/brs.0b013e3 182387fed. 9. holm lw, carroll lj, cassidy jd, skillgate e, ahlbom a. expectations for recovery important in the prognosis of whiplash injuries. plos med. 2008;5(5):e105. https://doi.org/10.1371/journal.pmed. 0050105. 10. lentz ta, sutton z, greenberg s, bishop md. pain-related fear contributes to selfreported disability in patients with foot and ankle pathology. arch phys med rehabil. 2010;91(4):557-561. https://doi.org/10.1016/j.apmr.2009.1 2.010. 11. wylie jd, suter t, potter mq, granger ek, tashjian rz. mental health has a stronger association with patientreported shoulder pain and function than tear size in patients with fullthickness rotator cuff tears. j bone joint surg am. 2016;98(4):251-256. https://doi.org/10.2106/jbjs.o.00444 . 12. westermann rw, lynch ts, jones mh, et al. predictors of hip pain and function in femoroacetabular impingement: a prospective cohort analysis. orthop j sports med. 2017;5(9):2325967117726521. published 2017 sep 15. https://doi.org/10.1177/2325967117 726521. 13. diener i, kargela m, louw a. listening is therapy: patient interviewing from a pain science perspective. physiother theory pract. 2016;32(5):356-367. https://doi.org/10.1080/09593985.20 16.1194648. 14. louw a, goldrick s, bernstetter a, et al. evaluation is treatment for low back pain. j man manip ther. 2021;29(1):413. https://doi.org/10.1080/10669817.20 20.1730056. 15. beneciuk jm, lentz ta, he y, wu ss, george sz. prediction of persistent musculoskeletal pain at 12 months: a secondary analysis of the optimal screening for prediction of referral and outcome (ospro) validation cohort study. phys ther. 2018;98(5):290-301. https://doi.org/10.1093/ptj/pzy021. 16. kinney m, seider j, beaty af, coughlin k, dyal m, clewley d. the impact of therapeutic alliance in physical therapy for chronic musculoskeletal pain: a systematic review of the literature. physiother theory pract. 2020;36(8):886-898. https://doi.org/10.1080/09593985.20 18.1516015. 17. sajid im, parkunan a, frost k. unintended consequences: quantifying the benefits, iatrogenic harms and downstream cascade costs of musculoskeletal mri in uk primary care. bmj open qual. 2021;10(3):e001287. https://doi.org/10.1136/bmjoq-2020001287. https://doi.org/10.1001/jama.2010.344 https://doi.org/10.1001/jama.2010.344 https://doi.org/10.1097/brs.0b013e3182387fed https://doi.org/10.1097/brs.0b013e3182387fed https://doi.org/10.1371/journal.pmed.0050105 https://doi.org/10.1371/journal.pmed.0050105 https://doi.org/10.1016/j.apmr.2009.12.010 https://doi.org/10.1016/j.apmr.2009.12.010 https://doi.org/10.2106/jbjs.o.00444 https://doi.org/10.2106/jbjs.o.00444 https://doi.org/10.1177/2325967117726521 https://doi.org/10.1177/2325967117726521 https://doi.org/10.1080/09593985.2016.1194648 https://doi.org/10.1080/09593985.2016.1194648 https://doi.org/10.1080/10669817.2020.1730056 https://doi.org/10.1080/10669817.2020.1730056 https://doi.org/10.1093/ptj/pzy021 https://doi.org/10.1080/09593985.2018.1516015 https://doi.org/10.1080/09593985.2018.1516015 https://doi.org/10.1136/bmjoq-2020-001287 https://doi.org/10.1136/bmjoq-2020-001287 improving care for individuals in pain through a biopsychosocial view 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 2 – september 2021 18. ogston jb, crowell rd, konowalchuk bk. graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain. j back musculoskelet rehabil. 2016;29(4):673684. https://doi.org/10.3233/bmr160669. 19. watson ja, ryan cg, cooper l, et al. pain neuroscience education for adults with chronic musculoskeletal pain: a mixed-methods systematic review and meta-analysis. j pain. 2019;20(10):1140.e1-1140.e22. https://doi.org/10.1016/j.jpain.2019.0 2.011. https://doi.org/10.3233/bmr-160669 https://doi.org/10.3233/bmr-160669 https://doi.org/10.1016/j.jpain.2019.02.011 https://doi.org/10.1016/j.jpain.2019.02.011 manuscript type abstract presentation 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 2 – september 2021 southwest athletic trainers’ association free communications abstract presentations the following abstracts were accepted and presented at the 67th southwest athletic trainers’ association (swata) symposium, 2021. athletic trainers’ perceived readiness to recognize mental health symptoms in student athletes sumrall km, salisbury, h a.t. still university, mesa, az context: athletic trainers (at) may report a lack of confidence in decision-making as they transition to professional practice. there is limited research on how prepared ats feel managing mental health conditions in athletes. objective: the purpose of this study was to explore the perceived readiness and confidence of master’s at students, transitioning to professional practice, to recognize mental health symptoms and provide appropriate referral strategies. design: quantitative, descriptive study. setting: texas master’s at programs. patients or other participants: non-probability consecutive sampling method. the target population was 2ndyear master’s at students in texas who were eligible to graduate and sit for the boc. a total of 33 students attempted the electronic survey; 17 met the inclusion criteria and completed the entire survey for a response rate of 61%. interventions: program directors of at programs received a recruitment letter asking them to distribute the participant recruitment letter and survey link to their 2nd-year master’s at students. students completed the survey via surveymonkeytm. the adapted survey included a set of three vignettes with two associated multiple choice response questions for each vignette, and a binary scale with an additional “not sure” option for assessing athletic trainer responsibility. a 5-point likert scale was created to assess perceived readiness and confidence. subject matter experts were used to establish face and content validity. main outcome measures: perceived readiness and confidence were the main outcome measures assessed. identification of the correct mental health symptom and best referral option for each vignette was also assessed. data analysis was conducted using spss statistics v. 27.0. all data were analyzed using descriptive statistics and appropriate measures of central tendency and dispersion. results: normality testing was run for the variable, age, using the shapiro-wilk test (p < .001). the median survey participant age was 23.00 years (iqr= 2; min/max = 22, 28) and the majority of students were female (n = 15; 88.2%). when asked if ats were responsible for implementing psychological interventions, 52.9 % (n =9) students incorrectly chose yes and 41.2% (n = 7) reported not sure. athletic training students reported preparedness to recognize signs and symptoms of mental health conditions in athletes (n =11; 64.7%), but not as prepared to provide referral strategies. they also agreed or strongly agreed they had the confidence to identify an athlete in need of a mental health referral (n = 10; 58.8%), but lacked confidence to manage the referral. conclusions: at students perceived readiness and confidence to recognize signs and symptoms of mental health conditions in athletes, but felt unprepared to provide appropriate referrals. the lack of preparedness and confidence may illustrate a need for further instruction in at education programs. abstract presentation 64 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 hiring practices among ncaa division i head athletic trainers cage sa*†, winkelmann zk‡, warner bj†§, tuell c?, gallegos dm* *the university of texas at tyler, tyler tx; †the university of north carolina greensboro, greensboro, nc ‡university of south carolina, columbia, sc §grand canyon university, phoenix, az; ?university of texas health science center, houston, tx context: limited empirical evidence exists on how athletic trainers (ats) are hired by ncaa institutions. current legislation protects many demographics from discrimination during hiring, but these laws may not be enforced by institutions. objective: the purpose of this study was to describe potential factors that might influence the hiring practices of ncaa division i head athletic trainers. design: cross-sectional design. setting: electronic survey distributed to certified athletic trainers. participants: a web-based survey (qualtrics) that was distributed to by email to 329 ncaa division i head athletic trainers. a total of 114 ats completed the survey (response and completion rate=34.7%). interventions: ncaa division i head athletic trainers were emailed an invitation to participate in an electronic survey. the survey included a prompt for hiring an assistant athletic trainer for an ncaa division i athletics program, questions on demographic data, impact of candidate demographic factors on hiring practices, and impact of candidate skills and education on hiring practices. after the collection window had closed, we calculated central tendencies for participant responses. main outcome measures: traits and characteristics of applicants preferred by ncaa division i head athletic trainers. results: most ats reported they would be most likely to hire a candidate with three to five years of experience (90.3%). most ats also reported that they would be most likely to hire a candidate with primarily collegiate athletics experience (91.2%). regarding education, most ats were most likely to hire a candidate with a post-professional master’s degree in athletic training (95.6%). for demographic factors, most ats responded in the mid-range of agreement about the impact these factors had on hiring practices. more athletic trainers stated a willingness to hire a candidate of a different race (50%), different religion (45.6%) and different sex (48.2%). responses regarding sexual orientation were near the mid-range for both same and different sexual orientation. when asked about the most attractive credentials for candidates, ats ranked corrective exercise specialist, graston technique certified, and performance enhancement specialist highest. conclusions: most head athletic trainers agreed that three to five years of professional experience, previous experience with collegiate athletics, and a master’s degree in athletic training were the attributes most likely to influence a candidate being hired. however, many ats responded toward the mid-range of agreement when asked about demographic factors when considering candidates. this may indicate an unwillingness to respond favorably or unfavorably on the topic. future research should focus on assessing hiring practices in a manner that requires a favorable or unfavorable response. athletic trainers involved in the hiring practice at their institutions must work to ensure that they are hiring the best candidate irrespective of demographic factors that have no bearing on technical standards of the position. abstract presentation 65 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 attitudes among collegiate volleyball and women’s soccer players prior to the covid19 altered 2020-21 season gallegos dm*, warner bj†‡, cage sa*† *university of texas at tyler, tyler, tx; †university of north carolina greensboro, greensboro, nc; ‡grand canyon university, phoenix, az context: in response to the global spread of sars-cov-2, the national collegiate athletic association cancelled all 2020 winter and spring championships that had not been completed. additionally, the majority of 2020 fall spring championships were rescheduled to take place in the spring semester of 2021. objective: the purpose of this study was to describe the attitudes, moods, and motivations of collegiate women’s soccer and women’s volleyball players toward the alteration to the 2020-2021 season. design: cross-sectional design. setting: web-based survey. participants: a total of 46 female collegiate soccer and volleyball players participated in this study (age = 17.8 years ± 1.3; women’s soccer = 24; women’s volleyball = 22). interventions: participants were sent an electronic survey that collected demographic information, assessed attitudes and motivations regarding the altered season, and asked items found on the phq-9 and gad-7 to assess depression and anxiety related feelings. data was downloaded and analyzed using commercially available statistics software. main outcome measures: emotions experienced following the alteration to the 2020-2021 competitive season, depression related symptoms, and anxiety related symptoms. results: the vast majority of participants stated that they were disappointed and sad when they received news that the 2020-2021 season would be altered (disappointed = 80.4%). in contrast, the least commonly experienced emotion was happiness (happy = 19.6%). on the phq-9, the majority of participants reported symptoms consistent with either moderate or severe depression (moderate depression = 15, severe depression = 13). 82.6% (n=38) of participants reported experiencing symptoms consistent with at least moderate depression. on the gad-7, all participants reported symptoms consistent with at least mild anxiety (n = 46). the majority of participants reported symptoms consistent with mild or moderate anxiety (mild anxiety = 16, moderate anxiety = 14). conclusions: the majority of surveyed collegiate women’s soccer and volleyball players reported feeling disappointed or sad upon receiving news that the 2020-2021 competitive season would be altered. less than 20% of respondents reported feeling happy about this news. the majority of participants reported feeling symptoms consistent with depression and anxiety shortly after receiving the news that their seasons would be altered. as athletic trainers, coaches, and administrators prepare to move forward, it is important to consider the possible implications and effects the alteration of the 2020-2021 competitive season will have on the mental health of student-athletes. consideration of these factors may allow for intervention should student-athletes continue to experience these negative mood states. abstract presentation 66 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 effect of tissue flossing on grip strength in collegiate baseball players eilers ma*, warner bj*†, gallegos dm‡, hopper i‡, cage sa†‡ *grand canyon university, phoenix, az; †the university of north carolina, greensboro, greensboro, nc; ‡the university of texas at tyler, tyler, tx context: tissue flossing bands are a relatively new therapeutic modality that has increased in popularity in recent years. while there is evidence to suggest that tissue flossing bands can decrease pain and increase perceived range of motion, there has been little research conducted to determine the effects of tissue flossing on muscular strength and performance. thus, the aim of this study was to assess the effects of a single tissue flossing treatment on grip strength among healthy collegiate baseball players. methods: twenty apparently healthy collegiate baseball players (21.4 ± 1.54 years, 181.9 ± 3.56 cm, 84.5 ± 8.56 kg) were recruited and consented to participate in this study. the tissue flossing treatment was performed from the wrist to the elbow on the participant’s throwing arm. grip strength was then measured three times using a hand grip dynamometer both before and after treatment. the patient’s non-throwing hand was tested before and after a one minute rest period to serve as a control. data analysis was performed using a paired samples t-test to determine statistical significance of differences in maximum grip strength before and after intervention for both the treatment and control arms, and a one sample t-test was performed to determine the statistical significance of differences in maximum grip strength between groups. all statistical analyses were performed using spss statistics software (ibm, armonk, ny). the level of significance was set at p < 0.05. results: following one round of tissue flossing treatment, the participants experienced a 4.3% decrease in grip strength (111.69 ± 16.95 to 106.89 ± 16.19, p = 0.001). however, participants did not experience a significant decrease in grip strength compared to the control arm (4.90 ± 11.12 to 1.93 ± 12.93, p = 0.143). none of the participants reported any adverse effects as a result of the tissue flossing band treatment other than mild soreness and redness of the skin that resolved within 10-15 minutes. conclusions: these findings demonstrated that in healthy young baseball players, tissue flossing bands did not significantly decrease grip strength when compared to a healthy control. thus, it would be reasonable to perform a tissue flossing band treatment prior to performing physical activity that involved gripping. clinicians must use discretion when choosing a treatment option if a patient will be performing physical activity afterwards. abstract presentation 67 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 athletic trainers’ perceived and actual knowledge of cold related modalities warner bj*†, mckenney m*, gallegos dm‡, cage sa†‡ *grand canyon university, phoenix, az; †university of north carolina greensboro, greensboro, nc; ‡university of texas at tyler, tyler, tx context: to date, there does not appear to be a study published that has examined the perceived and actual knowledge of cold related modalities that athletic trainers process. objective: the purpose of this study was to determine the perceived and actual knowledge of cold related modalities among athletic trainers. design: cross sectional study. setting: electronic, web-based survey sent to credentialed athletic trainers. patients or other participants: 191 certified athletic trainers completed the study (age = 42 ± 12 years, years of certified experience = 19 ± 11 years). interventions: participants were sent an electronic survey via email that assessed frequency of usage, perceived knowledge, and actual knowledge of cold related modalities. data was downloaded and analyzed using a commercially available statistics package (spss version 26, ibm, armonk, ny). measures of central tendency (means, standard deviations, frequencies) were calculated for all survey items. a pearson correlation was calculated for the perceived and actual knowledge items to assess for a knowledge gap between what one believes they know and what they actually know. significance was set at p < .05 a priori. main outcome measures: usage of cold related modalities, perceived knowledge of cold related modalities, actual knowledge of cold related modalities. results: the majority of athletic trainers reported using cold related modalities to treat acute, chronic, and post-operative pain. regarding perceived knowledge, most respondents indicated some level of confidence in their knowledge of cold related modalities. average scores on actual knowledge were 6.07 ± out of 10 questions. no significant relationship was found between perceived and actual knowledge (r = 0.127, p = 0.081). conclusions: while the majority of athletic trainers reported confidence in their knowledge of cold related modalities, their demonstration of actual knowledge was not commensurate. however, individuals who recently participated in postprofessional continuing education related to cold related modalities demonstrated better actual knowledge of the topic than those who did not. this suggests that clinicians may benefit from continuing education interventions to improve knowledge of the definition, modes of action, indications, and contraindications of cold related modalities. abstract presentation 68 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 nonsurgical management of unilateral, nondisplaced lateral malleolus fracture in 17-year-old outside linebacker tallman, k*†, bautista r*, spencer b† *houston methodist sugar land orthopedics & sports medicine, sugar land, tx; †john foster dulles high school, sugar land, tx background: ankle fractures, specifically unilateral fractures, are among the most common injuries encountered by orthopedic surgeons. ankle fractures have an incidence of 187 out of 100,000 individuals. current treatment options for ankle fractures are dependent on stability of the ankle mortise, determined through number of fracture sites and ligamentous integrity. the management of the fracture scan either be surgical or nonsurgical, the majority being surgical. in this case report, a 17-yearoldmaleoutside linebacker sustained a left lateral ankle injury during a regular season football game. as he attempted to make a tackle, his left foot got caught in the turf, he fell backwards, and heard a pop. he continued to play in the game, but the pain progressively got worse. upon halftime evaluation, the injury was deemed a lateral ankle sprain and the student-athlete (sa) was taped for external support. the sa could no longer ambulate. the sa was given crutches postgame and returned to the athletic training room the next day for further evaluation. the tuning fork test, squeeze test, and bump test were all positive, but only 2 out of 5 criteria for ottawa ankle rules were met. differential diagnosis: differential diagnoses include lateral ankle sprain, lateral malleolus fracture, and subluxation of peroneal muscle. treatment: the sa was given a walking boot and referred to a physician for imaging. radiographic images showed a minimally displaced, left lateral malleolus fracture. the sa was referred back to the athletic training room to complete a rehabilitation program. after 7 weeks of rehabilitation working on regaining range of motion, strength, proprioception, and neuromuscular control, the sa was cleared for participation and was able to play in the last football game of the season. uniqueness: most lateral ankle fractures are treated surgically, but because there was no displacement or ligamentous disruption in this case, the fracture was treated nonsurgically. conclusion: minimally displaced lateral ankle fractures that are treated nonsurgically have excellent outcomes. a thorough examination and evaluation is vital in overall ankle management. the best rehabilitation program depends on a lot of factors, but the stability and mobility of the ankle should be considered along with the pain levels with weight bearing, time elapsed from injury, bone quality, and risk factors for healing. while radiographic imaging is the gold standard when fractures are suspected, examination findings by an athletic trainer can play an important role in identification and triage. abstract presentation 69 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 treatment and management of complex knee injury: a case report braunreiter k*, kerwin s† *houston methodist sugar land orthopedics & sports medicine, sugar land, tx, †fort bend austin high school, richmond, tx background: the “unhappy triad” injury includes tears of the anterior cruciate ligament, medial collateral ligament, and medial meniscus. there is limited research on the prevalence and outcome of this injury. the unique surgical repair consisting of lateral extra-articular tenodesis (let) was utilized to reinforce the anterior cruciate ligament repair (aclr) and to prevent rerupture. due to this extensive surgery, the patient struggled to regain full range of motion and quadriceps activation. this case is a level 2 case study that explores the different interventions used to address the aforementioned objective deficits and return him safely to play. patient: the patient is an 18-yearold male soccer player that presents to physical therapy and the athletic training room for postoperative rehabilitation after aclr, let, mcl repair, and medial meniscus repair. the initial injury was non-contact and occurred while playing soccer; he reports planting his left leg and feeling his knee shift. he denies feeling or hearing a pop. swelling in the knee was present and he was unable to continue playing. upon examination, the knee was not tender to palpation, loss of range of motion was not significant, and valgus and varus stress tests were negative; lachman’s was positive. differential diagnosis: the differential diagnosis of this injury was acl tear with mcl and medial meniscus involvement; and acl tear with concomitant chondral injury. the physician’s assessment, including mri imaging, revealed a torn acl with mcl sprain and medial meniscus tear. treatment: surgical repair was performed 2.5 weeks after the initial injury and consisted of bone-patellar tendon-bone acl reconstruction with lateral extra-articular tenodesis, mcl and medial meniscus repairs. the patient began physical therapy 2 days post-op with treatment consisting of manual techniques to target range of motion and blood flow restriction to promote quadriceps strength and hypertrophy. due to weight-bearing precautions, the alter-g machine was utilized to aid in gait training. according to an aclr study, the knee should have full range of motion at week 6. the patient still lacked 43 degrees at week 6. outcomes: there are no specific guidelines for return to play after an aclr, let, mcl repair, and medial meniscus repair, therefore, a unique treatment plan was created by the treating physical therapist and athletic trainer to meet the patient’s needs. the patient achieved full extension and continues to lack 5 degrees of flexion at 7 months. conclusions: the complexity of the surgical repair and the patient's response to the interventions created challenges. recommendations for clinical practice include implementing early interventions of blood flow restriction to inhibit muscle atrophy, alter-g to initiate early gait training and more manual techniques to improve range of motion. clinical bottom line: this case stresses the importance of involving the entire medical team (physician, athletic trainer, physical therapist) in the care of the patient as well as the ability to find ways to be creative with rehabilitation when there are protocols inhibiting traditional interventions. abstract presentation 70 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 evaluation and treatment of the water-polo player with anterior glenohumeral instability zimmerman m houston methodist willowbrook hospital, houston, tx background: glenohumeral (gh) instability is a common shoulder condition with a range of characteristics from laxity within the gh joint to complete dislocation of the humerus. the gh joint is held in place by static and dynamic stabilizers that need to be functioning appropriately to center the humerus in the glenoid fossa. acquired shoulder instability is defined as chronic stress of the humerus in an externally rotated and abducted position on the shoulder joint from repetitive overhead (oh) sports causing anterior instability of the shoulder. diagnosing shoulder instability is reliant on the patient’s history and physical examination findings during testing. using a combination of anterior apprehension, relocation, sulcus sign, and load and shift tests are recommended in the clinical examination to effectively diagnose gh instability. current evidence treating non-operative shoulder instability starts with restoring rom with the use of mobilization techniques, followed by strengthening exercises targeting the serratus anterior (sa), rhomboids, deltoids, and rotator cuff to improve overall stability. the purpose of this case is to show that manual therapy followed by specific therapeutic exercise is effective in treating acquired anterior shoulder instability in an adolescent water polo player. patient: the subject is a seventeen-year-old female water polo player who has been suffering from left shoulder pain for two months. her pain is intermittent throughout the day but worsens with swimming and the late cocking phase of her throw. she has no specific mechanism of injury (moi). she rated her pain a dull and achy 5/10 at rest and a sharp 9/10 pain while throwing during practice. her pain starts on the anterior aspect of the shoulder at rest and moves to the superior/posterior aspect during movement. she complains about neck stiffness with any movement along with shoulder pain. she reported no radiating symptoms down her back or arm. she reported no popping or clicking within the shoulder. she was unable to sleep on the left side and is frequently woken up due to the pain. her goal for treatment is to learn how to manage her pain if the pain comes back after being treated. she also wants to be able to practice and participate in games pain-free. treatment: treatment consisted of manual intervention and therapeutic exercise throughout four sessions. manual techniques performed included: soft tissue stripping of the pectoralis (pec) minor, lattisimus dorsi (lats), upper trapezius (traps), and subscapularis (subscap), inferior and posterior mobilization gh mobilizations, thoracic gapping and manipulations. the goals of manual therapy was to improve the patient’s rom and postural deficits. the posterior mobilizations were used to increase flexion and internal rotation while the inferior mobilizations were utilized to increase abduction and flexion at 0-60 degrees. therapeutic exercises targeting thoracic mobility, internal and external rotation. while strengthening and stability exercises were aimed towards the rotator cuff, deltoid, serratus anterior, and rhomboids. outcomes: by the end of all four sessions every deficit was addressed. she has been able to fully participate in practices and games completely without pain. her functionality score progressed from a 49% to a 96.3% in two weeks. all the patient’s goals were completed showing increased strength and stability within the gh joint. conclusion during the four-session rehabilitation program, this case showed that acquired anterior gh instability can be treated with the previous techniques to increase stability within the dynamic stabilizers of the gh joint. clinical bottom line: the results shown in this case of a water-polo player with acquired anterior gh instability showed that manual therapy and abstract presentation 71 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 specific exercise can efficiently treat acquired instability with only four visits. diagnosis and intervention of posterior shoulder impingement in a non-throwing athlete orrick k houston methodist willowbrook hospital, houston, tx background: posterior impingement, also commonly called internal impingement, is identified by a repetitive compression of the posterosuperior aspect of the glenoid by the greater tuberosity of the humeral head when the arm is in an abducted and externally rotated position. there are multiple possible causes of this impingement. one of the most frequent contributors is scapular dyskinesis, where the scapula does not track properly with overhead movement due to weakness. other contributors include kinetic chain instabilities found in the spine, core, and lower extremity, as well as glenohumeral instability causing a shift in the humeral head. posterior impingement is commonly seen in upper extremity athletes during the late cocking and early acceleration phase of throwing, however this level two case report looks at the dysfunction in the less commonly occurring sport of volleyball. patient: the patient is a fifteen-year-old female volleyball athlete that came to the athletic training facility complaining of left posterior shoulder pain. she has been playing the sport for 2 years, and claims the pain started around two years ago. at the time of evaluation the patient was in the off-season and was preparing to play in the upcoming season. the patient reported moderate pain at rest which increased to major pain while performing overhead movement. her most recent season saw the greatest increase in pain, and the athlete attributed it to an increase in hitting and serving. the patient reported frequent popping in the shoulder, but no pain accompanied it. with passive movement, the patient had pain at end range in external and internal rotation, and actively had pain with flexion and abduction twenty degrees before end range. patient presented as well was a lack of scapular upward rotation during shoulder movement, and the patient reported no pain with flexion when assisted with scapular upward rotation. a load and shift test presented with a grade 2 on the involved side. the posterior impingement test was performed and found to be positive. this led to a diagnosis of posterior shoulder impingement, caused by scapular dyskinesis and glenohumeral instability. treatment: treatment was focused on improving glenohumeral stability and activating the upward rotators of the scapula to improve the dyskinesis. initially, manual therapy was used to mobilize the scapula into upward rotation and decrease tension in the latissimus dorsi and upper trapezius. therapeutic exercise consisted of strengthening of the upward rotators, focusing on functional positions and overhead activities to mimic athletic play. glenohumeral stability was improved through closed kinetic chain exercises for the shoulder. with the patient being a volleyball athlete, a larger importance was placed on overhead stability with the elbow in near full extension when compared to the typical throwing athlete with posterior impingement. outcomes: the patient progressed well, with manual and exercise therapy interventions improving the patient back to pain free active daily living. rehabilitation is still ongoing to return to a competitive level, however sport specific activity has been performed by the athlete pain free for short amounts of time. conclusions: overall the patient’s progression was in line with current research, however modifications to rehabilitation needed to be made to fit the athlete’s sport. research for posterior impingement is centered on throwing athletes, and does not take into account the different demands of volleyball. while the patient herself did not have an atypical presentation, her sport called for an atypical approach when forming a rehabilitation plan based on current research. this approach placed a greater emphasis on stabilization in overhead activities, especially in situations where power is needed to generate the force for serving and hitting. abstract presentation 72 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 2 – september 2021 cervical kyphosis in a collegiate baseball player trail le*, warner bj†‡, gallegos dm§ ‡university of north carolina greensboro, greensboro, nc; §university of texas at tyler, tyler, tx background: a 21-year-old collegiate baseball player reported to the athletic training staff complaining of pain along the superior angle of the scapula, decreased shoulder range of motion, and transient numbness and tingling in the 4th and 5th digits of his right hand. physical evaluation revealed substantial spasm and rigidity of the upper trapezius and scapular stabilizer musculature, along with myofascial adhesions in the rhomboids and levator scapulae, in addition to weakness with shoulder abduction and external rotation. all thoracic outlet syndrome testing yielded no positive tests. thorough patient history revealed a history of shoulder arthroscopy the previous summer to address minor fraying of the rotator cuff after which the patient reported participating in minimal therapeutic exercise. at this time, the patient was advised to begin icing following every practice, along over the counter nsaids as directed. the patient was also instructed to begin therapeutic exercise on a daily basis with the athletic training staff. differential diagnosis: scapular dyskinesis, scar tissue following improper rehabilitation of shoulder arthroscopy, general deconditioning of the shoulder musculature. treatment: day 1, patient began therapeutic exercises with the athletic training staff aimed at addressing scapular stabilizer weakness and decreased shoulder range of motion. during exercise, patient reported increased pain along the superior angle of the scapula when performing shoulder abduction with dumbbells. this exercise was discontinued at this time while the remainder of the therapeutic exercise program was continued. day 2, patient reported that his shoulder and the surrounding musculature felt fatigued, but did not feel sore. following reevaluation, it was determined that the fatigue was a normal response to therapeutic exercise following deconditioning and exercise was continued. day 5, patient began seeing the team chiropractor during regular weekly clinics. evaluation from the team chiropractor confirmed both weakness and tightness of the shoulder musculature. at this time the patient was informed that they would be referred to the team physician if their symptoms worsened or did not significantly improve two weeks after the initial evaluation. day 9, patient reported worsening symptoms during practice. patient was then removed from team activities and scheduled to see the team physician. day 10, upon evaluation, the team physician concurred with the evaluation of poor scapular stabilizer strength while also diagnosing the patient with poor postural stabilization of the cervical spine. following the updated diagnosis, the patient’s therapeutic exercise plan was revised to address the new found weakness. day 14, during treatment at the team chiropractor’s office cervical spine x-rays were obtained that revealed cervical kyphosis. with this new finding, patient began undergoing dry needling and cupping treatments in an attempt to address tight anterior musculature while continuing to address weakness. day 21, patient continued current treatment plan, and presented with an increase in strength and range of motion. throughout the remainder of the season, the patient continued treatment and rehabilitation plan and was able to participate in practices and competitions with minimal symptoms. uniqueness: while cervical kyphosis is not a unique diagnosis in and of itself, the continued participation in competitive intercollegiate activity is noteworthy. furthermore, patients suffering from cervical kyphosis often require surgical intervention to be able to maintain quality of life. in this case, the patient was able to continue with activities of daily living through the utilization of conservative measures. conclusions: when treating a patient with an uncommon condition in their population, it is paramount that the clinician exhaust all resources to find proper treatment to address all associated pathologies. should a clinician be treating a condition they are unfamiliar with, evaluation and re-evaluation of outcomes is crucial for an optimal prognosis. manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 1 – february 2021 minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery toni m. torres-mcgehee, phd, scat, atc*; nancy a. uriegas, ms, scat, atc*; kenya moore, ms, scat, atc† *university of south carolina, sc, †columbia college, sc key phrases diversity, inclusion, equity, health disparities, patientcentered care correspondence dr. toni m. torres-mcgehee, university of south carolina, blatt pe center-exsc, columbia, sc 29208. e-mail: torresmc@mailbox.sc.edu twitter: @torres_mcgehee full citation torres-mcgehee tm, uriegas na, moore k. minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery. clin pract athl train. 2021;4(1): 1-7. https://doi.org/10.31622/2021/0004.1.1. submitted: january 23, 2021 accepted: february 11, 2021 editorial in the last 5 years, there have been lessons learned about our country. a lesson of history, in general, is that disunity poses a threat to healthcare; our general health is a product of the connections that we share as individuals and healthcare providers. the covid-19 pandemic has elevated the importance of these connections. this means we all need to work towards a collective vision of health and peace at all levels. this vision must be built on values of equity, mutual respect, openness, trust, and tolerance. to be successful, we must focus on creating communities that are welcoming to everyone, including those with perspectives that differ from our own. this requires us, as individuals and as a community, to rise above and set a clear example to our faculty, students, patients, and others of how a strong inclusive society operates, both professionally and personally, thus, enhancing our healthcare systems and patient-centered care for athletic training. specifically, perspectives from minoritized females as healthcare providers and educators are critical in understanding the challenges as well as the positive endeavors that make us successful in our roles. cultivating cultural proficiency through education: stories from a minoritized educator as a female mexican-american faculty member at a large public institution, i acknowledge that there are many challenges we face as minoritized female faculty members at a predominantly white institution. however, there are also positive experiences starting with the environment of your institution. a positive environment values diversity, equity, inclusion, and social justice and there is a support system in place for minoritized faculty, staff, and students. the location where your athletic training program is housed may impact the education and research opportunities for faculty and students. from personal experience, being housed in an accredited school of public health allows for minoritized faculty and our athletic training programs to prepare professional practitioners and scholars to best serve our communities and impact disease prevention through healthcare, public health education, and intervention. it also provides a platform for faculty and students to collaborate in interprofessional practice, education, and research with public health professionals and healthcare providers. these collaborations improve the lives of individuals, families, communities, and diverse populations through a variety of educational and research endeavors (e.g., health inequalities, children’s physical mailto:torresmc@mailbox.sc.edu https://doi.org/10.31622/2021/0004.1.1 minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 activity, community health workers, latino immigration studies, disability research, global health, speech and hearing, nutrition, exercise, rural and minority health). it is our mission to work closely with the communities that we serve to provide the best patient-centered care to our underserved populations. through our work (i.e., teaching, research, and service) and patient care we have an opportunity to advocate for making an impact on changing socioeconomic marginalization, disparities in healthcare, and racial injustice. we do this by educating our students on the diversity, equity, inclusion, and the concepts of cultural competence and cultural humility. these are all critical components of patient-centered care. diversity in medical education signifies inclusiveness, mutual respect, and multiple perspectives and serves as a mechanism for change resulting in health equity.1 in this context, diversity includes all aspects of human differences such as race, ethnicity, religion, national origin, age, marital status, disabilities, sexual orientation, gender, gender identity and expression, and socioeconomic status. inclusion can be achieved by fostering an understanding of culture and climate of your organization or within patient care settings. culture competence highlights the demand for health care system and providers to be aware of and responsive to patient’s cultural perspectives and backgrounds;2 and requires healthcare providers to appreciate and respect the patient’s individual viewpoints. cultural competency also encourages awareness of health disparities and discrimination, which is a skill that can be taught, trained, and achieved and is often described as essential for working effectively with diverse patients to improve access to healthcare, increase health literacy, improve health care quality, and promote health equity.3-5 cultural humility is often confused with cultural competence; these terms are defined independent of each other but can be used at the same time. for example, cultural humility involves entering a relationship with another person with intentions of honoring their beliefs, customs, and values.2 this is an on-going process of self-reflection and self-critique, combined with the willingness to learn from others and addressing power imbalances and avoidance of stereotyping. when we merge these two concepts, this allows for a more meaningful connection with each patient as a unique individual, with diverse perspectives, culture, and lifestyles. this concept was coined cultural competemility,3 which is a synergistic process between cultural humility and cultural competence in which cultural humility permeates each of the five components of cultural competence: cultural awareness, cultural knowledge, cultural skill, cultural desire, and cultural encounters.3 faculty, students, and practitioners must be cognizant of these concepts and how they all intersect with patient-centered care, student-centered learning, and research collaborations. our healthcare system is professionally driven toward patient-centered care, which incorporates an individual’s perspective and more involvement in his/her/their care results in better health outcomes and satisfaction.6 however, it is important to note there are certain populations such as low-income individuals, uninsured persons, immigrants, racial and ethnic minorities, veterans, the disabled, and the elderly who are typically underserved by the health system. thus, in turn, facing greater barriers to patient-centered care. to best tackle these challenges, it is critical to collaborate outside your organization and develop community partners. a goal of our program is to expose our faculty, postprofessional athletic trainers, and professional athletic training students to a variety of patient populations and settings (i.e., historically black colleges and universities, private colleges, public colleges/universities, private and public high schools, rural private and public high schools, and inner-city schools). minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 to be successful in these environments, it is critical to prepare young professionals prior to their clinical placements and provide on-going mentoring while they are providing patient care. often young professionals are not aware of the social determinants of health in the population that they work with. therefore, preparation begins with onboarding activities to include but are not limited to reviewing issues of diversity, equity, inclusion, social justice, how to become culturally proficient; ways to combat racism, and identify social determinants of health, healthcare, and health disparities within the community the serve. it is recommended, administrators integrate an activity during onboarding related to the clinician/student conducting thorough assessment on the community/city they serve (table 1). with most of our students being from out-of-state, this not only allows them to familiarize themselves with the community/city, but also allows them to identify social determinants of health, potential resources, community collaborations and identify other healthcare practitioners to engage in interprofessional practice. this may also be conducted in a field trip manner.7 developing relationships with community partners allows for the integration of best practices with patient care and opens opportunities for research between clinicians, faculty, and marginalized communities. building trust and mutual respect with these communities, allows for ethical recruitment of marginalized or vulnerable groups. in turn, this allows successful research in the identification of patient health care needs for each population and organization. toni m. torres-mcgehee, phd, scat, atc patient care perspectives in the clinical setting as a black woman in health care, i have been on the receiving end of the negative preconceived notions, discrimination, and microaggressions that table 1: exploring the community you serve 1. identify community/city population and distribution of race/ethnicity 2. identify community/city cost of living 3. identify community/city average household income 4. familiarize yourself with surrounding neighborhoods, parks, and shopping areas 5. familiarize yourself with public transportation 6. identify types of community/city health services (e.g., financial support, communication resources such as speech and language services, behavioral resources, sensory and motor services, social and recreational services, family support services, school services, research opportunities, etc.) 7. identify health care facilities (e.g., hospitals, clinics, urgent care, veteran services, dentists, optometrist, physical therapy, occupational therapy, disability services, specialty clinics, social work, counselors, etc.) 8. identify current community/city social determinants of health data (e.g., social and community, neighborhoods/environment, demographics, educational attainment, economics, insurance coverage, health status – disabilities, heart disease, chronic disease, etc.) 9. identify the location of public library 10. identify communities of faith (religious facilities) 11. identify locations of private and public schools 12. identify cultural events in the community/city are projected onto minoritized populations. as humans we all wrongly assume things about those we do not know or understand. however, for too long the distorted images of people of color and minoritized persons that stem from racism and stereotypes, have been supported not only by individuals but also by institutions like our government, educational system, healthcare, and workplace. within these institutions, we find that minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 4 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 policies and laws, were by design, created to exclude. systemic oppression creates barriers that are often covert, and inherently carry negative messages to minoritized persons about our “place” in society and what is or is not accessible to us. i recall stories from my parents about their experiences as children. enduring everything from racial slurs to the struggles of segregation and integration. because i was surrounded by a loving community and such a rich culture, my eyes were often blind to some of those racial tensions. but as a high school student my heart filled with many emotions as i marched for the first time to protest the murder of trayvon martin, a murder that that took place near my home in a neighborhood i had been several times to visit with family friends. fast forwarding to 2020, and our country's issues with police brutality towards people of color are still high. it is a very sad reality that some believe lives like mine are expendable or do not matter enough. these physical, emotional, and psychological traumas add to the subliminal messages that ring through society about race. i have experienced times of being racially profiled in stores, and as a college student even been asked where i learned to speak and if there were others like me where i come from. being categorized as “exceptional for a black student,” was concerning as to suggest students of color are not bright, articulate students. the stigma of having to “work twice as hard” just to be on a level playing field seemed all too true. usually being one of few students of color in my academic spaces illuminated the impression that i had to carry my culture alone. it highlighted this misconception, that what i do or how i perform will positively or negatively affect the way that others like myself would be perceived and accepted in those spaces. and while one's presence may aid in opening the door for those to come, minoritized persons certainly have the weight of feeling the pressure to succeed. for success was not only for one’s self, but for others as well. as a clinician today, i recognize how those feelings and encounters i faced have led me to be more mindful in the way i practice and interact with my patients. i began working at a low socioeconomic school in south carolina, where most of the student-athletes were black. although i felt i could relate to the students i did not want to assume that i knew them. i did not want to take for granted that i knew their story, what their home life was like, nor what their passions were, or what they valued in life. i was intentional about being visible in the school, getting to know not only the athletes and coaches, but also people like the custodians, nurses, bookkeeper, receptionist, parents, and campus police. establishing those relationships allowed me to better understand the overall culture, and advocate for the student athlete’s health. i often verbalized my treatment plans and involved both the student, parent/guardian, team physician and coaches into the plan of care. i explained why i did something and made room for them to ask questions regarding their own health and progress. i consistently led with openness and transparency, as i wanted each student to feel like they were involved in what was happening to them. if i could, i would accompany students when seeing our collaborating physician to help them feel at ease because for many of them doctors represented people who were just there to capitalize on their pain and provide services they could not afford. i tried to take my time to dismantle the social disparities in health care experienced by my population. and while it was not my role to solve every issue in my time there, my efforts helped set the standard for what those student athletes now expected from health care professionals and improved the care that was available to them. regardless of the setting, becoming more aware of the patient population aids in establishing appropriate relationships with those we serve. this ultimately helps guide the process of decisionmaking that considers and respects their beliefs, minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 values, language, and traditions. it has caused me to even evaluate what i tolerate as acceptable behavior and speech in the athletic training facilities. as one who is both ethnically diverse and a healthcare provider in athletic training, i recognize the influence i have in igniting change where i am. i have experienced firsthand the benefits and power of representation, mentorship, and leadership from minoritized athletic trainers as well as the benefits of diversity regarding collaboration and innovation. when we think about research and how it leads the way in creating the standards of how we care for our patients, overlooking the importance of diversity, even here, can be detrimental. most research in the realm of athletic training does not currently reflect such inclusion, having shown to provide gaps in applicability. as clinicians we talk about evidence-based practice and integrating available research, merging that with clinical knowledge. this should include efforts in both addressing a lack of diversity amongst research participants involved, as well as research that gains the perspectives of diverse certified and athletic training students. it may be easier said than done to operate in a way where we are proficient in interacting with those across an array of backgrounds. so, how do we transition from just merely having a “one size fits all” mentality in our care to one that is a lot more progressive and considerate of our patient’s needs, background, health concerns, health beliefs, and values? historically, there have been many systemic barriers that exist for minoritized persons pertaining to health care, along with other racial disparities that perpetuate discrimination and stereotypes. we must learn to come from a place of empathy and compassion with a desire to understand our patients. additionally, there must be acknowledgment of any biases that hinder us from effectively treating others or that cause us to treat one group different from another. these steps are key to change from the inside out. it will take a willingness to be uncomfortable, as there is always difficulty with having to realize biases thoughts and feelings that sit within the subconscious mind. kenya moore ms, scat, atc blending cultures within patientcare settings through my academic and professional career, i have been an athletic training student, an undergraduate teaching assistant, a secondary school athletic trainer, a performing arts athletic trainer, a military athletic trainer, a doctoral research and teaching assistant and in each setting – a minoritized person. twenty years ago, if you were to ask my parents what they expected of their children regarding education, they would both state, and i translate: “to accomplish more than i did.” i am the daughter of two mexican born and raced individuals, one whom completed 4th grade and the other not much further, 6th grade. the resources were so limited that they had one classroom and one teacher to teach students regardless of their grade level or age; and where 6th grade was the highest level of education you could attain. living there, never did high school cross their minds, and let us not even mention college, because odds are, they had no idea what that was or how to even get there. if asked that same question ten years ago and knowing what a college education meant, that was the new expectation; an expectation soon to be met by all five children of a meagerly educated mexican couple. in 2015, i became a 1st generation college graduate; that same year my oldest sister and brother received their master’s degree. it did not stop there; today i am a second year phd student and scholar in the making. following my education and clinical rotations at an institution with many resources available at hand, i began my journey as a clinician in the same minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 community i came from a predominately spanish speaking and low-income city on the mexican border. health literacy is extremely low and often i found myself translating orthopedic or concussion associated terminology to patients and parents, which is quite difficult for anyone who went through an english-only curriculum, even when spanish is your first language, and you speak it daily. information always had to be simplified, and though difficult, i was comfortable; i was around those that looked like me, talked like me, and shared the same culture and values as me. the students could reflect on me and i could reflect on them. i was once in their shoes and the concerned parents reminded me of my own mother driving me to urgent care to get an x-ray because that is what you do when your ankle looks like a balloon, right? it was here i learned the importance of patient education, whether that was in english or in spanish. i learned to have open discussions about their injuries, their goals, their accessibility to care and medical insurance, and what the best plan of care and treatment would be for them. it was here i learned to be patient centered, around the same community i grew up in, around the same struggles i, as a patient, faced. i transitioned to practice across the country in a small rural high school in st. matthews, south carolina, where the state’s hispanic or latino population is less than 6%. i was an outsider; my patients constantly asked if i played soccer growing up, because “that is the only sport the hispanic kids play here.” as much of an outsider as i was, there were some things that remained the same—my work was in the best interest of my patients and their well-being. i was now in a predominately black school, coaches were predominately white males, and the community was close knit; i was no longer in my comfort zone. head coaches constantly questioned and undermined me, parents always asked where i was from; people around me said i spoke “funny.” one of my biggest challenges was being told i was not a doctor and my medical opinion did not count compared to that of a nurse practitioner who signed a clearance note. once again, education was my most powerful tool. i do not think coaches ever expected a female athletic trainer to hold her ground, as i did; and to make it known that my number one priority was the health of the patients. all the patients had different upbringings from mine, but in some ways so similar. i submerged myself into the community there too, i made it known that my job was not 2-7pm and that where i came from did not mean i did not understand what they were going through. the greatest appreciation came from parents; i gained their trust simply through education and patientcentered care. we learned about each other in the process; we respected our diverse backgrounds and adapted to what their needs were. when the resources were not available, i went out of my way collaborating with our collaborating physician and orthopedic network to provide as much as we could for them. what goes unnoticed in these settings is the power of research, constant self-assessment, and patientreported outcome measures. to bring change and more resources, others must see the value of our work. lastly, a few things we always kept in mind: an open-door always meant you were welcomed in, respect was reciprocated and practiced daily, and patient care and goals were the priority. i learned that the patient-clinician rapport can only evolve with continuous communication, trust is earned, and happiness in the workplace is not dependent on the resources available but network you build in the community. nancy a. uriegas ms, scat, atc summary our experiences are diverse and unique in their own way. however, all three of us have faced similar challenges as minoritized female clinicians and educators. we have also seen the challenges minoritized females in athletic training: educator and clinician perspective on exploring barriers to healthcare delivery 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 1 – february 2021 faced by our diverse patients and students. we as an athletic training profession, should promote and practice diversity, equity, inclusion, and social justice across our settings. we must come together, rise above, and lead by example and this begins with providing opportunities of education, research, and patient-centered care equally across our communities. let us all take a step back, evaluate where we are, who we serve, and how we can improve in the best interest of those around us. references 1. nivet ma, castillo-page l, schoolcraft conrad s. a diversity and inclusion framework for medical education. acad med. 2016;91(7):1031. 2. betancourt jr, green ar, carrilo je. cultural competence in health care: emerging frameworks and practical approaches. 2002. https://www.commonwealthfund.org/sites/d efault/files/documents/___media_files_publ ications_fund_report_2002_oct_cultural_com petence_in_health_care__emerging_framew orks_and_practical_approaches_betancourt _culturalcompetence_576_pdf.pdf. 3. campinha-bacote j. cultural competemility: a paradigm shift in the cultural competence versus cultural humility debate, part i. online j issues nurs. 2019;24(1). 4. powell dl. social determinants of health: cultural competence is not enough. creat nurs. 2018;24(1):5-10. 5. wong wf, laveist ta, sharfstein jm. achieving health equity by design. jama. 2015;313(14):1417-1418. 6. rathert c, wyrwich md, boren sa. patientcentered care and outcomes: a systematic review of the literature. med care res rev. 2013;70(4):351-379. 7. chang ay, bass tl, duwell m, et al. the impact of “see the city you serve” field trip: an educational tool for teaching social determinants of health. j grad med educ 2017;9(1):118-122. https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2002_oct_cultural_competence_in_health_care__emerging_frameworks_and_practical_approaches_betancourt_culturalcompetence_576_pdf.pdf manuscript type patient-centered care commentary 65 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 providing athletic training resources to deaf and hard-of-hearing persons molly m. osborn, ms, lat, atc*; courtney m. meyer ms, scat, atc‡; zachary k. winkelmann, phd, scat, atc, chse‡ *florida international university, miami, fl; ‡university of south carolina, columbia, sc correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation osborn mm, meyer cm, winkelmann zk. providing athletic training resources to deaf and hard-of-hearing persons. clin pract athl train. 2023;6(2): 65-70. https://doi.org/10.31622/2023/0006.02.11. introduction athletic trainers are responsible for the care and health of active individuals in various settings, leading them to interact with diverse patient populations characterized by unique personal backgrounds, socioeconomic status, culture, physical ability, and medical disabilities. the people often overlooked in the realm of sports and recreation is the deaf community. approximately nine percent of the total world population is a member of the deaf or hard of hearing community (see table 1 for definition).1 some deaf athletes have other comorbidities; for example, approximately 1 in 4 special olympic athletes with intellectual disabilities have failed a hearing screening.2 on the other hand, many deaf individuals often have no other bodily disorder or condition requiring the removal from regular sports participation or athletic competition. many high-profile deaf athletes have shared their stories and advocated for the acceptance of their fellow deaf or hard of hearing athletes. several national football league players, like bonnie sloan, larry brown, kenny walker, flozell adams, and derrick coleman, either acquired deafness slowly throughout their careers or were deaf before successful participation in the league.3 with the increase in participation and the necessity of equitable medical care among all athletes, athletic trainers need additional education, resources, and support to assist deaf athletes when they experience an injury or illness during their athletic participation. table 1. deaf terminology4 deaf refers to a person with complete or profound hearing loss; the capital d is often used to describe the community or culture. deaf refers to the medical condition of having complete or near complete hearing loss hard of hearing refers to a person who has mild or moderate hearing loss hearing impaired refers to any degree of hearing loss barriers to care one significant barrier to deaf athletes' sports participation is their ability to seek medical care like their peers. communicating with patients is a large part of patient education and honoring a patient’s beliefs, experiences, and wishes in a patient-centered care model. healthcare providers should facilitate the care of deaf athletes, empowering their ability to choose their healthcare options.5 interpreters that were interviewed as part of a previous study made statements like, “many patients just don’t even know their communication rights. so on top of feeling disempowered, they may not even know what they can mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.02.11 providing athletic training resources to deaf and hard of hearing persons 66 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 advocate for”.6 without proper modes of communication, misdiagnosis or medical errors are more likely to occur. therefore, deaf individuals are more at risk than hearing individuals for misdiagnosis, misunderstanding, and coercive medical care.1 while there is a lack of data relating to communication with and the care of deaf patients in athletic training, studies have been conducted on communication barriers in other healthcare settings. during a study on issues related to providing care for deaf individuals who use american sign language (asl), nurse practitioners noted three critical levels at which barriers occurred (intrapersonal, interpersonal, and organizational).5 barriers across each of these levels included language barriers/not knowing asl, lack of access/presence of an interpreter, little experience with deaf individuals, and a lack of means to communicate with deaf individuals.5 only a small portion of healthcare professionals are fluent in asl or know basic terms, thus creating a communication gap between providers and patients.5 similar barriers exist in the athletic environment and undoubtedly pose an equally impactful barrier to medical care. previous research identified that while healthcare providers recognize the role of interpreters as a facilitator of reasonable care, they did feel that using an interpreter was a “…last resort when all other means of communication failed.”5 while it may be new and uncomfortable for the provider, interpreters are essential healthcare team members when the patient and provider use different languages for their primary communication. in the absence of a formal interpreter, a family member may be available for ease of communication. however, using a patient-centered approach may pose a threat to unbiased patient education. the parent, sibling, spouse, or other family member may intentionally or unintentionally bias the information or patient responses due to personal beliefs or biases about the medical care. for this reason, the most reliable method of communication in the absence of a hired interpreter may be to write down important information and consent for all procedures. a final barrier addressed by the nurse practitioners in the study was the rarity of deaf patients in their practice.5 with any situation, familiarity with procedures and resources and comfort level with different cases increases with regular review and use. since many healthcare providers do not encounter deaf patients regularly, they do not have this in routine practice. interpreters as a member of the medical team in the absence of a healthcare provider trained in medical asl, interpreters are the gold standard of medical care. the healthcare provider must recognize the value interpreters bring to their practice and the care team.7 the americans with disabilities act (ada) describe situations where an interpreter may be necessary to ensure effective healthcare communication.8 these situations include obtaining consent for treatment, taking a medical history, explaining therapeutic interventions and procedures, and providing a diagnosis.8 in a study by chatzidamianos et al., researchers interviewed asl interpreters in the mental health setting.9 they found that the triangle of care between the patient, interpreter, and healthcare provider was the most important theme in caring for a deaf patient.9 as deaf individuals do not communicate verbally, their non-verbal cues and body language are, by necessity, more important and more prominent. asl interpreters are responsible for conveying not only the signed words but also the patient's non-verbal emotional cues.7,9 it is important when using an interpreter to continue conversing with the patient as if the interpreter is not there and mainly speaking with the interpreter to provide clarifying information.1 maintaining eye contact with the patient and allowing them to read any facial expressions or body language is important to building trust with them.7 it is also important to avoid using third-person language or having side conversations with the interpreter during the appointment.7 if needed, a postencounter debrief can be scheduled with the interpreter to improve communication or further explain concepts.7 providing athletic training resources to deaf and hard of hearing persons 67 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 consistent use of a single interpreter may be important in ensuring all relevant information is communicated in both directions. this also builds the trust essential for the foundation of the triangle of care. without trust created between all three team members, trust cannot exist between any two members.9 as healthcare providers, athletic trainers can integrate this triangle of care by building a relationship with interpreters within the community before working with deaf patients. whether that is through accessibility resource offices, community resources, or private interpreter services, athletic trainers should build relationships with asl interpreters before the need for their services. this can help develop that triangle of care with the patient more quickly by already having one strong side in the triangle. other strategies to improve care another option for increasing the efficiency and availability of health care for deaf individuals has emerged and gained prevalence in recent years: telemedicine. telemedicine allows the provider, interpreter, and patient to access the appointments remotely.10 this option allows athletic trainers in rural areas to access care for their deaf patients if their area does not have any medical interpreter for asl. telemedicine systems designed for the triangle of care have been deemed acceptable for healthcare use on simulated patient interactions for most medical appointments.10 also, if an interpreter is unavailable for an appointment, many telemedicine modalities have closed captioning functions. however, it should be noted that the closed captioning function is imperfect due to errors in the software captions, lack of ability to interpret non-verbal cues, and unreliability of the technology. telemedicine can offer a low-cost alternative to schedule appointments with an interpreter on the call, even if the appointment is last minute.11 patient education via brochures, pamphlets, and printed materials about their appointment, health conditions, or treatments should be incorporated to ensure continuity of care and informed decisionmaking.12 when choosing effective patient education strategies, athletic trainers must consider each patient's means, access, resources, and goals. some individuals respond better to spoken word versus written materials, making presentations, podcasts, videos, and peer-to-peer discussion a more effective pathway for information and education. however, written communication is one of the most accessible ways to convey medical information without an interpreter present for deaf patients. it can represent a way to clarify any words that are not translated well through asl, even with the help of a medical interpreter.1 special care should be given to providing deaf athletes with an encounter note reviewing everything covered in their appointment and whom to contact with questions. in a blog post by an asl using deaf individual,1 she outlines many small things healthcare providers can do to provide a better patient experience. one simple thing to do that hearing people only sometimes consider is getting their attention before signing, speaking, writing, or performing any examination or treatment.1 deaf people cannot orient to sound the way hearing people do, so healthcare providers should tap the arm or flicker lights to alert them to you. it is also important to face them directly and not stand straight in front of the light source.1 this will allow the deaf person to see and interpret the provider's body language and facial expressions, whereas a hearing person may focus on speech tone instead. some deaf individuals are proficient in reading lips, so wearing a mask will inhibit communication in these situations. see table 2 for more communication practices to incorporate in patient care. it is important to note that most deaf persons cannot proficiently lip read, so assuming that you will be able to communicate this way with ease is inappropriate.1 even in ideal situations, lip reading only yields 30-40% understanding, so its use as the sole method of communication should be discouraged.11 additionally, provider time constraints and rushing appointments have been described as barriers to proper communication and patient education when an interpreter is absent.6 prior to the appointment or providing providing athletic training resources to deaf and hard of hearing persons 68 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 athletic training services, a conversation about the preferred method of communication and the patient's need for additional resources should occur. medical interpreters, including those fluent in asl, are legally required to be available if requested by a patient under the ada.13 while not all patients will elect to have a medical interpreter present, it is essential to establish relationships with community partners in advance to ensure access to these resources should they be needed. if an emergent situation arises and an interpreter is not readily available, athletic trainers should implement strategies for communicating with deaf or hard-of-hearing individual. table 3 provides recommendations for resources for the provider to learn more about. table 2. best practices in communication14 positioning avoid standing in front of bright light. the face should be visible. speech speak at a typical speed. refrain from over-enunciating. verbalize one idea at a time. ask only one question at a time. non-verbal cues maintain eye contact. use typical facial expressions to guide ideas. introduce the patient to the location of information being discussed on any visual aids by pointing. environment avoid discussions in areas with visual distractions. conclusions deaf individuals are members of physically active populations that athletic trainers work with regularly. athletic trainers should work with these individuals to provide thorough care while allowing them the same autonomy as hearing patients. interpreters provide a great resource in healthcare and function as a part of the healthcare team, just as many other professions do. for this reason, athletic trainers should seek out asl interpreters before requiring their services and build a professional relationship. in addition, written notes explaining their diagnoses, options, and current treatment should be provided. overall, extra care should be taken to incorporate any accommodations deaf athletes need to be satisfied with their medical care and ability to communicate with their healthcare provider. providing athletic training resources to deaf and hard of hearing persons 69 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 table 3. resources for athletic trainers resource hyperlink description price time commitment signing online15 this educational online course consists of 4 courses of 10 classes each. $300 total 24 months basic medical sign language16 this pamphlet teaches basic signs needed for communicating in a medical setting. free n/a language line telehealth interpreting17 this website provides on-demand medical interpreters $4.95 per minute must prepurchase package deaf athletes how to provide care podcast18 this is a podcast made by and for ats. in this episode, two ats who have experience with deaf or hard-of-hearing athletes answer questions and discuss care. free 1 hour 5 minutes handling relay service phone calls…19 this pamphlet has tips for using relay services via phone with patients who are deaf or hard of hearing. free n/a references 1. little kj. healthcare and the deaf: the healthcare experience from a deaf perspective. lifeprint. https://www.lifeprint.com/asl101/topics/healthcare_and_the_deaf02.htm. 2. hild u, hey c, baumann u, montgomery j, euler ha, neumann k. high prevalence of hearing disorders at the special olympics indicate need to screen persons with intellectual disability. j intellect disabil res. 2008;52(pt 6):520-528. https://doi.org/10.1111/j.1365-2788.2008.01059.x. 3. von büren j. 4 deaf nfl players you probably didn’t know about. hearing like me. may 16, 2019. https://www.hearinglikeme.com/4-deaf-nfl-players-you-probably-didnt-know-about/. 4. connecthear. the difference between d/deaf, hard of hearing and hearing-impaired. connecthear. august 18, 2020. accessed 2022. https://www.connecthear.org/post/the-difference-between-ddeaf-hard-of-hearing-and-hearing-impaired. 5. pendergrass km, nemeth l, newman sd, jenkins cm, jones eg. nurse practitioner perceptions of barriers and facilitators in providing health care for deaf american sign language users: a qualitative socio-ecological approach. j am assoc nurse pract. 2017;29(6):316-323. https://doi.org/10.1002/2327-6924.12461. 6. hommes re, borash ai, hartwig k, degracia d. american sign language interpreters perceptions of barriers to healthcare communication in deaf and hard of hearing patients. j community health. 2018;43(5):956-961. https://doi.org/10.1007/s10900-018-0511-3. 7. hadziabdic e, hjelm k. working with interpreters: practical advice for use of an interpreter in healthcare. int j evid based healthc. 2013;11(1):69-76. https://doi.org/10.1111/1744-1609.12005. 8. u.s. department of justice. communicating with people who are deaf or hard of hearing in hospital settings. ada business brief. https://www.ada.gov/hospcombrprt.pdf. accessed september 22, 2022. 9. chatzidamianos g, fletcher i, wedlock l, lever r. clinical communication and the 'triangle of care' in mental health and deafness: sign language interpreters' perspectives. patient educ couns. 2019;102(11):2010-2015. https://doi.org/10.1016/j.pec.2019.05.016. https://signingonline.com/ https://www.ellismedlibrary.org/uploads/9/1/9/0/91901496/asl.pdf https://www.ellismedlibrary.org/uploads/9/1/9/0/91901496/asl.pdf https://www.ellismedlibrary.org/uploads/9/1/9/0/91901496/asl.pdf https://www.languageline.com/ https://www.languageline.com/ https://www.languageline.com/ https://sportsmedicinebroadcast.com/caring-for-deaf-athletes/ https://sportsmedicinebroadcast.com/caring-for-deaf-athletes/ https://sportsmedicinebroadcast.com/caring-for-deaf-athletes/ https://www.ncdhhs.gov/media/10976/download https://www.ncdhhs.gov/media/10976/download https://www.ncdhhs.gov/media/10976/download https://www.lifeprint.com/asl101/topics/healthcare_and_the_deaf02.htm https://doi.org/10.1111/j.1365-2788.2008.01059.x https://www.hearinglikeme.com/4-deaf-nfl-players-you-probably-didnt-know-about/ https://www.connecthear.org/post/the-difference-between-d-deaf-hard-of-hearing-and-hearing-impaired https://www.connecthear.org/post/the-difference-between-d-deaf-hard-of-hearing-and-hearing-impaired https://doi.org/10.1002/2327-6924.12461 https://doi.org/10.1007/s10900-018-0511-3 https://doi.org/10.1111/1744-1609.12005 https://www.ada.gov/hospcombrprt.pdf https://doi.org/10.1016/j.pec.2019.05.016 providing athletic training resources to deaf and hard of hearing persons 70 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 10. hughes g, hudgins b, macdougall j. using telehealth technology to improve the delivery of health services to people who are deaf. paper presented at: the 26th annual international conference of the ieee engineering in medicine and biology society; 1-5 sept. 2004, 2004. http://dx.doi.org/10.1109/iembs.2004.1403871. 11. richardson kj. deaf culture: competencies and best practices. nurse prac. 2014;39(5). https://doi.org/10.1097/01.npr.0000445956.21045.c4. 12. bukstein da. patient adherence and effective communication. ann allergy asthma immunol. 2016;117(6):613-619. https://doi.org/10.1016/j.anai.2016.08.029. 13. essex-sorlie d. the americans with disabilities act: i. history, summary, and critical components. acad med. 1994;69(7):519-524. https://doi.org/10.1097/00001888-199407000-00001. 14. shuler gk, mistler la, torrey k, depukat r. bridging communication gaps with the deaf. nursing. 2022. 2013;43(11):24-30. https://doi.org/10.1097/01.nurse.0000435197.65529.cd. 15. online asl classes: learn sign language online. signing online. june 24, 2023. https://signingonline.com/. 16. services cdos, access ood. basic medical sign language. in: services sochahsados, ed. https://www.ellismedlibrary.org/uploads/9/1/9/0/91901496/asl.pdf 17. solutions l. language translation and interpreting services. languageline solutions. https://www.languageline.com/. 18. jackson j. deaf athletes – how to provide care. the sports medicine broadcast. 2021. accessed may 12, 2022. https://sportsmedicinebroadcast.com/caring-for-deafathletes/#:~:text=talking%20slower%20or%20louder%20does,have%20empathy!!!. 19. hearing dosftdaho. handling relay srice calls with patients that have hearing loss. in: services ncdohah, ed. www.ncdhhs.gov/dsdhh2020. http://dx.doi.org/10.1109/iembs.2004.1403871 https://doi.org/10.1097/01.npr.0000445956.21045.c4 https://doi.org/10.1016/j.anai.2016.08.029 https://doi.org/10.1097/00001888-199407000-00001 https://doi.org/10.1097/01.nurse.0000435197.65529.cd https://signingonline.com/ https://www.ellismedlibrary.org/uploads/9/1/9/0/91901496/asl.pdf https://www.languageline.com/ https://sportsmedicinebroadcast.com/caring-for-deaf-athletes/#:%7e:text=talking%20slower%20or%20louder%20does,have%20empathy https://sportsmedicinebroadcast.com/caring-for-deaf-athletes/#:%7e:text=talking%20slower%20or%20louder%20does,have%20empathy http://www.ncdhhs.gov/dsdhh2020 manuscript type abstract presentation 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 southwest athletic trainers’ association free communications abstract presentations the following abstracts were accepted and presented at the 68th southwest athletic trainers’ association (swata) symposium, 2022. critically appraised topic suspension training as an effective intervention to improve core stability: a critically appraised topic stiltner s, boham m, melrose d: texas a&m university-corpus christi, corpus christi, texas clinical scenario: the core is a functional unit connecting the upper and lower extremities consisting of abdominal, back, and hip musculature. core stability is a determining factor in patient motor performance and provides optimal force production and precision of movement. a highly functional core is essential in injury prevention and rehabilitation. traditional means of core stability training are performed on a stable surface. emerging research suggests patients may benefit from core stability training on unstable mediums such as is used with suspension training. clinical question: does suspension training improve core activity in an active population? search strategy: key words used to guide the search were core strength or core stability and suspension training, unstable surface and strength. inclusion criteria included articles published in or after 2017, manuscripts that explored suspension training and core stability, strength, endurance, and were completed using an active adult population. manuscripts were excluded if they were published prior to 2017, did not assess pre and post measurements, and were completed on a sedentary or injured population. data bases searched included ebsco host, sportdiscus, and pubmed. search results: overall 11 articles were collected and appraised to determine relevance to answering the clinical question. evidence was appraised by three researchers using the oxford centre for evidence-based medicine level of evidence criteria and the pedro scale to determine validity of evidence. evidence at a level 1b or higher and a pedro score of 5 or higher were included. best evidence: in total, two relevant studies emerged to meet inclusion criteria. these studies utilized suspension training or trx to facilitate activation of the core musculature. all three studies met level 1b criteria of the cebm. clinical bottom line: evidence suggests improvement to core strength, endurance, and stability can be achieved with the inclusion of suspension training. suspension exercises of push-up, inverted row, bridge, and planks show greatest activation of core musculature. a 6 month program of incorporating suspension training in addition to a routine program shows most beneficial. this evidence combined suggests suspension training is an effective tool in improving core activity. further, evidence to identify the lasting benefits of suspension training to train core activity is inconclusive and should be continued. strength of recommendation: grade b evidence exists that suspension training is an effective intervention to improve core activity in an active population. abstract presentation 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research a perfect storm?: the association of vitamin d with injury prevalence among acrobatics & tumbling athletes lee k, gallucci a, funderburk l, cherpe de souza l, irvin l, boyer e: baylor university waco, tx context: acrobatics and tumbling (a&t) was recently placed on the ncaa’s emerging sports list. due to the novelty of the sport, limited research related to injury prevalence and correlates are available. anecdotal evidence suggests that the sport presents with high injury rates and associated costs. information related to causes and prevalence of injury would help ats working in the collegiate setting. increased understanding of injury and its correlates in this population may allow ats to provide better care. objective: to examine descriptive injury data of acrobatics and tumbling athletes and evaluate the relationship between serum vitamin d, injury and time loss. design: cohort study setting: ncaa division i university sponsored athletic department patients or other participants: forty-two participants on the active a&t roster consented to participate in the study. average age in the sample was 19.69 ± 1.199 years. positional composition: 19 tops, 23 bases. interventions: serum vitamin d was analyzed at two timepoints 8 weeks apart. main outcome measures: serum vitamin d (ng/ml), injury history (i.e., prevalence, mechanism, outcomes), time loss (i.e., no time loss, time loss). descriptive statistics were utilized in addition to t tests and anovas to determine if significant differences existed in injuries and time loss based on serum vitamin d levels, or athletic position (i.e., top, base). results: twenty-eight injuries were sustained during the 8-week period. 11 participants sustained a time loss injury. between week 1 and week 8, participants serum vitamin d decreased an average of 6.093 ± 10.973. there was no significant difference in serum vitamin d or change in vitamin d based on injury status (i.e., injured, non-injured) or time lost. there was a significant decrease in the serum vitamin d levels of participants between week 1 and week 8. conclusions: no significant differences were found in injuries or time loss related to differences in serum vitamin d. however, identifiable patterns were found in injuries sustained by participating a&t athletes. injuries identified included a high prevalence of lower extremity and soft tissue injuries. in a sport with multiple components, the majority of injuries were sustained during tumbling activities. fifty percent of injured participants missed time due to their injuries. serum vitamin d levels at the beginning and end of the study period showed a significant decrease as volume and intensity increased. a direct relationship between serum vitamin d and injury prevalence was not identified. however, significant decreases in serum vitamin d and high injury prevalence was found amongst participants over the eight-week period. this indicates a need for further monitoring of biomarkers such as vitamin d in these athletes, and further research to determine additional injury prevention strategies. abstract presentation 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research hiring practices among ncaa division ii head athletic trainers warner bj*†, winkelmann zk‡, cage sa†§, gallegos dm§?, trail le§?: *grand canyon university, †the university of north carolina, greensboro, ‡university of south carolina, §university of texas at tyler, ?ut health east texas context: to the authors’ knowledge, there are few studies on how athletic trainers (ats) are hired by ncaa institutions. current legislation protects many demographics from discrimination during hiring, but these laws may not be enforced by institutions. therefore, the purpose of this study was to describe factors that might influence the hiring practices of ncaa division ii head athletic trainers. methods: we used a web-based survey (qualtrics) that was distributed to by email to 278 ncaa division ii head athletic trainers. a total of 96 ats completed the survey (response and completion rate=34.5%). the survey included a prompt for hiring an athletic trainer for an ncaa division ii athletics program, questions on demographic data, impact of candidate demographic factors, and impact of candidate skills and education on hiring practices. after the collection window had closed, we calculated central tendencies for all responses. results: most ats reported they would be most likely to hire a candidate with three to five years of experience (3-5 years experience=96.9%, 1-2 years experience=87.6%, 6-10 years experience=86.4%). most ats also reported that they would be most likely to hire a candidate with primarily collegiate athletics experience (college experience=89.6% , high school experience=61.5%, clinic experience=40.7%). regarding education, most ats were most likely to hire a candidate with a master’s degree in athletic training (master’s in athletic training=92.8%, masters not in athletic training=78.2%, clinical doctorate=64.5%). for demographic factors, most ats responded in the midrange of agreement about the impact these factors had on hiring practices. more athletic trainers stated a willingness to hire a candidate of a different race, different religion, different sex, and different sexual orientation. when asked about the credentials most likely to improve chances of being hired for candidates, ats ranked corrective exercise specialist, graston technique certified, and certified strength and conditioning specialist highest. conclusions: most head athletic trainers agreed that three to five years of professional experience, previous experience with collegiate athletics, and a master’s degree in athletic training were the most attractive characteristics a candidate could possess. however, many participants answered in the mid-range of agreement when asked about the effect of demographic factors on hiring practices. these responses may suggest an unwillingness to respond favorably or unfavorably on the topic. future research should focus on examining hiring practices in a way that requires participants to respond favorably or unfavorably. athletic trainers and administrators must work to ensure that they are hiring the best candidate regardless of demographic factors that have no bearing on performing the tasks related to the position being filled. abstract presentation 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research hiring practices among ncaa division iii head athletic trainers goza jp*, cage sa†‡, winkelmann zk§, warner bj†?, mckenney m?: *collin college, †university of texas at tyler, ‡the university of north carolina, greensboro, §university of south carolina, ?grand canyon university context: limited empirical evidence exists on how athletic trainers (ats) are hired by ncaa institutions. current legislation protects many demographics from discrimination during hiring, but these laws may not be enforced by institutions. thus, the purpose of this study was to describe potential factors that might influence the hiring practices of ncaa division iii head athletic trainers. methods: we used a web-based survey (qualtrics) that was distributed by email to 329 ncaa division iii head athletic trainers. a total of 114 ats completed the survey (response and completion rate=34.7%). the survey included a prompt for hiring an assistant athletic trainer for an ncaa division i athletics program, questions on demographic data, impact of candidate demographic factors on hiring practices, and impact of candidate skills and education on hiring practices. after the collection window had closed, we calculated central tendencies for participant responses. results: most ats reported they would be most likely to hire a candidate with three to five years of experience (3-5 years experience=90.3%, 6-10 years experience=82.4%, 1-2 years experience=82.4%). most ats also reported that they would be most likely to hire a candidate with primarily collegiate athletics experience (college experience=91.2% , high school experience=41.2%, clinic experience=30.7%). regarding education, most ats were most likely to hire a candidate with a master’s degree in athletic training (master’s in athletic training=95.6%, masters not in athletic training=86.8%, clinical doctorate=64%). for demographic factors, most ats responded in the mid-range of agreement about the impact these factors had on hiring practices. more athletic trainers stated a willingness to hire a candidate of a different race (50%), different religion (45.6%) and different sex (48.2%). responses regarding sexual orientation were near the mid-range for both same and different sexual orientation. when asked about the most attractive credentials for candidates, ats ranked corrective exercise specialist, graston technique certified, and performance enhancement specialist highest. conclusions: most head athletic trainers agreed that three to five years of professional experience, previous experience with collegiate athletics, and a master’s degree in athletic training were the attributes most likely to influence a candidate being hired. however, many ats responded toward the mid-range of agreement when asked about demographic factors when considering candidates. this may indicate an unwillingness to respond favorably or unfavorably on the topic. future research should focus on assessing hiring practices in a manner that requires a favorable or unfavorable response. athletic trainers involved in the hiring practice at their institutions must work to ensure that they are hiring the best candidate irrespective of demographic factors that have no bearing on technical standards of the position. abstract presentation 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research effect of dry needling on sinus congestion in otherwise healthy adults gallegos dm*†, warner bj‡§, peebles r†?, cage sa*§: *university of texas at tyler, †ut health east texas, ‡grand canyon university, §the university of north carolina, greensboro, ?university of texas health science center context: dry needling refers to the practice of inserting monofilament needles into the skin without injecting any liquids. many of the principles of needle insertion are similar to those used in acupuncture. previous literature has suggested that acupuncture may be a potential adjunct treatment for nasal congestion. however, there are not any studies examining the efficacy of dry needling to alleviate nasal congestion. therefore, the purpose of this case series was to present the cases of four patients suffering from nasal congestion who experienced immediate relief following treatment with dry needling. methods: four male patients (23.25 ± 2.36 years, 182.25 cm ± 8.39, 92.99 kg ± 15.61) were recruited and consented to participate in this study. all patients were afebrile and without other symptoms of illness, except for nasal congestion. none of the patients reported using any medications besides over-the-counter pseudoephedrine. prior to treatment, all patients completed the congestion quantifier 7 (cq7). the treatment site was then cleaned using an isopropyl alcohol prep pad, and the patients were instructed to use hand signals to answer questions once needles were inserted. the dry needling treatment consisted of inserting 1.27 cm needles bilaterally above the orbital rim, along the zygomatic arch, and into the nasal fold for 10-minutes. within 2-minutes of completion of the treatment all patients were asked to complete the cq7 a second time. data analysis was performed using a paired samples t-test to determine statistical significance of differences in cq7 scores before and after treatment. results: following one dry needling treatment, the patients experienced a significant decrease in congestion symptom severity (3.00 ± 1.19 to 1.61 ± 0.09, p < 0.01). patient’s average a 46.3% decrease in symptoms. none of the participants reported any adverse effects as a result of the dry needling treatment. conclusions: these findings demonstrated that in otherwise healthy patients, dry needling significantly decreased symptoms of nasal congestion. while dry needling does not treat the root cause of nasal congestion, it may warrant consideration as a non-medicinal treatment for congestion. clinicians must use discretion when choosing a treatment option if a patient will be performing physical activity afterwards. abstract presentation 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research characteristics of sickle cell trait policies and procedures at ncaa division i institutions parker h*†, warner bj‡§, gallegos dm*†, cage sa*: *university of texas at tyler, †ut health east texas, ‡the university of north carolina, greensboro, ‡the university of texas at tyler, §grand canyon university context: in 2010, the national collegiate athletic association (ncaa) introduced a proposal addressing sickle cell trait screening. this proposal later became a policy that required student-athletes in their first year of eligibility to provide their institution with accurate information regarding their sickle cell trait status. there does not appear to be a recent study published that has examined the sickle cell trait policies and procedures currently being used by ncaa division i institutions. the purpose of this study was to describe the characteristics of sickle cell trait policies and procedures at ncaa division i institutions. methods: we used a web-based survey (qualtrics, qualtrics inc., provo, ut) that was distributed to the 329 ncaa division i head athletic trainers . a total of 67 athletic trainers accessed and completed the survey (response and completion rate=20.4%). the survey tool included questions to assess the availability of sickle cell trait testing, availability of sickle cell trait waivers, and policy and procedure revision processes. after the collection window had closed, we calculated frequencies of participant responses using a commercially-available statistics package (spss version 26, ibm, armonk, ny). results: the majority of head athletic trainers reported their institutions requiring sickle cell trait testing for their student-athletes (74.6%, n=50). all responding institutions offered sickle cell trait testing to their student-athletes either at the institution’s or the student-athlete’s expense. however, the majority of these institutions did not provide their student-athlete population with yearly education on sickle cell trait (64.2%, n=43). on average, institutions (82.1%) and team physicians (80.6%) reviewed their sickle cell trait policies and procedures on a yearly basis. 16.7% (n=11) of institutions had not reviewed their sickle cell trait policies within the past two years, and 17.9% (n=12) of institutions did not have sickle cell trait policies and procedures that had been reviewed by their team physician in the past two years. conclusions: while the majority of responding ncaa division i institutions appear to be compliant with ncaa requirements, athletic training staff and institutions should conduct annual reviews of their sickle cell trait screening policies and procedures with athletic training staff, the team physician, institutional legal counsel and institutional risk management departments. athletic trainers should ensure that they have current knowledge of the pathology, recognition and management of patients with sickle cell trait. lastly, institutions should require annual sickle cell trait education for student-athletes, regardless of sct status. abstract presentation 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research characteristics of sickle cell trait policies and procedures at ncaa division iii institutions eilers ma*, warner bj*†, gallegos dm‡§, clark ja‡§, cage sa‡: *grand canyon university, †the university of north carolina, greensboro, ‡the university of texas at tyler, §ut health east texas context: in 2010, the national collegiate athletic association (ncaa) introduced a proposal addressing sickle cell trait screening. this proposal later became a policy that required student-athletes in their first year of eligibility to provide their institution with accurate information regarding their sickle cell trait status. there does not appear to be a recent study published that has examined the sickle cell trait screening policy and procedures currently being used by ncaa division iii institutions. thus, the purpose of this study was to describe the characteristics of sickle cell trait policies and procedures at ncaa division iii institutions. methods: we used a web-based survey (qualtrics, qualtrics inc., provo, ut) that was distributed to the 442 ncaa division iii head athletic trainers . a total of 158 athletic trainers accessed and completed the survey (response and completion rate=35.7%). the survey tool included questions to assess the availability of sickle cell trait testing, availability of sickle cell trait waivers, and policy and procedure revision processes. after the collection window had closed, we calculated frequencies of participant responses using a commercially-available statistics package (spss version 26, ibm, armonk, ny). results: the majority of head athletic trainers reported that their institutions did not require sickle cell trait testing (70.25%, n=111). the majority of head athletic trainers also stated that their institutions offered sickle cell trait testing to their student-athletes in some form (institution’s expense=119, individual’s expense=13). additionally, a slight majority of institutions required all student-athletes to undergo yearly sickle cell trait education (56.33%, n=89). on average, institutions (79%) and team physicians (56.7%) reviewed sickle cell trait policies and procedures on a yearly basis. however, 18.9% (n=30) of institutions did not have sickle cell trait policies and procedures that had been reviewed by their team physicians at any point. when asked whether sickle cell trait and sickle cell disease were different conditions, 8 head athletic trainers (5%) stated they were not. conclusions: while the majority of responding ncaa division iii institutions appear to be at least compliant with ncaa regulations, athletic training staff and institutions should be encouraged to conduct annual reviews of their sickle cell trait screening policies and procedures with athletic training staff, the team physician, institutional legal counsel and institutional risk management. athletic trainers should ensure that they are well versed in the pathology, recognition and management of patients with sickle cell trait. also, institutions should require annual sickle cell trait education for studentathletes, regardless of sct status. abstract presentation 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 original research impact of a virtual education presentation on perceived and actual knowledge of cupping therapy among athletic trainers cage sa*†, gill dl*, brown pk*, schmitz r*, warner bj*‡: *the university of north carolina greensboro-kinesiology, †the university of texas at tyler, ‡grand canyon university context: within the athletic training profession, there are continuing education requirements in order to maintain national certification. although the profession mandates completion of continuing education, little research has assessed the effectiveness of continuing education interventions. furthermore, there has been even less research conducted on the effectiveness of virtual continuing education interventions. the purpose of this study was to determine the effect of a virtual continuing education presentation on perceived and actual knowledge of cupping therapy among certified athletic trainers. methods: 31 certified athletic trainers began this study (age = 38 ± 11, years of credentialed experience = 15 ± 11). a web-based survey assessed education, usage, and perceived and actual knowledge of cupping therapy. upon completing the initial survey, participants were asked to watch a recorded continuing education presentation on cupping therapy and take a second survey with 19 completing the survey. one month after completion of the second survey, participants were sent a follow up survey to assess retention of knowledge. for all rating questions means with standard deviations and frequencies were recorded. paired t-tests were performed to determine if there were any differences in perceived and actual knowledge before and after the intervention and one month after the completion of post-presentation survey. significance was set with a p value of p < 0.05. statistical procedures were performed using spss v26 (ibm, armonk, ny). results: prior to the presentation participants had a mean perceived knowledge score of 29.1 ± 19.4 out of 60 indicating that on average, they had at least some confidence in their knowledge of cupping therapy. following the presentation, the mean perceived knowledge score was 20.2 ± 6.1 out of 60 with lower scores indicating more confidence. this represented a significant improvement in perceived knowledge, t(16) = 4.31, p < .01. at the one-month follow the mean perceived knowledge score was 17.3 ± 6.2 with no significant change over the month, t(7) = -.07, p = .943. initially, participants had a mean sum of correct actual knowledge items (n=22) of 19.5 ± 1, which was equivalent to 88.5% had this been a written exam. following the presentation, the mean sum of actual knowledge items was 19.9 ± 1.62, with no significant increase in actual knowledge (p = .382). conclusion: these findings suggest that a virtual presentation directed toward athletic trainers may be effective in improving perceived knowledge. although there was no significant improvement in actual knowledge, this may be due to the high initial scores on actual knowledge items. further research should be conducted to determine the effectiveness of virtual continuing education on topics with which individuals are less knowledgeable. abstract presentation 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 case report anisocoria as the sole initial symptom of concussion in a collegiate volleyball player: a case report hopper i*, warner bj†‡, mckenney m†, galbraith rm§?, cox c*, cage sa*: *the university of texas at tyler, †grand canyon university, ‡the university of north carolina greensboro-kinesiology department, §ut health east texas, ?university of texas health science center background: a 21-year-old female collegiate volleyball player reported to the athletic training staff after a competition upon noticing that her pupils were unequal. the patient stated that she was not experiencing any other signs or symptoms that would indicate a concussion, but did recall striking her head on the court during pre-competition warmups. the patient reported no previous history of concussion or eye injury. further evaluation did not reveal any issues with the patient’s reflexes, balance, or memory. at this time, the decision was made to preemptively withhold the patient from participating in athletic activities so she could be monitored for the development of further signs and symptoms. differential diagnosis: concussion, oculomotor nerve palsy, acute eye trauma treatment: approximately six hours after the patient was removed from competition, the patient began experiencing a headache and pressure in her head. the onset of new symptoms furthered the athletic training staff’s belief that the patient had sustained a concussion when she struck her head. the coaching staff was then informed that the patient would be admitted into the institutional concussion protocol, and not allowed to participate in physical activity until receiving clearance from the athletic training staff. two days after the patient began experiencing symptoms she was evaluated by the team physician who confirmed the diagnosis of a concussion. with the confirmed diagnosis, the patient continued to be withheld from team activities and was instructed to abstain from all other activities that increased severity of symptoms. within four days of experiencing symptoms, the patient’s pupils were symmetrical once again. the patient’s headache and sensation of pressure had resolved within five days. on day six, the patient began the institutional return to participation protocol. twelve days from the onset of symptoms, the patient was cleared to return to full participation in team activities. for the remainder of the season, the patient did not experience anisocoria or any of the previously experienced symptoms. uniqueness: to the authors’ knowledge, no previous case studies or original research have described anisocoria as the only initial symptom that a patient experienced following a concussion. given that anisocoria is not one of the more common signs or symptoms of concussion, it is possible that the concussion would not have been recognized had the patient not self reported her asymmetrical pupils. conclusions: when caring for patients, it is paramount that the clinician take into account all patient reported signs and symptoms. in the event that a patient reports an unusual sign or symptom, the clinician must exhaust all possible options to explain the sequelae. furthermore, thorough preparticipation concussion education is critical to helping patients understand the importance of reporting symptoms after potentially concussive trauma. abstract presentation 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 case report herpes zoster as an incidental finding during treatment for thoracic back pain in a collegiate baseball player trail le*†, warner bj‡§, peebles rl†?, galbraith rm†?, cox c*, cage sa*: *the university of texas at tyler, †ut health east texas, ‡grand canyon university, §the university of north carolina greensboro-kinesiology department, §ut health east texas, ?university of texas health science center at tyler background: a 21-year-old male collegiate baseball pitcher reported to the athletic training staff complaining of thoracic back pain when throwing during the non-traditional season. the patient did not recall a specific mechanism of injury, and noted that his pain had gradually increased over time. the patient reported no previous history of thoracic or lumbar spine injury. further evaluation revealed multiple myofascial adhesions that did not resolve with conservative treatments. after the failure of conservative treatment, the patient was referred to the team physician for further evaluation.. differential diagnosis: myofascial adhesions, rib subluxation, thoracic disc herniation treatment: upon referral, the team physician obtained x-rays and an mri of the patient’s thoracic and lumbar spine. x-rays were negative for abnormalities, and the mri only revealed a mild degenerative disc disease at the l4-l5 level. after confirming that the degenerative disc disease was not related to the thoracic back pain, the physician began a course of lidocaine trigger point injections under fluoroscopy. this course of treatment was effective, and the patient was able to return to sport-related activities. during the winter break, the patient contacted his athletic trainer and stated that his back pain had returned. when the patient returned for the spring semester, he was referred to the team physician for another round of trigger point injections. during this examination and treatment, the team physician noted that the patient’s myofascial adhesions had improved, and his muscular tenderness had largely resolved. while performing the exam, the physician noted a seven cm by three cm patch overlying the right side of the lumbosacral region with pink base and numerous one mm papules. when asked, the patient did not report any itching or pain over lesion, but did state that he had noticed a paresthesia in the area over the past few days. the patient reported having not noticed the rash previously, and had never had a similar lesion. the physician diagnosed the patient with herpes zoster, and prescribed a seven day course of valacyclovir. at one week follow up, the lesion had begun to resolve and paresthesia had completely resolved. following this round of trigger point injections and valacyclovir, the patient was able to participate in their competitive season without further complication. uniqueness: while the lifetime risk of contracting herpes zoster has been reported as 30-50%, the majority of cases occur in patients over the age of 50. additionally, herpes zoster patients often report pain and itching at the site of the lesion. had this patient not already been undergoing treatment near the area the lesion occurred, it is likely it would have gone undiagnosed for some time. conclusions: when performing physical exams, it is important to take note of any unusual lesions. should an incidental finding be observed, it is still crucial to patient care to ensure that the finding is addressed. while some conditions may be uncommon in the patient population a clinician is treating, it is still important to be aware of the possibility of occurrence. manuscript type evidence-to-practice review 67 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 review of diagnostic accuracy of the ottawa knee rules in adult acute knee injuries sean l. glover, ms, atc*; amy m. loveless, ms, atc†; sara a. posson ms, atc‡; zachary k. winkelmann, phd, scat, atc *north greenville university, tigerville, sc; †george washington university, washington d.c.; ‡texas a&m university – corpus christi, corpus, christi, tx; §university of south carolina, columbia, sc abstract acute knee injuries are commonly found in athletic populations. the wide range of knee injuries can present a challenge deciding which injuries require imaging. currently, radiography is considered the gold standard of imaging for knee fractures. however, imaging is often costly not only for the patient, but also for the healthcare system. since imaging is expensive, it is critical that clinicians decipher which patients require such testing. the ottawa knee rules (okr) is a predictor tool created by stiell et al in 1995 to help clinicians accurately distinguish potential knee fractures from non-fractures for imaging purposes. the okr guidelines state that a patient should be referred for radiography if he/she meets at least one of the following criteria: (1) 55+ years of age (2) tenderness over fibular head (3) secluded pain on the patella (4) cannot flex knee to 90 degrees (5) cannot bear weight for at least four steps. the okr has been used in clinical settings to rule out knee fractures in patients. the ability of okr to accurately differentiate knee fractures from non-fractures has been investigated to determine how effective the tool is. this article examined eight research studies including over 7,000 participants to determine the diagnostic accuracy of okr in adults. this examination showed that okr exhibited high accuracy in diagnosing knee fractures needing imaging. the okr demonstrated a sensitivity of 0.99, specificity of 0.49, lr+ of 1.86, and lrof 0.07. this data indicates a confidence interval (ci) of 95%. furthermore, okr showed low risk of bias and was beneficial to reducing medical costs and medical wait times. more than half (5) of the studies indicated a reduction rate in imaging completed when utilizing okr. therefore, okr is a beneficial and accurate tool to implement in clinical decision-making when making imaging referrals for acute knee injuries in adults. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation glover sl, loveless am, passon sa, winkelmann zk. review of diagnostic accuracy of the ottawa knee rule in adult acute knee injuries. clin pract athl train. 2023;6(1): 67-72. https://doi.org/10.31622/2023/0006.01.10. original reference sims ji, chau mt, davies jr. diagnostic accuracy of the ottawa knee rule in adult acute knee injuries: a systematic review and meta-analysis. emerg radiol. (2020);30:4438-4446. doi: 10.1007/s00330-020-06804-x. summary clinical problem and question acute knee pain is a common complaint amongst the patients seen in emergency departments. despite a high incidence of this, only a small number of cases are due to fractures.1 plain radiography has minimal use in detecting injuries to soft-tissue structures in the knee such as muscular and ligamentous anatomy. in addition there is a significant financial burden for ordering radiographs in high volume.1 by performing an economic analysis of the effect of the ottawa knee rules (okr), it was reported that when used, there was a $3m usd dollar annual reduction in healthcare cost nationwide. the savings were found to be about a $34 usd per patient.2 before the establishment of the okr in 1995 by stiell et al, there were no uniform methods to rule out knee fractures.1 currently, the suggestion to refer for imaging due to a potential knee fracture includes one or more the following criteria: inability to bear weight after injury (regardless of limp), injury mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.01.10 review of diagnostic accuracy of the ottawa knee rule in adult acute knee injuries 68 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 to the patella specifically, tenderness over the fibular head, inability to achieve 90° of knee flexion, and any patient older than 55 years old.1-4 leading up to this study there are no systematic reviews or metaanalyses regarding the accuracy of the okr in the adult population only.1 to prevent the ordering of unnecessary radiographs and cut down on costs, there is a need for a clinical decision aide to enable health care professionals to predict the presence of a knee fracture prior to an emergency department visit. therefore, the purpose of this article was to examine the accuracy of the okr in clinical settings. summary of literature the databases embase (elsevier), medline, pubmed, and scopus were searched to gather articles to include in the systematic review and meta-analysis. the criteria for articles included was original works where the okr was utilized by physicians in emergency settings to diagnose the presence of acute knee injuries. acute knee injuries were defined as the timespan of the first seven days after the initial trauma.2 to begin the process, abstracts were first manually screened by two reviewers to determine the potential eligibility of each article. once eligible articles were established, complete reading took place. upon final evaluation, the articles from 1995 to present that provided sufficient data about the diagnostic accuracy of okr in adults were used. each study within the articles included a follow-up radiography report to confirm the presence of a fracture. articles looking at the accuracy of the okr in pediatric patients were excluded. after the initial search, 116 articles were found. there were 54 duplicate articles and after screening, 8 articles were deemed eligible and included in the study. summary of interventions the ottawa knee rules are intended to help clinicians accurately distinguish when to refer a potential knee fracture for imaging using the criteria found in figure 1.1 summary of outcomes eight studies were enrolled in the meta-analysis, which involved a total of 7,385 adult patients. the patient and study characteristics included a patient age range of 18 to 101, seven prospective studies, one controlled clinical trial, and only two patients identifying as false-negative diagnoses. the quadas-2 tool identified most studies presented with a low risk of bias and concern regarding applicability. several studies stood out in terms of presenting bias. one study presented with a high risk of bias for patient selection, while a different study presented with a risk of bias to the “flow and timing” criterion.5,6 another study demonstrated bias related to the reference test. this is because the radiographs were read by both the physician and traumatologist.7 however, the gold standard for the radiograph is to be interpreted by the radiologist alone.7 heterogeneity, a random effects model, between the eight studies was examined by the calculation of i^2 statistic, as well as, a bivariate random effects meta-analysis to calculate sensitivity, specificity, lr(+), and lr(-). spearman’s rank correlation test and begg’s test for publication bias were also calculated. findings and clinical implications the meta-analysis demonstrates that there is a strong ability to rule out knee fractures using the okr for adults who sustain acute knee injuries. the rule was derived from stiell et al, and was validated and implemented over 2 years, yielding a 1.0 sensitivity and negative predictive value in all trials that were conducted.6,8 the analysis of eight studies exploring 7385 adult patients demonstrated a high diagnostic review of diagnostic accuracy of the ottawa knee rule in adult acute knee injuries 69 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 performance of okr with a pooled sensitivity of 0.99 (95% ci, 0.97-1.00) and specificity of 0.49 (95% ci, 0.47-0.51). a pooled lr+ of 1.86 (95% ci, 1.72-2.01), lrof 0.07 (95% ci, 0.02-0.24) and dor of 25.10 indicated that a positive okr increased the odds of having a knee fracture twofold, whereas the odds decreased by 99.03% given a negative okr. furthermore, a moderate non-significant heterogeneity sensitivity range of 0.86-1.0 and a high significant heterogeneity specificity range of 0.23-0.54 were calculated. this means that there was low variability between the eight studies for sensitivity and high variability between the eight studies for specificity (i2 = 27.6%; i2 = 79.3% respectively). table 1 provides the full results. spearman’s rank correlation test demonstrated that there was no evidence of a threshold effect. begg’s test for publication bias was moderate with a p value of 0.805. this means that there was moderate association between the eight studies used in this meta-analysis and moderate risk of bias. however, within the eight studies, it was unclear whether there was a need for further imaging giving a negative result on radiograph. according to the american college of radiology appropriateness criteria, evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary panel, both magnetic resonance (mr) and computerized tomography (ct) imaging are not recommended for acute knee injuries unless significant trauma or dislocation is observed.9 although insurance may influence which tests are performed based on coverage and the sequency of testing, mr and ct imaging should not be dismissed when evaluating an acute knee injury because ct shows high accuracy in diagnosing table 1. results from original studies study authors participants country results clinical significance overall risk of bias atkinson et al.10 130 england sensitivity: 1.00 specificity: 0.54 n/a very low cheung et al.14 90 netherlands sensitivity: 0.86 specificity: 0.23 n/a very low emparanza et al.7 1522 spain sensitivity: 1.00 specificity: 0.52 49% rr low jalili and gharebaghi11 283 iran sensitivity: 0.95 specificity: 0.44 41% rr low ketelslegers et al.5 261 belgium sensitivity: 1.00 specificity: 0.43 25% rr low stiell et al.8 1096 canada sensitivity: 1.00 specificity: 0.49 28% rr very low stiell et al.6 3907 canada sensitivity: 1.00 specificity: 0.48 26.4% rr moderate szucs et al.4 96 united states sensitivity: 1.00 specificity: 0.47 n/a low *rr estimated reduction rate review of diagnostic accuracy of the ottawa knee rule in adult acute knee injuries 70 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 occult and tibial plateau fractures, while the mr also plays an important role in the diagnoses of soft tissue pathologies.9 although further radiography may be needed, this review showed that five of the eight studies produced a reduction of 26.4%-49% in radiography when using okr.%. clinical bottom line it is important for clinicians to understand the most accurate tools to use in the evaluation and diagnostic processes of their practice. this allows a clinician to operate in their settings in the most efficient and practical manner. the okr is a beneficial tool that can be used to rule out knee fractures in patients which prevents futile imaging from taking place. based on the results of this study, okr demonstrated an impressive ability to accurately rule out knee fractures. the okr had a 0.99 sensitivity indicating that utilizing these guidelines has a significantly high capability of correctly identifying those who do not need imaging and the ability to rule out an acute knee fracture.10 furthermore, okr has exhibited high consistency between examiners, meaning multiple examiners are able to obtain the same results as each other when utilizing this tool.2 accurately identifying those who may have a knee fracture from those who do not is vital to appropriately referring patients for imaging only when necessary to reduce healthcare costs. as previously mentioned, use of the okr can save $34 usd per patient and $3m usd annually in healthcare costs.2 with fewer people going to medical facilities, such as hospitals and urgent care, the time a person spends waiting to be seen decreases as a result.5,11 this allows people who absolutely need medical care to be seen and treated more quickly. diagnostic tools are extremely useful for athletic trainers, physical therapists, and other healthcare professionals to use in clinical settings. one such tool, okr, is a quick, easy, and costless tool that can be used in a clinic or on-field examination to determine if a patient needs imaging for a knee fracture. the okr has demonstrated high accuracy when identifying those who do not have a knee fractures a highly accurate tool to use to minimize the number of unnecessary imaging, reduce costs, and limit the amount of time spent waiting in medical facilities.12-14 therefore, it is beneficial for clinicians to apply okr in their evaluation processes to reduce needless imaging, reduce medical costs, and decrease the time spent waiting in medical facilities. references 1. sims ji, chau mt, davies jr. diagnostic accuracy of the ottawa knee rule in adult acute knee injuries: a systematic review and meta-analysis. eur radiol. 2020;30(8):4438-4446. https://doi.org/10.1007/s00330-020-06804-x. 2. beutel bg, trehan sk, shalvoy rm. the ottawa knee rule: examining use in an academic emergency department. west j emerg med. 2012;13(4):366-372. https://doi.org/10.5811%2fwestjem.2012.2.6892. 3. sims ji, chau m, davies j. validation of the ottawa knee rule in adults: a single centre study. j med radiat sci. 2020;67(3):193-198. https://doi.org/10.1002/jmrs.411. 4. szucs pa, richman pb, mandell m. triage nurse application of the ottawa knee rule. acad emerg med. 2001;8(2):112-116. https://doi.org/10.1111/j.1553-2712.2001.tb01274.x. 5. ketelslegers e, collard x, vande berg b, et al. validation of the ottawa knee rules in an emergency teaching centre. eur radiol. 2002;12(5):1218-1220. https://doi.org/10.1007/s00330-001-1198-9. 6. stiell ig, wells ga, hoag rh, et al. implementation of the ottawa knee rule for the use of radiography in acute knee injuries. jama. 1997;278(23):2075-2079. https://doi.org/10.1007/s00330-020-06804-x https://doi.org/10.5811%2fwestjem.2012.2.6892 https://doi.org/10.1002/jmrs.411 https://doi.org/10.1111/j.1553-2712.2001.tb01274.x https://doi.org/10.1007/s00330-001-1198-9 review of diagnostic accuracy of the ottawa knee rule in adult acute knee injuries 71 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 7. emparanza ji, aginaga jr, estudio multicentro en urgencias de osakidetza: reglas de ottawa g. validation of the ottawa knee rules. ann emerg med. 2001;38(4):364-368. https://doi.org/10.1067/mem.2001.118011. 8. stiell ig, greenberg gh, wells ga, et al. prospective validation of a decision rule for the use of radiography in acute knee injuries. jama. 1996;275(8):611-615. 9. tuite mj, kransdorf mj, beaman fd, et al. acr appropriateness criteria acute trauma to the knee. j am coll radiol. 2015;12(11):1164-1172. https://doi.org/10.1016/j.jacr.2015.08.014. 10. atkinson p, boyle a, chisholm e. x-ray requesting patterns before and after introduction of the ottawa knee rules in a uk emergency department. eur j emerg med. 2004(11):207-207. https://doi.org/10.1097/01.mej.0000136697.49343.c6. 11. jalili m, gharebaghi h. validation of the ottawa knee rule in iran: a prospective study. emerg med j. 2010;27(11):849-851. https://doi.org/10.1136/emj.2009.080267. 12. yao k, haque t. the ottawa knee rules a useful clinical decision tool. aust fam physician. 2012;41(4):223-224. 13. vijayasankar d, boyle aa, atkinson p. can the ottawa knee rule be applied to children? a systematic review and meta-analysis of observational studies. emerg med j. 2009(26):250-253. https://doi.org/10.1136/emj.2008.063131. 14. cheung tc, tank y, breederveld rs, tuinebreijer we, de lange-de klerk es, derksen rj. diagnostic accuracy and reproducibility of the ottawa knee rule vs the pittsburgh decision rule. am j emerg med. 2013;31(4):641-645. https://doi.org/10.1016/j.ajem.2012.11.003. https://doi.org/10.1067/mem.2001.118011 https://doi.org/10.1016/j.jacr.2015.08.014 https://doi.org/10.1097/01.mej.0000136697.49343.c6 https://doi.org/10.1136/emj.2009.080267 https://doi.org/10.1136/emj.2008.063131 https://doi.org/10.1016/j.ajem.2012.11.003 the ottawa knee rules a predictor tool to help clinician decision-making when making imaging referrals for acute knee injuries in adults a patient should be referred to radiography if they meet at least one of the following criteria: inability to flex to 90 degrees tenderness over the fibular head (b) 55+ years of age isolated pain over the patella (a) inability to weight bear immediately after and in the emergency department (at least 4 steps) https://piktochart.com/?utm_source=dynamic&utm_medium=watermark abstract manuscript type disablement model case study 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study sarah branning, atc*; neeru jayanthi, m.d†; zachary k. winkelmann, phd, scat, atc* *university of south carolina, columbia, sc; †emory sports medicine, atlanta, ga abstract a 19-year-old female, ncaa division i collegiate tennis player presented with a burning and aching sensation halfway up the lateral portion of her right calf following an extensive period spent in a squatting position. this discomfort began distal to the fibular head, then ran along her lateral calf, reached into her ankle, and wrapped behind the lateral malleolus. initially, the patient only noticed this discomfort during long durations of physical activity. however, she began to report symptoms with activities of daily living (adls) and following workouts. the patient first received a working diagnosis of a stress reaction along the mid shaft of the tibia and was restricted from activity to allow for rest and proper healing. following the three-week rest period, the patient returned to activity but reported no improvement in symptoms. she returned for a follow-up appointment where an mri was conducted and showed a posterior tibial stress reaction, which was treated with limited activity for an additional three weeks. following the second rest period, the patient decided to visit another physician for an additional opinion. there, the physician performed a series of tests and imaging. the findings, along with the clinical presentation were consistent with superficial peroneal nerve (spn) entrapment. following this diagnosis, the patient was prescribed with a topical nsaid for pain relief, along with an individualized plan for management and return-to-activity. after a few weeks of consistent treatment, the athlete reported an improvement of symptoms and was able to return to full, pain-free activity. spn entrapment is an interesting pathology due to its high rate of misdiagnosis and relatively uncommon nature. while spn entrapment is not a frequently recognized condition, having the ability to observe signs, symptoms, risk factors, and etiologies is critical for accurate patient diagnosis and proper treatment to return to full, pain-free activity. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation branning s, jayanthi n, winkelmann zk. superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study. clin pract athl train. 2023;6(1): 29-38. https://doi.org/10.31622/2023/0006.01.5. introduction superficial peroneal nerve (spn) entrapment is considered a relatively uncommon, lower limb neuropathy that is typically caused by mechanical compression of the nerve.1 this nerve is originally part of the common peroneal nerve (cpn) before it is divided into the deep peroneal nerve (dpn) and the spn just distal to the fibular head.1,2 the spn runs throughout the lateral compartment of the leg and is responsible for the motor innervation of the peroneus longus and peroneus brevis muscles, as well as the sensory innervation of the dorsal aspect of the foot and the lower leg.1,2 entrapment commonly occurs when the spn is overstretched, typically caused by repetitive or forced inversion and plantarflexion (inversion ankle sprains), or actions of prolonged kneeling, squatting, leg crossing, and sitting. soft masses, peripheral injury, direct trauma, or variations in patient anatomy are also common forms of compression that can cause nerve entrapment and elicit symptoms. 1,3-5 initially, patients may only report symptoms of burning, numbness, or tingling over the lateral leg and dorsal aspect of the foot with exercise.1 however, if left untreated, these symptoms can progress to cause pain ranging from a pinprick to severe, as well as affecting sleep with night pain and muscle cramps.1 peroneal neuropathy, although relatively unusual, is the most commonly identified neuropathy in the lower extremity.6 a study found that in 480 patients with chronic leg pain, 3.5% were found to have spn entrapment.2 this pathology can affect patients of all ages and genders by causing significant lower leg pain and weakness, but patients who experience a traumatic injury, such as a knee dislocation or fibular fracture, are at a higher mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.01.5 superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 risk due to potential damage or injury the nerve, creating inflammation and leading to entrapment.3,4 rapid weight loss has also been linked to nerve compression, specifically at the fibular head, due to the loss of subcutaneous fat around this area.4 some surgeries often report post-operative peroneal nerve compression symptoms. this is most commonly reported with total knee arthroplasty’s, specifically in those requiring the setting of preoperative valgus knee.3 as commonly seen in dancers and athletes, forced inversion and plantarflexion (inversion ankle sprains) can also lead to the stretching, injury, and compression of the spn.3 soft masses in the lower extremity, like ganglion cysts, may also need to be treated or removed to relieve the pressure being placed on the spn.1,3,4 finally, patients with diabetes can be at a higher risk of spn entrapment due to sorbitol, a sugar alcohol slowly metabolized by the body, depositing into the nerves, causing neural edema, and leading to nerve compression.3,4 entrapment of the spn is commonly identified and diagnosed following the presentation of symptoms and a physical examination.1,3,4 in most cases, diagnostic imaging, including ct, mri, emg, or ultrasonography, may be ordered to identify areas of impingement or masses that may be causing irritation. a nerve velocity conduction (nvc) study may also be performed to identify any functional nerve damage.4 following the diagnosis, a conservative, non-surgical treatment approach is initially attempted. treatment typically begins with placing the patient in a knee brace or padding the fibular head, activity modification, and lifestyle changes. rehabilitation interventions, including muscle strengthening, pain management, neurodynamic exercises, and orthotics are also utilized in the beginning stages of treatment. hydrodissection may also be utilized as an alternative treatment before surgical intervention. this treatment typically involves the injection of a solution (saline, dextrose, plasma, steroids, or anesthetics) around the nerve in an attempt to relieve pressure from surrounding structures.3 this treatment can also attempt to restore the nerve’s function by releasing any adhesions that may be causing entrapment.3 if symptoms do not resolve or improve within 36 months, surgical intervention may be necessary.1,3,4 because spn entrapment is rather unconventional, a proper diagnosis can often times be difficult to identify and the injury can go unnoticed.3 symptoms among patients can vary greatly in frequency and severity, injury recognition is critical to begin treatment and avoid the progression of sensory abnormalities or increasing symptoms. entrapment of the spn can limit a patient’s quality of life by hindering their ability to comfortably perform daily activities, participate in physical activity pain free, and receive an adequate amount of rest each night. patient information patient a 19-year-old female, ncaa division i collegiate tennis player presented with a burning and aching sensation about halfway up the lateral portion of her right calf. she reported this pain as a 6/10 on the numerical pain rating scale (nprs) and stated that this sensation had begun a few days prior after she had spent “a few hours” in a deep squat position building a dresser. the patient first reported feeling this sensation about an hour into the building process, however, she reports no noted snapping or popping during this event. this discomfort began just distal to the fibular head, then ran along her lateral calf, reached into her ankle, and wrapped behind the lateral malleolus. initially, the patient only noticed this discomfort during long durations of physical activity, but as the injury progressed, she began to report symptoms with activities of daily living (adl’s) and at rest following workouts. the patient also reported pain and discomfort throughout the night when trying to sleep. upon initial evaluation, athlete was slightly tender to the touch, but reported no numbness or tingling with normal neurologic function, range of motion (rom), and strength. superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the patient presented with normal strength and rom at the hip, ankle, and knee with no apparent signs of swelling, redness, or discoloration. differential diagnosis and evaluation: the differential diagnosis list for this case also included: tibial stress reaction, sural nerve entrapment, peroneal muscle strain, or peroneal neuralgia. after four weeks of continued symptoms, the patient was first diagnosed with a stress reaction along the mid shaft of the tibia and was restricted from activity to allow for rest and proper healing. initially, the team athletic trainer noted suspicions of sural nerve entrapment and expressed these impressions to the physician during the appointment. however, at the time, the physician identified signs of a stress reaction and chose to conservatively treat the patient accordingly. following the three-week rest period, the patient returned to activity but reported no change or improvement in symptoms. she returned for a follow-up appointment where a magnetic resonance image (mri) was conducted and showed a posterior tibial stress reaction, which was treated with a walking boot, along with restricted tennisrelated and conditioning activity for an additional three weeks. the patient was also prescribed 50mg of daily naproxen to assist with pain and inflammation. during the second rest period, the patient began to become frustrated with the diagnosis and lack of symptom relief she was experiencing. she chose to visit a family friend orthopedic physician for an additional evaluation. there, the physician interviewed and evaluated the athletes’ signs, symptoms, and previous treatment methods and was able to rule out a peroneal muscle strain based on his findings. following their evaluation, a proximal tibiofibular joint injection of an anesthetic was administered into the area of pain and discomfort.1 this injection is commonly used as a diagnostic tool to locate the nerve entrapment zone. a relief of symptoms can help to confirm a suspected diagnosis.1,3 this patient experienced a diagnostic relief of symptoms from the injection, indicating an irritation of the joint, also associated with irritation of the superficial peroneal nerve. the patient was not prescribed any additional medication to assist with pain relief, inflammation reduction, or nerve function. following this, an ultrasound and a second mri were also taken to identify any obstructive structures and rule out additional injury. mri’s and ultrasounds are commonly utilized to identify any anatomical abnormalities that could be compressing the nerve, including an increase in the size of the nerve, the intensity of the nerve signal, or identify any soft-tissue areas that may have a mass, swelling, or could be causing impingement.1,4,5 as a result of this imaging, the physician noticed some proximal tibiofibular joint irritation/injury, as well as signs of superficial peroneal neuralgia, or superficial peroneal nerve entrapment. body structure and function: the spn is a structure of the somatic nervous system, which is a branch of the peripheral nervous system responsible for voluntary movement functions and sensation related to the skin.7,8 the peripheral nervous system is made up of sensory and motor nerves that extend from the brain and spinal cord and are responsible for sending messages between the body and the brain.7,8 when a nerve becomes compressed or entrapped, the ability of the nerve to accurately send and receive messages is compromised.9 because of this, patients with nerve entrapment may experience symptoms of a sharp, burning, or achy pain, paresthesia, muscle weakness, or numbness.7,9 in this specific case, the patient noted her pain as a burning and achy sensation just below the fibular head and throughout the lateral portion of her calf. she reported discomfort when running or walking, ultimately hindering her ability to function normally in her sport and daily life. superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 activity and participation the patient has been participating in tennis since she was three years old and began competing at an elite level around the age of 12. the symptoms of spn entrapment impacted her ability to participate in practice and competitions, as well as caused her pain and discomfort while completing her daily routine. the painful burning and deep aching sensations the patient felt throughout her calf during activity were the most debilitating and restricting symptoms. in the sport of tennis, individual competition requires constant movement, including cutting from side to side, hopping, jumping, and running to retrieve balls. matches can last for several hours with few short breaks between games and sets. because of the essence of the sport, a large amount of stress and fatigue can take a toll on the lower body. inflammation in the body, both during and after activity, can compress the nerve and elicit symptoms throughout the lower leg. following activity, the patient described feeling sore and achy throughout the calf for the remainder of the day and symptoms would often linger into the night and next day. because of these challenges, the patient was limited to nonweight bearing cardiovascular conditioning, including swimming and biking. she was also allowed to participate in stationary tennis activities that did not include running, jumping, or cutting motions. outside of sport, the patient also described discomfort and pain performing daily activities, including walking to and from class, climbing up and down stairs of apartment complex, and going out with friends and teammates. the patient explained that the limitations of sport were difficult, but the everyday pain and restrictions were specifically more challenging, due to its effect on her physical, mental, and social health. after receiving an accurate diagnosis, the patient was able to return to tennis by monitoring and controlling her symptoms and activity to avoid reaching a high level of pain or discomfort. the patient has been able to control the symptoms by adequately warming up before activity, including daily stretching and foam rolling, as well as recognizing muscle tightness and receiving treatment as needed. she has also incorporated a recovery routine (table 1) including static stretching of the lower extremity, post-practice foam rolling, and recovery (compression boots, ice bath, massage therapy, etc.) following practice and competition to allow her body the proper cool down and rest. the patient is aware and able to determine when it is important to modify conditioning and activity levels to avoid further injury and inflammation causing compressive symptoms. patient education and recognition, as well as the integration of healthy daily habits, have allowed the patient to successfully return to a high level of physical practice and competition. table 1. return-to-activity plan day 1 day 2 day 3 day 4 day 5 prepractice therapeutic interventions as needed therapeutic interventions as needed therapeutic interventions as needed therapeutic interventions as needed therapeutic interventions as needed practice practice warmup ~25 min (can gradually increase by 5 min each day as tolerated) 50% of practice ~1.5 2 hours 75% of practice ~1.5 – 2 hours full practice ~ 2 – 2.5 hours full practice ~ 2 – 2.5 hours cardio bike, elliptical, antigravity treadmill ~20-30 min sports-specific conditioning ~30 min sports-specific conditioning ~15 20 min n/a n/a postpractice recovery/treatment recovery/treatment recovery/treatment recovery/treatment recovery/treatment superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 environmental and personal factors in this case, the nerve entrapment presented as an acute injury following an event that required prolonged squatting and repetitive stretching of the superficial peroneal nerve. as studies show, this is one of the most common causes and risk factors of injury.1,3,4 the patient reported consistent symptoms with minimal variance regardless of environment or weather conditions. however, symptoms were slightly less severe with proper stretching and warm-up of the muscles prior to activity. she also stated that walking on softer surfaces (grass, sand, etc.) minimized the intensity of the pain and discomfort when compared to competing on cement or sidewalks. this patient did not have a car during the fall semester, so she relied heavily on teammates or public transportation to bring her to and from class or team related activities. typically, this was not a problem as she was able to find transportation most of the time, but on some occasions, she would be required to walk long distances, causing a flare-up of symptoms. although this particular athlete did not experience any of these conditions, some of the most common personal risk factors for superficial peroneal nerve entrapment may also include direct or traumatic injury, rapid weight loss, surgery, frequent inversion ankle sprains, soft masses, and diabetes.1,3,4 a direct or traumatic injury to the lower leg, such as a fibular fracture or complete knee dislocation, can damage or injure the nerve, creating inflammation and leading to nerve entrapment.4 rapid weight loss has also been linked to nerve compression, specifically at the fibular head, due to the loss of subcutaneous fat around this area.4 some surgeries often report post-operative peroneal nerve compression symptoms. this is most commonly reported with total knee arthroplasty’s, specifically in those requiring the setting of preoperative valgus knee.3 as commonly seen in dancers and athletes, forced inversion and plantarflexion (inversion ankle sprains) can also lead to the stretching, injury, and compression of the spn.3 soft masses in the lower extremity, like ganglion cysts, may also need to be treated or removed to relieve the pressure being placed on the spn.1,3,4 finally, patients with diabetes can be at a higher risk of spn entrapment due to sorbitol, a sugar alcohol slowly metabolized by the body, depositing into the nerves, causing neural edema, and leading to nerve compression.3,4 the patient came into the athletic and academic year as a freshman eager to begin her career as a collegiate tennis player. however, this injury led to several setbacks, both physically, mentally, and emotionally. the biggest physical challenge was managing symptoms and determining treatment and rehab plans to keep the patient most comfortable. mentally, the patient struggled with frustrations of lost time and a delayed diagnosis that resulted in losing most of the fall season, as well as placing her at an athletic disadvantage to earn a spot in the line-ups. an emotional toll was placed on the patient as she attempted to navigate through feelings of uncertainty, stress, and fear with a lack of symptom improvement for the initial portion of the injury process. however, the athlete was persistent on participating in team activities to the best of her physical capability and determined to discover a diagnosis and treatment plan that would return her to full activity as soon as possible. communication and collaboration between the patient, physician, coaches, support staff, and the athletic trainer was critical in determining the best care plan, appropriate modifications, and ultimately determining an accurate diagnosis for the patient. interventions following the accurate diagnosis of spn entrapment, the patient was prescribed with a treatment protocol for symptom relief, as well as an outlined return-to-activity plan. the patient was provided with a neoprene sleeve to use during practice and competition. the goal of this intervention was to limit muscle inflammation to prevent nerve compression. she was also instructed to use voltarentm gel (diclofenac) 3-4x daily to treat superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 symptoms. voltarentm gel is a topical solution used to treat joint pain and tenderness, typically associated with arthritis. diclofenac sodium, the active ingredient of this topical, is an nsaid medication that works by limiting substances in the body that can cause pain and inflammation.10 the patient was also provided with a vibracool® device, a wearable modality that utilizes vibration therapy, thermotherapy, and cryotherapy to assist with pain management and inflammation. she was instructed to utilize this following activity and as needed for recovery. dry needling was also recommended as needed to limit muscle tightness and neurological symptoms. finally, the patient was cleared to begin a lower extremity, return-to-activity plan as tolerated and determined by the athletic trainer. a five-day return-to-activity protocol was utilized, beginning on day one with a return to the full tennis warm-up (~30 minutes), followed by 25% of the practice on day two, 50% of practice on day three, 75% of practice on day four, and full practice on day five. the physician explained that the patient may experience some associated pain but should continue to treat with symptomatic relief as directed. however, if the symptoms began to worsen or show no improvements, she was instructed to return for a re-evaluation and alternative treatment options. outcomes as presented in the icf figure 1, the level of functioning holds a fluid relationship between the patient’s health conditions, environmental factors, and personal factors. these factors play a significant role in the activity, participation, and body function/structure of a patient when dealing with an injury or condition. because of this, it is important to acknowledge all aspects of the patient’s life and provide holistic care to promote adequate healing and recovery. figure 1. icf table body function/structure: neurologic symptoms including burning and aching with activity, along with night pain activity: severe pain with running, jumping, cutting, walking long distances, and climbing stairs participation: unable to play tennis. struggled walking long distances to class affecting school participation. health condition: superficial peroneal nerve entrapment environmental factors: patient did not have a car which caused transportation issues, sometimes requiring her to walk long distances. personal factors: mental and emotional stresses of frustration, fear, worry and uncertainty. difficulty with team dynamics and creating friendships with teammates. struggled with trusting medical providers. superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 body structure and function the first semester of the patient’s freshman year was challenging as she dealt with navigating injury and participation restrictions. however, once she received the necessary diagnosis and treatment, her symptoms dramatically decreased, and she was able to return to full athletic activity and pain free adl’s. prior to diagnosis and treatment, the patient rated her pain as 6/10 on the nprs, with pain as high as an 8/10 when at its worst. following diagnosis and treatment, the patient rated pain as a 0/10, with an occasional 1/10 during intense physical activity. although a part of the symptom decrease may be a result of the chosen treatment intervention, some further psychological effects may have played a role in the noted pain and discomfort relief. the physical component of experiencing treatment via the injection, as well as a determined plan to return to activity may have played a positive role on the mental health and outlook of the treatment, resulting in a noted relief of symptoms. the 36-item short form survey, or sf-36, is a patient self-reporting survey that analyzes a variety of scales including general health, physical functioning, bodily pain, vitality, social functioning, emotional role functioning, and mental health to measure overall patient quality of life regarding illness or injury.11 the short musculoskeletal function assessment (smfa) is also a patient self-reporting survey that is utilized to assess and evaluate the impacts of a musculoskeletal condition or injury on the patient’s ability to functionally perform daily activities.12 the sf-36 questionnaire and the smfa (table 2) were both administered to the patient. in the initial sf-36 questionnaire, the patient reported difficulty or limitations with all questions related to the category “role limitations due to physical health.” however, in the post-survey, the patient reported no limitations or difficulties in this same category. she also saw major improvements in “physical functioning,” “pain,” and “health change” when comparing baseline and follow-up measures, with all subject areas returning to full function with no limitations or symptoms. in the initial smfa survey, the patient rated her difficulty in completing her daily routine with normal functioning. in the baseline survey, she scored a 123/230, but in the follow-up survey the patient reported 0 limitations or difficulties managing her daily activities. within weeks of proper treatment and diagnosis, the patient was able to return to full daily and athletic activity pain free and work her way into both the singles and doubles line-up in time for the spring season. table 2. survey outcomes initial sf-36 post-intervention sf-36 physical functioning 25% 100% role limitations due to physical health 0% 100% role limitations due to emotional problems 0% 100% energy/fatigue 45% 65% emotional well-being 44% 84% social functioning 25% 100% pain 22.5% 100% general health 75% 80% health change 25% 100% superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 activity and participation following the patient’s return-to-play protocol, she reported no further symptoms or pain during practice or competition. she continued to receive treatment and rehabilitation 2-3 times a week, including exercises for pain management and muscle strengthening. on the court, the patient had no restrictions and was able to fully participate in tennis-related activity and conditioning as tolerated. as the spring season approached, the patient was able to earn a spot in both the singles and doubles line-up for several matches and saw success in her rookie season. environmental and personal factors in the spring semester, the patient returned to campus with a car for easier transportation to and from class and team activities. however, the patient also reported no remaining pain or discomfort with walking long distances or going up and down stairs. she also showed large improvements in the “role limitations due to emotional problems” and “social functioning” categories of the sf-36 questionnaire. when comparing baseline survey, she jumped from 0% and 25% respectively, to 100% in the follow-up survey. in an interview, the patient also reported an overall better mood and happiness after returning to her sport and life pain-free. she noted feeling a stronger sense of belonging among the team and with her teammates. sharing the experiences of participating at a high level of athletics, while also attending college-level classes allowed the patient to relate to her peers and create a bond with teammates that may have been lacking in the first semester as a result of her injury. the patient also noted more enjoyment and excitement for tennis and academic-related activities. overall, the patient expressed increased feelings of happiness and inclusion amongst her team and peers. discussion this case is particularly interesting due the high rate of missed diagnoses and the relatively uncommon occurrence of entrapment neuropathies.3 due to the infrequency of these injuries, proper diagnosis may often times be difficult or overlooked.3 the variance of individual anatomy can also play a role in the perplexity of accurate injury recognition. as seen in numerous patients, there is an observed discrepancy in the topographic anatomy of the spn, which can lead to misdiagnosis of a nerve lesion, or further injury during surgery.1 for example, nerve entrapment typically occurs near the fibular head, but may also occur in peripheral areas of the lower leg including calf, foot, or ankle.3 because of these anatomical fluctuations, clinical presentation or nerve innervation may differ between cases, ultimately complicating the diagnosis of injury.3 many other injuries or complications may also occur from the etiologies or risk factors of spn entrapment, including fracture, sprain, strain, or, in serious cases, cancer or diabetes.1,3,4 therefore, spn entrapment commonly gets brushed off or merely listed as a differential diagnosis while more common or serious injuries are initially ruled out. because of this, spn entrapment may take longer to be properly treated and diagnosed. therefore, taking a detailed patient history, and identifying common signs, symptoms, and complaints of this condition becomes even more important in the evaluation process. early recognition and treatment can be critical to quickly returning the patient to pain-free athletic and daily living activities. in comparison to other cases, this patient had a mild case of nerve entrapment that was able to be managed through conservative treatment including topical medication, compression during activity to limit inflammation, and pain management modalities. some cases of spn entrapment are more severe and are unable to be managed with conservative treatment. in those cases, surgical intervention may be required to decompress superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the nerve and relieve lingering neurological symptoms. as reported in a small study of five participants, all five patients experienced immediate relief following surgical decompression of the spn with only one reporting reoccurring complications.3 in another larger and more extensive study, 69% of 54 participants reported some improvement of symptoms on quality of life following surgical decompression. finally, an 85% success rate was reported in another study of surgical spn decompression. overall, the success outlook for full recovery and relief for symptoms is favorable for spn entrapment once a proper diagnosis and adequate treatment is provided. as with most injuries, several strengths and limitations were presented throughout the duration of this case. the patient was extremely detailed and willing to provide history, background, and a comprehensive description of symptoms or changes throughout the entire evaluation process. she was also very cooperative and patient when dealing with the evolving diagnoses and frustrations of seeing little to no improvements throughout her opening semester. she handled her emotions in a positive manner and continued to put great trust in the medical staff to discover a way to relieve her symptoms and return her back to the sport she loved. the patient also had a desire to improve and participate in team activities any way she was physically able. overall, she handled very difficult, and sometimes discouraging, circumstances with overwhelming grace and determination. her ability to communicate and make light of a challenging situation made a large difference in the outcome of her case. on the other hand, some limitations included the initial injury recognition of a stress reaction, ultimately leading to extended diagnosis process. however, the way this case developed and progressed provided the opportunity to tell a story and portray this patient’s case in a way that helps to raise awareness of a relatively uncommon condition, as well as show others that patience, perseverance, and a positive outlook can dramatically change an outcome. clinical bottom line while spn entrapment is not a frequently recognized condition, having the ability to observe signs, symptoms, risk factors, and etiologies is critical for accurate patient diagnosis. spn entrapment can present and affect individuals differently, leading to variations of pain severity and activity limitations. commons signs and symptoms can include burning, numbness, or tingling over the lateral leg and dorsal aspect of the foot with exercise, along with associated night pain and muscle cramps. when accurately diagnosed, the patient may feel long-term symptom relief through a variety of conservative treatment options including padding, rehabilitation therapy, or injections. however, some patients may require surgical intervention for nerve decompression. because of this, early injury identification and proper treatment can greatly impact a patient’s life by returning them to pain free activities. to do this, strong communication is needed within the patient’s care team to create an individualized treatment and rehabilitation plan. in this specific case, the patient, along with her athletic trainer, physicians, coaches, and parent, were involved with her condition and collaborated to reach a correct diagnosis. ultimately, precise injury recognition and sufficient treatment intervention were key factors in allowing this patient to return to life and the sport she loved, pain-free. patient perspective “looking back on my injury, i didn’t recognize the toll it had taken on both my mind and body at the time. i obviously felt the pain and discomfort of the injury itself, but i also experienced the pain and feelings of disappointing my coaches and teammates by being physically unable to participate in practices and competitions. i also felt feelings of frustration as time was passing, but my symptoms didn’t seem to be improving. sometimes i started to think my injury may be more psychological than it was physical, and i could make myself better by being tougher or pushing through the pain. my mental health was also affected as i superficial peroneal nerve entrapment in female collegiate tennis athlete: a disablement model case study 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 started to feel upset and worried about my ability to return from this injury and earn a spot in the line-up. i also started to draw back from friends and remove myself from social situations. although i experienced a physical injury, the mental toll was just as painful. however, i continued to stay positive and seek different opinions and options that were able to help me return to tennis pain-free. i am very grateful i continued to search for a diagnosis and treatment to ease my symptoms, rather than just playing through the pain. i am also very thankful for my family, athletic trainer, and physician for helping me to get back to feeling happy and healthy.” references 1. tzika m, paraskevas g, natsis k. entrapment of the superficial peroneal nerve: an anatomical insight. j am podiatr med assoc. mar 2015;105(2):150-9. https://doi.org/10.7547/0003-0538-105.2.150. 2. valisena s, gamulin a, hannouche d. the intraseptal course of the superficial peroneal nerve: an anatomic study. fai. 2021;42(9):1171-1178. https://doi.org/10.1177%2f10711007211002508. 3. fortier lm, markel m, thomas bg, sherman wf, thomas bh, kaye ad. an update on peroneal nerve entrapment and neuropathy. orthop rev. 2021;13(2):24937-24937. https://doi.org/10.52965%2f001c.24937. 4. poage c, roth c, scott b. peroneal nerve palsy: evaluation and management. j am acad orthop surg. jan 2016;24(1):1-10. https://doi.org/10.5435/jaaos-d-14-00420. 5. van zantvoort a, setz m, hoogeveen a, van eerten p, scheltinga m. chronic lower leg pain: entrapment of common peroneal nerve or tibial nerve-german version. unfallchirurg. nov 2019;122(11):854-859. https://doi.org/10.1007/s00113-019-0644-6. 6. craig a. entrapment neuropathies of the lower extremity. pm&r. 2013;5(5 suppl):s31-40. https://doi.org/10.1016/j.pmrj.2013.03.029. 7. health usd. about peripheral nerves. regents of the university of california. accessed april 14, 2022. https://health.ucsd.edu/specialties/neuro/specialty-programs/peripheral-nervedisorders/pages/about-peripheral-nerves.aspx. 8. institute nc. the peripheral nervous system. national institutes of health. accessed april 14, 2022. https://training.seer.cancer.gov/anatomy/nervous/organization/pns.html. 9. jersey naoc. nerve entrapment. neurosurgical associates of central jersey. accessed april 14, 2022. https://neurosurgerycnj.com/peripheral-nerve/nerve-entrapment/. 10. iftikhar n. about using voltaren gel for arthritis pain. healthline. updated september 30, 2021. accessed april 16, 2022, 2022. https://www.healthline.com/health/voltaren-gel#about. 11. lins l, carvalho fm. sf-36 total score as a single measure of health-related quality of life: scoping review. sage open med. 2016;4:2050312116671725. https://doi.org/10.1177/2050312116671725. 12. bouffard j, bertrand-charette m, roy j-s. psychometric properties of the musculoskeletal function assessment and the short musculoskeletal function assessment: a systematic review. clin rehabil. 2016;30(4):393-409. https://doi.org/10.1177/0269215515579286. https://doi.org/10.7547/0003-0538-105.2.150 https://doi.org/10.1177%2f10711007211002508 https://doi.org/10.52965%2f001c.24937 https://doi.org/10.5435/jaaos-d-14-00420 https://doi.org/10.1007/s00113-019-0644-6 https://doi.org/10.1016/j.pmrj.2013.03.029 https://health.ucsd.edu/specialties/neuro/specialty-programs/peripheral-nerve-disorders/pages/about-peripheral-nerves.aspx https://health.ucsd.edu/specialties/neuro/specialty-programs/peripheral-nerve-disorders/pages/about-peripheral-nerves.aspx https://training.seer.cancer.gov/anatomy/nervous/organization/pns.html https://neurosurgerycnj.com/peripheral-nerve/nerve-entrapment/ https://www.healthline.com/health/voltaren-gel#about https://doi.org/10.1177/2050312116671725 https://doi.org/10.1177/0269215515579286 abstract manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 clin at – the year in review, 2021: an outlet for the clinician matthew j. rivera, dat, lat, atc indiana state university, terre haute, in correspondence dr. matthew rivera, 567 n 5th st, terre haute, in 47809. e-mail: matthew.rivera@indstate.edu twitter: @maat_riveradat full citation: rivera mj. clin at – the year in review, 2021: an outlet for the clinician. clin pract athl train. 2022;5(2): 1-2. https://doi.org/10.31622/2022/0005.02.1. a look back clinical practice in athletic training had a monumental year as we continue to evolve and grow as a journal. in total, clin at had 25 articles published across the three issues throughout the year. in 2021, we saw our first special issue published that elevates the voices of athletic trainers and patients who represent historically marginalized and minoritized populations in their role in healthcare and scholarship contributions. there was a total of seven articles published in this issue including disablement model case studies, evidence-to-practice reviews, and clinical outcomes research resulting in nearly 1,500 downloads since publication. we look forward to continuing special issue opportunities and will be announcing our next topic soon. last year also saw both continued and growing partnerships with other organizations. we continued our partnership with the athletic trainers in physician practice society (atpps) to publish the abstracts from their annual conference which included four abstracts this year, which can be found here. furthermore, clin at is thrilled to announce a new partnership with the southwest athletic trainers’ association (swata) from nata district 6 to publish their annual conference free communication professional track abstracts. as a result of this partnership, we published 10 abstracts from the 2021 swata conference. we are excited for the future of these partnerships and continued development of sharing the work that athletic trainers are doing. lastly, we would like to thank the members of the editorial staff that have concluded their service to the journal. we want to thank kim barber foss for her oversight as the section editor for the point-of-care research section. additionally, we want to recognize ellie rippy for her expertise and role as copyeditor for the past two years. i want to personally thank them both for their time, dedication, and service to the journal. without the contributions of the editorial staff, we would not be able to deliver the high-quality product that we do. we would like to also recognize our outstanding reviewers of the year for their dedication and quality of reviews provided in the last year: dr. kelly brock, dr. kim keely, dr. alicia lacy, dr. nathan newman, and kacey ohlemeyer. journal advancements over the last year, the editorial staff has been working on advancements to elevate the process, timeliness, and quality of the journal. we have created a new section and manuscript style to the journal: translational research. with the advent of the covid-19 pandemic and consequence of athletic training scholarship outlets closing, we want to offer authors an avenue to continue to share clinically relevant projects. though this section is open to more traditional research designs, the focus should be clinically mailto:matthew.rivera@indstate.edu https://doi.org/10.31622/2022/0005.02.1 http://clinat.indstate.edu/index.php/clinat/issue/view/10 http://clinat.indstate.edu/index.php/clinat/issue/view/10 http://clinat.indstate.edu/index.php/clinat/article/view/148/91 clin at – the year in review, 2021: an outlet for the clinician 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 5 – issue 2 – september 2022 applicable topics that are meaningful to clinicians and have impact for everyday clinical practice. you can find the full description of this section here. we want to emphasize our commitment to be a journal that focuses on practice-based research and clinician friendly resources to improve clinical practice. additionally, we have made major revisions to our preceptor case study section to expand the opportunity for authors, clinicians, mentors and teachers to share the meaningful work they are doing. the newly minted clinical mentorship case studies section encompasses papers that span a variety of topics such as clinical immersion from the preceptor perspective, designing quality patient interactions, and assessment of student growth during the clinical experience. you can find the full description of this new section here. among our newest changes, we are working on changes to our submission process that are specifically targeted at improving the submission, review, and production procedures. as a journal that is sustained by only volunteers and do not charge article processing fees, these changes will help the editorial staff better serve the authors, reviewers, and readers. starting fall 2022, all authors who are submitting a new paper to the journal will be asked to use the corresponding template to the specific section. the template for each manuscript type can be located within the author guidelines for each of the different sections. further, in an attempt to align with recommendations from the strategic alliance research agenda task force, authors will be asked to designate one of the five research agenda priorities.1 the research priorities are: health care competency, vitality of the profession, health professions education, health care economics, and health information technology. we continue to evolve as a journal, and we are happy to introduce new editorial team members. we want to welcome dr. ashley marshall (point-of-care research), j’nai pittman (clinical mentorship case studies), and dr. kelsey picha (translational research) as section editors. dr. justin young has also joined the editorial team as a staff editor. we are honored that each of these individuals have accepted the invitation to join the editorial team and offer their time, expertise, and knowledge to the journal. finally, and most importantly we would like to recognize the reviewers and readers of clinical practice in athletic training. without the invaluable contributions and service to the journal that our reviewers provide throughout the year, none of the other accomplishments would be possible. particularly in a time where time seems to be scarce and athletic trainers are commonly asked to do more with less, we are immensely grateful. to our readers, we are thankful that you continue to turn to clinical practice in athletic training as one of the sources of information to advance and better the quality of care and education that you are providing to your patients, students, and stakeholders. references 1. eberman le, walker se, floyd rt, et al. the prioritized research agenda for the athletic training profession: a report from the strategic alliance research agenda task force. j athl train. 2019;54(3):237-244. https://doi.org/10.4085/1062-6050-374-18. http://clinat.indstate.edu/index.php/clinat/translationalresearch http://clinat.indstate.edu/index.php/clinat/clinicalmentorshipcasestudy https://doi.org/10.4085/1062-6050-374-18 manuscript type evidence-to-practice review 55 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 burnout in sport specializers versus samplers: an evidence-topractice review katherine godfrey, ms, atc*; justin disanti, phd‡; tamara valovich mcleod, phd, atc, fnata*† *athletic training programs and school of osteopathic medicine, a.t. still university, mesa, az; ‡rangos school of health sciences, duquesne university, pittsburgh, pa abstract the prevalence of sport specialization is a common concern in contemporary youth sports and has been linked to potential negative physical and psychological effects for developing athletes. while the evidence regarding negative physical effects, such as overuse injury, are consistent in the literature, the psychosocial outcomes are unclear due to the lack of published studies on the topic. specialization is thought to lead to added stress, which may affect an athlete’s mental health, whereas athletes who sample multiple sports are believed to have a healthier psychosocial experience. burnout is characterized as physical and emotional exhaustion, sport devaluation and a reduced sense of accomplishment in athletics. this guiding review evaluates the evidence regarding burnout levels between specializers and samplers. two of the articles included in the review directly assessed burnout in samplers vs specializers and noted inconsistencies in higher burnout rates. the six other articles studied burnout only in specializers by indirectly assessing burnout through perfectionism, fear of failure, motivation, and drop out. the comparisons of these variables illustrated heightened burnout in athletes who specialize. the results from these studies provide moderate evidence for recommendations that athletes should delay specializing in one sport. content focus: health care competency correspondence dr. tamara c. valovich mcleod, school of osteopathic medicine in arizona, a.t. still university, 5850 e. still circle, mesa, az 85206. e-mail: tmcleod@atsu.edu twitter: @ tamaracvmcleod full citation godfrey k, disanti j, valovich mcleod t. burnout in sport specializers versus sampler: an evidence-to-practice review. clin pract athl train. 2023;6(1): 55-60. https://doi.org/10.31622/2023/0006.01.8. original reference giusti ne, carder sl, vopat l, et al. comparing burnout in sport-specializing versus sport-sampling adolescent athletes: a systematic review and meta-analysis. orthop j sports med. 2020;8(3):2325967120907579. summary clinical problem and question sports specialization is generally defined as year-round intensive training in a single sport at the exclusion of other sports,1 while athletes who participate in multiple sports are often labeled as sport samplers.2 there are concerns among healthcare providers that athletes who specialize early have increased potential for physical and psychological negative outcomes. while the link between sport specialization and negative physical outcomes (e.g., rates of overuse injuries) have been well-established,3 the relationships to psychosocial outcomes remain largely unclear. it is postulated that sport specialization introduces athletes to additional stressors (e.g., increased time demands, low quantity, quality sleep, and drive for elite status) that can negatively affect the mental health of these athletes,4 including loss of passion, burnout, and development of a unidimensional identity.5 mailto:tmcleod@atsu.edu https://doi.org/10.31622/2023/0006.01.8 burnout in sport specializers versus samplers: an evidence-to-practice review 56 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 burnout refers to physical, emotional, and psychological withdrawal from sports that were once found enjoyable due to over training and chronic stress.6,7 the increase in training volume often associated with sport specialization may result in burnout, which may decrease an athlete’s likelihood to have the motivation or drive required to be successful in their sport.8 unfortunately, there is very little published empirical evidence that directly correlates sport specializers and non-specializers with levels of burnout.9,10 therefore, the purpose of this guiding meta-analysis and systematic review was to assess burnout among youth athletes who specialize compared to those who sample. summary of literature to answer the clinical question, a literature search was conducted using various electronic databases, including pubmed, cinahl, sportdiscus, and psychinfo. search terms included sport specialization; adolescent burnout; sport burnout; athlete burnout questionnaire to find relevant titles and abstracts to be screened. full-text articles that passed the initial screening were assessed for eligibility using the following criteria: english language, adolescent athlete participants between 12 and 18 years of age, classification of samplers or specializers, and burnout was measured using the athlete burnout questionnaire (abq). for data extraction the authors were primarily interested in the results of the abq. patient demographics, sport demographics and specialization status were also extracted from each study. sport specialization status was determined based on the jayanthi scale which classifies athletes as “high, moderate, or low” specialized based on whether an individual has a main sport, competes for more than eight months of the year, and competes in the one sport at the exclusion of other sports.1 in the meta-analysis all levels of specialization were simply grouped as specializers. additionally, athletes who were enrolled in schools or academies with a sport focus, engaged in their sport at least 8 months per year and participated in a single sport were included in the sport specializer group. the authors of the systematic review defined sport sampler as athletes who participate in multiple sports.2 participants that were grouped into the sampler group participated in more than 1 sport per year or did not meet all 3 criteria of specialization. summary of outcomes the primary outcome measure assessed in this systematic review and meta-analysis was burnout, assessed through the abq. the abq has been shown to have acceptable construct validity across a number of athletic populations in similar ages.7 the abq measures three dimensions of burnout: emotional-physical exhaustion, reduced sense of accomplishment, and sport devaluation with five items included for each dimension. each dimension is measured on a 5-point likert scale (1 almost never to 5 almost always) and an average response score is calculated for each dimension. athletes completing the abq are presented with statements about their sports and then asked to rate how often they feel that way. the abq is scored with a global score of the 15 items, as well as three dimension-specific subscale scores, that include 5 items for each of the respective subscales. higher scores on the abq denote higher levels of burnout and lower scores on the abq denote lower levels of burnout. findings and clinical implications there were seven cross-sectional studies and one longitudinal prospective survey study included in the metaanalysis. of the eight included studies, only two directly compared specializers vs samplers in regards to burnout and reported inconsistent findings. specifically, levels of burnout were present in both samplers and specializers; however the burnout scores were not significantly different among female non-elite youth soccer, volleyball, and tennis athletes.10 in contrast, another study reported higher levels of physical and emotional exhaustion and burnout among swimmers, gymnasts, and divers who specialized in their respective burnout in sport specializers versus samplers: an evidence-to-practice review 57 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 sport.11 the other six studies assessed burnout only among specializers, directly or indirectly through the use of additional outcome measures, such as fear of failure, motivation, self-worth, and perfectionism. one study found no evidence of a link between early specialization and increased burnout and drop out,9 another noted a higher burnout profile was indicative of ceasing sport participation,12 and a third study identified athletes with higher symptoms of burnout tended to detach from their sport.13 of the studies that used indirect additional outcome measures, the outcome measures were chosen based on their relationship with burnout. specifically, fear of failure was related to burnout and psychological stress in one study.14 amotivation and intrinsic motivation were found to be mediators of perfectionism and burnout symptoms in another study.15 lastly, self-worth and perfectionism were noted to increase one’s vulnerability to burnout.16 collectively, the majority of participants were assigned to the sport specialization group (95.9%, n=1371) and 4.1% (n=58) to the sport sampling group. almost all (99.5%, n=1422) participants completed the abq. the primary meta-analysis findings of the guiding review noted that specialized athletes reported higher levels of burnout on the abq compared to samplers. specifically, all three abq dimensions were significantly higher in the specializers, who had a greater sense of reduced accomplishment [2.51±0.66 vs 1.64±0.60, δ0.87 (95%ci: 0.67-1.08), p<.01], greater exhaustion [2.44±0.79 vs 1.99±0.71, δ0.46 (95%ci: 0.240.68), p<.01], and more devaluation (1.82±0.54 vs 1.40±0.54, δ0.41 (95%ci: 0.22-0.60) p<.01]. this information is clinically meaningful in the sense that it gives clinicians the awareness and evidence that there is an increased rate of burnout within specialized athletes, which can then be translated into practical settings in which athletes specialize. of note is that the highest mean abq score in the meta-analysis was 2.51, among the specializers for the reduced sense of accomplishment subscale. however, the abq is scored out of five for each section, suggesting that while there were significant group differences, even the specializers were not reaching the ceiling of the instrument. this finding aligns with previous studies in this area which have commonly found athletes to exhibit burnout scores on the lower half of the scales’ range.17 practical interpretation of these scores remains a challenge in using this measure, as no explicit cutoffs have been provided to precisely classify an athlete’s severity of burnout.18 therefore, athletes have tended to be classified as more “at risk” of burnout or “more/less” burned out than others, rather than classified as high, moderate, or low severity of burnout.18 based on these prior studies, the scores calculated through the meta-analysis are indicative of relatively lower burnout across all domains in the samplers in comparison to the specializers. while this means that specializers are more “at risk” of being burned out, since neither group reached levels that exceeded the midpoint of the scale, it appears that athletes who specialize are still able to maintain a relatively positive sport experience. while the findings of the guiding manuscript provide insight into the relationship between sports specialization and burnout, there are several limitations of the meta-analysis that should be considered. first, only two of the eight included studies had a sport sampler group, thus the distribution of athletes among the groups was skewed, with less than 5% of the total sample included in the sport sampler group and only those two studies had direct comparisons. furthermore, only three studies directly assessed burnout, while the other five included secondary measures that were compared to burnout and specialization. lastly, the athlete participants across the included studies varied in geographic location, sport, and level of competition and ranged from elite academy athletes to non-elite youth athletes. burnout in sport specializers versus samplers: an evidence-to-practice review 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 clinical bottom line evidence from this review suggests that athletes who specialize in their sport are likely to score higher on each of the three abq subscales compared to sport samplers, suggesting higher levels of burnout within athletes who specialize. it is noted that the values were only slightly higher, but did not hit the midpoint of the scale. further guidance on interpreting the meaning of abq scores would aid in practical application. these findings provide a degree of evidence to support the notions regarding the potential psychosocial implications of sports specialization and the recommendations put forth by numerous medical associations to limit or delay specializing in one sport.5,6,19,20 athletic trainers and other healthcare professionals providing care to youth and adolescent athletes should ask questions regarding sport specialization practices during pre-participation physical examinations and during injury evaluations. these discussions should include questions regarding training load, volume, and intensity, rest days, time off throughout the year, and include patient-report outcome measures, such as the abq to assess psychosocial constructs that may impact sport participation and recovery following injury. including questions regarding burnout or symptoms of burnout as part of the pre-participation physical examination or secondary to an injury should be included in clinical practice. furthermore, athletic trainers and other clinicians can use the findings of the guiding manuscript to educate patients and other stakeholders and advocate for the inclusion of safe sport recommendations by schools and leagues. specifically, education and advocacy around this issue should include recommendations to have two days off from sport per week, participate in sport-related activity for fewer hours per week than their age, and spend at least one month away from organized sport each year.20 these recommendations, along with encouragement to be a sport sampler, can assist athletes with the needed physical and mental recovery to reduce the risks of overuse injury and burnout risks.20 lastly, clinicians should be knowledgeable regarding the signs and symptoms of burnout (table 1) to be able to appropriately recognize athletes at risk and assist in proper treatment, management, and referral. table 1: physical and mental signs and symptoms of burnout physical mental athletic changes in eating problems with concentration, memory, or ability leveling off or diminished performance or conditioning unable to complete tasks feeling overly worried higher resting heart rate and/or blood pressure sensitivity to sound, sight, smell, and touch feeling sad, empty, hopeless, or worthless cognitive issues irritability and restlessness loss of interest in activities you previously enjoyed illnesses as result of suppressed immune system changes in energy levels and sleep patterns withdrawn or disconnected from others emotional issues feeling like your brain is playing tricks on you low self esteem loss of interest in activities increased anxiety and depression burnout in sport specializers versus samplers: an evidence-to-practice review 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 references 1. jayanthi n, pinkham c, dugas l, patrick b, labella c. sports specialization in young athletes: evidencebased recommendations. sports health. 2013;5(3):251-7. https://doi.org/10.1177/1941738112464626. 2. feeley bt aj, laprade rf. when is it too early for single sport specialization? am j sports med. 2006;44(1):234-241. https://doi.org/10.1177/0363546515576899. 3. bell dr, post eg, biese k, bay c, valovich mcleod t. sport specialization and risk of overuse injuries: a systematic review with meta-analysis. pediatrics. 2018;142(3). https://doi.org/10.1542/peds.20180657. 4. brenner js, council on sports medicine and fitness. sports specialization and intensive training in young athletes. pediatrics. 2016;138(3). https://doi.org/10.1542/peds.2016-2148. 5. brenner js, labotz m, sugimoto d, stracciolini a. the psychosocial implications of sport specialization in pediatric athletes. j athl train. 2019;54(10):1021-1029. https://doi.org/10.4085/1062-6050-39418. 6. difiori jp, benjamin hj, brenner js, et al. overuse injuries and burnout in youth sports: a position statement from the american medical society for sports medicine. br j sports med. 2014;48(4):287-8. https://doi.org/10.1136/bjsports-2013-093299. 7. raedeke td sa. development and preliminary validation of an athlete burnout measure. j sport exerc psychol. 2001;23(4):281-306. https://doi.org/10.1123/jsep.23.4.281. 8. myer gd, jayanthi n, difiori jp, et al. sport specialization, part i: does early sports specialization increase negative outcomes and reduce the opportunity for success in young athletes? sports health. 2015;7(5):437-42. https://doi.org/10.1177/1941738115598747. 9. larson hk, young bw, mchugh tf, rodgers wm. markers of early specialization and their relationships with burnout and dropout in swimming. j sport exerc psychol. 2019;41(1):46-54. https://doi.org/10.1123/jsep.2018-0305. 10. russell w ms. a comparison of female youth sport specializers and non-specializers on sport motivation and athletic burnout. j sport behav. 2018;41(3):330. 11. strachan l, cote j, deakin j. “specializers” versus “samplers” in youth sport: comparing experiences and outcomes. sport psychol. 2009;23(1):77-92. https://doi.org/10.1123/tsp.23.1.77. 12. isoard-gautheur s, guillet-descas e, gustafsson h. athlete burnout and the risk of dropout among young elite handball players. sport psychol. 2016;30(2):123-130. https://doi.org/10.1123/tsp.2014-0140. 13. gerber m, brand r, antoniewicz f, et al. implicit and explicit attitudes towards sport among young elite athletes with high versus low burnout symptoms. j sports sci. 2019;37(14):1673-1680. https://doi.org/10.1080/02640414.2019.1585313. 14. gustafsson h, sagar ss, stenling a. fear of failure, psychological stress, and burnout among adolescent athletes competing in high level sport. scand j med sci sports. 2017;27(12):2091-2102. https://doi.org/10.1111/sms.12797. 15. appleton pr, hill ap. perfectionism and athlete burnout in junior elite athletes: the mediating role of motivation regulations. j clin sport psychol. 2012;6(2):129-145. https://doi.org/10.1123/jcsp.6.2.129. 16. hill ap, hall hk, appleton pr, kozub sa. perfectionism and burnout in junior elite soccer players: the mediating influence of unconditional self-acceptance. psychol sport exerc. 2008;9(5):630-644. https://doi.org/10.1016/j.psychsport.2007.09.004. 17. gustafsson h, kenttä, g., & hassmén, p. athlete burnout: an integrated model and future research directions. intl rev sport exerc psychol. 2011;4(3-24). https://doi.org/10.1080/1750984x.2010.541927. https://doi.org/10.1177/1941738112464626 https://doi.org/10.1177/0363546515576899 https://doi.org/10.1542/peds.2018-0657 https://doi.org/10.1542/peds.2018-0657 https://doi.org/10.1542/peds.2016-2148 https://doi.org/10.4085/1062-6050-394-18 https://doi.org/10.4085/1062-6050-394-18 https://doi.org/10.1136/bjsports-2013-093299 https://doi.org/10.1123/jsep.23.4.281 https://doi.org/10.1177/1941738115598747 https://doi.org/10.1123/jsep.2018-0305 https://doi.org/10.1123/tsp.23.1.77 https://doi.org/10.1123/tsp.2014-0140 https://doi.org/10.1080/02640414.2019.1585313 https://doi.org/10.1111/sms.12797 https://doi.org/10.1123/jcsp.6.2.129 https://doi.org/10.1016/j.psychsport.2007.09.004 https://doi.org/10.1080/1750984x.2010.541927 burnout in sport specializers versus samplers: an evidence-to-practice review 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 18. gerber m, gustafsson h, seelig h, et al. usefulness of the athlete burnout questionnaire (abq) as a screening tool for the detection of clinically relevant burnout symptoms among young elite athletes. psychol sport excerc. 2018;39:104-113. https://doi.org/10.1016/j.psychsport.2018.08.005. 19. laprade rf, agel j, baker j, et al. aossm early sport specialization consensus statement. orthop j sports med. apr 2016;4(4):2325967116644241. https://doi.org/10.1177/2325967116644241. 20. valovich mcleod tc, loud kj, micheli lj, paker jt, sandrey ma, white c. national athletic trainers' association position statement: prevention of pediatric overus injuries. j athl train. 2011;46(2):206-220. https://doi.org/10.4085/1062-6050-46.2.206. https://doi.org/10.1016/j.psychsport.2018.08.005 https://doi.org/10.1177/2325967116644241 https://doi.org/10.4085/1062-6050-46.2.206 abstract editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 past, present, and future of lgbtq health care emma nye, dat, lat, atc grand view university, des moines, ia key phrases patient-centered care; inclusion correspondence dr. emma nye, select medical, grand view university, 3164 sw arlan lane, ankeny ia, 500023. e-mail: enye@grandview.edu twitter: @eanye15 full citation nye e. past, present, and future of lgbtq health care. clin pract athl train. 2021;4(3):1-4. https://doi.org/10.31622/2021/0004.3.1. editorial lesbian, gay, bisexual, transgender, queer, intersex, and asexual (lgbtqia+) individuals have largely faced bias, stigma, and victimization in health care settings.1 factors such as lack of knowledgeable providers and access to inclusive facilities have led to reduced utilization of the healthcare system, and therefore, negative long term health outcomes.1 although the lgbtqia+ community is most often tied together as one population, each letter may represent an individual of diverse socioeconomic status, race, ethnicity, abilities, and identities. in recent years, the athletic training profession has largely focused on how to create inclusive spaces for lgbtqia+ patients and have worked towards a more culturally competent membership. now that athletic trainers (ats) have a foundational level of knowledge, we must move to considering how intersectionality, or an approach which considers the interaction of different factors or social categories, rather than each in isolation,2 impacts patient outcomes. the concept of intersectionality was first introduced to highlight the connections between race and gender and has gained interest by healthcare providers looking to better serve patients. intersectionality recognizes the multidimensionality of each individual and argues the social oppression they may experience is caused from the intersection of different social inequalities, rather than one marginalized identity.3 ats must recognize the patients we treat are comprised of multiple identities, have varying values and beliefs, and should not be categorized into one group. although we are bound by the board of certification’s standards of professional practice, and specifically to render quality patient care regardless of the patient’s race, religion, age, sex, ethnic or national origin, disability, health status, socioeconomic status, sexual orientation, or gender identity,4 now is the time to begin considering how each of these demographics connect to one another. patterns of discrimination and substandard care have been well documented across health care settings, particularly for those who identify as lgbt.1 healthcare providers’ refusal of care, refusing to touch patients or use additional precautions, the use of harsh or abusive language, or being rough or abusive was reported by more than half of respondents in one of the largest studies on lgbt health care.5 staggeringly, respondents of color experience even higher rates of discrimination and substandard care, and were twice as likely as white people to report experiencing physically rough or abusive treatment by medical providers.5 in a 2020 study, researchers found gender minority blacks were more likely to report experiencing severe mental distress, longer periods of being physically or mentally unwell, longer periods of activity limitations due to poor health, than cisgender blacks, as well as cisgender whites.6 additionally, the us transgender survey, a 2015 nationwide survey with 27,715 transgender respondents, revealed that black transgender women reported higher hiv prevalence rates mailto:enye@grandview.edu https://doi.org/10.31622/2021/0004.3.1 past, present, and future of lgbtq health care 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 compared with the overall transgender sample, and that transgender people of color reported higher rates of attempted suicide and lack of health insurance.7 in an effort to reduce these poor health outcomes, ats must not only continue to seek out educational resources to become more culturally agile, but also go beyond seeing our patients through single identifiers. a valuable step in bridging the knowledge gap of intersectionality is to incorporate not only lgbtqia+ related themes into at curricula, but also to integrate how additional racial and ethnic identities impact the patients ats care for. a recent study appearing in the athletic training education journal outlined that 45% of at educators who responded have had athletic training-specific diversity or cultural competency training. further, 21% reported being taught cultural competence concepts during their professional education.8 formal educational training which focuses on best practices for treating marginalized patient populations should be implemented not only for at educators, but for practicing clinicians as well. the commission on accreditation of athletic training education (caate) has proposed accreditation standards for diversity, equity, inclusion, and social justice. as new cultural competence standards are implemented into at education programs, ats should look to incorporate intersectionality into the standard educational content. in this issue, the authors address several action steps for ats looking to better serve patients of diverse identities. as we continue to provide patient-centered care and work towards a more culturally competent profession, ats should seek out ways to bridge the knowledge gap, demonstrate empathy and understanding, and practice patient advocacy. references 1. iom (institute of medicine). the health of lesbian, gay, bisexual, and transgender people: building a foundation for a better understanding. washington, dc: the national academies press (us); 2011. https://doi.org/10.17226/13128. 2. bauer gr. incorporating intersectionality theory into population health research methodology: challenges and the potential to advance health equity. soc sci med. 2014.1;110:10-7. https://doi.org/10.1016/j.socscimed.2014.0 3.022. 3. rai ss, peters rm, syurina ev, irwanto i, naniche d, zweekhorst mb. intersectionality and health-related stigma: insights from experiences of people living with stigmatized health conditions in indonesia. j equity health. 2020 19(1):1-5. https://doi.org/10.1186/s12939-02001318-w. 4. national athletic trainers association code of ethics. accessed 2.23.2021 https://www.nata.org/membership/aboutmembership/member-resources/code-ofethics. 5. when health care isn’t caring: lambda legal’s survey of discrimination against lgbt people and people with hiv. new york: lambda legal, 2010. accessed 2.23.2021 www.lambdalegal.org/health-care-report. 6. lett e, dowshen nl, baker ke. intersectionality and health inequities for gender minority blacks in the us. am j prev med. 2020.1;59(5):639-47. https://doi.org/10.1016/j.amepre.2020.04. 013 . 7. howard sd, lee kl, nathan ag, wenger hc, chin mh, cook sc. healthcare experiences of https://doi.org/10.17226/13128 https://doi.org/10.1016/j.socscimed.2014.03.022 https://doi.org/10.1016/j.socscimed.2014.03.022 https://doi.org/10.1186/s12939-020-01318-w https://doi.org/10.1186/s12939-020-01318-w https://www.nata.org/membership/about-membership/member-resources/code-of-ethics https://www.nata.org/membership/about-membership/member-resources/code-of-ethics https://www.nata.org/membership/about-membership/member-resources/code-of-ethics http://www.lambdalegal.org/health-care-report https://doi.org/10.1016/j.amepre.2020.04.013 https://doi.org/10.1016/j.amepre.2020.04.013 past, present, and future of lgbtq health care 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4 – issue 3 – november 2021 transgender people of color. j gen intern med. 2019: 34(10):2068-74. https://doi.org/10.1007/s11606-01905179-0. 8. grove dh, mansell j. cultural competence: where are we as athletic training educators?. athl train educ j. 2020;15(1):4954. http://dx.doi.org/10.4085/150119041. https://doi.org/10.1007/s11606-019-05179-0 https://doi.org/10.1007/s11606-019-05179-0 http://dx.doi.org/10.4085/150119041 editorial 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 clinical expertise commentary 31 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 concussion profiles: moving beyond the graded symptom scale tamara valovich mcleod, phd, atc, fnata*; brian vesci, dat, atc† *a.t. still university, mesa, az; † northwestern university, evanston, il key phrases diagnostic testing and physical examination: nonmusculoskeletal conditions, patient-reported outcomes, patient education correspondence dr. tamara c. valovich mcleod, athletic training programs and school of osteopathic medicine in arizona, a.t. still university, 5850 e. still circle, mesa, az 85206. e-mail: tmcleod@atsu.edu twitter: @tamaracvmcleod full citation valovich mcleod tc, vesci b. concussion profiles: moving beyond the graded symptom scale. clin pract athl train. 2022;5(1): 31-35. https://doi.org/10.31622/2021/0005.01.5. commentary with the increased focus over the last decade on evidence-based practice, the majority of the discussion has been on evidence and the need for high quality evidence to assist athletic trainers in making important clinical decisions. often left to last in the discussion of evidence-based practice, is the patient perspective. in the area of concussion evaluation and treatment, the patient perspective is critical. the assessment of symptoms has always been part of the multifactorial assessment paradigm for concussion, at baseline and postinjury. the use of these scales has been criticized as subjective in nature, although they are often the only aspect of the concussion clinical examination that assesses the patient perspective. as an injury that does not demonstrate many outward signs, reliance on the patient to provide input regarding symptoms is vital for the athletic trainer’s concussion evaluation. however, the graded symptom scale is often administered independent of more detailed outcome measures or with limited follow-up questions, which limits its utility. in this commentary, we will discuss how to go beyond the graded symptom scale, using concussion profiles and patient-report outcome measures (pros) to better understand the patient perspective following concussion. while there are many symptom checklists and scales available, athletic trainers are probably most familiar with the symptom evaluation that is part of the sport concussion assessment toolversion 5.1 this symptom scale allows clinicians to assess a patient’s symptom status across 22-items and allows the patients to express the severity of each symptom on a 0-6 scale. these short symptom scales allow the clinician to understand the number of symptoms a patient has and the individual and total symptom severity, resulting in the ability to document two scores: symptoms endorsed and total symptom severity or classify a patient as symptomatic vs. asymptomatic. the brevity and non-descript nature of the included symptoms can provide a high level symptom screen; however it is up to clinicians to take a deeper dive in their evaluation process to aid in a differential diagnosis and to better understand the influence of the patient’s symptoms on their functional abilities. first, in order to aid in our differential diagnosis and determine appropriate treatment strategies, we should be asking additional questions regarding endorsed symptoms. for example, a patient who endorses headache on a graded symptom scale should be asked follow-up questions regarding the onset, location, duration, characterization, aggravating factors, relieving factors and treatment. similarly, an endorsement of dizziness can be related to concussion, but also a number of other differential diagnoses. as such, it is important to ask follow-up questions regarding the quality, timing and duration, triggers, and other associated symptoms. this approach can be taken with most of the symptoms mailto:tmcleod@atsu.edu https://doi.org/10.31622/2021/0005.01.5 concussion profiles: moving beyond the graded symptom scale 32 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 on a graded symptom scale to assist in learning more about the reported symptoms. the next step in the evaluation process extends our interpretation of the graded symptom scale by grouping or categorizing the various symptoms into concussion profiles or sub-types. authors have published different classifications for assigning concussion profiles (table 1) allowing athletic trainers the ability to use the one that fits best with their clinical practice and directing physician standing orders. regardless of which classification is used, clinicians should classify their patient’s symptoms to determine their patient’s primary concussion profile or sub-type. due to the overlap of symptoms between profiles, often patients will have a secondary profile and in some cases a tertiary profile. once the profiles are determined, the next step allows clinicians to learn more about how the patient’s symptoms are affecting aspects of their lives. while there has always been the recommendation to assess and manage each patient with an individualized approach, this philosophy becomes more important in our current era where we are moving to an active treatment paradigm. to facilitate active treatment of concussion, clinicians should be using the graded symptom scale as a screen to assign a symptom cluster or profile to each patient.2 once a symptom profile is assigned, further assessment using a patientreport outcome measure is indicated to allow a more thorough understanding of the patient’s perception of elements of those symptoms on their perceived health (figure 1). this will allow for a more thorough understanding of the patient’s complaints and direct the clinician to an appropriate treatment strategy. while there is not one single pro for sport-related concussion, there are many established pros that could be used with the various concussion profiles (table 2)3 clinicians should review the various options, understand licensing requirements (if applicable), and determine question relevance in their patient population. in the following section, we discuss an example in practice using the cervical profile. example in practice the 22-item symptom evaluation previously mentioned evaluates the symptoms of headache, dizziness, cognitive impairment, and neck pain. these specific symptoms are important in a clinical context because they have been identified as common and shared symptoms of both concussion and whiplash associated disorder, and they are associated with similar mechanisms of injury.4 this suggests that a patient history alone, including mechanism of injury and symptom profile, is unlikely to differentiate these conditions. the neck disability index (ndi) is a pro that, although not currently validated for concussion, has been validated in a wide variety of patient populations and languages for acute and chronic neck pain. the ndi is a 10-item scale measured 0 (no disability) to 5 (full disability) and the authors of a systematic review found that a mdc of 5/50 is appropriate and that a score between 0-10 likely is approaching a floor effect.5 a study aiming to characterize cervical spine impairments in a younger population following concussion found that 90% of subjects demonstrated impairments in at least three out of five assessment categories; further, of those subjects for which the ndi was administered on initial physician assessment, over 80% were interpreted as having disability due to neck pain. the five assessment categories utilized by the authors for their analyses were posture/movement quality, muscle strength and endurance, myofascial tension to palpation, joint mobility, and selective tissue testing for upper extremity radicular symptoms.6 due to the interrelationship of both mechanism and symptoms following trauma between concussion and whiplash associated disorder, it is of paramount clinical importance to evaluate a patient with suspected concussion for a cervicogenic origin of these symptoms. the ndi can offer a reliable and valid means to determine the need to complete a thorough assessment of the cervical spine concussion profiles: moving beyond the graded symptom scale 33 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 table 1. concussion profile or sub-type classifications. author classifications collins, 20147 vestibular, ocular, cognitive, migraine, anxiety/mood, cervical craton, 20178 cognitive, oculomotor, affective, cervical, headache, cardiovascular, vestibular harmon, 20192 vestibular, cognitive, fatigue, anxiety/mood, headache/migraine, ocular lumba-brown, 20209 cognitive, ocular-motor, headache/migraine, vestibular, anxiety/mood associated conditions: sleep disturbance, cervical strain kontos, 202010 anxiety/mood, cognitive/fatigue, migraine, ocular, vestibular modifying factors: sleep, neck table 2. possible patient-report outcomes for patients with different concussion symptom profiles. clinical profile patient-report outcomes anxiety/mood beck depression inventory generalized anxiety disorders-7 profile of mood states patient health questionnaire brief symptom inventory-18 neuroqol depression and anxiety subscales cognitive/fatigue pediatric quality of life inventory cognitive subscale multidimensional fatigue scale neuroqol cognitive subscale migraine headache impact test-6 migraine disability assessment pediatric migraine disability assessment migraine specific quality of life questionnaire ocular convergence insufficiency symptom survey national eye institute visual function questionnaire–25 vision-related dizziness questionnaire vestibular dizziness handicap inventory ucla dizziness questionnaire vertigo symptom scale cervical neck disability index northwick park neck pain questionnaire. copenhagen neck functional disability scale whiplash disability questionnaire sleep basic nordic sleep questionnaire leeds sleep evaluation questionnaire medical outcomes study sleep problems measures pittsburgh sleep diary pittsburgh sleep quality index self-rated sleep questionnaire sleep dissatisfaction questionnaire concussion profiles: moving beyond the graded symptom scale 34 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 as well as benchmarking to track progress. a cervical spine exam would be indicated for any patient reporting at least mild disability on the ndi. this exam should begin with an assessment of ligamentous and vascular integrity in the upper cervical spine. at minimum, screening for the atlanto-occipital (sharp-purser test) and atlantoaxial (alar ligament test) joints in combination with a screen for vertebral basilar insufficiency is indicated. the clinical exam is then recommended to consist of the previously identified categories of assessment found in these patients.6 utilizing the graded symptom scale as an initial screen, followed by a pro specific to patient’s clinical profile can allow clinicians to further investigate the impact of the concussion in a more thorough manner and develop an appropriate treatment plan. references 1. echemendia rj, meeuwisse w, mccrory p, et al. the sport concussion assessment tool 5th edition (scat5). br j sports med. 2017. https://doi.org/10.1136/bjsports-2017097506. 2. harmon kg, clugston jr, dec k, et al. american medical society for sports medicine position statement on concussion in sport. br j sports med. 2019;53(4):213-225. https://doi.org/10.1136/bjsports-2018100338. 3. valovich mcleod tc, register-mihalik jk. clinical outcomes assessment for the management of sport-related concussion. j sport rehabil. 2011;20(1):46-60. https://doi.org/10.1123/jsr.20.1.46. 4. rebbeck t, evans k, elliott jm. concussion in combination with whiplash-associated disorder may be missed in primary care: key recommendations for assessment and management. j orthop sports phys ther. 2019;49(11):819-828. https://doi.org/10.2519/jospt.2019.8946. 5. macdermid jc, walton dm, avery s, et al. measurement properties of the neck disability index: a systematic review. j orthop sports phys ther. 2009;39(5):400-417. https://doi.org/10.2519/jospt.2009.2930. 6. tiwari d, goldberg a, yorke a, marchetti gf, alsalaheen b. characterization of cervical spine impairments in children and adolescents post-concussion. int j sports phys ther. 2019;14(2):282-295. 7. collins mw, kontos ap, reynolds e, murawski cd, fu fh. a comprehensive, targeted approach to the clinical care of athletes following sport-related concussion. knee surg sports traumatol arthrosc. 2014;22(2):235246. https://doi.org/10.1007/s00167-0132791-6. 8. craton n, ali h, lenoski s. coach cv: the seven clinical phenotypes of concussion. brain sci. 2017;7(9). https://dx.doi.org/10.3390%2fbrainsci709 0119. 9. lumba-brown a, teramoto m, bloom oj, et al. concussion guidelines step 2: evidence for subtype classification. neurosurgery. 2020;86(1):2-13. https://doi.org/10.1093/neuros/nyz332. 10. kontos ap, elbin rj, trbovich a, et al. concussion clinical profiles screening (cp screen) tool: preliminary evidence to inform a multidisciplinary approach. neurosurgery. 2020;87(2):348-356. https://doi.org/10.1093/neuros/nyz545. https://doi.org/10.1136/bjsports-2017-097506 https://doi.org/10.1136/bjsports-2017-097506 https://doi.org/10.1136/bjsports-2018-100338 https://doi.org/10.1136/bjsports-2018-100338 https://doi.org/10.1123/jsr.20.1.46 https://doi.org/10.2519/jospt.2019.8946 https://doi.org/10.2519/jospt.2009.2930 https://doi.org/10.1007/s00167-013-2791-6 https://doi.org/10.1007/s00167-013-2791-6 https://dx.doi.org/10.3390%2fbrainsci7090119 https://dx.doi.org/10.3390%2fbrainsci7090119 https://doi.org/10.1093/neuros/nyz332 https://doi.org/10.1093/neuros/nyz545 concussion profiles: moving beyond the graded symptom scale 35 copyright © indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 1 – april 2022 figure 2. example using the symptom scale to identify a patient profile anxiety/mood migraine sleep cervical cognitive fatigue vestibular ocular • dizziness handicap inventory • vertigo symptom scale • ucla dizziness questionnaire manuscript type quality improvement reports 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 4 – issue 3 – november 2021 a proposed return-to-ride protocol for united states jockeys following concussion carolina quintana, phd, atc*; kimberly i. tumlin, phd, ms, mph†; matthew c. hoch, phd, atc†; nicholas r. heebner, phd, atc†; bianca l. grimshaw‡, ms, atc, otc; carl g. mattacola, phd, atc** *california state university, fresno, fresno, ca; †university of kentucky, lexington, ky; ‡university of louisville health sports medicine institute, louisville, ky; **university of north carolina greensboro, greensboro, nc abstract professional horse racing jockeys participate in a high-risk sport, however there is limited research and policies regarding welfare and safety. despite the high incidence and risk of concussions, there are not standardized protocols for returning these unique athletes to participation following concussion. a return-to-ride concussion protocol for thoroughbred horse racing athletes must take into account the unique considerations and practices of the sport. current concussion management strategies suggest removal from riding and activity when a concussion is suspected. this is followed by further evaluation for diagnosis, a period of both cognitive and physical rest before a gradual return-toactivity prior to full medical clearance and a return to previous levels of activity and competition. the proposed protocol follows suggested strategies while tailoring the graduated return-to-activity to meet the needs of the us jockey population. this protocol may be used following injury to ensure an adequate recovery and safe return-to-activity and is outlined such that it can be followed by an individual athlete and provides descriptions for each activity and stage. key phrases concussion; policy and procedure development; risk management and mitigation correspondence dr. carolina quintana department of kinesiology, california state university, fresno, 5275 n. campus dr. m/s sg28 fresno, ca 93740-8018. e-mail: carolinaquintana@mail.fresnostate.edu twitter: @cquintanaatc full citation quiutana c, tumlin ki, hoch mc, heebner nr, grinshaw bl, mattacola cg. a proposed return-to-ride protocol for united states jockeys following concussion. clin pract athl train. 2021;4(3):17-27. https://doi.org/10.31622/2020/0004.3.4. submitted: february 25, 2021 accepted: june 15, 2021 introduction concussions have been cited as one of the most frequently occurring injuries in professional horse racing jockeys around the world.1,2 the centers for disease control and prevention defines a concussion as a type of traumatic brain injury (tbi) that is “caused by a bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth.”3 these injuries may result in a disruption of brain function including, but not limited to, loss of consciousness, memory loss, disorientation or confusion, and other functional deficits.4 it is well documented that the majority of injuries that jockeys sustain are a result of falls.1,2,5-11 hitchens et. al. reported that of 360 reported falls during thoroughbred races, 184 injuries occurred indicating that 51% of falls resulted in injury.8 additionally there were 1.99 falls reported per 1000 rides.8 concussions have represented a higher percentage of overall injuries in jockeys, as high as 13% in a four month time frame.10 despite concussions representing a large proportion of injuries in jockeys very few policies and procedures are in place throughout the united states that require adequate documentation and record keeping surrounding this type of injury. as a result, the actual injury prevalence in this population remains undocumented. while it is clear there is both high risk and high incidence of these injuries, there are many factors specific to horse racing that need to be considered to impose the healthcare of jockeys. despite concussion being recognized as the most frequently occurring injury among jockeys,10,12 it has been reported in other sports that many head injuries go unrecognized, unreported, or undiagnosed,13,14 therefore, it may be assumed that the estimates of the true number of racingrelated concussions are skewed or inaccurate. reasons for not reporting concussions have been attributed to overall lack of access to medical mailto:carolinaquintana@mail.fresnostate.edu https://doi.org/10.31622/2020/0004.3.4 a proposed return to ride protocol for united states jockeys following concussion 18 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 professionals when an injury occurs, education regarding the injury risks, signs and symptoms, and sport-specific guidelines to return athletes to competition, the importance of treating these injuries appropriately.15 recent literature from amateur and professional jockeys in ireland also cite not considering a concussion to be serious, risk of losing a ride and therefore wages, and seeing the injury as a sign of weakness as additional reasons riders would not report a concussion and continue to ride.16 the overwhelming lack of resources and education is especially apparent within the thoroughbred horse racing industry in the united states, as availability of onsite healthcare or resources at the racetrack is inconsistent and procedures used are not universally adopted. while other racing jurisdictions such as the british horseracing authority have implemented concussion protocols to manage concussions,17 the united states has yet to implement or adopt protocols unique to the needs of riders in the united states. in the united states, equestrian sports remain some of the only organized competitive activities that have not adopted national and comprehensive concussion management protocols or guidelines. while significant progress has been made to improve the management of concussions in horse racing and other equestrian sports,18-24 a gap continues to exist on contextuallyappropriate return-to-sport protocols.25 at this time, there is no consistent healthcare management or practices from track to track across the country. additionally, there is a lack of standardized baseline concussion protocols and tracks and jurisdictions are left to make their own protocols, policies and procedures. while information may be circulated or provided, there are not standard guidelines or recommendations for the racing community. non-racing equestrian24 and professional rodeo have established concussion return-to-ride guidelines,23 but these do not consider the unique qualities of time pressures to resume racing, need for comprehensive medical oversight, and lack of training protocol for personnel on concussion management at all racing tracks. therefore, the uniqueness of thoroughbred horse racing and the occupational demands placed upon race-riding jockeys warrant contextually appropriate protocols for concussion management in this sport that can be implemented regardless of resources or healthcare personnel available. generic return-to-sport guidelines have been developed by groups such as the concussion in sport group26 and the american academy of neurology;27 however, these guidelines do not reflect the sport-specific needs of the united states jockey population to ensure the best standard of care and practice. despite clear need for concussion education for jockeys, the lack of a systems-wide support to decrease perceived negative connotations of addressing concussion still exists.16 as such, addressing the need for a jockey-specific return-to-ride guideline following concussion injury which considers the racing environment, physiological demands, and potential health disparities is not only necessitated, but required to advance safety in these athletes. therefore, the proposed return-toride progression protocol is based on other sport protocols but is specific to the needs and demands of race riding. the proposed protocol is similar to wicklund et al.23 who created a protocol for the rodeo athlete, and serrano and wu’s24 management policy for collegiate hunter/jumper equestrian athletes, is an adaptation of the widely accepted graduated return-to-sport strategy suggested by the concussion in sport group,26. it must be acknowledged that while concussion management is being addressed in international racing jurisdictions the diversity of needs and practices within us horse racing sport necessitates the proposed protocol. a proposed return to ride protocol for united states jockeys following concussion 19 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 current model protocol description existing standards for horse racing injury management include having at least one medical professional at a racetrack during both morning workouts and live racing. the medical professional, such as a physician or licensed medical professional, must be trained to diagnose concussion and clear riders for additional riding post-fall.28 although the sport lags behind other organizations in the development and practice of concussion management guidelines, it is important that any suggested protocols stay current with recommendations in other sports. thus, current recommendations are moving away from the idea of complete rest, dark rooms and isolation from stimulation, the suggested protocol promotes an active recovery and expedites exposure to physical, mental, and social activity.29,30 to create a riding specific protocol, existing live racing data were analyzed and compared to data collected using a riding simulator.31 a racewood racing simulator (racewood equestrian simulators, cheshire, uk) was utilized so that heart rate data of race-riders of various professional levels could be monitored in simulated racing conditions.31 utilizing a racehorse simulator and removing the live horse provides a much safer environment for the rider to increase physical exertion and gradually return-to-riding without the risk of injury from a fall from an unpredictable event. the proposed protocol focuses on a gradual increase in intensity as monitored by percent heart rate, and exercise demands (repetitions) until sportspecific intensity has been reached. mean heart rates measure during live and simulated racing were used to set parameters for each stage. one standard deviation above and below the target heart rates, derived from the mean heart rates, were identified and compared to previously set standards for validity for each stage.26 simulated races were used to mimic a physical situation close to what a jockey would encounter in a live race. a previous study31 investigating heart rate during live and simulated rides demonstrated that although there is not a significant difference in peak heart rate between the two, there was a nearly 15% gap in achieved peak heart rate during the simulated ride when compared to the peak heart rate during live racing. although horse simulators have not been compared to treadmill exercise, prior research indicating that heart rate at 80% of heart rate achieved at symptom exacerbation using the buffalo concussion treadmill test is an acceptable level. given the work comparing live racing and simulation and the buffalo concussion treadmill test,32 it is concluded that a goal of achieving 85% of the maximum peak heart rate during live racing was selected as the final exertion stage for simulated riding in our return protocol is appropriate to prevent symptom exacerbation.31 from there, a reversed approach was then taken to graduate heart rates from the 85% maximum; equivalent to return of racing while mounted on a live horse. through this process, average peak heart rate during live racing was used to create a range of target heart rates for each stage moving at 10% from the prior state. the suggested heart rate zones are expected to be achieved and maintained during an exercise bout lasting at least two minutes, the duration of an average horse race in the united states. this step also mimics the intensity and timing of workouts and training bouts on the horse, as workout lengths typically range between 2 to 8 furlongs while race lengths range from 5 to 12 furlongs. furthermore, use of peak heart rate to inform stage thresholds is contextually simplistic to use and implement in the jockey community, thus enhancing a culture of acceptance during postconcussion recovery (table 1). this approach is advantageous to ensuring reduction of risk moving through the first three stages of the protocol a proposed return to ride protocol for united states jockeys following concussion 20 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 ensuring the jockey has reached cardiovascular exertion without exacerbating prior injury. as in the guidelines outlined by mccroy et al.,26 if at any point during the return-to-ride graduated protocol the individual experiences a return or provocation of concussion symptoms, the athlete should return to the previous asymptomatic level and work to progress from that stage forward after a 24-hour period without concussion-related symptoms at that level. monitoring the progression of the protocol and advancing riders to the next step should be done by licensed healthcare professionals. athletic trainers are keenly suited for this role due to their knowledge and experience managing these injuries. as an additional consideration, riders should strive to maintain good nutrition, hydration and sleep, to promote good health and recovery, such as those described in the american college of sports medicine joint position statement: nutrition and athletic performance.33 stage 1: light activity in stage 1, the aim is to gradually reintroduce light activity that does not aggravate postconcussion symptoms (e.g., headache, dizziness, nausea). riders should only participate stage 1 once they have been deemed asymptomatic by a table 1: proposed return-to-ride protocol by activity stage and with target heart rate progression objective target heart rate zone criteria to progress to next stage stage 1: light activity gradually reintroduce light activity and activities of daily living that do not aggravate symptoms or place individual at risk for secondary impact or fall ≤100 bpm participate in activities in daily living without an increase in symptoms for 24 hours stage 2: light aerobic activity introduce light aerobic cardiovascular effort while minimizing secondary fall or impact by doing activities away from a horse that do not present a high risk 98-111 bpm or ≤ 60-70% of maximum heart rate maintenance of heart rate within target heart rate zone for ten, twominute simulated rides on a race horse simulator stage 3: sport-specific exercise work to increase heart rate to 75% of maximum heart rate as the goal of the cardiovascular fitness levels in ways other than riding a live horse, incorporating race horse simulator 112-151 bpm or ≤ 75% of maximum heart rate maintenance of heart rate within target heart rate zone for ten, twominute simulated rides on a race horse simulator stage 4: high intensity sport-specific exercise simulated rides should be continued with the intention of increased heart rate greater than 85% of the peak heart rate experienced during live racing. 151-171 bpm or ≤ 85% of maximum heart rate maintenance of heart rate within target heart rate zone for ten, twominute simulated rides on a race horse simulator stage 5: return to live horse reintroduce live horse and begin to restore riding performance and confidence 151-171 bpm or above confidence on live horse and ability to maintain composure and fitness during workouts stage 6: full participation return to race related activities and full competition bpm=beats per minutes a proposed return to ride protocol for united states jockeys following concussion 21 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 licensed healthcare professional. these activities may include activities of daily living that do not place the individual at risk for secondary injury or provocation of symptoms (e.g., walking, bathing, doing household chores). these activities should be initiated after a period of at least 24 hours of physical and cognitive rest. encouraging the rider to stay involved in everyday activities outside of riding may promote motivation and positively affect mood and general emotional and mental well-being while they are unable to participate in riding. to graduate from stage 1 the rider, at a minimum, should be able to participate in activities of daily living without an increase in symptoms but should be guided by a clinician. stage 2: light aerobic activity stage 2 of the progression places an emphasis on light aerobic cardiovascular activity while minimizing secondary fall or impact by doing activities away from a horse that do not present a high fall risk. this stage should begin 24-hours after the successful completion of stage 1 with no return of symptoms. riders gradually begin light aerobic activities that may be done at the racetrack, in a gym or anywhere they may be able to walk, jog or complete other light activities with minimal risk of falling or impact to the head. successful completion of this stage will depend heavily on whether or not the increased intensity of activity causes a return of symptoms. riders should be monitored before, during, and following activity to detect any potential symptom return. the intensity and duration of light aerobic activity in stage 2 should demonstrate a marked increase from stage 1 before progressing to the next stage. additionally, progression should only occur when riders are able to complete the activity without complications or a provocation of symptoms. graduation from this stage requires the maintenance of heart rate within the target heart rate zone (98111 beats per minute or ≤ 65% of maximum heart rate) for ten, twominute simulated rides on a racehorse simulator. if the rider is able to complete these exercise bouts without a provocation of symptoms, as monitored by a licensed medical professional who is managing their care, they may move onto stage 3. stage 3: sport-specific exercise the goal of stage 3 is to have the rider increase their heart rate to 75% of maximum heart rate in ways other than riding a live horse. based on previously reported physiological heart rate data during live racing,31 increasing heart rate to a percentage (<75%) of the jockey’s maximum heart rate is appropriate in this stage. as indicated previously, this value is based on the overall target heart rate of 85% of the jockey’s maximum heart rate31 and working backwards to create attainable and meaningful heart rate targets and based on prior research indicating that exercise intolerance post-concussion is achieved at 85-90% of heart rate.32 use of a self-propelled racehorse simulator like the racewood racetrainer rt (racewood ltd, tarporley, england) (figure 1), equicizer (equicizer, norwalk, oh), or fully mechanized and computer integrated simulator such as mk10 racehorse simulator (racewood ltd) is frequently part of united states jockeys’ training regime and is appropriate in this stage (figure 1). on these simulators, arm motions are increased during practices to simulate “chasing” or motivation of the live horse. arm cranking in other port results in higher heart rate, heart rate variability, increase in sympathetic outflow.34-36 if a racehorse simulator is not available for any or all of the steps in the return-to-ride progression, other activities with a cardiac demand, with low risk of reinjury, i.e. elliptical or treadmill, may be utilized to achieve the target heart rate. a proposed return to ride protocol for united states jockeys following concussion 22 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 utilizing a racehorse simulator allows the ability to mimic racing through a sport-specific activity with limited risk of secondary impact or falls. additionally, to better prepare for the return-toriding and racing, riders should consider incorporating dynamic balance activities into their exercise routines. dynamic balance is a crucial component to riding and balance dysfunction is a common consequence of concussion. the bosu® pro balance trainer provides a method for training balance and stability and can be adapted to create a sport-specific training environment. riders can progress through basic balance exercises such as single leg stance to holding a low squat or “riding stance” on a foam pad and progress to using the bosu® pro balance trainer for longer periods of time, mimicking a race. in order to warrant progression to the next step, riders should be able to attain 75% of their maximum heart rate and maintain a heart rate within the zone using a racehorse simulator for ten, two-minute bouts. additionally, the rider should be able to demonstrate acceptable levels of balance. maintaining upright balance on the bosu® pro balance trainer for a minute and a half to two minutes would provide evidence of acceptable balance as the time would be equivalent to the duration of most thoroughbred horse races (figure 2). this can be done in double limb standing stance and progressing in difficulty from standing, to squatting to in a crouching position, closer mimicking the riding stance with both feet on the flat side of the bosu® pro balance trainer. added perturbations to the balancing riding stance would better assess dynamic balance while also replicating the outside influences on riding during live races. similarly to the simulated ride, this should be completed a total of ten rounds, to better demonstrate the ability to maintain repeated exercise bouts. in addition, light aerobic activity may be completed in stage 3 to increase endurance and maintain a baseline level of fitness. stage 4: high intensity sport-specific exercise during the stage 4, simulated rides should continue with the intention of increasing the heart rate to greater than 85% of the peak heart rate experienced during live racing. when returning athletes from concussions, increasing cardiovascular demands without symptom provocation continues to be the standard. thus, more challenging and sports-specific training should be added such as decision-making tasks during a simulated ride, challenges of reaction time, and continued balance training/exercises while also increasing the heart rate. this may be done through the implementation of cognitive tasks that require the rider to provide a “correct” figure 1. examples of racehorse simulators figure 2. bosu® pro balance trainer balance exercise a proposed return to ride protocol for united states jockeys following concussion 23 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 answer based on a provided stimulus or catching a ball or object thrown that they are unable to anticipate at varied speeds. successful progression from stage 4 should only occur if the rider is able to maintain the heart rate zone during another set of 2-minute riding bouts without symptoms. stage 5: return to live horse following medical clearance to return-to-riding by an appropriate licensed medical professional (i.e., md, do, ats, the return to live horse stage is the first stage in which the rider is reintroduced to the live horse. before returning to full race riding, the rider should gradually progress from breezing horses to breaking from the gate before competing in a full race, over the course of consecutive days. breezing is the term used for a “workout in which a horse is easily running under a hold without encouragement from the rider.”37 at this point, there is not a limit on the activity. it is important that the rider has restored confidence on the horse and functional skills before returning to pre-injury activity levels. this may be completed during morning workouts or at a training center, galloping and/or breezing horses. track conditions listed at least as “good” for dirt or “firm” for turf are recommended. through a gradual reintroduction to race riding, without a return of symptoms and regained confidence, riders may return to full competition. stage 6: full participation when athletes successfully complete the reintroduction to race riding without a provocation of symptoms or other unforeseen issues, it is then safe for the jockey to return to race related activities and participation in full races. in accordance with the association of racing commissioners international’s model rules of racing,28 the jockey must be cleared by a physician or licensed medical professional before returning to racing. discussion policies that protect the jockey profession are minimal in the united states, including the lack of standardized protocols to manage injury. concussion experts and groups have developed guidelines and protocols to return athletes to sport following concussion; however, these guidelines do not provide directed goals based on the physiological and biomechanical demands and unique nature of the sport of horse racing. the proposed protocol provides specific heart rate metrics and guidance on progressive activities to achieve a gradual, safe return-to-sport for horse racing jockeys. professional horse racing is a highrisk sport with unique considerations and physical demands for its athletes. with high inherent risk of injury, and documented high rates of concussions, it is imperative that professional jockeys have guidelines designed for athletes to achieve high levels of athletic activity necessary to safely compete and perform at pre-injury levels. injury management protocols not only protect the injured rider but improve the overall safety of the other horses and riders by removing riders that are not fit to ride from the field. these recommendations are consistent with the protocols of major sports organizations such as the national football league (nfl), national collegiate athletic association (ncaa), and other professional and collegiate sports. this alignment is important in making strides towards recognition that the jockey has the access to and similar protections as other sport’s athletes. previous return-to-sport progressions included graduated progressions, increasing exercise intensity, incorporating sports-specific exercise to gradually and safely return athletes to sport. metrics that are easy-to-understand and implement into practice will facilitate compliance to various post-injury policies for united states jockeys. intentionally, this protocol was designed to build on existing protocols and consider athletic a proposed return to ride protocol for united states jockeys following concussion 24 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 performance requirements. progression through the protocol, similar to other return-to sport protocols, includes a period of rest, as suggested, immediately following concussion injury, monitoring of self-reported symptoms, and the use of other assessment tools to objectively assess function.26 progression through the proposed protocol should be monitored closely and managed by a healthcare professional such as athletic trainer or sports medicine physician; adoption of this protocol highlights the importance of having these professionals available to jockeys during workouts and live racing. the presence of an athletic trainer at the racetrack presents many benefits for the racing community including the management of concussions and safely returning jockeys to sport. the versatility, skill and training position athletic trainers to be ideal and dynamic healthcare professionals suited to serve the horse racing community. this protocol sets the groundwork for putting united states jockey health at the forefront of return-to-sport considerations, limiting the risk of premature return-to-participation, and providing benchmarks through progression as well as exercises specific to the population. current literature on ncaa athletes suggests the time to return to play and time that to the symptom free window have increased over time. these data should be investigated in this population and kept in mind for clinical decision making moving forward.38 return-to-sport guidelines are only one piece to the concussion management puzzle and should be backed by standards and accrediting criteria to ensure proper implementation and practices. additionally, this protocol does not minimize the risk of concussion injury in sport, but rather provides an opportunity for improved clinical practice following concussion injury. in this protocol, heart rate as a measure of physiological demands was evaluated in racehorse jockeys during live racing in a cohort of professional jockeys, predominately male (n=29, 2 female).31 peak heart rate was documented at 187±11 beats per minute with an overall average peak heart rate of 169±10 beats per minute, demonstrating a high cardiovascular demand.31 these data support that in addition to resolution of injuries sustained in return-to-sport protocol, demonstration of high cardiovascular fitness is necessary for a safe return. heart rate is integral to assess the brain’s ability to maintain pressure changes due to increased activity, without a return or exacerbation of symptoms. exercise post-concussion is an effective strategy if heart rate is monitored to ensure that exacerbation of symptoms is not achieved.32,39 an increase in symptoms may occur with an increased heart rate because as severity of brain injuries increases, the autonomic nervous and cardiovascular systems become increasingly uncoupled.40 therefore blood flow regulations and adaptations to the disruption from concussion may explain why symptoms reappear or worsen with physical exertion or other stressors that increase blood pressure.30 this protocol is the first of this kind specific to the sport of horse racing, however limitations are based on lack of data at the population level. building on existing protocols from other sports, the recommendations for each stage are clearly linked to progression in cardiovascular exertion measured by heart rate. despite being evidencebased on live heart rate collected during competition, the sample size is small and may not be representative of all jockeys by experience level and age. we did not control the impact of social behaviors; however the potential impact should not be overlooked. the impact of social behaviors on heart rate such as weight reduction methods including intentional dehydration will alter cardiovascular output. as such, this protocol sets guidelines for optimal performance, and individual health behaviors will need to be considered in use of the guidelines. additionally, a proposed return to ride protocol for united states jockeys following concussion 25 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 4issue 3 – november 2021 other factors may influence the recovery timeframe including the various concussion pathways such as vestibular involvement or sleep difficulties. the recommended protocol meets many of the needs and fills current gaps in the thoroughbred horse racing industry and improves the safety and welfare of professional jockeys. however, the suggested protocol is not without limitations. while the authors have proposed a protocol that utilizes licensed medical professionals to monitor the progress through the stages and the safe returnto-riding , not all riders have access to the proposed level of healthcare. to better meet the needs of this unique population, racetracks should consider employing athletic trainers to provide quality healthcare to the riders and manage injuries. an additional limitation is the potential lack of access to a racehorse simulator as suggested throughout. activities that place similar demands on the body such as running or riding a stationary bike may be used in a similar way to reach the target heartrate for each stage when a simulator is not available. the suggested protocol serves as a starting point, continued efforts should work to improve and build on the work suggested to ensure the best possible protocols and practices in the sport. future iterations should examine scores on neurocognitive tests, objective balance tests, vestibular and oculomotor tests, and mental health assessments to provide a more robust evaluation and data driven return to ride criteria. clinical bottom line current concussion guidelines recommend sportspecific intensity through three stages of return-tosport following concussion. this research is important because it initiates the implementation of a graduated return-to-sport protocol, a comprehensive understanding of the recovery process, and intervention for a safe return-to-ride for professional jockeys.39 a riding simulator adds controlled, sport-specific exercise when returning a jockey to athletic performance that is based on the percentage of peak heart rate values previously established. these recommendations may also be suitable for other equine sports including but not limited to polo, show jumping, and eventing, but further evidence is necessary to establish maximal sport-specific exertion of these disciplines or other criteria that may be critical to clinical decision-making following concussion. references 1. turner m, mccrory p, halley w. injuries in professional horse racing in great britain and the republic of ireland during 1992–2000. br j sports med. 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1093659. https://doi.org/10.31622/2020/0002.4 http://dx.doi.org/10.1136/bjsports-2017-097699 http://dx.doi.org/10.1136/bjsports-2017-097699 https://dx.doi.org/10.1212%2fwnl.0b013e31828d57dd https://dx.doi.org/10.1212%2fwnl.0b013e31828d57dd https://doi.org/10.1016/j.jpeds.2017.02.072 https://doi.org/10.1016/j.jpeds.2017.02.072 https://doi.org/10.1097/jsm.0b013e3181fdc721 https://doi.org/10.1097/jsm.0b013e3181fdc721 https://doi.org/10.3389/fneur.2019.00395 https://doi.org/10.1249/mss.0000000000000852 https://doi.org/10.1249/mss.0000000000000852 https://doi.org/10.2165/11538590-000000000-00000 https://doi.org/10.2165/11538590-000000000-00000 https://doi.org/10.1007/s00421-007-0574-9 https://doi.org/10.1007/s00421-007-0574-9 https://doi.org/10.1152/jappl.1980.49.5.863 https://doi.org/10.1152/jappl.1980.49.5.863 https://doi.org/10.1136/bjsports-2019-100579 https://doi.org/10.1136/bjsports-2019-100579 https://doi.org/10.1097/htr.0000000000000252 https://doi.org/10.1097/htr.0000000000000252 https://doi.org/10.3109/02699052.2015.1093659 https://doi.org/10.3109/02699052.2015.1093659 manuscript type clinical mentorship case study 58 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 prioritizing patient-centered care when integrating athletic training students into clinical practice amber kingsley, ms, atc*; amy l. fraley, phd, scat, atc; krista m. richards, ms, scat, atc; matthew j. drescher, phd, lat, atc†; zachary k. winkelmann, phd, scat, atc, chse* *university of south carolina, columbia, sc; †north dakota state university, fargo, nd abstract athletic trainers are responsible for the patient care of student-athletes but also can be responsible for the education and mentorship of athletic training (at) students through the role of preceptor. atss require extensive first-hand clinical experiences to prepare them for autonomous practice but must first feel comfortable with the skills they have learned to apply them in clinical practice. the unique clinical experience these atss experienced was the combined experience of a graduate assistant athletic trainer preceptor who also assisted as a teaching assistant in the classroom. this allowed the preceptor to help the atss expand on the information provided in the classroom and apply it directly to clinical experiences. the atss also used standardized patient encounters to practice clinical skills in a moderated environment to improve patient care before directly treating patients. the atss at this clinical education site each had the opportunity to practice autonomously in the treatment of patients. the preceptors taught by example and allowed each student to progress independently, making clinical decisions autonomously. mock scenarios and standardized patients provided real-life clinical scenarios to the atss. these experiences helped determine the skills and knowledge that lacked proficiency and needed to be practiced before treating patients. to maximize patient-centered care, atss should be allowed to assist in daily decision-making and patient encounters until they feel ready to work more autonomously. each at student has a different learning style; early and frequent communication with atss will allow for a more beneficial clinical education experience. content focus: health professions education correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation kingsley a, fraley al, richards km, drescher mj, winkelmann zk. prioritizing patient-centered care when integrating athletic training students into clinical practice. clin pract athl train. 2023;6(2): 58-64. https://doi.org/10.31622/2023/0006.02.10. introduction athletic trainers work with various patient populations to deliver patient-centered care at the highest standard. patient-centered care is a shared decision-making process that considers patients' needs while treating them.1 this can be achieved through cultural competency, using personal pronouns, setting short and long-term goals with the patient, and using patient-reported reported outcome measures. athletic trainers typically work with patients daily and gain their trust through patient interactions. for many athletes, athletic trainers are the main point of contact when it comes to their healthcare needs. according to collegiate student-athletes, the two main strengths of athletic trainers regarding patient-centered care were providing culturally competent care and care that was respectful to what they wanted.2 these athletes also responded that they wanted the care provided to them to be individualized and for them to be treated as a priority.2 one of the six core competencies required for accredited professional athletic training programs is patient-centered care.3 the athletic training students (ats) are taught the principles of patient-centered care in the classroom and expected to implement these concepts into clinical education experiences under the guidance of the supervising athletic trainer, otherwise referred to as the preceptor. athletic trainers who serve as preceptors are tasked with the role of providing atss with mentorship and feedback in their clinical education. atss need direct clinical education experiences to improve their skills and confidence when treating patients, but the patient preference about their preferred provide must be considered when mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.02.10 prioritizing patient-centered care when integrating of athletic training students into clinical practice 59 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 being treated by an ats or their supervising athletic trainer. it is the job of this preceptor, along with the athletic training program, to determine if the at student is prepared to provide patient care and to ensure that the care they are providing is patient-centered and appropriate. research has been conducted analyzing patient satisfaction and patient-centered care of the services provided by athletic trainers. however, limited research is available on the athlete’s perception of patientcentered care provided by atss because the patient care provided falls under the preceptor's responsibility. atss need to gain experience and confidence in preparation for certification, which occurs through direct patient care. this paper aims to provide a case study on a unique clinical experience to achieve the goal of proficiency in patient-centered care by atss. athletic training student characteristics throughout the academic year, four professional-level atss were assigned to two preceptors who provided care to university of south carolina swim and dive student-athletes. the atss were all enrolled in the same post-baccalaureate athletic training program. during the fall semester, a second-year at student was present for the entirety of the semester and acted as a mentor to two different first-year atss assigned to the clinical education site. the second-year student had completed all classes for evaluation and therapeutic intervention and was able to perform injury evaluations and assist with designing treatment and rehabilitation plans. the two first-year atss were enrolled in evaluation and therapeutic intervention of lower extremity injuries and could implement evaluation and treatment skills learned in the classroom directly into clinical practice. during the spring semester, one first-year ats had completed the lower extremity orthopedic evaluation class and was learning evaluation skills for head, neck, spine, and abdominal injuries. the program curriculum is detailed in table 1 below. clinical mentor characteristics two athletic trainers were employed at this clinical education site and both served as preceptors for the students throughout the year. the patient population consisted of ncaa division 1 collegiate men’s and women’s swim and dive student-athletes aged 18 to 24 years old. the head athletic trainer was in their third year as the athletic trainer for swim and dive and has been certified for six years with previous experience working with patients in the ncaa division i, high school, and orthopedic clinic settings. the head athletic trainer had four years of previous preceptor experience. the graduate assistant athletic trainer worked with the swim and dive team for the entirety of the academic year. the graduate assistant was in their second year as an athletic trainer and had previous experience working with secondary school patients between 10 and18 years old. this was the first year of preceptor experience for the graduate assistant. in addition to their duties with the swim and dive team, the graduate assistant athletic trainer was also a teaching assistant for the first-year students in both the fall and spring semesters, assisting in the evaluation and therapeutic intervention courses while providing additional help in the lab portion of the class, proctoring exams, and grading assignments. experience the goals of this clinical experience for the atss were to implement skills learned in the classroom and to improve autonomous clinical decision-making under the supervision of assigned preceptors. the atss assigned to this clinical site both in the fall and the spring semesters experienced unique clinical prioritizing patient-centered care when integrating of athletic training students into clinical practice 60 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 table 1. professional athletic training education program curriculum year 1 classes summer human anatomy for health sciences introduction to therapeutic interventions in athletic training principles of evidence-based medicine principles of athletic training lab fall evaluation & therapeutic intervention of lower extremity injuries (+lab) behavioral health & wellness clinical experiences in athletic training i spring evaluation & therapeutic intervention of head, neck, spine, and abdomen injuries (+lab) clinical pathology & pharmacology in athletic training (+lab) transforming health care for the future clinical experiences in athletic training ii year 2 classes summer evaluation & therapeutic intervention of upper extremity injuries (+lab) emergency management practices in athletic training clinical experiences in athletic training iii fall athletic training administration advanced clinical skills in athletic training clinical experiences in athletic training iv teaching by having a preceptor (the graduate assistant athletic trainer) who was also a teaching assistant and helped educate atss in both the classroom and clinical setting. the two preceptors were able to work together to provide educational examples and different views on patient care. in the fall semester, the second-year ats mentored both first-year atss and took autonomy when writing rehabilitation programs for lower extremity injuries. the first-year atss, with the assistance of the graduate assistant athletic trainer, took the information they had just learned in class regarding lower extremity injuries and transferred that information into sport-specific demands required of the patients by designing rehabilitation plans that conformed to the needs of the sport. in the spring semester, the first-year atss had the opportunity to evaluate any lower extremity injury as they had completed that class in the fall and any spine, neck, or abdomen injuries once they learned about them in class that spring. the graduate assistant athletic trainer was able to observe in the classroom exactly how the atss were being taught and assist during additional, structured practice lab sessions to ensure the students were performing all skills correctly. the practice lab was a time for atss to review class material, including skills learned in their orthopedic evaluation and clinical pathology courses. while some atss practiced their skills and signoffs in practice lab only, the atss at this clinical site practiced evaluation and patient care skills weekly with the preceptors because the graduate assistant athletic trainer was aware of the material they were practicing in class. the graduate assistant athletic trainer would portray a patient and have the atss perform clinical skills and practice patient-centered care in a mock scenario first to offer corrections and advice before allowing the atss to work with patients. because the graduate assistant athletic trainer was present one day a week in the evaluation classes for the first-year atss, they could also implement material the atss were learning directly into clinical practice prioritizing patient-centered care when integrating of athletic training students into clinical practice 61 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 that same day. this included implementing new rehabilitation exercises, documentation, range of motion and special tests, and conversations reviewing classroom material and applying it to real-life experiences and patients. by observing the atss working one-on-one with a patient, even in a mock scenario, the graduate assistant athletic trainer was able to find ways to improve the atss’ patient care and help implement these improvements directly into clinical practice. as the atss became more proficient in their clinical skills, as graded on a 0-2 point scale (0 being could not complete, 1 being able to complete skill but not proficiently, and 2 being proficient application of clinical skill), the preceptors allowed the atss to become more involved in the decision-making process of patient care instead of directing the atss with what to do. the professional master’s athletic training program also uses a standardized patient (sp) encounter as a part of the evaluation and treatment education courses. a sp is a layperson evaluated by the ats and pretends to have a certain injury/illness.4 these encounters can be observed via webcam, so the simulation is realistic for the student, providing additional training and practice in real-life scenarios in a moderated environment. the role of the graduate assistant athletic trainer was to watch the live recording of the sp encounters and provide feedback and grading to the atss as part of the teaching assistant duties. results and discussion outside of providing patient care, another potential part of an athletic trainer’s job is to educate atss about the profession by working as a preceptor. atss work with their preceptors to gain confidence in patient care by implementing core competencies required for certification. atss have shown that they do implement core competencies in their patient encounters.5 in a study examining atss, as the number of patient encounters for each ats increased, the total number of core competencies students used in clinical practice also increased.5 it was also found that patient-centered care was the most likely core competency implemented into the clinical practice of these students.5 the atss had many opportunities to use patientcentered care throughout their time with the swim and dive clinical experience as they became more comfortable performing clinical skills practiced with the preceptors. the atss were tasked with leading rehabilitation sessions with patients and performing evaluations on areas of the body they had already learned once they demonstrated competence in these areas. the ats in the spring semester was apprehensive when taking the initiative and working autonomously and relied on the guidance of the preceptors when making all clinical decisions. this ats was limited to gaining firsthand experience as they were in class four days a week during open treatment/clinic hours at the clinical site. in addition, this ats had fewer real-life evaluations because the teams were in their off-season for most of the clinical rotation. to supplement the ats’s learning, the preceptors implemented mock clinical scenarios throughout the week to allow the ats to practice evaluation and treatment skills. the preceptors at this clinical site allowed both the firstand second-year students as much autonomy while treating patients as the atss were comfortable with. according to a survey of approved clinical instructors (former term to describe preceptor), most reported that the professional athletic training program required students to be evaluated on clinical proficiencies in a controlled classroom setting before allowing them to practice on actual patients.6 as the atss develop their clinical skills through the classroom, they also practice those skills on patients at assigned clinical sites once the preceptor determines the professional students are ready. there is a balance in allowing atss to gain direct clinical experience while also putting the patient’s needs and safety first when students do not have enough experience to provide a practical evaluation. the roles of the preceptors at this clinical education site were to determine when the atss were ready to provide autonomous patient care, determined by competence in clinical skills and ability to determine clinical decisions. in the second semester, the ats struggled to take initiative with patient care, prioritizing patient-centered care when integrating of athletic training students into clinical practice 62 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 and the preceptors were flexible when allowing more time and resources and better address that individual at student’s needs through additional mock scenarios before they were ready to provide patient care to student-athletes. although the ats was less involved with direct patient care, the preceptors ensured the involvement of the ats when designing rehabilitation and treatment plans, using concepts taught in the classroom and explaining how they correlated to clinical practice. from the ats’s perspective, preceptors who allow students to grow in their clinical practice of critical thinking, decision-making, and independent thought help with their transition to autonomous clinical practice.7 it was found that atss benefited the most from and implemented the most core competencies when they assisted their preceptor during a patient encounter versus just observing or working independently.5 by assisting their preceptors, the atss were corrected and followed the lead of their preceptors when providing patient-centered care. allowing atss to be part of the decision-making process allows them to develop these skills. in a study examining patient outcomes after treatment performed by atss, there was no difference in the functional improvement of the patient when comparing treatment performed by atss in their first clinical internship versus those in their second.8 atss can provide patient care regardless of whether they are in the first or second year of their athletic training program and will benefit from gaining hands-on experience early in their education. being able to apply skills they learn in the classroom to “real-world athletic training learning experiences” is important to the ats’s education and development of confidence in themselves and their skills.9 each ats at this clinical education site learned best in different ways. the second-year student was proficient in most of their clinical skills and abilities but lacked confidence when making clinical decisions and looked to the preceptors for answers to specific treatment and exercises to do with patients. toward the end of the semester, the second-year ats was performing full evaluations, writing rehabilitation and treatment plans for patients, and conversing with coaches. this ats learned best through experience and was pushed to work outside their comfort zone to make clinical decisions autonomously. all three first-year atss learned best through collaborative practice, working with a preceptor to provide treatment and make clinical decisions. however, they all progressed throughout the clinical rotation to become more confident in their patient care choices. they became competent in clinical skills practiced at this clinical education site. other healthcare professions recognize the importance of teaching patient-centered care to their students and residents. in a survey among pharmacy residents, the program used interviews with veterans to improve patient-centered care.10 the residents reported that through the interview process, they helped create positive relationships with patients and improved upon their personal skills as a clinician.10 for medical school students, those in their clinical years of education had a more positive perspective towards empathy and, in turn, had better support toward patient-centered care.11 the results of this study show that as atss increase time in clinical education with patient interaction, they can incorporate more components of patient-centered care into their clinical practice and improve relationships with patients. however, medical students spend a great deal longer immersed in a clinical experience than atss do, forcing atss to develop communication and clinical skills much quicker. there is a lack of time and real-life opportunities for these atss to provide evaluations for various medical conditions and injuries.6 medical students participating in their clerkship rotation with clinical experience ranging from zero to 10+ previous clinical rotations recognized the impact of patient-centered care on patients and medical professionals.12 these students were aware that care that is individualized to the patient creates shared responsibility and decision-making between the patient and the health care provider.12 atss benefit from assisting their preceptor during patient encounters, meaning that the preceptor and ats can work as a team to evaluate athletes to ensure that the care provided is appropriate while allowing the ats firsthand experience.5 prioritizing patient-centered care when integrating of athletic training students into clinical practice 63 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 there has been an increased use of sp encounters as part of the clinical education of healthcare professionals. in a study on nursing students regarding the use of a sp encounter, it was found that those nursing students who participated found it to be more realistic when compared with using a simulated patient or mannequin.13 these nursing students also reported increased self-confidence after participating in the sp encounter.13 the atss are individually evaluated on their clinical skills using sp encounters several times throughout their two years in the education program. usiing the information gained from observing the atss in the sp encounters, the graduate assistant athletic trainer could implement specific skills or focuses that the atss struggled with during weekly practice sessions and daily encounters with patients. the sp encounter allows the ats to fully evaluate a patient, determine a diagnosis and treatment plan, and practice patient-centered care without the assistance of a preceptor. the use of sp encounters can help increase confidence in healthcare students by allowing them to perform a full evaluation autonomously and in a safe environment before clinical practice. clinical teaching bottom line patient-centered care can be improved among atss by implementing the core competencies during clinical education. this can be achieved by observing and working with preceptors in clinical practice. the safety and well-being of the patient are the priority of the healthcare provider; to prepare atss for autonomous clinical practice, they must be introduced to clinical situations and decision-making regarding patient care. it is always important to put the best interests of the patient first, and before any patient encounters, the athletic trainer should confirm with the patient that they are comfortable with atss assisting and providing patient care. being able to provide continuity of learning from the classroom to the clinical site can help improve atss’ retention and implementation of clinical skills and practice. still, as clinical educators, preceptors should strive to include atss in the patient care and decision-making process rather than relying solely on observation. each ats will learn best in different ways, and good communication and flexibility are required on the preceptor’s part to be an effective teacher. the recommendations for clinical practice based on the research to maximize patient-centered care and the ats’s experience are to allow atss to assist in daily decision-making, and patient encounters until they feel ready to work more autonomously. the professional athletic training educational program can also utilize sp encounters in didactic education to help create scenarios that atss might not see in clinical practice to give them a variety of experiences and practice in a controlled environment. further, athletic training programs should encourage the integration of preceptors into didactic education to enhance the connection between classroom and clinical education. the most important aspects of being a preceptor are good communication with the ats, instilling confidence in these students by providing constructive feedback, and allowing them to successfully practice their skills with proper guidance to prepare them for autonomous practice. atss are the profession's future and must obtain the skills to provide patient-centered care. references 1. mead n, bower p. patient-centeredness: a conceptual framework and review of the empirical literature. soc sci med. 2000;51(7):1087-1110. https://doi.org/10.1016/s0277-9536(00)00098-8. 2. redinger as, winkelmann zk, eberman le. collegiate student-athletes' perceptions of patientcentered care delivered by athletic trainers. j athl train. 2021;56(5):499-507. https://doi.org/10.4085/130-20. 3. professional program standards. caate. https://caate.net/programs/professional/professionalprogram-standards. https://doi.org/10.1016/s0277-9536(00)00098-8 https://doi.org/10.4085/130-20 prioritizing patient-centered care when integrating of athletic training students into clinical practice 64 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 4. howley ld. standardized patients. in: the comprehensive textbook of healthcare simulation. springer; 2013:173-190. 5. cavallario jm, van lunen bl, hoch jm, hoch m, manspeaker sa, pribesh sl. athletic training student core competency implementation during patient encounters. j athl train. 2018;53(3):282-291. https://doi.org/10.4085%2f1062-6050-314-16. 6. armstrong kj, weidner tg, walker se. athletic training approved clinical instructors' reports of realtime opportunities for evaluating clinical proficiencies. j athl train. 2009;44(6):630-638. https://doi.org/10.4085%2f1062-6050-44.6.630. 7. walker se, thrasher ab, mazerolle sm. exploring the perceptions of newly credentialed athletic trainers as they transition to practice. j athl train. 2016;51(8):601-612. https://doi.org/10.4085/1062-6050-51.9.12. 8. lebel fb, demont r, eberman le, dover gc. patient outcomes after treatment by athletic therapy students. j athl train. 2021;57(4):360-370. https://doi.org/10.4085/1062-6050-0589.20. 9. young a, klossner j, docherty cl, dodge tm, mensch jm. clinical integration and how it affects student retention in undergraduate athletic training programs. j athl train. 2013;48(1):68-78. https://doi.org/10.4085%2f1062-6050-48.1.22. 10. nathan s, woolley ab, finlay l, moye j. teaching pharmacy students and residents patient-centered care through interviewing veterans. am j pharm educ. 2021;85(8):8384. https://doi.org/10.5688/ajpe8384. 11. michael k, dror mg, karnieli-miller o. students' patient-centered-care attitudes: the contribution of self-efficacy, communication, and empathy. patient educ couns. 2019;102(11):2031-2037. https://doi.org/10.1016/j.pec.2019.06.004. 12. boggiano vl, wu y, bruce js, merrell sb, schillinger e. patient-centered care challenges and surprises: through the clerkship students' eyes. fam med. 2017;49(1):57-61. 13. johnson kv, scott al, franks l. impact of standardized patients on first-semester nursing students selfconfidence, satisfaction, and communication in a simulated clinical case. sage open nurs. 2020; 6:2377960820930153. https://doi.org/10.1177/2377960820930153. https://doi.org/10.4085%2f1062-6050-314-16 https://doi.org/10.4085%2f1062-6050-44.6.630 https://doi.org/10.4085/1062-6050-51.9.12 https://doi.org/10.4085/1062-6050-0589.20 https://doi.org/10.4085%2f1062-6050-48.1.22 https://doi.org/10.5688/ajpe8384 https://doi.org/10.1016/j.pec.2019.06.004 https://doi.org/10.1177/2377960820930153 abstract manuscript type clinician expertise commentary 73 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 concussion clinical pathway: headache and cervical assessment framework nicholas hattrup, ms, atc*; nicholas pfeifer, edm, atc†; tamara valovich mcleod, phd, atc, fnata‡ *university of oregon, eugene, or; †athletic training services, boston university, boston, massachusetts; ‡athletic training programs and school of osteopathic medicine, a.t. still university, mesa, az abstract the prevalence of sport specialization is a common concern in contemporary youth sports and has been linked to potential negative physical and psychological effects for developing athletes. while the evidence regarding negative physical effects, such as overuse injury, are consistent in the literature, the psychosocial outcomes are unclear due to the lack of published studies on the topic. specialization is thought to lead to added stress, which may affect an athlete’s mental health, whereas athletes who sample multiple sports are believed to have a healthier psychosocial experience. burnout is characterized as physical and emotional exhaustion, sport devaluation and a reduced sense of accomplishment in athletics. this guiding review evaluates the evidence regarding burnout levels between specializers and samplers. two of the articles included in the review directly assessed burnout in samplers vs specializers and noted inconsistencies in higher burnout rates. the six other articles studied burnout only in specializers by indirectly assessing burnout through perfectionism, fear of failure, motivation, and drop out. the comparisons of these variables illustrated heightened burnout in athletes who specialize. the results from these studies provide moderate evidence for recommendations that athletes should delay specializing in one sport. content focus: health care competency correspondence nicholas hattrup, boston university athletic training services, 285 babcock street, boston, ma 02215. e-mail: sa199462@atsu.edu twitter: @_nhattrup full citation hattrup n, pfeifer n, valovich mcleod t. concussion clinical pathway: headache and cervical assessment framework. clin pract athl train. 2023;6(1): 73-79. https://doi.org/10.31622/2023/0006.01.11. background the emphasis on the identification of vestibular-oculomotor dysfunction following concussion has brought attention to impairments associated with headache disorders and the cervical spine. utilizing a classificationbased approach for headaches can help to identify impairments associated with a patient’s headache.4 furthermore, encouraging the importance of impairments for headache disorders following concussion may help to adopt organized treatment approaches. a previous study identified athletic trainers who perceived a greater importance in identifying cervical impairments were more likely to use an intervention targeted the cervical spine following a concussion.1 the reassessment of the cervical spine to ultimately treat concussive symptoms is needed due to the potential presence of cervical impairments with symptoms of headaches and dizziness. creating a systematic approach to the assessment of headache disorders while acknowledging regional influences such as the cervical spine may help clinicians in implementing headache assessments. the purpose of this article is to describe the various differentials for headache disorders following a concussion, as well as the contributions of the cervical spine to headache and dizziness symptoms. clinical assessment when examining the cervical spine for possible symptom generators, various neurological and orthopedic impairments can generate headache and dizziness symptoms. the following sections will discuss headache and migraine disorders defined by the internal classification of headache disorders as well as regional dysfunctions of the cervical spine (i.e., cervical facet pain and cervicogenic dizziness).4 headache and migraine disorders mailto:sa199462@atsu.edu https://doi.org/10.31622/2023/0006.01.11 concussion clinical pathway: headache and cervical assessment framework 74 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the international classification of headache disorders (ichd) has developed criteria for the assessment of primary and secondary headaches,4 with secondary headaches caused by a co-presenting disorder.4 an example of a secondary headache disorder, is a post-traumatic headache which occurs in close temporal relation to the site of trauma or injury.4 various presentations of post-traumatic headache can occur, including cervicogenic headache, tension-type headache, headache attributed to cervical myofascial pain, occipital neuralgia, cluster headache, headache attributed to temporomandibular disorder, headache attributed to eye disorders, medication overuse headache and migraines (table 1). classification of headaches in patients with cervicogenic headache, the symptoms present unilateral with symptom location wrapping from the base of the skull around the ear to the lateral eye (i.e., ram’s horn sign).4 the clinical assessment of this pathology follows a local assessment to the cervical spine, with the addition of a cervical flexion rotation test as it is shown to have high discriminatory ability to identify cervicogenic headache.3 tension-type headaches usually present bilaterally with patient descriptors of “pressing” or “tightening” with non-pulsating quality.4 of importance, the absence of nausea and vomiting is important as if these symptoms are present, it may indicate migraine like symptoms.4 when utilizing pharmacological intervention, the use of ibuprofen early on either alone or in conjunction with acetaminophen has shown better outcomes than the use of acetaminophen alone for tension headaches.7 regarding headaches attributed to cervical myofascial pain, the headaches often start in relationship to the onset of cervical myofascial pain and pressure on the involved cervical muscles may increase the headache intensity. 4 in patients with occipital neuralgia, the presentation can be unilateral or bilateral within the sensory distribution of the greater, lesser and/or third occipital nerves.4 patients will describe recurring paroxysmal attacks lasting for a few seconds, severe in intensity, and shooting, stabbing, or sharp in quality.4 additionally, tenderness over the affected occipital nerve branches and/or trigger points at the emergence of the greater occipital nerve should be present. 4 while uncommon, there has been anecdotal cases of cluster headaches following traumatic head injury which is described as a unilateral headache presenting over the orbits and supraorbital region lasting from 15180 minutes. 4 an important distinction of this headache is the presentation of ipsilateral cranial autonomic for example forehead and facial sweating. 4 with headaches attributed to temporomandibular disorder, the headache presents in relationship to a temporomandibular disorder and is aggravated by active and passive movement of the jaw along with the palpation of muscles associated with mastication 4 typically, the headache is most prominent in the temporal regions, preauricular areas of the face, and/or masseter muscles.4 when patient’s present with temporomandibular disorders assessment of the atlantooccipital and atlantoaxial joint should be performed, previous research has identified co-morbid impairments within the upper cervical spine in temporomandibular disorders with headaches.8 headaches can often be accompanied with visual deficits or decreased oculomotor function. with headaches attributed to eye disorders, the patient may complain of either blurred vision, diplopia, or difficulty switching from near to far focus.4 this headache will be aggravated by sustained visual tasks and improve with the concussion clinical pathway: headache and cervical assessment framework 75 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 cessation of the visual task.4 these types of headaches are best resolved with treatment and improvement of the visual impairment whether it be refractive error, oculomotor phoria, or other oculomotor impairments indicating the need for optometric assessment.4 patients that have been taking over the counter medication for an extended period following their injury and continue to present with a headache may present with medication over-use headache. patients with medication-overuse headaches typically present with a headache occurring greater than or equal to 15 days/month with a pre-existing headache disorder and regular overuse of analgesic medication for greater than 3 months. 4 migraine it is important for providers who treat patients following concussion to realize a subset of patients may present with a headache with migraine like symptoms.9 a main difference in the assessment and treatment of migraines is with migraines the focus is on reducing the frequency of migraine episodes through the identification and avoidance of personal and environmental triggers. the clinical criteria for migraine with and without aura (i.e., sensory disturbances) can be found in table 1. in recent years, cervical afferents within migraine disorders have been identified as an important regional impairment.10 at this time there is no gold standard clinical approach to the physical assessment of cervical impairments in migraine disorders, therefore a comprehensive cervical spine assessment should be performed.10 treatments which have shown promise for the reduction of migraine symptoms and episodes span from the use of medications, dry needling, botulinum toxin injections, and lifestyle modifications (i.e., diet and fitness). regional influences pain from the cervical facet joints has been shown to radiate into the upper thoracic spine as well as the posterior skull. specifically, c2-c4 can generate pain in and around the occiput, temporalis, and trapezius regions. currently when examining the facet joints, the extension rotation test and unilateral posterior to anterior mobilizations eliciting the patient’s symptoms (i.e., concordant sign) have shown the most clinical utility to identify cervical facet dysfunction.5 if patients present with pain stemming from the cervical facet joint, joint mobilization and/or manipulation of the cervical spine as well as targeted treatment to the tonic (i.e., spastic) musculature has shown promise.3 when examining the upper cervical spine, an important dysfunction to consider is cervicogenic dizziness since it may present alone or in conjunction with vestibular dysfunction. for cervicogenic dizziness the cause of dizziness stems from impairment of the upper cervical structures which can influence both the oculomotor and vestibular systems causing generalized dizziness. the assessment of cervicogenic dizziness should utilize a multi-clinical test framework. the use of the head neck differentiation test can indicate the presence of possible cervical involvement, while the use of the cervical neck torsion test and smooth pursuit neck torsion test can assess the influence of the upper cervical afferent system on oculomotor control.6 further, the use of the cervical joint position error test can determine sensorimotor impairment.6 when creating a treatment plan for a patient with cervicogenic dizziness, joint mobilization and manipulation targeted to the upper cervical, soft tissue mobilization, and/or dry needling have shown promise.3 active exercises to reestablish kinesthetic sense should be prescribed in conjunction with passive interventions, furthermore oculomotor/head-shake exercise has shown promise for treating cervicogenic dizziness.3 concussion clinical pathway: headache and cervical assessment framework 76 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 sinister pathology while the focus of this article is on the post-acute identification of headache disorders, and the contribution of the cervical spine to headaches and dizziness, readers should understand severe pathology such as table 1. characteristics of migraines and headaches aura site characteri stics aggravating factors nausea or vomiting photo or phono phobia autonom ic features migraine possible unilateral pulsatile movement yes yes yes, subtle tension no bilateral: band like pressure, tightening sensations movement no no no cervicogenic no unilateral: occipital to orbital region tightening, burning sensations head movement no no no medication overuse no diffuse (nonspecific) pressing, tightening, pulsating pain no no no no cluster no unilateral: orbital, supra-orbital, temporal regions stabbing pain no maybe maybe yes occipital neuralgia no unilateral/bila teral: greater, lesser, third occipital nerve regions shooting, stabbing, sharp pain palpation no no no headache attributed to temporomandi bular disorder no unilateral/bila teral: temporal, preauricular, or masseter regions variable jaw movement no no no headache attributed to eye disorder no unilateral/bila teral: orbital and frontal regions variable visual & oculomotor tasks no no no headache attributed to cervical myofascial pain no unilateral/bila teral: pain referral regions from neck and/or face musculature variable referred pain from muscle palpations no no no concussion clinical pathway: headache and cervical assessment framework 77 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 fractures, vascular and ligament injuries as potential differentials. the canadian c-spine rules and international federation of orthopedic manipulative physical therapists vascular framework are useful resources for the assessment of severe osseous and vascular pathologies.2,3 without a gold standard clinical test for upper cervical spine integrity,3 if upper cervical spine instability is suspected, flexion, extension and odontoid x-ray views should be ordered to rule out serious pathology to the ligament structures. outline of evaluation while the above information provides a broad overview of headache disorders, a simple streamlined evaluation can differentiate headache disorders (figure 1). the post-acute clinical assessment of a patient with a headache following a concussion should consider the mechanism of injury and comorbid symptoms. if the mechanism were traumatic, but the patient has full range of motion of the neck they would be considered low risk for cervical fracture based on the canadian c-spine rules and a further cervical assessment should continue. next, determining if the patient has any possible signs (e.g., changes in blood pressure, carotid artery auscultation differences) and symptoms (e.g., ataxia, weakness, dysphasia, dysarthria, and aphasia) necessitating further examination for vascular pathology is important.2 if it is determined the patient is at a low risk for vascular pathology, the next consideration is upper cervical instability. while the use of sharppurser and transverse ligament selective tissue tests may be sensitive for upper cervical instability, they should be interpreted with caution due to low clinical utility in ruling out pathology.3 lastly, an upper quarter and lower quarter screen could be performed to assess reflexes, myotomes, and dermatomes. further assessment should be informed by the patient’s clinical presentation. understanding if the headache is unilateral versus bilateral would help to differentiate tension-type headache versus other headache disorders. additional key history information of prolonged analgesic use for headaches, worsening symptoms with oculomotor tasks which resolve after activity, and sharp intense headaches over the orbit and forehead area with facial sweating may suggest other headache disorders. the patient should be seated at the start the evaluation to complete range of motion and if dizziness is present, the assessment could include the head-neck differentiation test, cervical neck torsion test, smooth pursuit neck torsion test, and/or joint position error assessment before further manual physical examination is completed to decrease patient irritability. lastly, if the patient describes the headache in the area where a cervical facet joint can generate pain in the lower occiput and temporal regions, the extension rotation assessment could be performed in the same position. once these assessments are performed, palpation of the greater and lesser occipital nerves along with the sub-occipital and trapezius muscles in sitting can be completed. following this the patient can be placed in supine where the clinician can assess cranial cervical flexion and perform the cervical flexion rotation test for cervicogenic headache. in this position palpation of the orofacial muscles (i.e., temporalis, masseter, and pterygoid) are recommended to be performed. the patient can then be placed in a prone position where unilateral posterior to anterior mobilizations can be performed if further assessment for cervical facet and migraine is warranted. while the above examination is inclusive of the various headache and migraine disorders discussed, clinical expertise and judgement should be used to determine which assessments should be performed and which differentials should be considered. the data obtained from the patient’s history should help with planning for the physical examination as well as the specific order and priority for testing. decreasing the potential concussion clinical pathway: headache and cervical assessment framework 78 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 figure 1. evaluation flow chart concussion clinical pathway: headache and cervical assessment framework 79 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 for patient irritability when performing a physical examination is important to reduce the confounding results throughout the physical examination. lastly, various outcome measures can be utilized to gauge patient disability, treatment effectiveness, and monitor patient progress.11 interventions for post-traumatic headache are diverse consisting of cognitive behavioral therapy, massage, non-steroidal and steroidal medications, aerobic and therapeutic exercise, as well as manual therapy and dry needling based on the impairments. for patients with persistent headache or migraine symptoms a multidisciplinary approach may be warranted. conclusion like other pathways for concussion assessment, further assessment of headaches can allow for more targeted treatment. the use of an appropriate history and physical examination with consideration of differentials may help to improve outcomes, especially in the presence of headache disorders and cervical impairments. references 1. cheever k, kay m. certified athletic trainers’ use of cervical clinical testing in the diagnosis and management of sports-related concussion. j sport rehab. 2021;30(6):926-934. https://doi.org/10.1123/jsr.2020-0394. 2. de best rf, coppieters mw, van trijffel e, et al. interexaminer agreement and reliability of an internationally endorsed screening framework for cervical vascular risks following manual therapy and exercise: the go4safe project. phys ther. 2021;101(10). https://doi.org/10.1093/ptj/pzab166. 3. blanpied pr, gross ar, elliott jm, et al. neck pain: revision 2017. j orthop sports phys ther. 2017;47(7):a1-a83. https://doi.org/10.2519/jospt.2017.0302. 4. headache classification committee of the international headache society. the international classification of headache disorders, 3rd edition. cephalalgia. 2018;38(1):1-211. https://doi.org/10.1177/0333102417738202. 5. schneider gm, jull g, thomas k, et al. derivation of a clinical decision guide in the diagnosis of cervical facet joint pain. arch phys med rehabil. 2014;95(9):1695-1701. https://doi.org/10.1016/j.apmr.2014.02.026. 6. reiley as, vickory fm, funderburg se, cesario ra, clendaniel ra. how to diagnose cervicogenic dizziness. arch physiother. 2017;7(1):12. https://doi.org/10.1186/s40945-017-0040-x. 7. petrelli t, farrokhyar f, mcgrath p, et al. the use of ibuprofen and acetaminophen for acute headache in the postconcussive youth: a pilot study. paediatr child health. 2017;22(1):2-6. https://doi.org/10.1093/pch/pxw011. 8. grondin f, hall t, laurentjoye m, ella b. upper cervical range of motion is impaired in patients with temporomandibular disorders. cranio. 2015;33(2):91-99. https://doi.org/10.1179/0886963414z.00000000053. 9. lucas s, hoffman jm, bell kr, dikmen s. a prospective study of prevalence and characterization of headache following mild traumatic brain injury. cephalalgia. 2014;34(2):93-102. https://doi.org/10.1177/0333102413499645. 10. liang z, thomas l, jull g, treleaven j. cervical musculoskeletal impairments in migraine. arch physiother. 2021;11(1):27. https://doi.org/10.1186/s40945-021-00123-0. 11. valovich mcleod tc, vesci b. concussion profiles: moving beyond the graded symptom scale. clin pract athl train. 2022;5(1). https://doi.org/10.31622/2022/0005.01.5. https://doi.org/10.1123/jsr.2020-0394 https://doi.org/10.1093/ptj/pzab166 https://doi.org/10.2519/jospt.2017.0302 https://doi.org/10.1177/0333102417738202 https://doi.org/10.1016/j.apmr.2014.02.026 https://doi.org/10.1186/s40945-017-0040-x https://doi.org/10.1093/pch/pxw011 https://doi.org/10.1179/0886963414z.00000000053 https://doi.org/10.1177/0333102413499645 https://doi.org/10.1186/s40945-021-00123-0 https://doi.org/10.31622/2022/0005.01.5 abstract manuscript type evidence-to-practice review 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 the influences of the religious tradition of ramadan on dietary intake and body composition in adolescent athletes: an evidence-topractice review regina a. duncan, ms, scat, atc*; shannon e. ryan, ms, scat atc‡; erin m. watlington ms, atc†; nancy a. uriegas, ms, scat, atc§; zachary k. winkelmann, phd, scat, atc, chse§ *prisma health orthopedics, columbia, sc; ‡cintas, albany, ny; †quarterline, joint base lewis-mcchord, wa; §university of south carolina, columbia, sc abstract when participating in the religious tradition of ramadan, the body is subject to changes that adjust an athlete's regimented dietary intake. the guiding systematic review and meta-analysis were conducted to gather the results of the limited research on the effect of ramadan observance on body mass, body composition, and dietary intake in adolescent athletes. data were extracted from two different databases, and a search through several journals exploring body mass and/or body composition and/or dietary intake was conducted. the methodological quality of each study was assessed via qualsyst. no significant differences were found when comparing the body mass, body composition, body fat percentage, lean mass, and dietary intake pre-ramadan and throughout ramadan. body mass remained unchanged from pre-ramadan to the first week of ramadan, from pre-ramadan to the second week of ramadan, or from pre-ramadan to the fourth week. body composition did not change from pre-ramadan to the first week of ramadan or from pre-ramadan to the fourth week of ramadan. body fat percentage did not change from pre-ramadan to the second week of ramadan or from pre-ramadan to the fourth week of ramadan. lean body mass was unchanged from pre-ramadan to the fourth week of ramadan. finally, the dietary intake of total energy, fat, protein, carbohydrates, and water did not change throughout ramadan. therefore, adolescent athletes continuing to train throughout the duration of ramadan observance has no effect on body mass or composition and dietary intake. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation duncan ra, ryan se, watlington em uriegas na, winkelmann zk. the influences of the religious tradition of ramadan on dietary intake and body composition in adolescent athletes: an evidence-to-practice review. clin pract athl train. 2023;6(2): 21-27. https://doi.org/10.31622/2023/0006.02.3 original reference trabelsi, k, ammar a, boukhris o, et al. effects of ramadan observance on dietary intake and body composition of adolescent athletes: systematic review and meta-analysis. nutrients, 2020;12(6): 1574. summary clinical problem and question athletic success is often defined as an athlete’s performance on the field; however, several other factors contribute to one’s success. many athletes look to elevate their performance by turning to controllable and manipulatable factors such as body mass and composition. body composition is the percentage of fat, bone, and muscle in one’s body, whereas body mass index is a representation of one’s weight and height.1 these factors have been linked to a possible increase in performance outcomes when maintaining a low-fat mass and a high value of lean mass in athletic performance.1 therefore, optimizing intake, type, quantity, and timing of specific foods, fluids, and supplements is widely used across the athletic population to improve performance outcomes.1 however, these variables need to be highly individualized from athlete to athlete while maintaining positive dietary behaviors. not only does each sport have specific demands, but each athlete does as well. therefore, their own optimal body composition and mass will need to reflect these mailto:winkelz@mailbox.sc.edu the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 individual factors. recognizing this need between athletes and being able to adjust body mass and composition in accordance with proper dietary intake is a significant factor in athletic success. ramadan, observed during the 9th month of the islamic calendar, is a muslim tradition that requires anyone in observance to abstain from eating, drinking, and sexual activity from sunrise to sunset over a 29–30-day period.1,14,15 the observance is in commemoration of muhammad’s first revelation and is regarded as one of the five pillars of islam.1 during the observance of ramadan, an individual’s body may go through several changes to adjust to the new dietary demands. the known bodily change is significant to note in pubescent athletes who are under higher-than-normal physical demands during their sports training. therefore, these athletes may experience difficulty in performance training adaptations during ramadan due to less-thanoptimal training conditions.1 this period of change can impact dietary intake, body composition, and physical performance due to diet modifications to accommodate late-night training.1 additionally, pubescent athletes at this stage in life often rely on others for the purchase and preparation of foods due to their young age and lack of nutritional knowledge, which may lead to unhealthy eating habits placing an increased emphasis on the importance of monitoring changes during the observable period of ramadan.1,18-22 the evaluation of the effects of ramadan observance on the adolescent athlete’s body mass, body composition, and dietary intake is essential to note for athletic trainers working with youth and pediatric patients. therefore, the primary clinical question of the guiding systematic review and analysis was to evaluate the effects of ramadan observance on body mass, body composition, and dietary intake in adolescent athletes.1 summary of literature existing literature included in the guiding systematic review was chosen based on predetermined criteria to encompass the scope of the clinical question best. inclusion criteria were defined as studies 1) written in english and french languages, 2) published or accepted for publication in peer-reviewed journals, 3) investigated athletes continuing to train during ramadan observance, 4) included athletes 10-19 years old, and 5) were observed during the entire month of ramadan.1 exclusion criteria were defined as descriptive or review articles, conference proceedings, and articles based on sedentary or obese individuals. included articles must have assessed dietary intake made by a nutritionist and body mass and/or body composition. an initial search of electronic databases, pubmed, and web of science resulted in 40 potential studies. following the literature search, 45 articles were identified, including five additional sources cited in the 40 identified initially. once duplicate articles were removed, 36 remained. after screening the full texts and related citations, 12 studies were included in the guiding systematic review, totaling 192 male athletes ranging from 13 to 19 years old. the authors examined the methodological quality of the twelve quantitative studies using the qualsyst assessment tool. the guiding systematic review was the first to analyze the effects of ramadan observance on body mass, body composition, and dietary intake in adolescent athletes. summary of outcomes the authors from the guiding systematic review and meta-analysis examined the effects the religious month of ramadan has on body mass, body composition, and dietary intake in adolescent athletes between the ages of 10 and 19.1 of the twelve studies included in the systematic review and meta-analysis, eight studies reported data for body mass and seven studies reported data for body composition.2-13 body fat was measured in one study6 using a foot-to-foot bioelectric impedance analyzer and the remaining studies used a skinfold caliper.4-7,10,13 of the twelve studies included in the systematic review and meta-analysis, ten studies assessed dietary intake by assessing at least one component of the participant's dietary diary (table 1).3-8,10,11,13,14 components that were considered for assessment were caloric intake, proteins, fat, carbohydrate, and water intake. overall, the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 three studies examined caloric intake only,6,11,14 one study assessed caloric intake and water intake,5 two studies examined caloric intake, proteins, fat, and carbohydrate intake,7,8 and four studies examined caloric intake, proteins, fat, carbohydrate, and water intake.3,4,10,12 dietary diaries were used to record dietary intake for all participants in the ten studies.3-8,10,11,13,14 two studies used a 2-day dietary diary without an interview by a trained nutritionist,6,11 two studies used a 3-day dietary diary with an interview by a trained nutritionist,10,12 two studies used a 3-day dietary diary without an interview by a trained nutritionist,3,14 and four studies used a 7-day dietary diary without an interview by a trained nutritionist.4,5,7,8 table 1. participant dietary diary outcomes studies dietary intake assessed dietary diary / interview with nutritionist aziz et al.2 aziz et al.3 caloric, proteins, fat, carbohydrate, water 3-day dietary diary & no interview bouhlel et al.4 caloric, proteins, fat, carbohydrate, water 7-day dietary diary & no interview bouhlel et al.5 caloric, water 7-day dietary diary & no interview güvenç6 caloric 2-day dietary diary & no interview hammouda et al.7 caloric, proteins, fat, carbohydrate 7-day dietary diary & no interview hammouda et al.8 caloric, proteins, fat, carbohydrate 7-day dietary diary & no interview maughan et al.10 caloric, proteins, fat, carbohydrate, water 3-day dietary diary & interview meckel et al.11 caloric 2-day dietary diary & no interview zarrouk et al.12 caloric, proteins, fat, carbohydrate, water 3-day dietary diary & interview zarrouk et al.13 aloui et al.14 caloric 3-day dietary diary & no interview findings and clinical application a total of twelve studies were included, with participants residing in tunisia, turkey, singapore, morocco, and israel. furthermore, the mean age for the participants of the studies ranged from 15 to 19 years, and they predominately participated in soccer (n=6)3,6,7,9-11and karate (n=4),5,8,12,13 other sports included were boxing,4 martial arts,2 running,9 and basketball.3 the number of training sessions ranged from 3-7 across the studies, the duration was between 1-2 hours, and not all studies reported the time of day of training of those who did two reported training before breaking the fast3,10 and four trained after breaking the fast.6,7,12,13 overall, four outcomes were measured to examine the effects ramadan has on the human body over the course of participating in the observance of ramadan. the outcomes examined were body mass, body composition (i.e., fat mass, fat percentage), lean mass, and dietary intake (i.e., total caloric intake, macronutrient intake, fluid intake).1 outcome 1 – body mass the body mass of a varying number of participants was assessed before the start of ramadan and after either one, two, or four weeks of fasting. there were no significant changes to body mass from before ramadan to the first week of ramadan fasting.1 at one week, body mass was reported to have no changes in five studies,3,5,6,9,12 a decrease in one study,5 and an increase in one study.9 when comparing the effects of body mass before ramadan fasting to the second week of ramadan fasting, there were no significant changes in body mass.1 body mass was recorded to have no changes in three studies,3,9,10 a decrease in two the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 studies,7,8 and an increase in one study at two weeks.9 studies that compared body mass before ramadan fasting to after four weeks of ramadan fasting concluded there were no significant differences between the two.1 eight studies2,3,5,6,9-12 concluded no change in body mass, three studies4,7,8 reported a decrease in body mass, and one study9 showed an increase in body mass from before the start of ramadan fasting to after four weeks of ramadan fasting outcome 2 – body composition fat mass the body composition of a varying number of participants was assessed before the start of ramadan and after either one or four weeks of ramadan fasting. body fat mass was measured in kilograms for body composition.1 there was no significant change in body composition one week after ramadan fasting compared to before ramadan.1 all three studies concluded there were no changes to body fat mass at one week.4,5,13 when comparing the effects of before ramadan fasting to the fourth week of ramadan fasting, there were no significant changes in body composition.1 body fat mass did not change in three studies4,5,13 and decreased in one study at four weeks.8 body fat percentage the body fat percentage of a varying number of participants was assessed before the start of ramadan and after either two or four weeks of ramadan fasting. there were no changes in the two studies that examined the effects on body fat percentage before ramadan and after two weeks of ramadan fasting.7,10 after reviewing these two studies, it was determined that there was no significant change in body fat percentage from before ramadan to after two weeks of ramadan fasting.1 from before the fourth week of ramadan fasting, there was no significant change in body fat percentage.1 one study concluded a decrease in body fat percentage7 and two studies concluded no change in body fat percentage at four weeks.6,10 outcome 3 – lean mass the lean mass of a varying number of participants was calculated in kilograms before the start of ramadan and after four weeks of ramadan fasting.1 there was no significant change in lean mass from the two studies.1 both studies reported no change in lean mass from before ramadan to after four weeks of ramadan fasting.7,13 outcome 4 – dietary intake the dietary intake of a varying number of participants was recorded before the start of ramadan and during ramadan fasting. components of dietary intake that were examined over the twelve studies include total energy, protein, fat, carbohydrate, and total water intake. total energy intake was reported to have no change in four studies,3,6,11,14 an increase in two studies,10,12 and a decrease in four studies throughout ramadan.4,5,7,8 the findings from these studies conclude that ramadan fasting had no significant effect on total energy intake.1 ramadan fasting was shown to have no significant effect on protein consumption.1 throughout ramadan, protein intake did not change in three studies,7,8 increased in one study,10 and decreased in one study.4 fat intake had no significant change reported throughout ramadan.1 there was no change in fat intake reported in one study,10 an increase in one study,12 and a decrease in three studies.4,7,8 carbohydrate intake was also shown to have no significant effect from before to during ramadan.1 four studies noted no change,7,8,10,12 and one study noted an increase in carbohydrate intake throughout ramadan.4 there was no significant effect on total water intake from before to during ramadan.1 total water intake had no change in two studies,3,10 increased in one study,12 and decreased in two studies.4,5 the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 clinical bottom line as of 2017, an estimated 3.5 million americans practice the religion of islam.15 as this number continues to grow, one can only expect the prevalence of muslim adolescent athletes to increase. due to the physiological strain that fasting can have on the body, especially during adolescence, the guiding systematic review sought to describe the effects of ramadan observance on factors such as body mass, body composition, and dietary intake in adolescent athletes.1 following the analysis, it was determined that there were no statistically significant effects of ramadan observance on body mass, body composition, and dietary intake. muslim athletes may continue to train at least three times/week during this month.1 to provide the best patient-centered care, the sports medicine team must be culturally competent with the spiritual and religious practices of the athletes they provide care for.16 this means understanding the practices of the religion and how observing traditions such as ramadan may affect the health and well-being of the athlete. although the guiding systematic review did not find any significant effects on body mass, body composition, or dietary intake, this does not mean that every athlete will fit this trend.1 in that case, the athletic trainer should be prepared to provide patient-centered care by recognizing and addressing the many other factors that may affect an athlete during ramadan. body composition is the term used to describe the components of the human body, which include lean mass, fat mass, body water, and bone mass. overall, the authors in the studies observed no changes in overall body composition. one reason for observing no changes is that there were also no changes to the dietary intake and fluid intake in participants of their studies. it is important to note that changes in overall body composition (i.e., body mass, percent body fat, lean mass) are also impacted by changes in exercise, something that was not objectively measured in these studies. it would be important to consider the effects of ramadan fasting on energy availability, that is, the amount of dietary energy figure 1. dietary recommendations the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 remaining for physiological mechanisms of the body after exercise.17 measuring using this method would utilize both dietary energy intake and exercise energy expenditure, and changes can be related to two other components of the athlete triad: menstrual/reproductive function and bone mineral density.17,18 moreover, one should note that the newer “gold standard for body composition assessment” is dual-energy x-ray absorptiometry (dxa or dexa), which was not done by any of the studies included. therefore, the results should account for errors in the measures used (bioelectrical impedance and skinfolds). for adolescents who may not be solely responsible for the food available, it may be beneficial to include their legal guardians in conversations regarding the amount and quality of food consumed during ramadan. it could also prove useful to facilitate open discussions with athletes and coaches regarding accommodations to training schedules and expectations for performance during this time. in addition to the data’s recommendation of training three times a week during ramadan observance, scheduling these training times to accommodate the adolescent's fasting schedule may improve the performance outcomes.16,17 to support the health and well-being of young athletes during their observance of ramadan, there are three main recommendations for athletic trainers to consider. these involve the timing of events, minimizing sleep deprivation, and optimizing nutrient uptake and hydration.19,20 more details regarding these recommendations can be found in the attached infographic (figure 1). in addition to the previous recommendations, it is also vital to consider the accommodations that may be necessary in the instance of a medical emergency. this could include allowing access to cooling towels and/or cooling tubs to assist temperature regulation without the intake of fluids.20 if a medical emergency is believed to be caused by dehydration and/or heat stroke, the athlete should be provided with fluids, and the emergency action plan should be activated. in summation, adolescent athletes observing the religious tradition of ramadan can still compete without adverse effects, provided they continue a typical training pattern, ensure adequate sleep each night, and maintain their intake of energy and fluids.19,20 references 1. trabelsi k, ammar a, boukhris o, et al. effects of ramadan observance on dietary intake and body composition of adolescent athletes: systematic review and meta-analysis. nutrients. 2020;12(6):1574. https://doi.org/10.3390%2fnu12061574. 2. aziz ar, chia myh, low cy, slater gj, png w, teh kc. conducting an acute intense interval exercise session during the ramadan fasting month: what is the optimal time of the day? chronobiol int. 2012;29(8):1139-1150. https://doi.org/10.3109/07420528.2012.708375. 3. aziz ar, slater gj, chia myh, teh kc. effects of ramadan fasting on training induced adaptations to a seven-week high-intensity interval exercise programme. sci sports. 2012;27(1):31-38. https://doi.org/10.1016/j.scispo.2011.03.004. 4. bouhlel h, bogdanis g, hamila a, et al. effects of ramadan observance on repeated cycle ergometer sprinting and associated inflammatory and oxidative stress responses in trained young men. jnfh. 2016;4(1):39-47. https://doi.org/10.22038/jfh.2016.6890. 5. bouhlel h, latiri i, zarrrouk n, et al. effet du jeûne du ramadan et de l’exercice maximal sur le temps de réaction simple et de choix chez des sujets entraînés. science & sports. 2014;29(3):131-137. https://doi.org/10.1016/j.scispo.2014.02.002. 6. güvenç a. effects of ramadan fasting on body composition, aerobic performance and lactate, heart rate and perceptual responses in young soccer players. j hum kinet. 2011;29:79-91. https://doi.org/10.2478/v10078-011-0042-9. 7. hammouda o, chtourou h, aloui a, et al. concomitant effects of ramadan fasting and time-of-day on apolipoprotein ai, b, lp-a and homocysteine responses during aerobic exercise in tunisian soccer players. plos one. 2013;8(11):e79873. https://doi.org/10.1371/journal.pone.0079873. https://doi.org/10.3390%2fnu12061574 https://doi.org/10.3109/07420528.2012.708375 https://doi.org/10.1016/j.scispo.2011.03.004 https://doi.org/10.22038/jfh.2016.6890 https://doi.org/10.1016/j.scispo.2014.02.002 https://doi.org/10.2478/v10078-011-0042-9 https://doi.org/10.1371/journal.pone.0079873 the influences of the religious tradition of ramadan has on dietary intake and body composition in adolescent athletes: an evidence-to-practice review 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 8. hammouda o, chtourou h, aloui a, et al. does ramadan fasting affect the diurnal variations in metabolic responses and total antioxidant capacity during exercise in young soccer players? sport sciences for health. 2014;10(2):97-104. https://doi.org/10.1007/s11332-014-0179-8. 9. lotfi s, madani m, tazi a, zerdani i, boumahmaza m, talbi m. effets du jeûne de ramadan sur les performances physiques et la vo2 max chez les coureurs de demi-fond et les footballeurs. revue sci staps. 2010;17:27-37. 10. maughan rj, bartagi z, dvorak j, zerguini y. dietary intake and body composition of football players during the holy month of ramadan. j sports sci. 2008;26(sup3):s29-s38. https://doi.org/10.1080/02640410802409675. 11. meckel y, ismaeel a, eliakim a. the effect of the ramadan fast on physical performance and dietary habits in adolescent soccer players. eur j appl physiol. 2008;102(6):651-657. https://doi.org/10.1007/s00421-007-0633-2. 12. zarrouk n, hammouda o, latiri i, et al. ramadan fasting does not adversely affect neuromuscular performances and reaction times in trained karate athletes. j int soc sports nutr. 2016;13(1):1-10. https://doi.org/10.1186/s12970-016-0130-2. 13. zarrouk n, hug f, hammouda o, et al. effect of ramadan intermittent fasting on body composition and neuromuscular performance in young athletes: a pilot study. biol rhythm res. 2013;44(5):697-709. https://doi.org/10.5812%2fasjsm.34754. 14. aloui a, chtourou h, hammouda o, et al. effects of ramadan on the diurnal variations of physical performance and perceived exertion in adolescent soccer players. biological rhythm research. 2013;44(6):869-875. https://doi.org/10.1080/09291016.2013.780697. 15. mohamed b. new estimates show u.s. muslim population continues to grow. pew research center. may 30, 2020. accessed august 22, 2023. https://www.pewresearch.org/short-reads/2018/01/03/newestimates-show-u-s-muslim-population-continues-to-grow/. 16. jayadevappa r, chhatre s. patient centered care-a conceptual model and review of the state of the art. open health serv and policy j. 2011;4(1). http://dx.doi.org/10.2174/1874924001104010015. 17. nattiv a, loucks ab, manore mm, et al. american college of sports medicine position stand. the female athlete triad. med sci sports exerc. 2007;39(10):1867-1882. https://doi.org/10.1249/mss.0b013e318149f111. 18. nattiv a, de souza mj, koltun kj, et al. the male athlete triad-a consensus statement from the female and male athlete triad coalition part 1: definition and scientific basis. clin j sport med. 2021;31(4):345-353. https://doi.org/10.1097/jsm.0000000000000946. 19. maughan rj, zerguini y, chalabi h, dvorak j. achieving optimum sports performance during ramadan: some practical recommendations. j sports sci. 2012;30 suppl 1:s109-s117. https://doi.org/10.1080/02640414.2012.696205. 20. shephard rj. the impact of ramadan observance upon athletic performance. nutrients. 2012;4(6):491505. https://doi.org/10.3390%2fnu4060491. https://doi.org/10.1007/s11332-014-0179-8 https://doi.org/10.1080/02640410802409675 https://doi.org/10.1007/s00421-007-0633-2 https://doi.org/10.1186/s12970-016-0130-2 https://doi.org/10.5812%2fasjsm.34754 https://doi.org/10.1080/09291016.2013.780697 http://dx.doi.org/10.2174/1874924001104010015 https://doi.org/10.1249/mss.0b013e318149f111 https://doi.org/10.1097/jsm.0000000000000946 https://doi.org/10.1080/02640414.2012.696205 https://doi.org/10.3390%2fnu4060491 abstract manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 the value of using validated competency-based assessments across the career span of an athletic trainer matthew drescher, phd, dat, lat, atc *; lindsey eberman, phd, lat, atc† *north dakota state university, fargo, nd; †indiana state university, terre haute, in content focus health professions education correspondence 1340 administration ave, fargo, nd 58102 e-mail: matthew.drescher@ndsu.edu reference drescher md, eberman le. the value of using validated competency-based assessments across the career span of an athletic trainer. clin pract athl train. 2024; 7(2):1-4. https://doi.org/10.31622/2024/0007.02.1 commentary background in educating students, there is an inherent need to quantify and track student performance over time. this quantification is typically done with an outcome of some type, such as an assessment rubric or grading criteria, from which subjective student performance is translated to an objective value. traditionally, this objective value has been quantified as grades (on a numeric or alpha scale). to quantify those grades, assessments are given scores that contribute to the overall grade in a course or area of study. this method has proven so effective that it is the predominant way students are assessed in the united states, with high school and undergraduate students being categorized by their grade point average as a method to average a student’s performance over time or across content.1 grades and their subsequent derivatives can be an effective method of quickly and easily expressing student performance and aptitude in a particular area of study. we must, though, examine the assumptions supporting the system's use of grading performance. first, we must define what is meant by “measure of learning.” learning, as a concept is difficult to define, with conflicting definitions from different schools of thought.2 a more modern consensus is that learning is a process of gradual changes in behavior, mental processes, and critical thinking.2 how, then, do we objectively measure a continuous process? historically, measures of learning were considered to be methods such as memorization, knowledge assessment, and behavioral observation, as these were seen to be analogs to learning as a permanent change in behavior.2 when discussing a more holistic measure of learning from a modern understanding, we should also consider including competency-based assessment and overall performance assessment as well as measures of knowledge and behavior. these measures reflect the more modern definition of learning and create a more complete representation of a student’s learning process. this is the foundational idea behind competencybased education. when implementing competency-based education, there is an assumption that grades can still be applied as an accurate, objective measure of learning, whether using holistic student assessment or otherwise.1 however, this assumption relies on an assessment method's reliability and the assessor's objectiveness, which can vary widely. take, for example, an assessment of student knowledge on a traditional exam as a measure of learning. such an assessment could objectively quantify a student’s learning in a numeric grade (and even transferred to an alpha-coded grade), given that the items on the exam were accurate and encompassed https://doi.org/10.31622/2024/0007.02.1 the value of using validated competency-based assessment across the career span of an athletic trainer 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 expected content. now consider the student’s final grade in the course. if this final grade is an average of all graded assessments in the course, then this should be an accurate assessment of their competence relative to the learning outcomes. however, indirect and subjective measurements, such as student participation or time-on-task, are frequently included in a final grade, making the final grade less reflective of knowledge and rather a reflection of both subjective and objective factors, diminishing its accuracy as an objective measure of learning. other factors may also influence the objectiveness of grades, such as the study habits of students, different approaches to grading, or even students' motivations to receive a particular score or grade (e.g. contract grading). these factors indicate that grades might measure learning in certain situations but are not, and should not, be considered all-encompassing. to be clear, we do not suggest that all education should be moved to a competency-based education model and that traditional grading should be removed altogether. in higher education, numerous barriers block the adoption of such a model, from federal classification standards to educator training and buy-in. still, in fields and professions where competency in a skill is a necessary requirement for practice, integrating competencybased assessment strategies into more traditional education models can help bridge the gap between student course performance and competency in the field. in recent times, healthcare education programs have embraced the adoption of competency-based assessment methods, in lieu of traditional grading systems, to evaluate clinical competence. competency-based assessment approaches are deemed more effective in evaluating the clinical application of skills in healthcare students.3 however, it is imperative to acknowledge that these approaches carry certain assumptions that must be considered for their effective implementation in practice. namely, we must assume that competency-based assessment criteria are accurate and encompass the totality of a particular clinical skill or behavior. however, even when an assessment tool is critically appraised for its accuracy, there remains a level of subjectivity and bias within the tool, originating from its creator and assessor. to establish the validity of an assessment tool, it should ideally be based on a scientifically proven theory, and it should be validated. in athletic training, assessment tools have been created and validated based on the dreyfus model of skill acquisition,4,5 which is an established method for categorizing and evaluating skill acquisition.6 the dreyfus model uses a 5-point scale, with each point characterizing a particular level of skill acquisition, from novice to expert.6 using the dreyfus model as a framework helps to validate the theoretical development of a competency-based assessment tool. for a model like this to work, however, a list of the skills and behaviors that correlate to practice must be identified and paired with the framework. a team of experts, or those who are knowledgeable about the skills and behaviors required to perform a task, should be consulted to develop the list of competencies that constitute the comprehensive practice, in this case, the comprehensive practice of athletic training. the use of experts, rather than an individual creator, helps to prevent bias and ensure that all aspects of a skill are accounted for. this can seem like a lot of work for an educator to implement into an existing program. however, much of the groundwork has already been completed. the accreditation council for graduate medical education (acgme) has created a list of core competencies, in alignment with the healthcare core competencies, that provide list of behaviors for each broad competency and subcompetency. the acgme then applied the dreyfus model framework to characterize the range of performance from novice to expert for each competency and sub-competency. this has also been done in the athletic training profession, whereby 4 leaders in the profession developed the athletic training milestones (at milestones). the at milestones were built similarly to the acgme milestones with the dreyfus model framework applied across the core competencies and sub-competencies and are still in progress for some of the specialty areas of athletic the value of using validated competency-based assessment across the career span of an athletic trainer 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 training practice. subsequently, a different group of researchers validated the at milestones using a conservative approach to establishing a content validity index using 12 additional experts in the field. the overall scale index was very high (0.99) and the 28 subcompetency items ranged from 0.83 to 1.00.4 one of the benefits of the at milestones is that they identify skills and establish the behaviors consistent with competence for all athletic trainers, not just athletic training students. this provides students with a clear pathway to competence and provides practicing clinicians with effective tools for assessing their clinical practice. these milestones should be used across the continuum of practice, from education through retirement, as a guidepost to competent clinical practice.4 as with any assessment tool, assessment personnel should be trained. untrained individuals might incorrectly evaluate, which could lead to a false sense of competence. an understanding of the rankings and their requisite behaviors, along with knowledge of the profession and activity being performed, is critical to accurate assessment. proper training on the use of these tools helps to ensure alignment with tool design and to provide the individual being assessed with effective feedback on performance. in athletic training education, tools such as the at milestones are not frequently used,7 thus they are not yet a key metric for progression and matriculation. a validated tool can give educators confidence in assessing student performance and ensure that the totality of the behavior or skill is accounted for prior to graduation. such a tool also provides students with a path to mastery and helps to show a progression of skills that can help them continue to learn based on their capability rather than their knowledge alone.3 a validated tool can also be used for student education by showing them what skills and behaviors are expected of them in the profession. further, a competency-based assessment tool can be used across the career of a provider helping to ensure alignment with best practices across time. finally, using a validated competency-based assessment tool allows students to shift their mindset from acquiring knowledge, as is promoted by traditional grading schemes, to applying such knowledge to clinical practice.8 references 1. cain j, medina m, romanelli f, persky a. deficiencies of traditional grading systems and recommendations for the future. am j pharm educ. 2022;86(7):8850. doi:10.5688/ajpe8850 2. sehic s. redefining the definition of learning from an educational aspect. int j inf res rev. 2020;7:69406942. 3. mace kl, bacon cew. the future of health professions education: considerations for competency-based education in athletic training. athl train educ j. 2019;14(3):215-222. doi:10.4085/1403215 4. bacon cew, anderson be, cavallario jm, van lunen bl, eberman le. content validation of the athletic training milestones: a report from the association for athletic training education research network. j athl train. 2023;58(5):483-487. doi:10.4085/1062-6050-0332.22 5. eberman, le, edler, jr. developing, validating and establishing reliability of a standardized patient evaluation eool to measure healthcare core competency. j athl train. 2020;55(6s):s-240. doi:10.4085/1062-6050-55.6s.s-1 6. rousse b, dreyfus s. revisiting the six stages of skill acquisition. teach learn adult ski acquis appl dreyfus dreyfus model differ fields. published online 2021:3-28. 7. imanipour m, ebadi a, monadi ziarat h, mohammadi mm. the effect of competency-based education on clinical performance of health care providers: a systematic review and meta-analysis. int j nurs pract. 2022;28(1):e13003. doi:10.1111/ijn.13003 the value of using validated competency-based assessment across the career span of an athletic trainer 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 8. welch bacon ce, anderson be, cavallario jm, van lunen bl, eberman le. perceptions and use of the athletic training milestones in education: a report from the aate research network. clin pract athl train. 2024;7(2);xx-xx. doi: manuscript type abstract presentation 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 association for athletic training education (aate) abstract presentations the following abstracts were accepted and presented at the inaugural association for athletic training education symposium february 29 – march 2, 2024. digital health care: time for a new standard? winkelmann zk: university of south carolina, columbia, sc introduction: the rapid influx of digitalization in healthcare has presented opportunities for innovative engagement, delivery, and outcomes for patient care. however, it also presents with several barriers and challenges that require teaching and learning opportunities to prepare future athletic trainers for these tasks. currently, the caate curricular content standards integrate digital health care through standard 64 on health informatics and standard 87 on biometrics. however, the art and science of digital healthcare are expansive, including various skills such as digital literacy, computer skills, online communication, and privacy and security standards. methods: the presentation will provide an overview of current digital healthcare trends through artificial intelligence, machine learning, augmented reality, mhealth, ehealth, telehealth, precision genomics, wearables, sensors, and electronic health records. after discussing these options, an overview of digital competencies will be presented to explore if and how programs prepare learners to engage in the digital healthcare environment. expected outcomes: the expected outcomes include a retrospective analysis of how healthcare started, how it is currently going, and emerging trends relative to digital healthcare. next, the outcomes will explore integrating specific didactic learning opportunities, clinical education experiences in digital healthcare environments, and assessment of competence related to digital skills and tasks in peer healthcare professions and athletic training. translation to practice: overall, there needs to be an exploration of the knowledge and skills to implement digital healthcare in athletic training. with the rise in opportunities for patient care, it is essential that we prepare athletic training students for jobs that may not exist yet or tasks in their jobs that have yet to be present. in order to continue driving athletic training education, a new standard specific to digital healthcare should be proposed to capture the complex competencies related to integrating digital options for patient care. abstract presentation 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 burnout in athletic training: measured by survey in most common settings for athletic trainers johnson krug r, sand n, brooks s, smith t: university of mary, bismarck, nd introduction: burnout is a common problem in athletic training, affecting both athletic trainers (ats) and the athletes they serve. athletic trainers are responsible for the prevention, diagnosis, and treatment of sportsrelated injuries. long work hours, often including evenings and weekends, as well as frequently under pressure to meet the demands of athletes, coaches, and parents. athletic trainers face numerous stressors that contribute to burnout. these stressors may include heavy workloads, lack of control over their schedules, time pressures, and pressure to produce positive outcomes. athletic trainers may also experience emotional and physical exhaustion, depersonalization, and a reduced sense of personal accomplishment, all of which are common symptoms of burnout. burnout can have negative consequences for both ats and athletes. for ats, burnout can lead to decreased job satisfaction, decreased quality of care provided to athletes, and increased turnover rates. this can have a detrimental impact on the overall effectiveness of the athletic training field. for athletes, the effects of their at experiencing burnout can include decreased performance, increased risk of injury, and decreased psychological well-being. other healthcare professionals, such as physical therapists, nurses, and doctors, have examined burnout. athletic trainers can be overlooked due to the amount of burnout that may be present throughout the profession. the purpose of this study was to investigate what setting burnout, measured by the copenhagen burnout inventory (cbi), was most common in ats. the cbi is used to measure burnout in three subdomains which include personal, work, and client burnout. the core of the cbi looks at burnout through fatigue and exhaustion. the cbi score range start at moderate burnout with scores ranging from 50-74, high burnout rate consists of scores that range from 75-99, and severe burnout consists of scores higher than 100. methods: athletic trainers were sent an email through the nata directory as well as other ats known to the researchers. participants in this study were practicing ats in clinical, collegiate, high school, industrial, military, professional sports, physician practice, extreme sports, youth sports, occupational, and managers. the participants had no age or setting restrictions in order to complete the survey. a consent form was sent along with the survey outlining the potential risks involved in the survey. the survey included the cbi as well as demographic questions. results: there were a total of 57 surveys that were viable to use for data collection. there were 33% of the participants identified as male and 67% were female. most of the participants, 74%, did not have children. about half of the participants, 51%, were married. the settings with scores below 50 consist of the manager position at 49 demonstrating low burnout. the settings that have scores in the range of 50-74 reflecting moderate burnout consist of clinical, college, secondary, physician office, youth sports, military, and industrial with scores ranging from 51-69. the settings that have scores in the range of 75-99 reflecting high burnout consist of extreme sports and professional with scores ranging from 76-77.5. translation to practice: the participants who completed this survey reflected high burnout in two settings, professional and extreme sports. those working in these professions should reflect on their practices and schedules to be mindful of burnout. most settings have moderate burnout. as a practicing at it is best to know, understand, and find strategies to avoid burnout. knowledge of burnout is valuable not only to ats but also to employers. recognition of the importance of this is most important in helping prevent burnout from occurring. abstract presentation 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 educational outcomes of the dat: a document review and thematic analysis orr sh, eberman le, rivera mj: indiana state university, terre haute, in context: the transition in athletic training education allows for unique and new opportunities in postprofessional education. the doctor of athletic training (dat) degree is one of the postprofessional education pathways that could provide athletic trainers advancement in clinical practice, practice leadership, and scholarship. however, there is no data on the educational outcomes of dat programs and what graduates should expect from their experiences. the aim of this study was to explore whether dat programs are delivering curricula consistent with the development of clinical scholars with advanced knowledge and skills that are needed for high-level patient care and literature relative to dat programs and their publicly stated educational outcomes. methods: we used a qualitative design document review to explore dat program websites. the primary investigator collected the relevant data from each of the program websites and recorded the data into a custom spreadsheet. we used a combination of deductive and inductive coding. the professional definition and previous literature established the overarching themes: advanced practice leadership, advance clinical practice, scholarship, and individual programmatic uniqueness. a two-member analysis team used indictive coding of program outcome data to identify the sub-themes. researcher reflexivity, triangulation, and auditing were used to ensure trustworthiness and accuracy. results: a total of eight dat programs actively enrolling students with publicly available websites were included (table 1; figure 1). every program (n=8, 100%) claimed to engage students in each of the following thematic areas: advanced practice leadership, advance clinical practice, scholarship, and individual programmatic uniqueness. in the theme of advanced practice leadership, sub-themes organizational, educational, and practice-based leadership were identified among the areas where programs claimed to prepare the dat student for different roles. of the eight programs, 38% (n=3) listed outcomes related to organizational leadership, 50% (n=4) noted practice leadership, and 75% (n=6) noted learning outcomes related to educational leadership. the advanced clinical practice theme was comprised of sub-themes about advancing the dat student’s skills in providing patient-centered care (n=2, 25%), evidence-based practice (n=7, 88%), intervention (n=4, 50%), and evaluation (n=3, 38%). the scholarship theme indicated that programs required dat students to engage in traditional research (n=2, 25%) and practice-based research (n=7, 88%); one program requires no scholarship in the development of a dat credential holder. programs noted six different areas of programmatic uniqueness; however, overlap existed whereby 50% of the programs deliver curricula in manual therapy, 50% (n=4), 25% in business (n=2), and 25% in concussion recognition and care (n=2). areas of true uniqueness, where only one program had a focus in that area were integrative health, sports performance, and neuromechanics. there was no consistency in how programs communicated through their websites and how they were measuring or meeting their outcomes. translation to practice: all eight program websites noted program content related to advanced practice leadership, advance clinical practice, scholarship, and individual programmatic uniqueness, suggesting alignment with the professional definition and previous literature. through the review, there is a lack of clarity on what “role” programs believed a graduate from their program would play in athletic training (e.g., educator, practice leader, clinician). as applicants of dat programs become more and more savvy, there will likely be an increased expectation to demonstrate how programs are meeting their stated goals with publicly available outcomes data, which is consistent with best practices for regionally accredited and specialty accredited programs. abstract presentation 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 table 1. program characteristics characteristics percentage frequency enrollment status full-time status 50% 4 part-time status 25% 2 unspecified 50% 4 graduate assistantship positions available yes 25% 2 no 0% 0 unspecified 75% 6 accreditation status specialty accreditation commission on accreditation of athletic training education (caate) 13% 1 regional accreditation commission on colleges of the southern association of colleges and schools (sacs) 25% 2 higher learning commission (hlc) 37% 3 middle states commission on higher education (msche) 25% 2 northwest commission on colleges and universities 13% 1 average tuition costs (total) in-state $ 32,629 out-of-state $ 35,281 average credits (total) credits 54 program length (months) 23 13% 1 24 63% 5 36 25% 2 program type cohort model 75% 6 individualized model 25% 2 delivery mechanism predominantly online 75% 6 predominantly in person 25% 2 $ $5,000 $10,000 $15,000 $20,000 $25,000 $30,000 $35,000 $40,000 $45,000 $50,000 average cost program 1 program 2 program 3 program 4 program 5 program 6 program 7 program 8 cost of tuition tuition costs in state tuition costs out of statefigure 1. tuition cost per program abstract presentation 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 master’s-level professional athletic training program admissions data: does it matter if your institution is public or private? cavallario jm*, starkey c†, welch bacon ce‡: *old dominion university, norfolk, va; †ohio university, athens, oh; ‡a.t. still university, mesa, az introduction: recently, there has been speculation that the transition to a master’s degree for entry into the athletic training profession has resulted in a shortage of athletic trainers (ats) relative to the number of jobs available. the board of certification has announced that the total number of credentialed ats has not decreased, yet athletic training programs consistently report challenges in recruiting athletic training students to their programs. data provided by the caate from annual reports is typically two years old once it is made publicly available. program and institutional administrators need access to real-time data to make decisions regarding program continuation and enrollment targets. the purpose of this study was to examine enrollment data of professional graduate athletic training programs for the classes of 2024 and 2025. methods: we employed a cross-sectional online survey to capture current athletic training student enrollment in caate-accredited graduate professional athletic training programs. program director contact information was obtained from the caate and 260 graduate program administrators were emailed. we collected the number of students enrolled in the class of 1a) 2024, and 1b) 2025, 2) length of time the program has been at the graduate level, 3) whether an accelerated track (e.g., 3+2) existed, and 4) enrollment characterization (i.e., stable, unstable, increase, decreasing, too early to tell). of the 260 programs contacted, 20 were removed due to not having a cohort enrolled or being in their last year of offering the program. we received data from 207 (86.3%) of the remaining programs and determined each institution’s funding classification (public, private). descriptive statistics were used to characterize the data, an odds ratio was calculated to determine whether public or private institutions were more likely to have an accelerated program, and independent samples t-tests were performed to compare enrollment across public and private institutions with and without accelerated tracks. results: public institution programs (pui) represented 66% (n=136) of programs, of which 75 (55%) had an accelerated track. private institutions programs (pri) represented 34% (n=71) programs, of which 61 (86%) had an accelerated track. puis reported a mean enrollment of 19.6 ± 11.3 students, and pris reported a mean enrollment of 15.7 ± 9.1. approximately 41% (n=56) of puis reported increasing enrollment, while 30% (n=21) of puis reported enrollment trends as increasing. pris had greater odds of offering an accelerated track (or=4.96, 95%ci [2.35, 10.50], p<0.001) as compared to puis. when comparing enrollment of pris with and without accelerated tracks there was no significant differences in the enrollment (p=0.947); the same was true for the comparison of puis with and without accelerated track (p=0.558). when examining total enrollment, puis had significantly higher enrollment compared to pris [t(205)=-2.52, p=0.012]. translation to practice: professional athletic training programs at public institutions reported higher average enrollment than those at private institutions. pris appear to be developing and relying on accelerated tracks to promote enrollment. although there was no enrollment difference in toto, we recognize that this option may be advantageous to individual institutions for other reasons. overall, more puis reported stable enrollment trends. program administrators should use this information to determine the allocation of resources for program development and implementing marketing and recruitment strategies. abstract presentation 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 athletic trainers’ familiarity with potential concussion biomarkers: a descriptive study campbell tr, davis bj, martinez jc, cavallario jm: old dominion university, norfolk, va introduction: an estimated 3.8 million individuals sustain a concussion annually in the united states. despite the high number of cases, this number may not accurately depict the true incidence rate due to underreporting of symptoms by patients. with current concussion tools relying heavily on subjective input from patients, it is imperative that a valid and reliable objective tool, such as a clinical biomarker, is identified to improve concussion diagnosis and management. if such a biomarker is identified, it will be essential that athletic trainers (ats) be familiar with how biomarkers could be used. the purpose of this study was to determine ats’ familiarity with potential concussion biomarkers. methods: an online, cross-sectional survey that included six demographic questions. three content experts were solicited to establish the content validity of all survey items by scoring each item’s relevancy to the overall research question, and a mean content validity index of 0.9 was established for the overall instrument. the survey was distributed to 1,000 ats biweekly for eight weeks through the nata research survey service (response rate: 6%). additional participants were recruited through social media, resulting in a total of 238 ats who submitted the survey. participants were asked to identify biofluids and biomarkers they were familiar with (two questions) and were also asked to rate their knowledge of the literature on biomarkers for both concussion diagnosis and management using likert-scales (extremely knowledgeable, very knowledgeable, moderately knowledgeable, slightly knowledgeable, not knowledgeable at all). participants were asked to answer all questions but were not required to answer all questions to submit their responses. we used descriptive statistics to summarize participants’ demographics and responses to familiarity questions. results: of the 238 ats that submitted surveys, varying numbers responded to each of the questions: familiarity with biomarkers (n=214), familiarity with biofluids (n=216), self-rated knowledge of literature for concussion diagnosis biomarkers (n=215), and self-rated knowledge of literature for concussion management biomarkers (n=216). when identifying biomarkers they were familiar with, ats were most often familiar with protein (30.4%, n=80) and least often familiar with dna (3.7%, n=8). relative to biofluids, ats were most often familiar with blood (37.5%, n=110) and least often familiar with urine (3.2%, n=7). interestingly, 55.4% (n=119) of ats stated that they had “no knowledge at all” of the current literature regarding the use of biomarkers for concussion diagnosis, and 62.0% (n=134) stated they had “no knowledge at all” of the current literature regarding biomarkers used for concussion management. (figure 1.) translation to practice: despite the increase in research attempting to identify a concussion biomarker, ats remain unfamiliar with biomarkers and biofluids. targeted continuing education efforts are needed to familiarize ats with biomarkers and biofluids that will likely be used in the diagnosis and management of concussions in the future. abstract presentation 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 figure 2. most familiar biofluids and biomarkers as reported by athletic trainers and self-reported knowledge of biomarker use for concussion diagnosis and management. 0 20 40 60 80 100 120 blood saliva csf urine other not familiar n o. o f c er tif ie d at hl et ic t ra in er s ( n= 21 6) of the following biofluids, which are you familiar with as being linked to potential concussion biomarkers? (select all that apply) 0 20 40 60 80 100 120 n o. o f c et ifi ed a th le tic t ra in er s ( n= 21 4) of the following, which are you familiar with as acting as a concussion biomarker? (select all that apply) extremely knowledgable very knowledgable moderately knowledgable slightly knowledgable not knowledgable at all 0 20 40 60 80 100 120 140 no. of certified athletic trainers (n=215) please rate your knowledge on the current literature surrounding the use of biomarkers for concussion diagnosis. extremely knowledgable very knowledgable moderately knowledgable slightly knowledgable not knowledgable at all 0 20 40 60 80 100 120 140 160 no. of certified athletic trainers (n=216) please rate your knowledge on the current literature surrounding the use of biomarkers for concussion management. abstract presentation 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 employers’ perceptions of and experiences working with residency-trained athletic trainers welch bacon ce*, cavallario jm†, eberman le‡, wetherington jj§, pecha fq¶, van lunen bl†:*a.t. still university, mesa, az; †old dominion university, norfolk, va; ‡indiana state university, terre haute, in; §st. luke’s health system, boise, id; ¶steamboat orthopaedic and spine institute, steamboat springs, co context: athletic trainers (ats) who complete accredited residency training in a specialty area are considered clinical specialists, yet more information is needed to determine whether they are practicing within the higher capacity expected of a specialist. while some quantitative evidence demonstrating the value of residency-trained ats on patient satisfaction, patient throughput, and the financial impact specific to the physician practice setting exists, residency training is not limited to only ats who want to provide services in physician practice. moreover, as accredited athletic training residency programs continue to emerge, it is increasingly important to understand key stakeholders’ perceptions of residency-trained ats as well as their experiences working with these clinical specialists. understanding the employers’ perception of the value of athletic training residency training is especially important since these individuals are involved in the hiring decisions of a clinical practice setting. therefore, we aimed to explore employers’ perceptions of, and experiences working with, residency-trained ats. methods: we followed a consensual qualitative research design and recruited a purposeful sample of participants. we contacted our professional network of employers who have hired a caate-accredited orthopaedic-focused residency-trained at to participate voluntarily. we achieved data saturation following individual videoconference interviews with 14 employers (4 physicians, 10 ats; 11 men, 3 women; average age=42.0±7.2 years; clinical experience=17.2±7.4 years) working in the hospital/outpatient center (n=8), sports medicine/orthopaedic clinic (n=3), or college/university (n=3) setting. following development, the 10-item, semi-structured interview guide used for this study was reviewed by 3 residency experts for content validity and piloted with 1 employer that met the study criteria to ensure clarity and flow of the interview questions. following transcription, a 4-person analysis team coded the data into themes and categories. three researchers coded the data and met regularly throughout a 3-phase consensus process. we ensured trustworthiness of the data via memberchecking, multi-analyst triangulation, and the use of internal and external auditors. results: two predominant themes emerged during data analysis: employer perceptions of residency-trained ats and employer experiences working with residency-trained ats. employers perceived that residency-trained ats could assimilate into the practice setting faster than their non-residency-trained at counterparts. employers highlighted that residency-trained ats had a better depth and breadth of knowledge of athletic training practice and could practice at the top of their scope more quickly after orienting to the practice setting. employers also perceived that residency-trained ats experience increased compensation and faster career advancement than the non-residency-trained ats at the same employment sites. employers described how residency-trained ats increase the efficiency of the practice setting, allowing greater throughput and increasing patient accessibility to providers. employers discussed that residency-trained ats improved patient satisfaction scores in the practice setting and were also able to increase awareness of athletic training with other providers in the setting. translation-to-practice: our findings indicate that employers can discern differences between residency-trained ats and non-residency-trained ats. residency-trained ats add value to practice, and their residency training likely prepares them more adequately for assimilation into practice than professional education alone. positive outcomes of hiring residency-trained ats included increased patient satisfaction, increased practice efficiency, and added economic value to the care team. since residency training aims to develop clinical specialists, employers of ats should aim to hire a diverse group of clinicians that includes both generalists and specialists. mentors of athletic training students should guide them to accredited athletic training residency programs if becoming a clinical specialist aligns with the student’s professional development goals. disclosure: the findings presented in this abstract are from a study funded by the nata foundation (#1819egp01). abstract presentation 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 athletic training preceptors’ experience with interprofessional education and collaborative practice in the clinical learning environment bender a*†: ohio university, athens, oh*; university of north carolina at greensboro, greensboro, nc† introduction: professional athletic training (at) programs are now required to align their educational curricula with the institute of medicine's (iom) core competencies, preparing students to work in dynamic, interprofessional healthcare teams to strategically address patient outcomes. although interprofessional education and collaborative practice (ipecp) is commonly implemented in didactic settings, our understanding of how ipecp is implemented by at preceptors in various clinical settings is limited. the purpose of this study was to gain a greater understanding of at preceptors’ experience with ipecp and how they implement this with students in their clinical settings. methods: a convergent mixed-methods design was used with data collected through an online survey. at preceptors working in the nata district 3 (mid-atlantic) region (n=45) were recruited to participate using a snowball sampling approach, which began with an email to at program directors requesting participation from their affiliated preceptors. at preceptors’ responses gathered demographic information, ratings on ipecp knowledge and use in their clinical practice, as well as responses to open-ended questions about their experience implementing ipecp with students in their clinical practice. closed-ended responses were analyzed using descriptive statistics. open-ended responses were first analyzed using an open coding process and then an inductive process of reflexive thematic analysis. two faculty members with extensive experience in qualitative research reviewed the data analysis procedures to improve trustworthiness. results: roughly 70% of preceptors had ipecp training (n=32) and agreed (n=31) that it is very or extremely important to teach their students how to engage in ipecp in their workplace. most participants reported having some type of formal education/training in ipe, either precertification (n=15), post-certification (n=7), or both (n=10). some participants (n=13) indicated they did not have any education or training in ipe. at preceptors reported engaging in ipecp most often with physicians, strength coaches, and pts in their workplace setting, performing patient exams, and developing treatment plans more often than engaging in interprofessional research or professional development. most report that collaborative practice with staff and students occurs sporadically in their workplace, suggesting that ipecp may not be intentionally planned or embedded in their organizational culture. formal ipecp training, positive and impactful experiences, exposure to various professionals, and high teaching importance were identified as promoting factors for ipecp implementation. inhibiting factors such as scheduling/availability, lack of resources/“buy-in,” and disruption stemming from the covid-19 pandemic posed challenges for ipecp implementation. translation to practice: despite almost 30% of the participants not having any formal training in ipecp, at programs may require preceptors to facilitate this as part of the clinical education experience. more ipecp education and training for at preceptors may help close this gap and yield better teaching of collaborative practice behaviors with students transitioning to practice in various clinical settings. additional research should be conducted every couple of years to see trends in change over time as programs implement these competencies into their clinical learning experiences. abstract presentation 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 using alums involvement to increase student investment in an athletic training program heffner cj*, green al†: *texas state university, san marcos, tx; †tarleton state university. stephenville, tx introduction: student investment and retention are not new concerns among athletic training program directors. graduate programs are expected to meet minimum enrollment standards to demonstrate the need for the program. programs that are unable to maintain student enrollment will be eliminated by institutions experiencing financial stress. retention strategies and benefits have previously been investigated among undergraduate students and across disciplines. one common theme in the research is that student retention increases when students feel a sense of belonging from the faculty, staff, and peers in their program. there is less research on the retention of graduate students, but the themes tend to be similar to undergraduate students: students want a sense of belonging and support from faculty. as long-term program success becomes reliant upon enrollment and retention, program directors seek to create strategies to increase student investment in their program. the use of alums as active participants in the program has the potential to improve student pride in the program. students may seek advice from alums on successfully navigating the academic process from someone who has had the same experience. professional relationships may be built that can expand as students seek immersive experiences or full-time jobs. as students graduate, they can be helpful in referring new students to the program. methods: an athletic training program has developed several strategies to increase student investment in the program: use of alums to facilitate telehealth evaluations, use of alums to facilitate administrative and psychosocial case studies, creating an advisory board for program growth that includes alums as stakeholders, and student recruitment. alumni have been used as patients for telehealth experiences for both orthopedic and general medical conditions. alums also facilitate discussions that students have with parents, coaches, or other administrators for issues such as return to play, budget, pregnancy, or psychosocial situations such as mental health or disordered eating management. additionally, the institution created an advisory board that uses alums as a sounding board for any changes that may occur within the program. expected outcomes: in this program, alums become active stakeholders and interact directly with current students. professional relationships develop that benefit alums as mentors and students as they graduate and seek professional opportunities. students engage with alums in application-based scenarios that improve self-efficacy and efficiency in evaluations and problem-solving strategies. translation to practice: a graduate-level curriculum is a relatively new practice that alums of an undergraduate program may not fully understand. alums in this program have achieved a better understanding of graduate-level curriculum and standards by participating in telehealth, guest lectures, or preceptor opportunities. a reciprocal relationship emerges in which students gain an understanding of the history of the program and engage in one-on-one mentorship with alums that provide career opportunities such as immersive sites, internships, or full-time jobs. abstract presentation 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 using data in the classroom to drive instructional design and delivery eberman le, young jp: indiana state university, terre haute, in introduction: roughly half of atp program directors include education on transgender health care in their programs, and even fewer report having the competence to do so. however, professional-level accreditation standards (56, 57, and dei 2) require that programs have faculty with contemporary expertise to educate students on these outcomes. current research suggests a comprehensive transgender and sexual health curriculum, including safe-zone training, traditional lecture, lab, and project-based instruction, was partially effective at changing students’ attitudes toward transgender patients but did not improve sexual health care delivery during a standardized patient encounter. the purpose of this project was to evaluate the effectiveness of instructional design and delivery in changing student attitudes toward transgender patients at a regional-comprehensive, midwestern university atp. instructional delivery included both active and passive strategies (readings, discussion, lecture, and problem-based learning) with a focus on destigmatization, health and healthcare inequities, gender-affirming care, and regulations related to sports participation. methods: we used three measures to assess student attitudes, knowledge, and practical application. the validated attitudes toward transgender patients (attp) tool (10-item, 3 primary constructs (clinician education, transgender sport participation, and clinician comfort) was used immediately before the class discussion, immediately after the lecture, and 4 weeks later to evaluate student attitudes (n=8). a content-validated cognitive knowledge assessment (total score of 25 points; multiple-choice and multi-choice questions) was used immediately after the lecture and 4 weeks later. finally, we used a problem-based learning case to evaluate the students’ ability to apply knowledge within 1 week of the lecture. we used descriptive statistics to characterize student performance. we used a repeated measures anova to compare pre-, post-, and post-post attitudes for each item and each construct of the attp tool (clinician education, transgender sport participation, clinician comfort). we also used a paired t-test to evaluate knowledge after the lecture (post) and at the 4-week follow-up (post-post). results: we did not identify significant differences across each of the attp subscales over time, but did identify two items where student attitudes improved at some point in learning. their attitude about the importance “to receive training on transgender issues” significantly improved from pre-test to post-test (p=0.033), but not at any other time comparison. the attitude about feeling “safer treating a transgender patient in a group setting” at the postpost testing was significantly lower than the scores at the pre (p=0.009) and post-test times (p=0.004), indicating more clinician comfort. student construct scores were slightly elevated (table 1) compared to previous uses of the attp in professional and postprofessional students, suggesting higher levels of potential discord in learning about, permissibility to participate, and discomfort working with transgender athletes. knowledge scores demonstrated below-desired outcomes relative to gender-affirming care and transgender athlete participation in sport (mean=17.9/25 points ± 5.4; 71.6%), which did not change over time (mean=17.1/25 points ± 2.7; 68.5%). an analysis of problem-based learning performance indicated a superficial appreciation for the needs of transgender athletes considering participation throughout the transition. translation to practice: after completing the learning activities and assessments, faculty engaged in a root cause analysis to evaluate the effectiveness of the instructional design and delivery (figure 1). we summarized the minimal changes in attitude and below expectation results in learner performance. we identified the productive and inhibiting features for each of the four approaches to instruction and postulated the additional tactics necessary to reinforce and extend improved attitudes and increase knowledge. consistent with previous research, strategies that contextualize theoretical knowledge, including interpersonal interactions that yield transformational learning, will be prioritized. we plan to use contemporary media and a “teaching” standardized patient encounter to humanize transgender athletes to meet the desired knowledge and attitude outcomes and expectations. abstract presentation 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 using data in the classroom to drive instructional design and delivery eberman le, young jp: indiana state university, terre haute, in table 1. student attitudes toward transgender patients subscale prepostpost-post clinician education 6.9 ± 1.7 5.9 ± 1.7 6.1 ± 1.5 transgender sport participation 10.6 ± 3.9 9.8 ± 4.2 10.3 ± 3.7 clinician comfort 10.0 ± 3.2 9.6 ± 1.9 8.4± 2.4 figure 1. root cause analysis abstract presentation 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 traveling the pathway to a culturally competent health care provider: incorporating study abroad into your curriculum johnston green al*, heffner cj†: *tarleton state university, stephenville, tx; †texas state university, san marcos, tx introduction: as athletic training employment settings expand and diversify, so does the patient population with whom these healthcare providers interact. this growth furthers the need to ensure that students enrolled in an athletic training program (atp) accredited by the commission on accreditation of athletic training education (caate) are educated to provide culturally competent care. culturally competent care is provided when decisions made diminish the inequalities that may be present in a system based upon a patient’s individual circumstances. implementing cultural competency education may be integrated into athletic training education in various manners as necessitated by each institution’s unique circumstances. programs may choose to deliver cultural competency education through a traditional classroom setting utilizing assignments, guest speakers, and other conventional supplemental tools. other programs may utilize a study abroad or international experience to illustrate the importance of providing culturally competent care. a study abroad experience may help position athletic training students in situations that may make them uncomfortable. doing so will challenge the way these learners typically interact with diverse individuals, thus providing them the opportunity to develop and practice the skills needed to become confident in delivering culturally competent exchanges. not only can one see heightened capabilities through such an experiential learning process but is has been noted that individuals who participate in a study abroad as part of a health care education program often develop a changed personal perspective regrading patient centered care. such skills are important to those patients who may experience disparities based on a single characteristic of their background or the intersectionality of several components. methods: while the topic is interspersed throughout the entire program’s curriculum, a caate-accredited atp has developed a curriculum that culminates with a course focused on exploring cultural competency. the hallmark of this course is a study abroad experience which follows a traditional classroom exploration of numerous cultural and societal factors. the study abroad occurs in a different country each year, allowing for a broader spectrum of cultural interactions for both the learner and the faculty members. this type of event provides the students with an immersion into another culture, including but not limited to educational and health care systems. expected outcomes: students gain intimate knowledge into the impact that race, ethnicity, religion, sexual orientation, and socioeconomic status among other criteria may have had on healthcare during the didactic portion of their curriculum. during a study abroad experience, students will develop further confidence in communicating with those who do not speak the same language, navigating new forms of transportation, and develop an appreciation for healthcare systems in other countries. athletic training students will return with a broadened perspective of whole patient health care and the ability to apply first-hand what they have learned in the didactic portion of their program. translation to practice: students enrolled in an atp are educated in culturally competent, patient-centered care. often, the learners’ traditional clinical rotation sites are somewhat homogenous due to geography, and they may not be exposed to varying social determinants of health. the ability to take them beyond their norms and have them interact with those of another culture will aid in creating a more well-rounded, confident healthcare provider for their future patients. abstract presentation 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 athletic trainers in physician practice society (atpps) abstract presentations the following abstracts were accepted and presented at the 7th annual athletic trainers in physician practice society meeting and conference february 29 – march 2, 2024. exploring the work-related quality of life of athletic trainers in physician practice anderson nt, games ke, young jp, rivera mj, eberman le: indiana state university, terre haute, in introduction/context: the national athletic trainers’ association (nata) identified the vitality of the athletic training profession as a research priority, which includes exploring solutions to improve work-life balance. there is a common perception that athletic trainers (at) working in the physician practice setting have lower work-life conflict and increased job satisfaction, but no data to support this belief. work-related quality of life (wrqol) has been studied in some healthcare settings but has not been studied in any athletic training clinical practice setting. therefore, the purpose of this study is to investigate the wrqol of athletic trainers in physician practice. methods: a cross-sectional, web-based survey was used to explore the wrqol of ats in physician practice. the survey consisted of demographic questions, a description of daily work responsibilities, a characterization of autonomous clinical practice, and the pre-existing wrqol scale. the wrqol scale ranks agreement with statements related to home-work interface, general well-being, job and career satisfaction, control at work, working conditions, and stress at work on a five-point likert scale (1=strongly disagree, 5=strongly agree). the survey was distributed to 1000 ats through the national athletic trainers’ association. sixty-three participants accessed the survey (6.3%). of the 63 participants who accessed the survey, 4 did not finish, 18 reported they did not currently work in the physician practice setting, and 27 participants (age = 42.5 ± 7.8 years [range = 28-56 years], years of experience in physician practice setting = 7.74 ± 6.58 years [range= 1-24 years]) completed the entire instrument (42.9% completion rate). descriptive statistics were used to analyze demographic variables, individual wrqol scale items, and overall wrqol. results: participants reported years credentialed as an at as 18.5 ± 8.7 years. when asked about other at settings where they had previously worked, 81.5% (n=22) reported working in the secondary school setting at some point in their career, and 37.0% (n=10) reported previously working clinically in the college/university setting. the average wrqol scale score for participants was 81.38 ± 11.83 with scores ranging from 60 on the low end to 101 on the high end. of the 23 questions from the wrqol scale, the statement with the highest agreement was “i work in a safe environment” with a mean response of 4.26, and the statement with the lowest agreement was “i often feel under pressure at work” with a mean response of 2.85. other statements with a mean agreement of 4 or higher included “i have the opportunity to use my abilities at work” at 4.00 and “i have a clear set of goals and aims to enable me to do my job” at 4.11. for the statement “i am satisfied with the overall quality of my working life,” participants reported a mean agreement of 3.74, indicating feelings between neutrality and agreement. conclusion: the average wrqol scale score for participants in this study ranks in the 60th percentile, which is the high end of the average quality of working life. these percentiles were established in a large study (n=953) of healthcare workers to validate the wrqol scale. however, since this is the first study to use this instrument in the at profession, future work should consider measuring the wrqol scale across different practice settings. abstract presentation 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 1s march 2024 how do athletic trainers impact patient health literacy?: a critically appraised topic bouchard t: ochsner sports medicine institute, baton rouge, la introduction/context: health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” an estimated 80 million americans are estimated to have low levels of health literacy. low health literacy has been linked to poor patient outcomes and decreased usage of health services. athletic trainers are multiskilled medical professionals recognized by the american medical association, trained in, among other things, wellness promotion and education, injury prevention and rehabilitation, and primary care. although athletic trainers have traditionally been employed in collegiate/elite sports, many are now employed in a number of different settings, including physical therapy and orthopedic clinics, working as physician extenders. this critically appraised topic aimed to examine the impact of athletic trainers in the physician practice setting on patient health literacy levels. search strategy: the databases searched included pubmed and google scholar. results: the results from the search demonstrate three widely accepted interventions to improve the health literacy of patients: plain speak, teach-back, and limited concepts. clinical bottom line: athletic trainers working in the physician practice setting have a unique opportunity to improve patient understanding to help them achieve improved healthcare outcomes. editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 3s – november 2022 the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) luzita vela, phd, lat, atc*; meredith decker, phd, lat, atc†; ramonica scott, phd, lat, atc‡; brandon warner, m.ed., lat, atc**; & shaketha pierce, ms, lat, atc§ *university of arkansas, fayetteville ar, tx; †university of texas at arlington, arlington, tx; ‡abilene christian university, abilene, tx; **grand canyon university, phoenix, az; §newman smith high school, carrollton, tx moderator: s. andrew cage, med, lat, atc key phrases patient-centered care; dei, inclusive excellence full citation vela l, decker m, scott r, warner b, pierce s. the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata). clin pract athl train. 2022;5(3s): 1-7. editorial the southwest athletic trainers association (swata) is filled with gratitude and excitement as it continues its partnership with clinical practice in athletic training. this collaboration has allowed athletic trainers to have an opportunity to share their work in new ways, and the swata free communications and research committee (fcrc) anticipates continued growth of their program as a result. for the 2022 swata symposium, one of the goals of the committee is to bring more awareness to the diversity, equity, and inclusions (dei) standards adopted in the 2020 version of the commission on accreditation of athletic training education (caate) standards. the inclusion of these standards aligns with the swata mission statement, which states that the purpose of the organization is to enhance the quality of healthcare for the physically active; to promote and advance the athletic training profession; to promote a better working relationship among those who work toward care and prevention of athletic injuries; enhance the healthcare of persons served by the membership; safeguard and advance the membership; and to promote the free exchange of information with swata. in keeping with this mission, the fcrc has continued collaborative efforts with the swata lgbtq+ advisory committee and the swata ethnic diversity advisory committee (edac). these initial efforts have allowed for presentations at the regional, district, and local level, as well as publications on attitudes toward lgbtqia+ individuals. presently, there are manuscripts at varying stages of review and preparation on topics including the role of sexual harassment in burnout among athletic trainers, the use of teaching exercises to increase cultural competency, and perceived levels of cultural competency among athletic training students. through these efforts, the hope is to continue promoting a community of clinicians, academicians, and researchers working toward a common goal of creating an inclusive environment that allows patients and athletic trainers to pursue their physical activity and career goals. at the 2022 swata symposium, the fcrc will continue their collaboration with the lgbtq+ advisory committee and edac to host a panel on implementing and assessing the caate dei standards. to this end, the fcrc wanted to put forth an editorial in collaboration with the lgbtq+ advisory committee and edac, including an interview with university of texas at arlington clinical education coordinator and swata the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 2 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 lgbtq+ advisory committee chair, meredith decker, newman smith high school athletic trainer and swata ethnic diversity advisory committee chair, shaketha pierce, university of arkansas athletic training program director and caate member, luzita vela, abilene christian clinical immersive experience coordinator, ramonica scott, and grand canyon university athletic training program director, brandon warner. we asked this esteemed panel of clinicians and educators to provide information about their experiences with and feelings toward the caate dei standards and the importance of diversity, equity, and inclusion in athletic training through a few questions from swata free communications and research committee chair, andrew cage. cage: as a compliment to their dei standards, caate has defined an inclusive environment as “one that recognizes the contributions and supports of all, regardless of nationality, ethnicity, race, religion, age, sex, marital status, socioeconomic status, gender identity and expression, sexual orientation or ability”. why do you feel it is important to provide this type of environment from a patient care standpoint? vela: it is important that organizations like the caate make statements like this because it helps to foster a vision of the type of patient care that an at should provide. an inclusive environment signals to a patient that their at values patient-centered care. this statement demonstrates the aspirations of the profession and a desired culture within any space ranging from an educational institution to a treatment environment. decker: the biggest and most important reason is to serve all equitably and to not discriminate against anyone or deny care for any reason. the wording "recognizes the contributions and supports of all," also lends to the notion that we should see and appreciate everyone for exactly who they are. we can only really call our practice inclusive when patient care is provided that recognizes and aligns with all aspects of a person's identities. scott: it is important to provide this type of environment because it can allow for a comfortable experience for the patient. creating an inclusive environment shows patients that their different, individual needs are seen and are important to their overall care. this can lead to a better quality of care. warner: from a patient’s viewpoint, they are seeking a healthcare provider to address a problem or concern with their current health status. if the provider does not promote an open/non-judgmental environment or have the adequate interpersonal communication skills, the interaction will be less than satisfactory and may not facilitate a positive patient interaction or outcome. this type of environment may cause the patient to not properly disclose information relevant to the current situation. when the clinic or practitioner is not promoting an inclusive environment, the most venerable party is usually the most impacted. in this case, it is the patient and may result in sub-optimal outcomes. pierce: we encounter different patient populations and it is imperative that we understand the importance of the dei standards caate has provided so we do not allow our biases and personal beliefs to jeopardize the standard of care we provide to our patients. cage: why do you feel it is important to provide an inclusive environment for education of future athletic training professionals? vela: it is critical to create an inclusive environment in which a student can feel welcome, respected, and supported for numerous reasons. for one it helps the diverse set of learners within our space to feel welcomed and therefore more likely to see a home in the profession of athletic training. ideally, this will continue to the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 3 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 grow our own profession’s diversity so that our profession is reflective of the patients we serve. a second reason is that it helps to shape the values of our students so that they can, in turn, be able to provide the same inclusive environment to their patients when they are practicing clinicians. an inclusive environment also leads to a civil discourse which elevates the quality of the educational experience especially about topics that are complex and require innovative approaches and solutions. decker: in any situation, people want to feel safe and want to be given the opportunity to be authentic and true to themselves. i personally want to make sure every one of our students feels welcome in our program and at their clinical sites so that they can "pay it forward" to create that kind of environment for everyone they encounter as an at. scott: people from different backgrounds are entering the athletic training profession. having athletic training programs that support inclusive practices is key to retaining diverse individuals in the education programs and the profession. warner: these environments help promote soft skills in athletic training. to be inclusive, you need to know the vernacular of these populations to communicate effectively and compassionately. many of the athletic training competencies can be taught in the context of the athletic training programs, however, it is becoming clearer that employers seek athletic trainers that demonstrate effective soft skills. though programs have curricula on communication, critical thinking, leadership and teamwork, in-class and lab activities do not even come close to the authenticity of working with diverse populations. pierce: it is important to provide an inclusive environment as the classroom setting is where athletic training students learn how to provide patient-centered care. often times, we find that some athletic training programs do not provide inclusive environments which leads to problems with student retention. cage: what do you feel is the role of athletic training education is in ensuring these environments are created for patients, staff, faculty, and students? vela: this is an interesting question and one that i have thought about quite a bit. some of my own experience as an athletic training student have influenced my perspective. i recognize that people like preceptors, peers, faculty, advisors, etc., were critical to my development as a professional because they were student-centered and fostered inclusive environments. constructing an inclusive environment is a heavy lift and one that can't be done alone. it is a group endeavor and requires that every person in an environment is on the same page for the culture to flourish. therefore, each athletic training program has the challenge of co-constructing an environment where an inclusive culture is verbalized, taught, lived, and measured. this won’t be a “one size fits all” and must be specific to the context and needs of the institution. decker: we have to make a shift in the profession to truly being more inclusive of all and there's no better way to do that than educating the future generations of our profession on what it takes to legitimately practice in an inclusive manner. we need to be leading by example in all aspects of our program so that our students can be empowered and excited to facilitate these environments throughout their own practice. scott: the role of athletic training education in ensuring an inclusive environment for all those involved is to teach and evaluate. athletic training education should incorporate inclusion concepts into every domain and the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 4 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 into didactic and clinical education. athletic training educators should be responsible for providing inclusion, dei training for their preceptors and faculty who are involved in the students' education. warner: personally, i do not feel that the role of the education has changed since the implementation of the dei standards. it has always, and continues to be, the programs’ role to provide diverse clinical exposures to the next generation. failure to provide a variety of clinical experiences will fail future professionals and give an unrealistic expectation and view of the profession prior to certification. the new dei standards serve to hold programs more accountable for providing these inclusive environments and provide the caate a sense of maintaining quality education of future athletic trainers. as a program administrator, it is our responsibility to ensure the assessment of preceptors, clinical sites, and all associated stakeholders to meet the expectation of the profession and medical field regarding these standards. pierce: the role of athletic training education is to have trainings for faculty/staff and create opportunities for training in the graduate program curriculum. cage: when writing the current caate dei standards, what were some of the considerations you had when determining how best to write these standards? vela: there are a few things that we thought were really critical in the proper development and implementation of these new dei standards. first, we identified a timeline and process for creating the standards. we wanted to make sure to have a very thorough, thoughtful, and iterative process and we wanted to allow ourselves enough time to write standards that were going to be quality standards. to do this, we partnered with the caate diversity, equity and inclusion and leadership development committee. we also integrated some dei experts into the discussion by using a workgroup to identify critical content. like many new standards we also integrated multiple feedback sessions not only from our subject matter experts after working on the language of the standards but also from the larger public and other stakeholders. within our discussions we acknowledged that it was important that we not only created a new curricular content standard on dei, but we also recognized the importance of evolving existing standards that were related to dei. we also identified that we needed to create new standards to help programs to integrate dei into the process and how they run a program. therefore, we added a program delivery dei standard as well. cage: based off what you have seen since these standards were released, has there been a lot of buy in from accredited programs? what do you think accounts for this presence or absence of buy in? vela: i do believe that there is genuine “buy in” for the new dei standards. when we did have an open comment period for a draft version of the standards there were comments that voiced vocal opposition to the standards, and i felt were antithetical to who we are as healthcare providers. i also recognize that those comments were made by a minority of persons who commented. however, it didn't make it any easier to read the comments and may have even reinforced the necessity of these standards. i think where we are right now is that most programs are still trying to figure out how to integrate these standards in a meaningful way. i appreciate this because i believe that a reasoned, thoughtful process of trying to think through dei in a way that is context and situational specific to an environment helps to sustain the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 5 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 the desired culture that a program wants to build and helps to lead to a more truly inclusive environment for students, faculty, preceptors, staff, and patients. cage: having served as both a clinical education coordinator and a program director have you personally seen a noticeable shift in the inclusion of dei related materials in athletic training curriculums before the implementation of caate’s standards? vela: the answer is both yes and no. i did know of a good number of programs trying to integrate dei curricular content into their educational processes. some programs were teaching important concepts like cultural competency and humility, but this material wasn’t likely being consistently taught across all accredited programs. it may have also been done as a single lecture and done as an afterthought. as a side note, dei concepts were integrated into the 5th edition of the education competencies, which were previously used as the template for required educational content for professional programs. however, they were included in the section titled “foundational behaviors of professional practice”. because this content fell into this area, programs weren’t assessed on whether they taught that content during the accreditation process. we also noted that when dei content was embedded into the “patient-centered care” section of the 2020 professional standards that we could run into the same consistency problem. our intent was that dei is central to patient-centered care and therefore should be taught as a consistent thread across multiple courses. a concern was that the standards needed to be more directive on specific dei content. this is why the new content was created. i also did see programs that were cognizant of the importance of dei practices in the delivery of an educational program. having said that, we identified that without a specific program delivery dei standard, a program could view dei work as an afterthought for program development. by creating these standards, we wanted to shift the focus so that dei is an important element to the development of a program. cage: in your role interacting with clinical sites for your athletic training students, what are some of the common reasons you hear for clinical sites not assessing and implementing dei standards? decker: we are still rolling out some aspects of the dei standards within our clinical experiences, but i think a general barrier is how these standards are objectively assessed. preceptors who are excellent examples of being inclusive and incorporating dei into their practice may have never really assessed how well they are doing beyond an informal, personal assessment. objective assessments are necessary to determine progress and gaps that need to be filled, but there is often a learning curve when using them. scott: some common reasons include that they don't understand what exactly needs to be assessed and implemented. specific tools and resources are unavailable at this point. also, some clinicians do not believe that dei is necessary and they don't want to engage in it. sometimes this is true because they do not want things to change (even though the world is changing), or they have biases that they think are okay. cage: how do you assess how well these standards are being implemented? decker: for all standards assessed clinically, we use a likert scale to determine the level of proficiency that a student achieved. we have clearly defined each level of proficiency and we also provide preceptors and students with resources on how to implement each standard and what constitutes the score of proficient. this gives us the opportunity to review the data from each cohort on how they scored, but there is also the ability the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 6 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 to use the patient encounter data students submit along with each standard so i can recognize if there are any improvements that are needed with implementation. scott: at this time, we require the preceptor to assess the students' knowledge of social locations (age, gender, race, ethnicity, socioeconomic status, etc) of their patients. the students have to identify how addressing them can affect their quality of care for the patient. as far as assessing the standards being implemented within the clinical site, we do not assess it at this time. cage: what is some of the advice you have offered to clinical sites regarding better implementation of these standards? decker: it is incredibly important to me that these standards aren't assessed one time using a checklist, like would be the case if we were assessing a student on how they set up a patient on supplemental oxygen. these are aspects of practice that should be incorporated into every interaction we have with our patients, so my advice is to strategically sit down with students and discuss how these standards can be done regularly and assessed over time. scott: honestly, we have not fully addressed implementation of these standards with our clinical sites. future plans include incorporating resources and training into our preceptor training meetings at the beginning of the year. cage: as program director of an athletic training program with over 50 clinical sites, what are some of the challenges you encounter when ensuring that dei standards are upheld at clinical sites? warner: the only problems encountered for the dei standards is attestation of inclusivity and really seeing if the site is promoting this type of environment. we are up-front with preceptors and clinical sites on the affiliation agreement that all locations must follow the caate standards, including language on equal opportunity and non-discrimination. everyone is usually on-board with the affiliation agreement and seem to want to provide such environment. however, it is easier said than done. therefore, we are implementing questions on the clinical site, student, and preceptor evaluations. this may help identify sites that are struggling with these standards and more guided preceptor trainings may be used. cage: why do you feel the inclusion of dei skills is important for an athletic training curriculum? warner: as a medical provider, we must listen non-judgmentally and create an open environment. these standards help create transparency between the profession and education what is necessary for entry-level practice. the inclusion of these skills will help develop soft skills in future professionals. as we all know, athletics is very diverse in ”nationality, ethnicity, race, religion, age, sex, marital status, socioeconomic status, gender identity and expression, sexual orientation or ability”. therefore, it is important in the professional education to give authentic experiences for all these populations, if possible, to enhance clinical capabilities. cage: what would you say to a program director or athletic training faculty member who says they are having difficulty implementing and assessing these standards? warner: my advice would be to not be afraid of making hard decisions. i have had to make many hard choices on the retention of clinical sites. as educators and program administrators, it is our responsibility to train the next generation to progress and enhance the profession. also, we need to lead by example to the increased push for implementing caate diversity, equity, and inclusion standards in the southwest athletic trainers’ association (swata) 7 copyright © indiana state university clinical practice in athletic training issn online 2577-8188 volume 3 – issue 3s – november 2022 begin to hold ourselves and others accountable for basic human rights. if a clinical site or preceptor is unwilling to adhere to these standards, reflect on the boc standards of professional practice or the nata code of ethics. inclusivity has been around for quite some time and we may need to start being more selective of clinical sites due to failure to maintain contemporary expertise and ethics in the profession. cage: as a preceptor, what do you feel is the most important aspect of upholding the caate dei standards when serving as a preceptor/mentor for an accredited program? pierce: as a preceptor, i strive to educate on the diverse patient populations i serve in my athletic training facility. every summer, the accredited program i serve as a preceptor for offers a preceptor training. the preceptor training covers dei standards and how we can apply them as clinicians. cage: what soft skills do you think the current generation of athletic training students excel at? what skills do you feel they are lacking in? pierce: the current generation of athletic training students i have worked with excel at being outspoken, competitive, and having self-awareness. the current generation of athletic training students i have worked with are lacking in communication, teamwork, confidence, and cultural competence. cage: what advice would you have for other preceptors if they are concerned they are not implementing these standards in the best way possible? pierce: i would advise other preceptors to work closely with the clinical education coordinators and ask questions for clarity on how they can implement the standards. i would also advise preceptors to get feedback from graduate students. clinician expertise commentary 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary david tomchuk, dat, atc; kyle schneider, edd, atc; jacklyn bascomb-harrison, ms, atc *southeast missouri state university, cape girardeau, mo correspondence dr. david tomchuk, southeast missouri state university, department of kinesiology, nutrition, and recreation, ms 7650, cape girardeau, mo, 63701. e-mail: dtomchuk@semo.edu submitted: december 15, 2021 accepted: march 2, 2022 full citation tomchuk d, schneider k, bascomb-harrison j. creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary. clin pract athl train. 2022;5(2): 32-39. https://doi.org/10.31622/2022/0005.02.6. commentary the novel coronavirus disease of 2019 (covid-19) resulted in a worldwide pandemic that shut down various aspects of business, education, sport, recreation, and entertainment venues worldwide.1,2 these public health measures particularly disrupted the performing arts sector, resulting in hardships such as performance hall closures, decreased revenue, limited opportunities to transition to online work, and unemployment.3-5 additionally, colleges and universities implemented protective protocols to promote student, faculty, and staff safety. throughout the summer and fall of 2020 and into the spring of 2021, professional, collegiate, high school, recreational, and amateur sports leagues across the globe commenced operations and competitions after developing and implementing covid-19 safety protocols.2,6 this clinician expertise commentary presents how athletic trainers at one united states public university developed and implemented a covid-19 safety protocol for its integrated performing arts academic campus during the 2020 – 2021 academic year. facility description the southeast missouri state university performing arts campus is separated geographically from the main university campus by approximately 3 miles and built to promote the constant interaction and creativity of the performing arts majors and faculty. the performing arts campus encompasses several interconnected buildings and complexes, including campus residential housing and living spaces for approximately 180 performing arts students, offices and studios for 30 faculty and staff, a dining hall, areas designed for classroom instruction and rehearsals, and public performance spaces for large and small-scale productions (190 to 950 audience members). the layout and daily operations of the performing arts campus contrasts with the design of the main university campus, where residence halls and living spaces, dining areas, classrooms, and faculty offices are separated across multiple buildings, and individuals rarely spend more than 2 hours in any one location. compared to the main university campus, these differences present unique covid-19 challenges. most of the daily personnel traffic in the performing arts campus results from individuals who live in the buildings or spend 40+ hours of work functions inside a confined collaborative space. additionally, the performing arts campus contains the clinic for health in the arts (chart clinic), a joint venture between the university and a regional hospital system that provides two on-site athletic trainers throughout the day and during university-sponsored performances and shows. these athletic trainers work mailto:dtomchuk@semo.edu https://doi.org/10.31622/2022/0005.02.6 creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 cooperatively with physicians and the performing arts faculty to provide health care that focuses on the prevention, evaluation, treatment, and rehabilitation of musculoskeletal and general medical conditions specific for undergraduate performing arts majors across various dance disciplines, theater, musical theater, and the university marching band. lived experiences and skill development during the summer of 2020, the chart athletic trainers, collaborating physicians and hospital, and the performing arts faculty met to review university and county public health covid-19 safety protocols to determine how best to implement these guidelines, specifically the performing arts campus. these meetings resulted in a multi-pronged approach based on county and universityprotocols to mitigate the transmission of covid-19 among the students, faculty, staff, and visitors while allowing the performing arts campus to operate and promote on-campus learning, social interactions, and inclusive creative thought. additionally, these stakeholders agreed that the chart athletic trainers would be the covid-19 experts of the performing arts campus by implementing, creating, and adjusting policies and procedures as appropriate. before covid-19, athletic trainers could not foresee that their job descriptions would include group and facility-level infection prevention protocols of a novel airborne virus. the chart athletic trainers were previously trained and understood how to prevent the spread of skin infections,7 influenza, and other communicable diseases. however, these policies and protocols were insufficient for managing covid-19. like all healthcare providers, the chart athletic trainers rapidly adapted to develop covid-19 specific prevention and mitigation protocols and implementation measures on a unique university academic campus and patient population that required guest access. this clinician expertise commentary describes the framework of creating, adjusting, and implementing a covid-19 mitigation protocol for a university performing arts campus, the unique challenges that arose, and their solutions. education, preventative sanitation, and minimized group gatherings the chart athletic trainers instituted covid-19 transmission prevention protocols recommended by the county health department and the university by mandating the wearing of face coverings, social distancing, and placing capacity limits on classrooms and facilities.8 wall signage, floor stickers, modeling, and electronic communication educated and promoted covid-19 personal responsibility prevention methods. the only daily situations where removing a face-covering was allowed were when students were physically inside their primary residence and when faculty and staff were alone inside their offices. the university employed part-time workers to stock hand sanitizer, surface disinfectants, and facemasks throughout the rooms and traverse the public areas throughout the day to disinfect high-touch areas such as doorknobs, elevator buttons, and communal furniture. during weekly campus meetings and gatherings, the chart athletic trainers educated the faculty, staff, and students about the importance of mask-wearing and disinfecting chairs, tables, desks, and shared equipment after classroom and academic sessions. faculty and staff meetings, media events, and community gatherings transitioned to online video platforms (e.g., zoom) or otherwise restricted to prevent unnecessary congregation inside the performing arts campus. to promote safety within the 300 square foot chart clinic, all patients and providers minimally wore double-layer cloth facemask over their mouth and nose, enforced handwashing and hand sanitizer usage, and disinfected touched surfaces and equipment after each patient encounter. only two patients were allowed physical entry into the chart clinic simultaneously, and the chart athletic trainers screened each creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 patient for covid-19 symptoms before allowing access (table 1). these same screening and entry protocols occurred for all rehearsal and production situations where physical distancing could not be ensured. the chart athletic trainers implemented an electronic appointment system for all non-emergency injury evaluations and treatment sessions to facilitate clinic safety and maximize capacity. additionally, the chart athletic trainers created a telehealth process to check in with patients and perform virtual covid-19 symptom screening without requiring physical attendance in the chart clinic. table 1. pre-screen (before entering chart clinic)* current symptoms • fever/chills • cough • shortness of breath/difficulty breathing • fatigue • muscle/body aches • headache • loss of taste/smell • sore throat • congestion/runny nose • nausea/vomiting • diarrhea exposures/diagnosis in past 14 days • been in contact with a confirmed covid-19 patient • visited an area with a high covid-19 community transmission rate • received a positive covid-19 test/diagnosis body core temperature • obtained each patients' body core temperature. any reading above 100.4°f (38°c) was considered a "yes." *all patients were required to answer these questions utilizing the emr system before entering the chart clinic for athletic training services. all questions required the patient to designate a yes/no response. any "yes" response prompted further investigation and/or contact tracing by the chart athletic trainers. symptom monitoring, reporting, and contact tracing under the supervision of the chart athletic trainers, the performing arts campus implemented the university's general covid-19 symptom monitoring and reporting guidelines, which mandated that faculty, staff, and students self-report any symptoms of illness (e.g., fever, sore throat, or excessive tiredness) and interactions with a known or potential covid-19 positive individual. all potential exposures and covid-19 symptoms were reported to a centralized system and were investigated by the university's designed contract tracing personnel. because of the performing arts campus's unique nature and off-campus location, the chart athletic trainers advocated for and received approval from university administrators to become the lead individuals to identify and perform contact tracing activities for the performing arts students and report those findings to university personnel. the chart athletic trainers sought this capability at the beginning of the fall 2020 semester because the university contact tracers were overwhelmed, requiring up to a week for some investigations. this extended timeline potentially jeopardized required student productions by enabling potential positive patients to spread covid-19 or delayed the decision to adjust casting. with the chart athletic trainers performing contact tracing for the 180 performing arts students, investigations and contact tracing required only 24-48 hours. based on the contact tracing findings, rehearsal and production schedules could remain or be quickly altered. this independence further allowed the chart athletic trainers to create creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 targeted policies for the unique needs of the performing arts campus and population. the chart athletic trainers administered contract tracing for the performing arts campus students and transmitted the names to the dean of student's office, who maintained the list of quarantined and isolated students campus-wide and communicated findings to non-performing arts faculty. the performing arts campus was the only academic entity to have health care providers implement university policies, contract trace, or perform and track a daily symptom monitoring system. isolation and quarantine the chart athletic trainers operated and enforced the university isolation and quarantine protocols for the performing arts campus. any dormitory-resident student who tested positive for covid-19 or was identified through contact tracing as a potential positive was quarantined and isolated in their room with any roommate(s) per university, county, and cdc requirements for between 10 and 14 days.8 the chart athletic trainers informed the performing arts campus dining services, which coordinated meal deliveries for the duration of the isolation or quarantine. off-campus residents had identical requirements, except no meal delivery service. all isolated and quarantined students attended their courses via video streaming and completed assignments through the online learning management platform. quarantined and isolated students were required to maintain and track their symptoms and upload the results to the chart clinic online database daily. the chart athletic trainers would visit the isolated and quarantined students via video chat to confirm symptoms and timelines for return. transition of evidence into practice and unique challenges the university canceled all fall 2020 athletic competitions. however, the performing arts campus could not discontinue student productions because participation was a required component of the academic degree programs for graduation and course credit. the prior sections described how the chart athletic trainers were charged with implementing the general university covid-19 protocols, received the authority to adjust university protocols, contact trace, and created a targeting symptom monitoring program. the subsequent sections contain specific instances where the chart athletic trainers created and implemented enhanced covid-19 mitigation policies during the 2020 – 2021 academic year that only affected the performing arts campus, students, and faculty because the general university covid-19 protocols primarily discussed masking during social and academic gatherings, room capacity limitations, and surface disinfection. vocal performance alterations the chart athletic trainers and performing arts faculty worried that the forceful movement of air during the act of singing rehearsals and performances could potentially transmit covid-19.9,10 to decrease droplet and aerosol transmission risk during solo rehearsal, detailed voice coaching sessions transitioned to online video platforms (e.g., zoom). background vocal and group rehearsals occurred in smaller gatherings when video platforms were impractical. in the days immediately preceding the show performance, the production recorded passages of background vocal sessions in the recording studio to be played during the live performance. prerecording of singing (lip-syncing) was limited to situations where multiple cast members must gather on-stage during the performance's aesthetics and narrative to eliminate the need for close group live singing and further reduce the risk of air droplet virus transmission. on-stage live solo vocals from the lead cast members or duets were allowed, with the singing individual(s) projecting their voice away from any other stage members (figure 1). finally, shared and non-personalized microphones during rehearsals creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 and performances were eliminated. each performer had their assigned microphone and was responsible for its cleaning and maintenance. microphones were stored in separate plastic bags when not actively used within the venues. masks, costumes, and stage design alterations during the 2020 – 2021 academic year, the chart athletic trainers used their position as the performing arts campus covid-19 coordinators to work with the faculty and students to develop and alter on-stage personas and characters based on the wearing of transparent face masks during performances. the chart athletic trainers educated and assisted the wardrobe and make-up designers who integrated masks into on-stage costumes that contributed to the character and story (figure 1). additionally, the chart athletic trainers collaborated with the costume and stage design shops, performers, and faculty to create fewer costumes for each character and reduce onstage physical background props and sets. the faculty, performers, and designers learned how to incorporate masks and fewer costumes and props that supported character portrayal while maintaining audience appreciation of the performance. performance alterations outside spectators were not allowed into the performance halls during the fall 2020 and the first half of the spring 2021 semester, and the performing arts campus implemented live-stream performances. the chart athletic trainers worked with the performing arts faculty to identify alternative productions that would require fewer participants on stage and backstage to promote social distancing and reduce potential covid-19 transmission. the chart athletic trainers ensured the backstage area was limited to only essential cast members or production personnel on the official casting roster. the reduction of physical on-stage backgrounds reduced the need for some backstage personnel to change stage design between acts, and on-stage performers utilized fewer props. electronically created and projected backgrounds and lighting effects replaced select physical stage backgrounds and props for the audience's appreciation of the storyline while serving as a modern way to create background and staging effects for the undergraduate students. the fewer number of costumes reduced quick costume changes during productions, the unnecessary congregation of multiple performers in enclosed backstage locations and made costume sanitation more effective between productions. the chart athletic trainers implemented a daily symptom self-report screening process (table 2) for any student assigned to a production throughout the 2020 – 2021 academic year to identify possible covid-19 infections that could potentially alter or cease a production run. during the final months of the spring 2021 semester, the main performance hall was allowed to sell 10% of its available 950 seats for in-person viewing. traditionally, the cast and faculty would have a meet-and-greet style interaction with the campus patrons and supporters after each production run. figure 1. example of a stage mask worn during performances and on-stage social distancing. photo by: kenneth l. stilson creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 table 2. daily symptom checklist for production participants* daily symptom checklist questions • have you had any signs or symptoms of a fever in the past 24 hours (chills, sweats, felt feverish)? • have you had a temperature above 100.4°f (38°c)? • have you had any of the following signs and symptoms: cough, shortness of breath, sore throat, nasal congestions, body aches, loss of smell/taste, diarrhea, or vomiting? • in the last 48-hours, have you been in direct contact with anyone positive or presenting covid-19 symptoms for longer than 15 minutes with no mask and within 6-feet? • if you have any "yes" responses, please explain how long the signs and symptoms have been present. body core temperature • obtained each patients' body core temperature before a rehearsal or performance. any reading above 100.4°f (38°c) was considered a "yes." *all participants in productions (cast and crew) were required to complete this online symptoms checklist at the beginning of each day during all rehearsals and production days. the results were reviewed by the chart athletic trainers daily, and any positive symptoms required consultation with the chart clinic staff before arriving on site. however, the chart athletic trainers requested alterations to enforce and promote social distancing requirements to prevent covid-19 infection between the community and the performing arts campus participants. table 3 describes other performance and rehearsal alterations. all 13 scheduled productions throughout the 2020 – 2021 academic year occurred without any incidence of covid-19 traced to a production. table 3. alterations to performances and rehearsals during the 2020-2021 academic year pre-recording music to be played during productions pre-recording group background vocals (lip-synching during performances) decreased dressing room admittance for non-essential personnel decreased backstage presence to only essential personnel limiting ensemble numbers (performers and stagehands) to the minimum needed decreased number of set-changes during performances/designing sets for entire performance less on-stage group performances cast members and stagehands learning more roles livestreaming events and productions online choosing and developing productions that would promote physical distancing integrating masks and physical distance into productions elimination of live orchestra during performances symptom screening before each performance and rehearsal marching band spit valves one unexpected issue that arose during the fall 2020 semester was the ability of the marching band members to discharge the spit valves of their brass instruments (e.g., trumpets) safely during rehearsal. the creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 chart athletic trainers worked with the marching band faculty to create a policy where the brass instrument performers had a designed area of the marching band rehearsal field to discharge their spit valve over indoor puppy pads to absorb the salvia and discard the potentially infected material into a receptacle safely. additionally, the marching band developed alternative formations and patterns to promote proper social distancing during rehearsals and performances. covid-19 vaccine education and tracking since the university administration designated the chart athletic trainers as the covid-19 experts for the performing arts campus, they were charged with vaccine education and tracking efforts. the chart athletic trainers provided scientific material about the covid-19 vaccine throughout the facility, distributed information about vaccine opportunities throughout the region, and discussed becoming vaccinated during weekly performing arts campus meetings and gatherings.8 the chart athletic trainers inserted documentation of all provided covid-19 vaccination cards into the student's electronic medical record and adjusted the quarantine and isolation policy for fully vaccinated students according to evolving local and federal recommendations. finally, when the university developed a campus-wide vaccination incentive for the students and staff, the chart clinic was 1 of 10 locations where students, faculty, and staff could provide their vaccination cards for entrance into incentive drawings and similar university vaccine drive efforts. conclusion athletic trainers can quickly become infectious disease experts, solve unique problems, and positively promote on-site athletic trainers' value to create and implement policies and procedures specific to the patients and populations in their care. this clinician expertise commentary demonstrated how a group of athletic trainers became covid-19 experts and advocated for their autonomy to develop and implement policies and procedures specific to the performing arts patient population within an academic structure. references 1. hughes d, saw r, perera nkp, et al. the australian institute of sport framework for rebooting sport in a covid-19 environment. j sci med sport. 2020;23(7):639-663. https://doi.org/10.1016/j.jsams.2020.05.004. 2. mulcahey mk, gianakos al, mercurio a, rodeo s, sutton km. sports medicine considerations during the covid-19 pandemic. am j sports med. feb 2021;49(2):512-521. https://doi.org/10.1177/0363546520975186. 3. guibert g, hyde i. analysis: covid-19's impact on arts and culture. 2021. covid-19 rsflg data and assessment working group. https://www.arts.gov/sites/default/files/covid-outlook-week-of1.4.2021-revised.pdf. 4. radermecker a-sv. art and culture in the covid-19 era: for a consumer-oriented approach. sn business & economics. 2020;1(1):4. https://doi.org/10.1007/s43546-020-00003-y. 5. spiro n, perkins r, kaye s, et al. the effects of covid-19 lockdown 1.0 on working patterns, income, and wellbeing among performing arts professionals in the united kingdom (april-june 2020). front psychol. 2021;11:594086-594086. https://doi.org/10.3389/fpsyg.2020.594086. 6. difiori jp, green g, meeuwisse w, putukian m, solomon gs, sills a. return to sport for north american professional sport leagues in the context of covid-19. br j sports med. 2021;55(8):417. https://doi.org/10.1136/bjsports-2020-103227. https://doi.org/10.1016/j.jsams.2020.05.004 https://doi.org/10.1177/0363546520975186 https://www.arts.gov/sites/default/files/covid-outlook-week-of-1.4.2021-revised.pdf https://www.arts.gov/sites/default/files/covid-outlook-week-of-1.4.2021-revised.pdf https://doi.org/10.1007/s43546-020-00003-y https://doi.org/10.3389/fpsyg.2020.594086 https://doi.org/10.1136/bjsports-2020-103227 creating and implementing a covid-19 prevention and response program in the performing arts: a clinician expertise commentary 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 5 – issue 2 – september 2022 7. zinder s, m. , basler r, s. w. , foley j, scarlata c, vasily d, b. national athletic trainers' association position statement: skin diseases. j athl train. 2010;45(4):411-428. https://doi.org/10.4085%2f1062-6050-45.4.411. 8. how to protect yourself & others. centers for disease control. updated august 13, 2021. accessed november 18, 2021. https://www.cdc.gov/coronavirus/2019-ncov/prevent-gettingsick/prevention.html. 9. westphalen c, kniesburges s, veltrup r, et al. sources of aerosol dispersion during singing and potential safety procedures for singers. j voice. 2021. https://doi.org/10.1016/j.jvoice.2021.03.013. 10. mariam, magar a, joshi m, et al. cfd simulation of the airborne transmission of covid-19 vectors emitted during respiratory mechanisms: revisiting the concept of safe distance. acs omega. 2021;6(26):16876-16889. https://doi.org/10.1021/acsomega.1c01489. https://doi.org/10.4085%2f1062-6050-45.4.411 https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/prevention.html https://doi.org/10.1016/j.jvoice.2021.03.013 https://doi.org/10.1021/acsomega.1c01489 manuscript type evidence-to-practice review 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 strategies to improve healthcare communication with non-native english speakers: an evidence to practice review skylar b. hudgens-wallace, ms, atc*; kaitlyn m. pierce, ms, atc‡; madison p. whitesell ms, atc†; nancy a. uriegas, ms, atc§; zachary k. winkelmann, phd, scat, atc, chse§ *ochsner sports medicine institute, new orleans, la; ‡life university, marietta, ga; †moore myoworx, denver, co; §university of south carolina, columbia, sc abstract as the number of non-native english speakers in the united states rises, the degree to which some patients understand their healthcare communication is decreasing. it is essential to recognize the areas of limited health literacy to ensure proper patient communication and education are achieved. the guiding systematic review aimed to examine different communication interventions and the reported patient experiences from those interactions. the main forms of healthcare communication interventions used in the study included inperson, telephone, and video call interpreters. patients have been shown to respond best to in-person interpreters, but using interpreters via telephone or video call was also effective and a suitable option. athletic trainers could use interpreters via telephone or video call to provide patients with a better understanding of their injury while improving communication between the provider and patient. the clinical bottom line of the guiding systematic review was to provide multiple forms of communication interventions to ensure the best outcome of health literacy for the patient. athletic trainers and other healthcare providers can advocate for nonnative english speakers by creating a healthcare communication policy that includes on-demand interventions such as a translation application or a formal medical interpreter. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation hudgens-wallace sb, pierce km, whitesell mp, uriegas na, winkelmann zk. strategies to improve healthcare communication with non-native english speakers: an evidence to practice review. clin pract athl train. 2023;6(2): 28-36. https://doi.org/10.31622/2023/0006.02.4. original reference rajiv p, riggs e, brown s, szwarc j, yelland j. communication interventions to support people with limited english proficiency in healthcare: a systematic review. j healthc commun. 2021;14(2):176-187. doi:10.1080/17538068.2021.1890518 summary clinical problem and question patient-centered care is defined as care that is respectful of and responsive to individual patient preferences, needs, and values and that ensures that patient values guide all clinical decisions.1 using patient-centered principles is essential to provide the best care available for patients, which includes shared decision-making and a holistic approach involving the social determinants of health.2 the social determinants of health dissect the driving forces behind social, environmental, and behavioral risk factors for poor physical and mental health.2 one of these factors is information and education, which indicates that patients often express fear that information is being withheld from them and not being completely informed about their condition. appreciation of some of the social factors that influence health-related behaviors and health status can help clinicians develop more effective treatment plans.3 mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.02.4 strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 proper communication can potentially improve the patient’s health literacy, defined as the degree to which individuals can obtain, process, and understand basic health information and services needed to make appropriate health decisions.4 increasing patient health literacy can greatly improve overall patientcentered care. comprehending and fully understanding the information provided can be difficult for most patients; however, the struggle could be magnified for patients and their support systems as non-native english speakers. the united states does not have a federal official language. still, most states have laws indicating english as the declared language, with more than 20 regional dialects and over 250 million native speakers.5 outside of english, the most common languages in the united states include spanish (43 million native speakers and rising)6 and chinese (3 million native speakers). in addition, it is important to note that there are estimates between 250,000-500,000 american sign language users in the united states.7 these data points emphasize the diversity of the languages used throughout the population and the need for providers to meet their needs in terms of communication. a study conducted in the united states assessed individuals' health literacy, indicating that over one-third of americans (36%) with below basic or basic health literacy were less likely to get information about their health issues.8 unfortunately, healthcare providers in the united states have seen an increase in patients with limited english proficiency. the language barrier may often hinder communication between patients and providers, highlighting the health disparity even further and increasing the chance for poor outcomes. however, it is important to note that using family members, teachers, friends, teammates, or coaches as interpreters can burden a patient’s health literacy and possibly compromise private health information.9 this is also true when asking an injured bilingual patient, specifically a minor at a secondary school, to interpret for themselves back to their non-english speaking support systems (e.g., parents, guardians, caretakers). limited resources for non-native english speakers across sports can affect their access to healthcare and patient outcomes. patients need to be able to understand diagnosis, injury instructions, treatment, and therapeutic interventions. the primary clinical question for the guiding systematic review was to examine different communication interventions and the reported patient experiences for individuals with limited english proficiency. summary of literature the guiding systematic review authors used medline, embase, psycinfo, cinahl, and the cochrane library in their search for the articles used in this review.10 all articles were published between 2009 and 2020 in english and incorporated a verbal communication intervention.10 additionally, studies were included if they met design characteristics for a randomized control trial (rct) and patient outcomes that were the focus of this study.10 studies were excluded if they included deaf or hearing-impaired populations, excluded only written communication interventions, or the study did not report patient outcomes.10 data were categorized into five types based on the type of communication support implemented: (1) professional interpretation, (2) audio and visual recording of consultation, (3) bilingual physician aids, (4) translation applications, and (5) written instructions supported by verbal interpretation.10 database searches resulted in 4297 studies after eligibility screening, and 23 studies met all the criteria for the systematic review.10 of the studies included in the review, 12 rcts were included, with no blinding achieved in these studies.10 five out of the 12 had similar patient characteristics at baseline and clearly recorded outcome measurements.11-15 there were 11 non-rcts included in the review.10 out of the 11 of the non-rcts, none had reported multiple measures of outcomes preand post-intervention, and only one had clear documentation.16 baseline characteristics were similar within only 3 out of the 11 non-rcts.16-18 for the 23 included studies, the assessment of methodological quality determined the studies to be of moderate quality.10 strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 summary of interventions the guiding systematic review authors included interventions for improving communication for non-english speaking patients receiving care in predominantly english-speaking countries. the two main interventions included either interpreters or translators. figure 1 provides a brief overview of the difference between interpreters and translators. fifteen of the included studies implemented the use of professional interpreters to improve communication. professional interpreters included in-person interpreters via telephone or via video call.11,12,14,16,18-27 two of the included studies reviewed bilingual practitioners communicating with patients in their native languages. other studies examined the use of recordings to assist in the translation and explanation of procedures. one study implemented the use of google translate to translate into the patient's native language during primary care visits. three studies looked at the use of visual and written explanations of medical information. some studies wrote the information in the patient's preferred language, and others used visual aids such as a pictogram accompanied by an audible explanation. figure 1. definition of interventions summary of outcomes twenty-three studies from the united states, australia, canada, india, sweden, germany, and qatar were used to evaluate language barriers between patients and healthcare professionals.11-33 most language groups included spanish and chinese-speaking patients.11,12,14-16,19,21,23,25,26,29,32-34 the group of researchers evaluated communication in the emergency department as well as post-operative rooms, •spoken language interpretation service •can occur in unison or consecutive speech •communicates directly with the patient and the provider in real time in both source and target languages (e.g. english and spanish) •provides sentence-by-sentence interpretation interpreter •written word translation service •typically provided using a digital tool and computer resources •occurs over time; not real-time •usally translates unidirectionally into native language (e.g. translating patient education file from english into spanish for non-native english speaker) translator strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 general hospitals, and birthing suites that used professional interpretation, audio and visual recordings of consultations, bilingual physician aids, translation applications, and written instructions supported by verbal interpretation.11,12,14-17,19,21-23,29,32 following the implementation of these methods, the most commonly evaluated patient outcomes were “patient satisfaction” and “patient comprehension.”11-19,23-26,29-33,35 a total of 15 out of the 23 studies had resulted in a preference for in-person interpretation versus videoconference interpretation.11,12,14,18-21,24,25,27,33 evaluation of bilingual physicians or bilingual tools used in the clinic also occurred in these studies. finding and clinical implications patient outcomes were measured as “patient satisfaction” and “patient comprehension.” of the 23 studies, 20 compared patient outcomes between in-person interpreters, interpreters via telephone, and interpreters via video conference. most patients self-reported being satisfied during their visits based on the knowledge of their diagnosis, treatment, and associated risks. while patients reported being satisfied with video conference interpreters, 82% of patients preferred in-person interpretation over the other, stating video-conference interpretation performed the ‘same,’ ‘worse,’ or ‘much worse.’ however, 98% of participants said they were satisfied with the video-conference encounter. 21,33 when comparing telephone interpretation versus video-conference interpretation, video-conference interpretation was preferred.21 most patients who were able to use bilingual tools in the clinic saw increased communication during their visit. the satisfaction of google translate compared to in-person interpretation proved to be comparable, although the accuracy of translation was not evaluated.31 clinical bottom line the lack of formal training for providing care for non-native english speakers could have negatively outcomes as providers have not been educated or know what resources they have available to them for support.9 using different communication interventions could be beneficial for non-native english-speaking patients to understand their health and healthcare fully. implementing different communication interventions, like using a professional interpreter, could be expensive and not as applicable to some athletic training facilities throughout the united states, but potentially beneficial. however, it is important to note the legal and ethical obligation under title vi of the civil rights act to provide and use a trained interpreter.36 based on the findings in the studies, more information regarding the use of interpretation in athletic training facilities is needed. based on the results from other healthcare settings, it can be assumed that athletic trainers providing care to non-native english-speaking populations or their support systems should use an interpreter to provide the best patient care. if possible, in-person interpreters should be utilized by having them sit next to or behind the patient.36 the athletic trainer should also speak directly to the patient in the first person rather than with the interpreter.36 the best practices for integrating a medical interpreter also highlight patient-centered communication, such as speaking in short sentences, asking only one question at a time, avoiding medical jargon, and using a ‘teach back’ to check comprehension.36 however, athletic trainers may not always have access to in-person interpreters and should, therefore, use interpreters via video conferencing or could consider using more nonverbal communication when providing care for these patients. this could maximize health information technology to be able to share information through images and resources.9 athletic trainers can advocate for our non-native english-speaking patients by obtaining tools for video-conference interpretation and/or google translate to ensure that their patients fully understand their health. obtaining translation tools for non-native english-speaking patients can help enhance the environment in athletic training facilities.9 furthermore, it can help demonstrate to patients that the healthcare system does not have to be confusing or difficult to navigate for them or their strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 families.9 knowing a list of common terms in spanish could be beneficial when you are not able to use a translator. table 1 provides a list of common medical terminology with phonetic pronunciations to assist athletic trainers. as seen in the guiding systematic review, the use of bilingual tools can increase communication during patient visits, and having bilingual patient-reported outcomes, sign-in sheets, health history forms, and any other intake forms can help to make the patient comfortable and more receptive to treatment. there are several free tools available, like translate on the apple app store and google translate, that can help when using a videoconference or in-person interpreter is not accessible. ultimately, improving communication with the patient and others involved in their care is essential to prevent improper care that can lead to poor patient satisfaction and serious injury.37-40 as we continue to work towards a more patient-centered approach to athletic training, we have to recognize the promotion of health literacy as a risk-reduction technique. the use of resources relative to health literacy for non-native english speakers and for athletic trainers caring for or communicating with non-native english speakers is critical for success with our diverse patient panels. strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 table 1. common terms and phrases healthcare terms (english) healthcare terms (spanish) phonetics of spanish translation surgery la cirugia lah see-roo-hee-ah concussion la concusión lah kohn-cuh-syohn insurance el seguro médico ehl seh-goo-roh meh-dee-co pain el dolor ehl doh-lohr fever la fiebre lah fyeh-breh hip la cadera lah kah-deh-rah dizziness el mareo ehl mah-reh-oh inflammation la inflamacion lah eem-flah-mah-syohn rehabilitation la fisioterapia lah fee-syoh-the-rah-pyah ankle el tobillo ehl toh-bee-yoh healthcare phrases (english) healthcare phrases (spanish) phonetics of spanish translation where does it hurt? ¿donde te duele? dohn-deh teh dweh-leh point to where it hurts? ¿señala dónde te duele? seh-nyah-lah dohn-deh dweh-leh do you take any medication? ¿tomas algún medicamento? toh-mahs ahl-goo-noh meh-dee-kah-mehntoh what is your diet like? ¿cómo es tu dieta? koh-moh ehs too dyeh-tah is the pain better or worse at night? ¿el dolor es mejor o peor por la noche? ehl doh-lohr ehs meh-hohr oh peh-ohr pohr lah noh-cheh did you bang/hit your head? ¿te golpeaste la cabeza? teh gohl-peh-ahr kah-beh-sah he is going to the emergency room. él va a la sala de emergencias. bah-ah-lah sah-lah deh eh-mehr-hehn-syah she fractured her wrist. se fracturó la muñeca. seh-frahk-too-rahr lah-moo-nyeh-kah did you get stung? ¿te picó? teh-pee-ko when did you faint? ¿cuándo te desmayaste? kwahn-doh teh dehs-mah-yahr 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video medical interpretation over 3g cellular networks: a feasibility study. telemed j e health. 2011;17(10):809-813. https://doi.org/10.1089%2ftmj.2011.0084. 26. meischke h, ike b, painter i, et al. delivering 9-1-1 cpr instructions to limited english proficient callers: a simulation experiment. j immigr minor health. 2015;17(4):1049-1054. https://doi.org/10.1007/s10903-014-0017-8. 27. yelland j, biro ma, dawson w, et al. bridging the language gap: a co-designed quality improvement project to engage professional interpreters for women duing labour. aust health rev. 2016;41(5):499504. https://doi.org/10.1071/ah16066. 28. hyatt a, lipson‐smith r, gough k, et al. culturally and linguistically diverse oncology patients' perspectives of consultation audio‐recordings and question prompt lists. psychooncology. 2018;27(9):2180-2188. https://doi.org/10.1002/pon.4789. 29. jang m, plocienniczak mj, mehrazarin k, bala w, wong k, levi jr. evaluating the impact of translated written discharge instructions for patients with limited english language proficiency. int j pediatr otorhinolaryngol. 2018;111:75-79. https://doi.org/10.1016/j.ijporl.2018.05.031. 30. lipson‐smith r, hyatt a, butow p, et al. are audio recordings the answer?—a pilot study of a communication intervention for non‐english speaking patients with cancer. psychooncology. 2016;25(10):1237-1240. https://doi.org/10.1002/pon.4193. 31. sreekanth g. the use of google language tools as an interpretation aid in cross-cultural doctor– patient interaction: a pilot study. inform prim care. 2010;18(2):141-143. https://doi.org/10.14236/jhi.v18i2.764. 32. stoneking lr, waterbrook al, garst orozco j, et al. does spanish instruction for emergency medicine resident physicians improve patient satisfaction in the emergency department and adherence to medical recommendations?. adv med educ pract. 2016;7:467-473. https://doi.org/10.2147/amep.s110177. 33. wofford jl, campos cl, johnson da, brown mt. providing a spanish interpreter using low-cost videoconferencing in a community study computers. j innov health inform. 2013;20(2):141-146. http://dx.doi.org/10.14236/jhi.v20i2.34. 34. the show must go on: band in 2 july 4 parades deals with extreme heat. cbs news. july 5, 2018. accessed august 23, 2023. https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwoodparade-marching-band-saints-brigade-extremeheat/#:~:text=due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on. 35. yeung ssy, trappenburg mc, meskers cgm, maier ab, reijnierse em. the use of a portable metabolic monitoring device for measuring rmr in healthy adults. br j nutr. 2020;124(11):12291240. https://doi.org/10.1017%2fs0007114520001014. 36. juckett g, unger k. appropriate use of medical interpreters. am fam physician. 2014;90(7):476-480. 37. forrow l, kontrimas jc. language barriers, informed consent, and effective caregiving. j gen intern med. 2017;32(8):855-857. https://doi.org/10.1007%2fs11606-017-4068-0. 38. goenka pk. lost in translation: impact of language barriers on children's healthcare. curr opin pediatr. 2016;28(5):659-666. https://doi.org/10.1097/mop.0000000000000404. https://doi.org/10.1016/j.pec.2017.07.026 https://doi.org/10.1007%2fs11606-009-1236-x https://doi.org/10.1007%2fs11606-009-1236-x https://doi.org/10.1089%2ftmj.2011.0084 https://doi.org/10.1007/s10903-014-0017-8 https://doi.org/10.1071/ah16066 https://doi.org/10.1002/pon.4789 https://doi.org/10.1016/j.ijporl.2018.05.031 https://doi.org/10.1002/pon.4193 https://doi.org/10.14236/jhi.v18i2.764 https://doi.org/10.2147/amep.s110177 http://dx.doi.org/10.14236/jhi.v20i2.34 https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7e:text=due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7e:text=due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://www.cbsnews.com/boston/news/fourht-of-july-bristol-norwood-parade-marching-band-saints-brigade-extreme-heat/#:%7e:text=due%20to%20extreme%20heat%20though,the%20show%20must%20go%20on https://doi.org/10.1017%2fs0007114520001014 https://doi.org/10.1007%2fs11606-017-4068-0 https://doi.org/10.1097/mop.0000000000000404 strategies to improve healthcare communication with non-native english speakers: an evidence to practice review 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 39. sodemann m, kristensen tr, sångren h, nielsen d. barriers to communication between clinicians and immigrants. ugeskrift for laeger. 2015;177(35). 40. steinberg em, valenzuela-araujo d, zickafoose js, kieffer e, decamp lr. the "battle" of managing language barriers in health care. clin pediatr. 2016;55(14):1318-1327. https://doi.org/10.1177%2f0009922816629760. https://doi.org/10.1177%2f0009922816629760 abstract manuscript type editorial 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 connecting patient-centered care research into athletic training clinical practice lindsey e. eberman, phd, lat, atc*; zachary k. winkelmann, phd, scat, atc, chse‡ *indiana state university, terre haute, in; ‡university of south carolina, columbia, sc correspondence dr. lindsey e. eberman, 567 n 5th st, terre haute, in 47809. email: lindsey.eberman@indstate.edu twitter: @isuathltrain full citation eberman le, winkelmann zk. connecting patient-centered care research into athletic training clinical practice. clin pract athl train. 2023;6(2): 1-14. https://doi.org/10.31622/2023/0006.02.1. editorial the prioritized research agenda for the athletic training profession identified five research priorities for athletic training, using a multi-layered approach, including a cross-sectional survey to ensure athletic trainers endorsed the research priorities and initiatives that would be addressed through a comprehensive research agenda.1 overwhelmingly, respondents indicated they agreed or strongly agreed (n=3590/3963, 90.6%) that examining the extent to which athletic trainers provide patient-centered care would benefit the profession.1 however, the concept of patient-centered care emerged decades ago in 1986 from harvey and jean picker.2 jean was experiencing long-term health issues and recognized that the care was innovative and evidence-based. still, it lacked humanism and was not responsive to the sensitive needs of the patients themselves and their support system.2 the pickers developed a non-profit organization for developing patient-centered care, spreading their eight principles2 to the united states in 1994: • respect for patients’ values, preferences, and expressed needs • coordination and integration of care • information, communication, and education • physical comfort • emotional support and alleviation of fear and anxiety • involvement of family and friends • continuity and transition • access to care since then, the profession of athlete training has been slow to adopt the concept. the post-professional educational competencies embodied patient-centered care since 2013,3 but professional education did not specifically state “patient-centered care” until the caate 2020 professional standards,4 leaving decades of athletic trainers with a gap in their training. thus, our research team has spent the last several years engaged in studies evaluating the extent to which athletic trainers offer patient-centered care. the data in table 15-26 provides an overview of our collaborations, including those where we served as first or senior authors with many post-professional graduate students and colleagues across the nation. the data suggest that most student-athletes have high levels of health literacy and believe their athletic trainers are using patient-centered principles during care delivery. however, student-athletes and athletic trainers differ somewhat in how they define patientcentered care and place value on that care. the concepts of “best” and “individualized” care emerge from mailto:lindsey.eberman@indstate.edu https://doi.org/10.31622/2023/0006.02.1 connecting patient-centered care research into athletic training clinical practice 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 student-athletes when asked to describe patient-centered care, while athletic trainers value patient preferences and respect. specifically, athletic trainers express a desire to respect a patient’s identity during care, acknowledging that marginalized populations like those with minoritized gender identities, races, ethnicities, religions, sexual orientations, and abilities should be acknowledged and supported. although there is a misconception that patient-centered care is only for these minoritized populations, patient-centered care is an individualized process that every person should have the opportunity to experience in healthcare. athletic trainers believe they are patient-centered and value the concept in their daily practice; however, as we know through the data, there seem to be marked discrepancies in the application of patient-centered care in practice. our studies on the disablement model identified that athletic trainers expressly desire to provide whole-person patient care. yet, they neither have the knowledge nor the skills to explore holistic care during a patient interaction. in essence, athletic trainers are in the range between the precontemplative stage and the preparation stage of change within the transtheoretical model of change,27 whereby they have “bought in” to the concept but have not yet resolved their knowledge, practice, and confidence gaps and taken action. as the preparation of athletic trainers has evolved, concepts like the social determinants of health, health literacy, and disablement models have emerged, but many practicing athletic trainers trained over three years ago have knowledge, practice, and confidence gaps relative to patient-centered care. patient-centered care was often considered treating others the same way you wish to be treated – the mantra of being a good person or the age-old “golden rule.”28 while fundamentally embracing respect, the concept often forgoes empathy for a patient’s lived experiences. the dynamics of a person’s biopsychosocial response to injury and illness must be considered beyond our own experiences, values, and biases, which may prohibit us from embracing the patient’s wants and desires.28 this begins with communication through history taking, patient-reported outcome measures, and interviewing, followed by respecting the response of someone being diagnosed with a new injury, their rehabilitation plan, and reintegration into activity or their termination of sport and physical activity. thus, allowing the patient to lead the care guided by their healthcare team. the foundation of patient-centered care is rooted in shared decision-making. the concepts we have studied over the past five years have highlighted that both sides of the table (patient and provider) believe in patient-centered care principles, want to do it, and believe it is helpful. but an expressed desire is not enough. we must resolve our knowledge, practice, and confidence gaps by engaging in ongoing education and professional development to embrace a culture that allows people to explore their patient-centeredness through skill development, learning about new cultures, and creating connections with support systems. too often, we seek to blame others when a patient’s case is not improving; introspective reflection is necessary to take responsibility for our contributions to the care. we challenge athletic trainers and other providers of athletic health care to embrace a ‘just culture’ that emphasizes shared accountability in our collaborative relationships with patients and their support systems. moving forward, athletic trainers should focus on connecting goal setting and communication by building more focused care plans. athletic trainers should focus on micro-skills to develop rapport and trust. highquality patient care focuses on collecting data and creating patient-centered versus clinician-centered goals (e.g., improving the ability to reach the top shelf vs. increasing the range of motion by 20 degrees). shifting your practice to use patient-reported data can ultimately lead to these positive outcomes by collecting the data we need to know we are being patient-centered in our practice. connecting patient-centered care research into athletic training clinical practice 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 we can move from precontemplation/contemplation/preparation into action! this begins with challenging our own thinking and questioning our assumptions. creating patient-centered interactions requires us to unlearn our habits of gathering only data that serves us as clinicians but fails to acknowledge the patient experience. instead, the integration of a clinician-centered examination and patient-centered interviewing, followed by patient education that explores all intervention options, including the possibility of doing nothing, and describing the likely consequences for each option. then, the patient should be given the time and space to make informed decisions about their interventions. in essence, the focus should be on the “platinum rule,” or treating others how they wish to be treated. the current body of evidence regarding patient-centered care is detailed throughout table 1 – integrate this evidence to create small changes while thinking big. we recommend exploring tools, scripts, and measures to guide this practice (figure 1).1,5-26,29-31 beyond this call to action for providers, we also call to action researchers in athletic health care to expand implementation science studies that evaluate effective strategies to resolve knowledge, practice, and confidence gaps in credentialed athletic trainers. a constructive collaboration between education, research, and clinical practice is essential to accomplish patient-centered care in athletic training. connecting patient-centered care research into athletic training clinical practice 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 figure 1. tools and techniques to improve patient-centered care8,10-14,25,26,29-31 feedback global perceptions of patientcentered care background, affect, trouble, handling, empathy (bathe) interview (patient satisfaction) improvement guide goal setting & care planning patient-specific functional scale (psfs) shared decision-making establishing therapeutic alliance data gathering clinical examinationtransparency in describing findings and rational patient teach back about what they have learned initial encounters focused history script (social determinants of health) ideas, concerns, expectations (ice) interview (perceptions of current situation) pre-participation interactions test of functional health literacy assessment (tofhla) (screen for health literacy) connecting patient-centered care research into athletic training clinical practice 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 table 1. contemporary evidence for the delivery of patient-centered care in athletic training study purpose key findings respect for patient's values, preferences, and expressed needs. eberman, et al. (2021)7 to gain more in-depth information about athletic trainers' knowledge and experiences regarding the health care needs of transgender student-athletes. participants described knowledge deficiencies in themselves, health care providers within their units, and providers able to provide safe transition care. the athletic trainers demonstrated misconceptions when defining transgender and transitioning and describing how the body responds to hormone replacement therapy. they expressed concern for the mental health and wellness, selfimage, and potential cost of transgender health care for transgender student-athletes. however, participants also described efforts to create safety within their units by validating transgender patients, instilling trust, adjusting the physical environment, and engaging in professional development to improve their knowledge. eberman, et al. (2023)6 to explore primary care sports medicine physicians' comfort, competence, education, and scope of training in caring for transgender and gender nonconforming patients/athletes. previous care relationships with transgender and gender nonconforming patients/athletes strongly influence the comfort and perceived competence of primary care sports medicine physicians. training from unbiased peer-reviewed data sources is critical to improving care for transgender and gender-nonconforming patients/athletes. schulman, et al. (2022)15 to assess how a curriculum, including a standardized patient encounter, influenced attitudes and skills in working with sexual health and gender minorities. the curriculum and standardized patient encounters influenced knowledge, attitudes, and comfort when working with gender minorities and screening for sexual health. shaughnessy et al. (2021)16 to explore the education, comfort, and experience of professional athletic training students and program directors few students reportedly practice patient-centered care during clinical education. both groups perceived deficiencies in competence related to connecting patient-centered care research into athletic training clinical practice 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 on patient-centered care and transgender patient care. transgender patient care. we suggest program directors integrate transgender health care into their curriculum and seek professional development to create meaningful educational experiences. walen et al. (2020)18 to measure athletic trainers' (1) perceived definition of transgender, (2) comfort and competence working with transgender student-athletes, (3) sources of education, (4) perceived legal concerns, and (5) perception of competitive advantage. although collegiate athletic trainers generally felt competent in treating transgender patients, they did not feel capable of addressing specific aspects of transgender patients' healthcare needs. regardless of the resulting perceived unfair advantage, athletic trainers must know the regulations and therapeutic effects associated with hormone-related therapy for transgender student-athletes. coordination and integration of care torres, et al. (2023)26 to explore the lived experiences of college student-athletes and the development of the therapeutic alliance with athletic trainers. we identified three domains regarding collegiate studentathletes’ perceptions of the athletic trainers' mindset, behaviors, and actions that aided in developing their therapeutic alliance: empowerment, transparency, and intentionality. efforts by the at that allowed the patient to feel empowered during their care included shared decisionmaking, clinician flexibility, and education for comprehension. during the mendoza, et al. (2023)10 to explore the degree to which secondary school athletic trainers perceive they are integrating the principles of patient-centered care and the biopsychosocial model in their practice. secondary school athletic trainers perceive they effectively integrate the principles of patient-centered care and the biopsychosocial model of health into their practice. redinger, et al. (2021)13 to identify collegiate studentathletes’ definitions of patientcentered care and measure their perceived level of patientcentered care from an athletic trainer. the qualitative analysis revealed 13 topics, the most used being individual, priority, and best. other issues needed to be more consistent with how the medical community has defined patientcentered care. on the global perceptions of athletic trainer patient-centered care tool, the participants strongly agreed with 12 of the 15 statements. connecting patient-centered care research into athletic training clinical practice 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 participants said that the athletic trainer was completely (mode = 4) patient-centered for all dimensions during their most recent encounter with the patient perception of patientcenteredness instrument. however, patient-centered care behaviors defined by the medical community may not be directly expressed according to collegiate student-athletes. wilson, et al. (2022)19 to determine how athletic trainers place importance on patient-centered care principles and examine the context of their viewpoints. overall, athletic trainers value patient's preferences and respect. however, a need for more importance was identified for incorporating the disablement model, a core competency adopted by the athletic training profession. information, communication, and education niles et al. (2022)12 to assess collegiate studentathletes digital health literacy and musculoskeletal health literacy levels. most student-athletes possess adequate digital health literacy and musculoskeletal health literacy. the findings directly impact patient education as student-athletes use their phones to access health-related information they feel comfortable with. still, they may need to find out if the source is trustworthy. roberts et al. (2022)14 to investigate the health literacy levels of collegiate studentathletes all participants displayed adequate health literacy, regardless of race, using the short test of functional health literacy assessment. physical comfort haffey, et al. (2023)9 to investigate athletic trainers’ recognition and use of disablement frameworks in current clinical practice the first three domains were related to the application of disablement model frameworks: (1) patient-centered care, (2) limitations and impairments, and (3) environment and support. participants described varying degrees of consciousness regarding these domains, including expressed desire, conscious competence, conscious incompetence, and unconscious incompetence. the fourth domain related to participants' exposure to disablement model connecting patient-centered care research into athletic training clinical practice 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 frameworks through formal or informal experiences. we characterized the data using the competence hierarchy, whereby conscious competence was demonstrated when participants accurately acknowledged or implemented a domain related to the disablement model framework used. findings suggest that athletic trainers demonstrate unconscious incompetence in using disablement frameworks in clinical practice. millet, et al. (2023)11 to examine athletic trainers’ familiarity, knowledge, application, and implementation of the international classification of functioning, disability, and health framework familiarity, knowledge, application, and implementation deficits related to the international classification of functioning, disability, and health framework exist. athletic trainers reported low implementation across all icf categories. emotional support and alleviation of fear and anxiety chandler, et al. (2022)5 to examine collegiate athletic trainers' use of behavioral health screening tools approximately 49% of participants used behavioral health screening tools in their practice; the most used tools were phq-9 (56.6%) and gad7 (27.3%). practice integration considerations and practice advancements occurred due to behavioral health screening. young, et al. (2022)23 to explore national collegiate athletic association division 1 student-athletes' experiences with mental health, access to and experience with mental health resources at their university. two domains: “increased expectations” and “resources and management” were identified. the participants shared balancing life as a college student, academic stressors, performance expectations, and a sport-first mindset they perceived from coaches and support staff. the participants discussed their experience with an internal support network of coaches, the athletic department, and sports psychology. participants remarked on their external support network, which included their family, friends, and psychology services. the resources available at their connecting patient-centered care research into athletic training clinical practice 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 institutions and the accessibility were perceived positively and negatively. collegiate studentathletes described resources as helpful, whereas other participants described a lack of timeliness for appointments, lack of advertisement, incomprehension of counselors to athlete demands, and no sportspecific counseling as barriers. involvement of family and friends stanton, et al. (2022)17 to investigate the experiences of secondary school athletic trainers who provided care to patients who were non-native english speakers or communicated with their non-native english speaker support systems. four domains emerged from the data: (1) communication, (2) welcoming environment, (3) cultural agility, and (4) resourcefulness. participants enhanced communication by relying on nonverbal communication, translated resources, and interpreters. the ats discussed a difference in care delivery based on fluency. respondents explained efforts to create a welcoming environment by speaking in the non-native english speaker's native language, increasing comfort, and serving as an advocate within the health care system. acknowledging customs, demonstrating respect, and understanding potential fear, shame, or both associated with language barriers were discussed as ways to increase cultural agility. the ats identified a need for more formal training, which increased their on-the-job training and health information technology use. participants perceived spending increased amounts of initiation, effort, and time on adaptability while caring for and communicating with nonnative english speakers. winkelmann, et al. (2023)24 to describe the perceptions and practices of family-centered care across secondary school athletic trainers the total mean score for the currently practiced scale was significantly lower than the perceived need. all familycentered care subscales compared between current connecting patient-centered care research into athletic training clinical practice 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 practice and perceived lack were very different, with each being of higher importance than current practice in athletic training. data analysis revealed four themes related to enhancing family-centered care in secondary schools: limited education and resources, staffing and space concerns, nontechnical skills, and social determinants of health. continuity and transition giorgi, et al. (2023)8 to validate a focused history script designed to facilitate social determinants of health conversations between clinicians and adolescents through the delphi method. after seven rounds of feedback from six individuals (1 clinician and five educators/researchers), the focused history script achieved content validity, with 100% of panelists agreeing on the final 40-item script. a concentrated history script for the social determinants of health was validated to aid conversations between healthcare providers and adolescent patients on factors affecting their lives, school, and play. addressing social determinants of health with adolescent patients will improve cultural proficiency and familycentered care delivered by school healthcare professionals. moll et al. (accepted) to explore athletic training students' abilities to screen for factors via standardized patient encounters and to describe the screening experience for social determinants of health factors. a focused history script increased the screening of social determinants of health factors but decreased the students’ selfconfidence. when students were not required to use the concentrated history script to screen for the social determinants of health, most athletic training students failed to elicit information about the social determinants of health factors or performed poorly during the screening. we identified a confidence gap for social determinants of health screening abilities, with athletic training students having a high self-confidence in their ability to connecting patient-centered care research into athletic training clinical practice 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 screen compared to their actual performance. winkelmann, et al. (2022)21 to determine whether infographics as a continuing professional development method changed patientcentered screening considerations and familiarities with the social determinants of health. a significant change-score improvement was identified for the intervention group relative to providing whole-person health care and recognizing the social determinants of health. no statistical differences were noted for screening and practices between the groups. however, familiarity with screening for four social determinants of health areas improved for the intervention group, including access to primary care, poverty, environmental conditions, and social cohesion. access to care winkelmann, et al. (2020)22 to investigate healthcare professionals' perceptions of and experiences with telemedicine. the interviews described the clinicians as telemedicine adopters (n = 14) or nonadopters (n = 8). the adopters reported higher levels of agreement on the theory of planned behavior and technology acceptance model tool than nonadopters for all constructs. when comparing adoption status, we identified a significant difference with nonadopters reporting a low level of agreement for the subjective norm construct. the interviews revealed five domains: integration challenges, integration opportunities, collaborative practice, anticipatory socialization to future use, and benefits of integration. the participants indicated that integration challenges centered on “buy-in,” whereas opportunities aligned with the patient's condition and technology ease of use. they reflected that the telemedicine encounters required more preparation, allowing for cooperative behaviors between clinicians. the benefits of telemedicine included convenience and scheduling connecting patient-centered care research into athletic training clinical practice 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 preferences that encouraged future use. winkelmann, et al. (2020)20 to investigate athletic training students' ability to transfer telemedicine skills confidently and accurately in a standardized patient encounter. exposure to telemedicine via a standardized patient encounter improved confidence in performing the tech-based evaluation. athletic training students demonstrated communication/interpersonal skills and patient education well, yet needed to improve their data gathering and telemedicine skills. overall, participants accurately diagnosed a musculoskeletal condition using telemedicine. references 1. eberman le, walker se, floyd rt, et al. the prioritized research agenda for the athletic training profession: a report from the strategic alliance research agenda task force. j athl train. 2019;54(3):237-244. https://doi.org/10.4085/1062-6050-374-18. 2. picker institute europe. https://picker.org/who-we-are/our-history/. published 2023. accessed august 28, 2023. 3. commission on accredidation of athletric training. standards for the accreditation of postprofessional athletic training degree programs. in:2013. https://caate.net/programs/postprofessional/post-professional-program-standards. 4. commission on accredidation of athletric training. standards and procedures for accreditation of professional programs in athletic training. in:2020. https://caate.net/programs/professional/professional-program-standards 5. chandler tb, rivera mj, neil er, eberman le. collegiate athletic trainers’ use of behavioral health screening tools. int j athl ther train. 2023;28(4):205-208. https://doi.org/10.1123/ijatt.20220026. 6. eberman le, winkelmann zk, crossway ak, et al. sports medicine physicians comfort and competence in caring for transgender and gender nonconforming patients and athletes. clin j sport med. 2023;33(1):33-44. https://doi.org/10.1097/jsm.0000000000001067. 7. eberman le, winkelmann zk, nye ea, walen dr, granger kc, walker se. providing transgender patient care: athletic trainers' compassion and lack of preparedness. j athl train. 2021;56(3):252262. https://doi.org/10.4085/1062-6050-0501.20. 8. giorgi em, drescher mj, winkelmann zk, eberman le. validation of a script to facilitate social determinant of health conversations with adolescent patients. int j environ res public health. 2022;19(22):14810. https://doi.org/10.3390/ijerph192214810. 9. haffey rt, rivera mj, young jp, winkelmann zk, eberman le. athletic trainer’s varying levels of awareness and use of disablement model frameworks: a qualitative study. int j environ res public health. 2023;20(5):4440. https://doi.org/10.3390/ijerph20054440. 10. mendoza am, drescher mj, eberman le. the integration of patient-centered care and the biopsychosocial model by athletic trainers in the secondary school setting. int j environ res public health. 2023;20(8):5480. https://doi.org/10.3390/ijerph20085480. https://doi.org/10.4085/1062-6050-374-18 https://doi.org/10.1123/ijatt.2022-0026 https://doi.org/10.1123/ijatt.2022-0026 https://doi.org/10.1097/jsm.0000000000001067 https://doi.org/10.4085/1062-6050-0501.20 https://doi.org/10.3390/ijerph192214810 https://doi.org/10.3390/ijerph20054440 https://doi.org/10.3390/ijerph20085480 connecting patient-centered care research into athletic training clinical practice 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 11. millet nj, snyder valier ar, eberman le, rivera mj, winkelmann zk. the knowledge and use of the international classification of functioning, disability and health (icf) framework in athletic training. int j environ res public health. 2023;20(7):5401. https://doi.org/10.3390/ijerph20075401. 12. niles tr, rivera mj, torres-mcgehee t, eberman le, winkelmann zk. digital and musculoskeletal health literacy of collegiate student-athletes. internet j allied health sci practice. 2022;20(2):9. https://doi.org/10.46743/1540-580x/2022.2119. 13. redinger as, winkelmann zk, eberman le. collegiate student-athletes' perceptions of patientcentered care delivered by athletic trainers. j athl train. 2020;56(5):499-507. https://doi.org/10.4085/130-20. 14. roberts jm, rivera mj, winkelmann zk, eberman le. health literacy levels of collegiate studentathletes. int j athl ther train. 2022;27(4):184-187. https://doi.org10.1123/ijatt.2021-0027. 15. schulman eh, eberman le, crossway ak, et al. integration of an inclusive health care curriculum for sexual health and gender minorities. athl train educ j. 2022;17(4):251-261. https://doi.org/10.4085/1947-380x-22-010. 16. shaughnessy gt, crossway ak, eberman le, rogers sm, winkelmann zk. program directors' and athletic training students' educational experiences regarding patient-centered care and transgender patient care. athl train educ j. 2021;16(3):219-234. https://doi.org/10.4085/1947380x-21-32. 17. stanton bm, rivera mj, winkelmann zk, eberman le. support systems and patient care delivery for nonnative english-speaking patients: a study of secondary school athletic trainers. j athl train. 2021;57(2):148-157. https://doi.org/10.4085/1062-6050-0181.21. 18. walen dr, nye ea, rogers sm, et al. athletic trainers' competence, education, and perceptions regarding transgender student-athlete patient care. j athl train. 2020;55(11):1142-1152. https://doi.org/10.4085/1062-6050-147-19. 19. wilson cj, eberman le, redinger as, neil er, winkelmann zk. athletic trainers’ viewpoints of patient-centered care: preliminary findings. plos one. 2022;17(9):e0274577. https://doi.org/10.1371/journal.pone.0274577. 20. winkelmann z, eberman le. the confidence and abilities to assess a simulated patient using telemedicine. athl train educ j. 2020;15(2):132-147. https://doi.org/10.4085/1947-380x-6219. 21. winkelmann zk, downs kc, charles-liscombe r, eberman le. continuing professional development using infographics improves the familiarity of the social determinants of health. athl train educ j. 2022;17(4):283-292. https://doi.org/10.4085/1947-380x-22-001. 22. winkelmann zk, eberman le, games ke. telemedicine experiences of athletic trainers and orthopaedic physicians for patients with musculoskeletal conditions. j athl train. 2020;55(8):768779. https://doi.org/10.4085/1062-6050-388-19. 23. young rd, neil er, eberman le, armstrong ta, winkelmann zk. experiences of current ncaa division 1 collegiate student-athletes with mental health resources. j athl train. 2022. https://doi.org10.4085/1062-6050-0180.22. 24. winkelmann zk, uriegas na, mensch jm, montgomery ce, torres-mcgehee tm. practices and perceptions of family-centered care: a cross-sectional survey of secondary school athletic trainers. int j environ res public health. 2023;20(6):4942. https://doi.org/10.3390/ijerph20064942. 25. moll k el, picha k, edler nye jr, uriegas n, winkelmann zk. exploring the use of a social determinants of health focused history script to facilitate patient conversations. athl train educ j. https://doi.org/10.3390/ijerph20075401 https://doi.org/10.46743/1540-580x/2022.2119 https://doi.org/10.4085/130-20 https://doi.org10.1123/ijatt.2021-0027 https://doi.org/10.4085/1947-380x-22-010 https://doi.org/10.4085/1947-380x-21-32 https://doi.org/10.4085/1947-380x-21-32 https://doi.org/10.4085/1062-6050-0181.21 https://doi.org/10.4085/1062-6050-147-19 https://doi.org/10.1371/journal.pone.0274577 https://doi.org/10.4085/1947-380x-62-19 https://doi.org/10.4085/1947-380x-62-19 https://doi.org/10.4085/1947-380x-22-001 https://doi.org/10.4085/1062-6050-388-19 https://doi.org10.4085/1062-6050-0180.22 https://doi.org/10.3390/ijerph20064942 connecting patient-centered care research into athletic training clinical practice 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 2 – september 2023 26. torres p ss, young jp, kiesel jd, eberman le, rivera mj. therapeutic alliance: exploring bonds, goals, and tasks from the perspective of collegiate student-athletes. j athl train. 2023;58(6s):s33. https://doi.org/10.4085/1938-162x-58.6s.s-1. 27. hashemzadeh m, rahimi a, zare-farashbandi f, alavi-naeini am, daei a. transtheoretical model of health behavioral change: a systematic review. iran j nurs midwifery res. 2019;24(2):83. https://doi.org/10.4103/ijnmr.ijnmr_94_17. 28. chochinov hm. the platinum rule: a new standard for person-centered care. in. vol 25: mary ann liebert, inc., publishers 140 huguenot street, 3rd floor new …; 2022:854-856. 29. horn kk, jennings s, richardson g, van vliet d, hefford c, abbott jh. the patient-specific functional scale: psychometrics, clinimetrics, and application as a clinical outcome measure. j orthop sports phys. 2012;42(1):30-42. https://doi.org/10.2519/jospt.2012.3727. 30. picker institute, inc. patient-centered care improvement guide. in:2008. http://www.hqontario.ca/portals/0/modals/qi/en/processmap_pdfs/tools/patientcentered%20care%20improvement%20guide.pdf. 31. stuart m, lieberman j. the fifteen minute hour: efficient and effective patient-centered consultation skills. crc press; 2018. https://doi.org/10.4085/1938-162x-58.6s.s-1 https://doi.org/10.4103/ijnmr.ijnmr_94_17 https://doi.org/10.2519/jospt.2012.3727 http://www.hqontario.ca/portals/0/modals/qi/en/processmap_pdfs/tools/patient-centered%20care%20improvement%20guide.pdf http://www.hqontario.ca/portals/0/modals/qi/en/processmap_pdfs/tools/patient-centered%20care%20improvement%20guide.pdf manuscript type disablement model case study 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study grant g. yee, atc*; zachary k. winkelmann, phd, scat, atc*; zoë j. foster, md, faafp*† *university of south carolina, columbia, sc; †prisma health department of family and preventive medicine, columbia, sc abstract this disablement-model case study is focused on a 23-year-old ncaa division i men’s tennis player that sustained an injury in a competitive singles tennis match. upon initial examination, the athletic trainer diagnosed the individual with an anterior talofibular ligament sprain and treated conservatively. the patient experienced significant disruptions to his activities of daily living due to his difficulties with ambulation during the early stages of his recovery. interestingly, the patient was eventually diagnosed with a cuboid avulsion fracture. midfoot fractures are uncommonly experienced in the general population, and are particularly uncommon in tennis athletes, making them difficult to recognize. clinical prediction rules may be used to guide the decision to order imaging, however, they must be used in conjunction with pertinent clinical findings when a midfoot fracture is suspected. with rest and targeted rehabilitation, the patient successfully returned to his pre-injury levels of strength, range of motion, and perceived level of physical function in his lower extremity. content focus: health care competency correspondence dr. zachary winkelmann, 1300 wheat street, columbia, sc 29208. e-mail: winkelz@mailbox.sc.edu twitter: @zachwinkelmann full citation yee gg, winkelmann zk, foster zj. return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study. clin pract athl train. 2023;6(1): 39-49. https://doi.org/10.31622/2023/0006.01.6. introduction foot and ankle injuries have been reported as the fourth and fifth most common sites of injury in tennis athletes, and sprains are the most frequently reported injury to the ankle for these athletes (66%).1 the abundance of ankle sprains amidst other possible injuries may confound the diagnostic process during the evaluation of a tennis athlete. among the conditions presenting in the foot and ankle, cuboid fractures have been shown to be the most common midfoot fracture (50%).2 cuboid fractures can be classified using a rating system of types 1-5. the most frequent type of cuboid fracture is a type 1 fracture (48.4%) which involves avulsion at the calcaneocuboid joint.3 consensus for the treatment of an avulsion fracture of the cuboid includes conservative management guided by symptom control.3 clinical decision-making tools, like the ottawa ankle rules, can be used to assist the evaluating clinician in deciding to order x-ray images in the acute setting of a midfoot injury. sensitivities for the ottawa ankle rules approximate 90-100% for “clinically significant” ankle and midfoot fractures.4 the use of such tools when evaluating a patient with an acute ankle or midfoot injury can reduce unnecessary radiographs by as much as 25% in the emergency room setting.5 such tools need to be utilized in conjunction with the patient’s history and clinical exam, as well as the examiner’s clinical suspicion for ankle or midfoot fractures. a lack of recognition of a fracture during an initial clinical evaluation may result in significant impairment of daily activities, societal roles, and exercise for an active individual. mailto:winkelz@mailbox.sc.edu https://doi.org/10.31622/2023/0006.01.6 return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 patient information patient the patient was a 23-year-old student-athlete who was participating on the men’s tennis team at a large, southeastern, ncaa division i university. he was injured while actively participating in a dual match at another division i institution during the fall tennis season. the patient stated that he first inverted his right ankle while retreating to hit a forehand and loading his right foot. he reported that he experienced some minor pain in his ankle and foot after falling to the ground, but despite this, he began playing the next point moments after standing back up and regaining his footing. several points in the match later, the patient reported inverting his ankle again while moving backwards diagonally to track down the ball. on this instance, he stated that he felt a considerable amount of pain in his lower extremity and remained on the ground. the host athletic trainers performed an immediate on-court evaluation within the allotted 2-minute medical timeout period. the patient officially retired from the match due to injury, and the athletic trainer provided ambulation assistance to the athletic training facility for further care. differential diagnosis and evaluation the initial differential diagnosis list for this patient included: anterior talofibular ligament sprain, avulsion fracture of the base of the fifth metatarsal, and peroneal tendon injury. the patient was diagnosed with a grade ii anterior talofibular ligament sprain following a structured evaluation by the host athletic trainer. he was given crutches and instructed to continue using them until he could return home. upon return to campus 72 hours post-injury, the patient was re-evaluated by the athletic trainer from his institution assigned to the men’s tennis patient panel. the patient presented to the athletic training facility upon return from the tennis competition with significant edema and ecchymosis throughout the phalanges of his right foot and along the length of his fifth metatarsal. edema was most prominent along the lateral side of his foot migrating into his midfoot. capillary refill was still intact in his distal phalanges, and the patient was not experiencing any neurological symptoms. the patient reported his pain was most intense through the midfoot zone, particularly along the dorsolateral surface near the cuboid. he stated his pain was a 6/10 while at rest. the patient could ambulate for five steps when asked to as part of the structured evaluation, but he did so with a significant antalgic gait pattern. this gait pattern consisted of an elongated heel strike and excessive pronation during midstance and push off to avoid placing pressure on the lateral aspect of his foot. excessive femoral retroversion bilaterally was also noted during the evaluation. no pain was elicited with palpation of the distal tibia, distal fibula, base of the fifth metatarsal, navicular bone, or through compression of the calcaneus. selective tissue tests such as the anterior drawer test and the inversion talar tilt test were both positive with pain elicited. a bump test was also performed, but it was found to be negative. he was then referred to be seen by a sports medicine physician that evening. the collaborating physician determined that imaging would not be necessary due to the absence of any significant findings indicated by the ottawa ankle rules. the patient was fitted for an aso® evo ankle stabilizing brace and instructed that he could begin weight-bearing as tolerated in the ensuing days. on the patient’s third day of treatment after returning to campus, he scheduled an appointment with another sports medicine physician affiliated with the university’s on-campus healthcare system. the patient scheduled this appointment at the request of his parents who had become increasingly worried about his condition. his parents had been encouraging him to be sure he had imaging performed for everyone’s contentment. the physician noted during this visit that the patient was continuing to use his crutches and demonstrated difficulty with weight-bearing. due to the persistent clinical picture and the absence of significant improvement in the return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 patient’s condition at day 8 post-injury, the physician ordered radiographs for the patient’s ankle and foot. upon reviewing the images, the physician diagnosed the patient with an avulsion fracture of the cuboid in his right midfoot. the patient was fitted for a tall walking boot in the clinic, and he immediately reported a decrease in pain while ambulating throughout the hallways. he was instructed to continue wearing the walking boot for 6 weeks and was scheduled for a follow-up appointment at that time. body structure and function this patient’s fracture of his cuboid directly impacted his musculoskeletal system. the patient presented with impaired joint mobility at his ankle and metatarsophalangeal joints shown through reduced range of motion while performing ankle inversion, ankle dorsiflexion, and flexion at each of the metatarsophalangeal joints. muscle power function was also shown to be impaired through manual muscle testing at the foot and ankle compared bilaterally. this testing revealed that inversion and eversion were both rated a 3/5 with pain, dorsiflexion was a 4/5 with pain, and plantar flexion was a 3/5. the presence of significant edema surrounding the injury site (figure 1) indicated disruption to his blood vessels and prohibited his body from being able to transport blood throughout his foot and ankle on the affected side. this would inevitably play a significant role in his body’s ability to complete the rest of the healing process in a timely manner. as shown in the images of the patient’s foot and ankle immediately post-injury (figure 1), the patient had likely already completed hemostasis and was on to the inflammatory stage of healing.6 when the patient returned to campus at 72-hours post-injury, his body was likely in transition between the inflammatory phase and the proliferation phase. the significant ecchymosis and subsequent reduction in joint mobility was most likely due to a rush of inflammatory markers and ensuing debridement taking place at the site of injury.6 it was paramount that the first stage of rehabilitation would restore the patient’s foot and ankle functioning by reducing the qualitative changes in structure, specifically the edema present. figure 1. patient photos 6 hours post-injury 24 hours post-injury 24 hours post-injury return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 activity and participation the patient’s injury had a profound effect on his participation in several activities throughout his daily routine. the patient reported struggling with walking short distances to and from the bathroom to urinate in the morning. he believed this was a result of a reduction in his foot and ankle mobility while sleeping. he also could not complete his daily routine of walking to and from class without the assistance of crutches due to the extended distance. he reported previously being highly dependent on his ability to walk to class due to the shortage of parking spaces near where his class was located. the walk to class was about one kilometer each direction, but this walk was particularly difficult to perform using crutches due to the variation in surfaces and sloped sidewalks. the patient estimated that his overall trip time to class was doubled while he was using the crutches. additionally, the patient noted that he had trouble ascending stairs after arriving at the building his class was held within due to the considerable distance he had already covered. as a result of this difficulty, the patient would do his best to avoid the stairs by utilizing the elevator in the building. unfortunately, he reported that the elevator inside the building was slow and located on the opposite end of the building from his classroom. these circumstances caused the patient to be tardy to class several times and meant that he had to allocate more time during his day for transportation to and from class. throughout his non-weight-bearing and partial-weight-bearing stages of recovery, the patient was unable to utilize his privately owned motorized vehicle. this was due to the impairment to his right extremity which would normally control the gas and brake pedals in the vehicle. instead, the patient routinely received transportation to tennis practice from a teammate using their own private motorized vehicle. the teammate’s daily schedule differed from the patient’s schedule, which made it more difficult for the patient to adhere to previously agreed-upon treatment times. finally, the patient was unable to participate in tennis practices and conditioning sessions in the same capacity as his teammates. he was able to complete a portion of his rehabilitation exercises in close proximity to the tennis courts, but he was unable to perform the same general actions as everyone else throughout the allotted practice times. the patient was also significantly limited during weight sessions, performing only upper extremity exercises for the first several weeks following the injury. environmental and personal factors the patient experienced reductions in his formal and informal relationships while recovering from his injury. he felt that his informal relationships with his teammates and friends were hindered due to the burden he felt that he was placing on them by relying on them for transportation and assistance with obtaining goods such as groceries (figure 2). he also felt his social relationships with teammates wore down due to his inability to connect with them after physically taxing practice sessions. another contributing factor to the reduction in his social relationships was due to the patient’s self-imposed pressure to return to tennis in time to compete for the final singles position for the upcoming spring season. he reported feeling like other members of the team were making strides forward with their skills, and that he was going to have even more work to do when he returned. the patient’s formal relationships with the coaching staff also frayed due to a perceived lack of concern about his recovery. he stated that he felt the coaches rarely checked in directly with him about his progress and overall condition. this made the patient more reluctant to be willing to engage with the coaches, which had a second-hand effect on his willingness to engage in some team activities and made him feel even more distant from his teammates. return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 figure 2. icf disablement model flow chart interventions while at the host institution where the injury occurred, the patient was fitted for crutches, a tubular compression bandage, and had cryotherapy compression treatment (gamereadytm, concord, ca) administered twice daily. the patient was also instructed to take 650 mg of ibuprofen every 4-6 hours as needed. following arrival back to campus, the patient continued to utilize cryotherapy treatment, and he also began treatments consisting of deep oscillation therapy (hivamat®, sebastian, fl) using parameters of 8 minutes at 120 hz, 6 minutes at 80 hz, and 6 minutes at 20 hz. deep oscillation therapy treatment was performed daily for the first week of rehabilitation with the goal of reducing the patient’s persistent edema in the distal foot. additionally, the patient was prescribed naproxen sodium 500mg to take twice daily during the acute phase of his injury. body function/structure: limited rom with inv, df, mtp flex mmt limited for inv, ev, df, pf cardiovascular system impaired activity: inability to ambulate and drive problems with stairs, finding the elevator in instructional buildings, arriving late to class inability to ambulate to bathroom in the morning participation: inability to play tennis and participate in practice sessions ue exercises only during weights no participation in soccer-tennis health condition: avulsion fracture environmental factors: perceived lack of coach’s concern for his condition parental concern for his condition personal factors: felt like a burden from relying on others for transportation self-imposed pressure of accelerated return due to teammates’ progress return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 throughout his rehabilitation, the patient utilized several other modalities for tissue warming and pain relief prior to exercise. these modalities included compex (djo globaltm, lewisville, tx), therapeutic ultrasound (djo globaltm, lewisville, tx) (1 mhz, 1.2 w/cm2, 7 minutes), and class iv laser therapy (lightforce®, new castle, de) (18 w for 4 minutes). beginning in the first week of rehabilitation, the patient began performing ankle range of motion exercises and intrinsic foot muscle exercises. he began without any resistance for the first week, and he progressed in resistance starting in the second week. the patient slowly progressed further with resistance using pain as a guide for intensity. blood flow restriction (bfr) therapy (delfi personalized tourniquet system, vancouver, bc, canada) was integrated into the patient’s partial-weight-bearing exercises following the third week of rehabilitation. bfr has been validated as an effective means of increasing strength when used in conjunction with low-load resistance training.7 this was especially useful throughout the partial-weight-bearing stage due to the inability of the patient to place high loads on his affected extremity. despite the discomfort from the restriction of blood flow, the patient seemed to respond well to the intervention and welcomed the challenge of participating in fatiguing exercise when he was otherwise unable to do so. the patient was subjected to 65% occlusion the first 2 times he completed exercises with bfr, before advancing to 70-80% occlusion for the remainder of bfr sessions. while the patient was unable to place high loads on his lower extremity, he also underwent aquatic therapy exercises and followed a progressive lower extremity strengthening program. in order to begin the patient’s aquatic exercises, the patient was fitted with a custom removable plastic cast (activarmor®, pueblo, co). the patient engaged in aquatic therapy (swimextm, fall river, ma) using the removable cast twice weekly. aquatic therapy for the patient included a 5-minute walk, 5-minute jog (4 mph), 10-minute run (6.0-7.0 mph), and a variety of lower extremity functional exercises. his lower extremity strengthening program began with open kinetic chain exercises. the program incorporated balance and proprioception for the contralateral extremity while he was partial weight-bearing. the goal of using the contralateral extremity was to promote neuromuscular advances for the affected extremity without placing a load on it.8 upon receiving physician clearance to cease wearing the walking boot at 7 weeks post-injury, the patient began engaging in anti-gravity running activity (alterg®, fremont, ca). these anti-gravity running sessions occurred three times per week and consisted of alternating running and light jogging for 5-minute intervals for a total of 30 minutes. the patient began at 60% body weight and progressed to 80% body weight before being allowed to begin running outdoors. when the patient reached 9 weeks post-injury, he began his agility exercise progression (table 1). the patient was given instructions for progressions of each of the agility exercises prior to leaving campus for winter break. at the conclusion of winter break and 12 weeks post-injury, the patient was consistently completing his agility exercises 4 times per week. upon returning to campus for tennis practices, the patient was gradually integrated into full tennis practice using a guided return to tennis protocol (table 2). after the patient successfully completed the return to tennis protocol, he officially returned to play in a full capacity at 13 weeks post-injury. table 1. patient’s home exercise program, including the agility exercises exercise prescription 4-way ankle 3x15 repetitions knee to wall 2x20 seconds toe raises 2x15 repetitions wall sit w/ calf raise 2x15 repetitions return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 wall sit w/ toe raise 2x15 repetitions seated calf raise 2x10 repetitions heel taps 2x15 repetitions (6-inch box or stair) lateral band walks 2x10 repetitions (each) monster walks 2x10 repetitions (each) 4-way hip 3x10 repetitions clam shells 3x10 repetitions (every other day) agility hurdles 2 in each (forward and lateral) icky shuffle normal and wide lateral shuffle 2x (down and back) back-pedal w/ lateral break 2x (down and back) a-skips lateral and forward carioca 2x (down and back) box drill 2x (down and back) 6-ball drill w/ tennis balls on cones) 2x (down and back) t drill 2x (down and back) outcomes body structure and function the patient completed the foot and ankle ability measure (faam), a survey designed to probe an individual’s perceived level of function in daily activities and in sport specific activities. the faam has been reported to be a valid and reliable measure for an individual’s overall physical function while recovering from a lower-extremity musculoskeletal injury.9 at the time of his return from winter break, the patient stated on the faam that his level of function during his activities of daily living was 80%, and he scored a 66% on the sports subscale. this indicated that he was still experiencing a moderate level of impairment while completing his sport-specific activities, but just a mild level of impairment throughout the rest of his daily activities. he stated that the perceived lack of function at that time was because he was still experiencing some discomfort while loading his right foot and forcefully pushing off to move laterally to the left. despite table 2. return to tennis program day 1 day 2 day 3 day 4 day 5 day 6 stationary hit: 30 forehands (fh) 30 backhands (bh) stationary biking (45 min) stationary hit: 30 fh 30 bh 15 crosscourt stationary biking (30 min) stationary hit: 30 fh 30 bh 15 crosscourt 15 volleys 15 serves stationary biking (30 min) complete warm up: 30 fh 30 bh 15 crosscourt 15 volleys 10 overheads 30 serves stationary biking (30 min) complete warm up ground points allowed (rally begins with an underhand feed) unrestricted return to play return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the perceived lack of function, the patient displayed normal levels of muscle power indicated through manual muscle testing for inversion, eversion, and ankle dorsiflexion. during the patient’s 6-week follow-up appointment with the university health services physician, he was cleared to begin weight-bearing exercises and to gradually cease wearing the walking boot. at approximately 13 weeks post-injury, the patient successfully returned to tennis activities in full capacity. the period to return to play was extended due to time spent away from tennis while at home for winter break, however, this allowed the patient to gradually return to sport following arrival back to campus. upon waking in the morning throughout his initial return to practice period, the patient expressed feeling limited mobility in his ankle that was still hindering his daily morning routine. the patient reported, however, that this limitation seemed to subside as he was awake and moving for several hours throughout the morning. currently, the patient reports that his level of function during his daily activities and sports related activities is not impacted by his injury. he no longer reports discomfort moving in any direction while playing tennis. he also states that he believes he has built up a significant amount of endurance in his foot and ankle muscles to withstand entire practices and competitions without complications. activity and participation the patient reported feeling much better about his role on the team and in society following his return to play. he stated that he felt the burden lifted when he was able to transport himself to class, meals, and tennis practices. he felt an improvement in his educational experience as his attendance in classes improved following his recovery. further, he felt a relief of pressure when he began playing tennis again. tennis was often an outlet for his emotions and stress in everyday life, and it felt more normal to him to be able to participate in all the team’s activities. among the most significant activities the patient felt he missed while recovering from his injury was the team’s daily match of soccer tennis before the beginning of practice. soccer tennis was a game invented by several team members to include a combination of foot and header skills. the game was played within the service boxes of a regulation tennis court with a soccer ball. this game was a major source of team bonding, and he felt a greater sense of belonging and an improvement in his informal relationships with teammates after finally being allowed to take part in the game again. altogether, the patient was successfully returned to all societal roles and activities that he was previously engaged in. environmental and personal factors overall, the patient presented with a positive attitude to improve his condition for all rehabilitation sessions. he seemed to have a strong social support system that wanted to see him recover and return to participation in previous activities. he was always eager to progress throughout his rehabilitation and advance to more challenging exercises. the patient did have moments where he was hesitant to schedule a time for rehabilitation due to feeling like a burden to the athletic trainer. he would often explain that he could complete his rehabilitation at any convenient time for the athletic trainer because he believed the other injuries his teammates were experiencing were more pressing. due to these remarks, the athletic trainer explained multiple times that his injury and condition were just as concerning, and that they would receive the same amount of attention and care prior to beginning his rehabilitation sessions. just 24-hours after receiving clearance from the physician to begin weight-bearing and gradually move away from utilizing the walking boot, the patient contracted influenza-a. the treating physician also suspected the patient had concurrently contracted viral pneumonia. he isolated himself at home and rested for about 3 days before feeling up to going to class. the presence of pneumonia complicated the patient’s return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 47 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 ability to complete his rehabilitation, specifically his return to cardiovascular conditioning activities. fortunately, no long-term consequences resulted from the pneumonia, and the patient was able to gradually work on conditioning activities without any further setbacks. finally, the patient’s care and overall return to play was disturbed by travel for winter break. the patient was about to progress into his agility exercises when the fall academic semester ended, and the break began. this break was a result of the educational system’s policies regarding scheduled holidays as well as societal norms that have been constructed for rest during the holiday season. over the break, the patient was going home to his parents’ residence and would not be available to work on his rehabilitation at the athletic training facility for 2 weeks. he was provided with an at-home exercise program and was guided through the variety of agility drills prior to traveling. in addition, he was instructed on the progression of exercises moving forward. the athletic trainer was tasked with consistently checking on the patient’s condition through virtual means before instructing him to progress further with his exercises. the patient’s lack of access to a tennis facility also acted as a barrier to his success over this break. as a result, he was only able to perform some functional sport-specific activities, and he was not able to begin his progression into full tennis activities until he returned from the break. discussion the high sensitivity of the ottawa ankle rules indicates it is a reliable tool to rule out fractures of the foot and ankle,4 but this case provides evidence that caution still needs to be taken during its acute implementation. it proved essential for the second physician in this case to order radiographs, as the patient was still presenting with pain and an inability to bear weight 5-7 days after his first visit. the use of additional clinical factors, such as the significant amount of edema as many as 72-hours post-injury, could have been an important indicator for the practical use of radiographs to rule out a possible fracture. in addition, it is also important to consider the relative ease of obtaining radiographs at the ncaa division i level, as well as the relatively low cost and low dose of radiation exposure compared to other sources of imaging. the plan of care initiated by the university heath affiliated physician followed the published recommendations regarding the treatment of low-energy cuboid fractures. this evidence currently suggests that about 4-6 weeks of partial weight-bearing in a walking boot is an effective intervention to promote healing of the bone.10 following that period, the patient could then transition away from the boot and begin weight-bearing as symptoms allow. a complication with the patient’s return to tennis program was the timing of the university’s winter break. the beginning of winter break coincided with the patient’s start of his functional agility exercises. this presented a challenge in terms of the delivery of form instruction and corrective cues. the athletic trainer could not be present for the entirety of his agility exercises, so the patient was first guided through all the baseline agility exercises prior to leaving for break. the athletic trainer included examples of the progressions for the athlete to utilize moving forward. many of the progressions for the agility exercises and the sport-specific exercises included drills that the patient had been regularly completing in fitness sessions prior to his injury. the patient was allowed to take several hurdles and cones for use at home throughout his program. the patient’s home exercise plan was also tailored toward utilizing objects the patient would already have access to at home. an example of this included performing heel taps using a single step of a set of stairs as the raised platform. throughout this period at home, the patient was instructed to check-in with the athletic trainer weekly to assess his condition and discuss his progression for the following week. return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 48 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 the patient’s subsequent return to tennis plan (appendix a) had to include consideration for the extended time he had been removed from activity. tennis can be a very physically demanding sport that combines aerobic exercise during long rallies with anaerobic bursts of power and agility. tennis also requires a large amount of upper extremity acceleration, deceleration, and dexterity. the patient required proper reconditioning of both his lower extremity and upper extremity during his return to tennis progression. this was performed using a progressive loading period that consisted of a combination of sport-specific tennis activities and low-impact aerobic exercise on a stationary bike. the patient was ultimately able to successfully return to his normal daily activities, roles in society, and level of functionality in sport following his injury. this process consisted of careful consideration of the patient’s physical condition and emotional stability. several confounding factors contributed to a delay in the patient’s complete return to play, however, he does not report any frustrations with this delay. the patient recognizes that the timing of contracting influenza and winter break had a significant impact on his recovery and does not attribute this delay to his persistent symptoms experienced throughout his first two weeks post-injury. overall, the patient is satisfied with his ability to perform his role in sport and society after his recovery despite the significant injury that occurred. clinical bottom line while midfoot fractures are not commonly seen in competitive tennis players, it is important that the health care team work to integrate clinical prediction rules and pertinent clinical findings to ensure suspected midfoot fractures are not missed. when implementing the ottawa ankle rules, consideration of the findings in the history and physical exam, as well as the examiner’s clinical concern, need to factor into the decision to have imagining performed on a patient. while it is important to limit unnecessary x-ray imaging, clinical concern may reasonably override the recommendation of a clinical prediction rule. patient perspective the patient emphasized the significant impact that not being able to transport himself had on his perceived role in society throughout his rehabilitation. he did not appreciate the burden that he felt he was on other people, and he also struggled with being on other individuals’ time schedules. he is typically an individual that enjoys arriving early for practices and competitions, and he was no longer able to do this after suffering the injury. interestingly, the patient expressed frustration with the accessibility of campus instructional buildings due to the lack of efficient elevator services. he noted how fortunate he was to only have to deal with these shortcomings for a relatively short amount of time. he could not imagine having to continue devoting such a large amount of additional time for his commute to daily activities. the patient was pleased with the outcome from his recovery, and he expressed gratitude for having the opportunity to play tennis competitively again. references 1. fong dt, hong y, chan lk, yung ps, chan km. a systematic review on ankle injury and ankle sprain in sports. sports med. 2007;37(1):73-94. https://doi.org/10.2165/00007256-200737010-00006. 2. court-brown cm, zinna s, ekrol i. classification and epidemiology of mid-foot fractures. the foot. 2006;16(3):138-141. https://doi.org/https://doi.org/10.1016/j.foot.2006.03.003. 3. fenton p, al-nammari s, blundell c, davies m. the patterns of injury and management of cuboid fractures. bone joint j. 2016;98-b(7):1003-1008. https://doi.org/10.1302/0301-620x.98b7.36639. https://doi.org/10.2165/00007256-200737010-00006 https://doi.org/https:/doi.org/10.1016/j.foot.2006.03.003 https://doi.org/10.1302/0301-620x.98b7.36639 return-to-tennis considerations and an elusive diagnosis for a cuboid avulsion fracture: a disablement model case study 49 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 4. jenkin m, sitler mr, kelly jd. clinical usefulness of the ottawa ankle rules for detecting fractures of the ankle and midfoot. j athl train. 2010;45(5):480-2. https://doi.org/10.4085/1062-605045.5.480. 5. stiell i, wells g, laupacis a, et al. multicentre trial to introduce the ottawa ankle rules for use of radiography in acute ankle injuries. multicentre ankle rule study group. bmj. 1995;311(7005):5947. https://doi.org/10.1136/bmj.311.7005.594. 6. houglum pa. therapeutic exercise for musculoskeletal injuries 4th edition. human kinetics; 2016. 7. slysz j, stultz j, burr jf. the efficacy of blood flow restricted exercise: a systematic review & metaanalysis. j sci med sport. aug 2016;19(8):669-75. https://doi.org/10.1016/j.jsams.2015.09.005. 8. oliveira as, brito silva p, farina d, kersting ug. unilateral balance training enhances neuromuscular reactions to perturbations in the trained and contralateral limb. gait posture. 2013;38(4):894-9. https://doi.org/10.1016/j.gaitpost.2013.04.015. 9. martin rl, irrgang jj, burdett rg, conti sf, van swearingen jm. evidence of validity for the foot and ankle ability measure (faam). foot ankle int. 2005;26(11):968-83. https://doi.org/10.1177/107110070502601113. 10. angoules ag, angoules na, georgoudis m, kapetanakis s. update on diagnosis and management of cuboid fractures. world j orthop. 2019;10(2):71-80. https://doi.org/10.5312/wjo.v10.i2.71. https://doi.org/10.4085/1062-6050-45.5.480 https://doi.org/10.4085/1062-6050-45.5.480 https://doi.org/10.1136/bmj.311.7005.594 https://doi.org/10.1016/j.jsams.2015.09.005 https://doi.org/10.1016/j.gaitpost.2013.04.015 https://doi.org/10.1177/107110070502601113 https://doi.org/10.5312/wjo.v10.i2.71 abstract manuscript type clinical outcomes research 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 perceptions and use of the athletic training milestones in education: a report from the aate research network cailee e. welch bacon, phd, atc, fnata*; barton e. anderson, dhsc, atc*; julie m. cavallario, phd, atc†; bonnie l. van lunen, phd, atc, fnata†; lindsey e. eberman, phd, lat, atc‡ *a.t. still university, meza, az; †old dominion university, norfolk, va; ‡indiana state university, terre haute, in abstract the athletic training milestones (at milestones) were developed as an evaluation tool to capture the breadth and depth of athletic training knowledge, skills, and behavior. however, it is unclear whether athletic training programs are implementing this tool or how they are implementing it to gauge the clinical progression of students or residents in athletic training. we aimed to explore the perceptions and use of the at milestones among educators in athletic training programs. we used a cross-sectional, web-based survey with open-ended questions to collect data from athletic training programs on if and how they implement the at milestones at a programmatic level. we recruited program/residency directors from 352 athletic training programs in november 2021; representatives from 101 programs accessed the survey (28.7% access rate) and 89 completed the survey (88.1% completion rate). a rigorous, multi-phase consensual qualitative research approach was used to analyze the textual data. of the 89 programs represented, 60.1% (n=54) indicated they did not use the at milestones, while 39.9% (n=35) did. three themes emerged from the open-ended responses provided by program representatives who did implement the at milestones: modes of use, value-added, and frequency of use. participants detailed how the at milestones were used as a student self-assessment measure, a tool to evaluate a student’s clinical experience performance, and a measure to evaluate course performance. participants described that the at milestones add value to the educational experience by providing a continuum, contributing to the programmatic framework, and promoting a standardized assessment structure. finally, participants described the frequency of use of the at milestones across their programs, ranging from once a year to after the completion of every clinical rotation. athletic training educators looking for a useful assessment tool to address student progression on a continuum should consider implementing the at milestones into their programmatic framework. content focus health professions education correspondence cailee welch bacon professor, department of athletic training research research professor, school of osteopathic medicine in arizona a.t. still university 5850 e. still circle mesa, az 85206 e-mail: cwelch@atsu.edu reference: welch bacon ce, anderson be, cavallario jm, van lunen bl, eberman le. perceptions and use of the athletic training milestones in education: a report from the aate research network. clin pract athl train. 2024;7(2): 12-25. https://doi.org/10.31622/2024/0007.02.3. introduction competency-based education is an outcome-oriented process by which students are assessed on a continuum of behaviors or activities to determine their readiness for independent practice.1 although athletic training educators are trying to implement competency-based education, research suggests they are not actually doing so.1–3 this failure of implementation may be caused by confusion about the actual definition of competency-based education or by the lack of awareness of tools to measure competence in athletic training. the athletic training milestones (at milestones)4 were created by a group of athletic trainers to address the need for competency-based education in athletic training education. when developing the milestones, the at milestones development group considered the educational outcomes mailto:cwelch@atsu.edu https://doi.org/10.31622/2024/0007.02.3 perceptions and use of the athletic training milestones in education: a report from the aate research network 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 identified by the accreditation council for graduate medical education for measuring performance in the 6 domains of clinical competency associated with medical education.5 the accreditation council for graduate medical education also provided a list of benefits associated with the development of a national framework for assessment that included the creation of comparison data across programs and professions to enhance the quality of education and improve the quality of patient care.5 the creators of the at milestones mimicked this process by identifying 8 domains of practice for individual competencies and developing a 6-level continuum that ranged from “critical deficiency” to “expert.”4 a national framework for assessment in athletic training has the potential to generate data across athletic training education programs, allowing researchers to compare and assess the quality of education and development of athletic trainers along the continuum of their education, prior to credentialing, as well as throughout the lifespan of their career. recently, researchers assessed the validity of the at milestones and reported the tool had excellent content validity across items and scales.6 theoretically, widespread adoption and use of the at milestones could provide educators with a competency-based framework to assess student readiness for independent practice. although the at milestones have been available for over five years, little data has been collected to determine how athletic training educators perceive this instrument or the extent of its use in athletic training programs. therefore, the purpose of our study was to explore the perceptions and use of the at milestones among educators in athletic training programs. methods we used a cross-sectional, web-based survey design with open-ended questions to explore perceptions and use of the at milestones. because of the open-ended survey items, textual data were analyzed using a systematic 4-phase consensual qualitative research (cqr) process described by hill et al.7,8 we used cqr for data analysis because of its rigorous consensus process, use of multiple researchers, and inclusion of auditors to ensure the credibility of the data and comprehensive representation of the participant's voice in findings.7,8 the current study was deemed exempt by the a.t. still university institutional review board. participants educators were recruited from professional and post-professional degree and residency programs accredited by the commission on accreditation of athletic training education (caate) at the time of the study (n=382). the survey was designed to be completed only once per program, so a single survey link was sent to each program or residency director. if the program had another faculty member who was better able to complete the survey about the at milestones, the director was asked to forward the survey link to that individual. instrumentation since no existing surveys were appropriate for the study, our research team developed a short, web-based survey using qualtrics (provo, ut). the survey included 10 demographic questions and 4 open-ended items (figure 1). the open-ended items were intended to explore the perceptions and use of the at milestones within each athletic training program or residency. because the survey used skip logic, only participants who indicated their program used the at milestones were asked to complete the open-ended items. after development, the survey was reviewed for face and content validity by three athletic training educators who were familiar with survey research design and the at milestones. using an established validation process,9 each individual was asked to assess the comprehension and readability of the survey items, evaluate the inclusivity of close-ended perceptions and use of the athletic training milestones in education: a report from the aate research network 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 survey item selection choices, and provide an estimation of the time to complete the survey. based on the reviewers’ feedback, no changes were made to the instrument. the survey was estimated to take approximately 10 to 15 minutes to complete, depending on the thoroughness of participant responses. given the nature of the open-ended items in the survey, we determined a reliability analysis was unnecessary. procedures we sent a recruitment email to each program or residency director of caate-accredited athletic training programs in november 2021 (figure 2). the email included the purpose of the study, the number of items in the survey, the estimated time to complete it, a unique url link to the web-based survey, and a request to have the most qualified individual in the program complete the survey. individuals were given six weeks to voluntarily complete the survey; 2 reminder emails were sent during that period. of the 382 identified programs, 24 duplicate email addresses were identified yes no 1. how familiar are you with the at milestones? [4-point likert scale] 3. are you interested in using the at milestones in your athletic training program in the future? 3. please describe the ways in which you use the at milestones in your athletic training program. [open-ended response] 4. please explain why you use the at milestones in your athletic training program. [open-ended response] 5. what value, if any, do the at milestones bring to your program and programmatic assessment? [open-ended response] 6. please describe how often and at which timepoints throughout the program you use the at milestones. [open-ended response] 2. do you use the at milestones in your athletic training program? [yes/no] figure 1. flow of open-ended survey items perceptions and use of the athletic training milestones in education: a report from the aate research network 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 and removed; 6 email addresses were identified as undeliverable. therefore, the initial recruitment email was sent to 352 athletic training programs. figure 2. study procedures flowchart according to the guidelines of exempt research and best practices for survey research, participant consent was implied by their voluntary completion of any portion of the survey, and participants were not required to answer every question.10,11 data analysis all responses were included in data analysis as long as the participant responded to at least one survey item. because skip logic was used in the survey, the number of responses varied by item: the total number of items for each participant depended on previous responses. further, because participants were not required to answer every survey item, some chose not to respond to particular items. descriptive statistics (i.e., frequency, percentage, mean, and standard deviation) or close-ended survey items were analyzed using spss version 27 (ibm corporation), and all open-ended survey items were analyzed using the cqr approach.7,8 to ensure consensus, the cqr approach uses a multi-analyst research team.7,8 therefore, we used a 5-person team to establish consensus and minimize potential researcher bias during data analysis. three team members (cewb, bea, jmc) were involved in every phase of analysis, and the other two members served as internal (lee) and external (blv) auditors. during the first phase of data analysis for open-ended survey items, the 3 team members independently reviewed responses from the first 15 participants and developed an initial codebook. the team met to discuss each individual’s coding and compiled a consensus codebook of themes and categories. to confirm the consensus codebook, each team member independently coded responses from the next 10 participants that completed the survey, and then the team met again to confirm the coding and establish consensus. next, the 3 team members coded all remaining participant responses and participant recruitment [november 2021] email sent to 352 program and residency directors of caateaccredited athletic training programs survey was available for 6 weeks [2 reminder emails] individuals from 101 athletic training programs accessed the survey individuals from 89 programs completed the survey and were included in data analysis consensual qualitative research coding [march may 2022] external audit [june 2022] d a ta a n a ly si s d a ta c o ll ec ti o n perceptions and use of the athletic training milestones in education: a report from the aate research network 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 met to confirm all codes. after these first 3 phases of data analysis were completed, the internal auditor conducted a comprehensive review of the analysis and findings to establish the credibility of the identified themes and categories. after the internal audit review, two categories were collapsed to minimize redundancy, and one category was removed because of a lack of saturation. we used the consolidated criteria for reporting qualitative research12 to ensure study findings were comprehensively reported, and the external auditor reviewed all final findings to ensure the participant’s voice was appropriately represented. results of the 352 athletic training programs that sent recruitment emails, individuals from 101 (access rate=28.7%) programs accessed the survey. individuals representing 89 (completion rate=88.1%) programs in 36 states (1 missing data) completed the survey and those responses were included in data analysis. the demographic characteristics of participants are presented in table 1. the familiarity with the at milestones of respondents that do or do not use them in their program is presented in figure 3. table 1. participants’ demographic information variable n (%) mean ± sd age 89 (100) 44.3 ± 8.2 years certified as an at 89 (100) 21.1 ± 7.8 years of clinical practice 89 (100) 13.9 ± 7.9 years as an educator 89 (100) 15.3 ± 8.3 years in current position 89 (100) 9.9 ± 7.5 gender woman 51 (57.3) man 37 (41.6) prefer not to respond 1 (1.1) highest degree attained bachelor’s degree 0.0 (0) master’s degree 14 (15.7) clinical doctorate 12 (13.5) academic doctorate 62 (69.7) professional degree (e.g. md, do) 1 (1.1) primary role program/residency director 81 (91.0) clinical coordinator 7 (7.9) core faculty member 1 (1.1) type of athletic training program professional program 77 (86.5) post-professional degree program 3 (3.4) residency program 5 (5.6) both professional and post-professions programs 4 (4.5) of the 89 completed surveys, 54 individuals indicated their program did not use the at milestones. these participants represented 50 institutions with a professional athletic training program, one institution with a post-professional athletic training degree program, two institutions with professional and post-professional athletic training degree programs, and one athletic training residency program. when asked whether they were interested in using the at milestones in the future, 18 (33.3%) reported they were interested, 4 (7.4%) were not interested, and 31 (57.4%) were unsure (1 missing data). perceptions and use of the athletic training milestones in education: a report from the aate research network 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 thirty-five individuals from the 89 programs indicated their program used the at milestones. these participants represented 27 institutions with a professional athletic training program, two institutions with a post-professional athletic training degree program, two institutions with professional and post-professional athletic training degree programs, and four athletic training residency programs. of the programs using the at milestones, the mean (sd) number of years using them was 2.2 (1.3) years. because their program used the at milestones, these respondents were asked to complete the four open-ended survey items. however, five did not provide responses; responses from seven participants were unclear and were removed from the analysis. therefore, 113 open-ended responses from 30 respondents (a maximum of 4 responses per participant) were included in the qualitative analysis. three themes were identified during the analysis: modes of use, value-added, and frequency of use. figure 3. respondents’ familiarity with the at milestones modes of use participants identified a variety of ways the at milestones were used throughout their athletic training program. during data analysis, 3 categories were identified for this theme: self-assessment, clinical experience performance, and course performance. self-assessment participants described using the at milestones in their program for student reflection and selfassessment. one participant from a professional program described how the at milestones were used to help students assess their own progress in the following way: 0 1 18 16 14 16 21 3 0 5 10 15 20 25 not familiar at all minimally familiar moderately familiar extremely familiar fa m ili ar ity l ik er t s ca le do not use at milestones use at milestones perceptions and use of the athletic training milestones in education: a report from the aate research network 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 the at milestones help the students prepare for the program by introducing them to the general competency areas and specialty competency areas early on as they self-reflect on their own personal development. the document gives them a framework to guide them in their development and help them decide future employment practice settings. likewise, another participant identified that their professional program used the at milestones as “a self-assessment tool for students during each semester of the professional program” and a third professional program participant shared that the at milestones were “introduced early to demonstrate how ats [athletic trainers] can create and assess a professional development plan.” yet another indicated that the tool was integrated into their post-professional program because it “allows students to reflect as to where they feel they are on the various milestones and how they progress throughout their education.” clinical experience performance participants described the ways the at milestones were used to assess clinical experience performance of students. specifically, they described how the tool was used to determine student readiness for clinical progression or a need for remediation. one participant from a professional program shared: “we have a clinical competency committee that meets at the end of the year and scores each student on the [at] milestones. if students are not at the predetermined level of skill, then remediation [activities are] assigned.” similarly, another professional program participant indicated the at milestones were used “at the end of the first year to assess student readiness for immersive experiences.” yet another professional program participant described how “the [at] milestones help guide clinical placement decisions based on identified deficiencies or areas in need of improvement during students’ clinical progressions.” participants also indicated the at milestones were incorporated as a part of the preceptors’ assessment of students. one participant from a professional program wrote: “after the student completes their self-assessment, their current preceptor also evaluates the student using the at milestones to evaluate the student on their progression during the clinical experience.” another professional program participant indicated the at milestones “allow targeted feedback from preceptors to highlight students’ strengths and weaknesses and how to improve.” one professional program participant discussed the multifaceted approach their program used for the at milestones in the following way: our students perform self-assessments, the preceptors' complete assessments of the students, and the educator uses the at milestones to complete assessments of the students as well. our intention is to use the milestones to see the students’ progression over their time in the program as well as to assess the students from both the didactic and clinical aspects to identify areas of improvement. perceptions and use of the athletic training milestones in education: a report from the aate research network 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 course performance participants also indicated the at milestones were used to assess course performance. one participant from a professional program indicated, “the at milestones are used in our clinical courses to assess students during our comprehensive practical exams.” another professional program participant described how the at milestones were used to evaluate students engaging with standardized patients. specifically, the participant shared: “we use them to assess student performance with standardized patients at the end of the first year in the program to demonstrate readiness for the second year.” finally, one professional program participant discussed how they incorporated the at milestones for course evaluations: we use the at milestones as criteria for our assurance of competence exams. we incorporate the competencies from the at milestones into our courses, when appropriate, as expectations of learning outcomes and identify the level we expect students to achieve. value added the value that the at milestones added to athletic training programs was another identified theme. this theme also had 3 categories emerge during analysis: provides a continuum, contributes to the programmatic framework, and promotes a standardized structure. provides a continuum several participants discussed how the at milestones provided a continuum for students that allowed them to see the trajectory of their professional growth. one participant from a professional program wrote: “we value the at milestones and how it will give students a solid framework to monitor their progress during didactic and clinical experiences as they transition to practice and begin to focus on their own professional development.” likewise, another professional program participant indicated: “i think it gives the students a more realistic representation of how they are progressing in the program with their knowledge and skills.” one participant from a residency program remarked: “the at milestones bring great value to our program because it allows us to supplement our other measures. it gives us another measure to evaluate their knowledge and skills and allows students to measure their own growth.” participants also described how the at milestones promoted conversation among stakeholders about the learning progress of students. one participant from a professional program indicated, “the [at] milestones provide an opportunity for students to reflect on their progress and to engage faculty and preceptors in conversations related to their personal assessment and clinical practice improvement.” another professional program participant summarized this aspect of the value of the at milestones in the following way: we believe that the at milestones reflect the continuum of learning that is experienced by professional athletic training students, instead of the typical “met” or “not met” system that has been historically used. the at milestones also reflect holistic patient care, which is a central theme across our program. perceptions and use of the athletic training milestones in education: a report from the aate research network 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 contributes to the programmatic framework participants also discussed how the at milestones contributed to their programmatic framework. one professional program participant wrote: “the at milestones are one of the major assessment tools we use to provide data for our assessment plan. additionally, they help us demonstrate compliance with many of the caate curricular content standards.” similarly, another participant from a professional program indicated: “they serve as a roadmap for our programmatic outcomes sequencing.” yet another professional program participant described the value the at milestones provided to their programmatic framework in the following: the at milestones bring the value of providing a framework to assess clinical competency. for years, we have had discussions regarding how well our students were progressing clinically, but we did not have a standardized way to measure and assess their progress. the at milestones helped fill that gap for us. our participants also discussed how incorporating the at milestones across the program helped program administrators make data-informed decisions. one participant from a professional program shared the following: the at milestones provide us with data to drive our decision-making. we review our programmatic framework and strategic plan annually and look at the data from all of our assessments to help us identify areas we are lacking or excelling in. we continually use data from the at milestones to improve the quality of what we are teaching. likewise, another professional program participant wrote: “the at milestones provide us with objective data points for student and program assessment. these data help us make sure we are meeting our intended outcomes laid out in our programmatic framework and plan.” in some instances, participants highlighted their need to adapt the at milestones to fit their programmatic framework and assessment plan. one participant from a professional program explained: “we use some of the wording from the at milestones exactly but have also modified some to better align with the needs of our program.” similarly, another professional program participant described how they modified the scoring of the at milestones to match their programmatic outcomes. that participant wrote: “we borrowed heavily from the at milestones to make our own but adjusted the scores so that a ‘4’ is ‘ready to take the board of certification exam while a ‘5’ is still considered ‘aspirational’.” yet another professional program participant described how they used the at milestones as intended but also used them as a template for additional milestones. the participant indicated: “we use the [at] milestones as designed, but we also created new milestones for other skills outlined in our assessment plan, such as initiative, communication, and compassion.” promotes a standardized structure several participants described how the standardized structure of the at milestones was valuable for their program. one participant from a professional program remarked that the primary reason they began to implement the at milestones was that: “[t]hey were already created, freely accessible, and provide the consistent language we were interested in for our assessment plan.” likewise, another professional program participant wrote: “the at milestones give us a great structure to build into our evaluations instead of ‘winging it’ and making something up on our own.” one participant from a post-professional program discussed the value of the standardized structure perceptions and use of the athletic training milestones in education: a report from the aate research network 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 by commenting: “the at milestones provide athletic training specific information on how students feel they are learning and progressing rather than just relying on our generic course evaluations.” participants also indicated the standardized structure of the at milestones strengthened aspects of their program. one participant from a professional program wrote: “our assessment plan has become more comprehensive. we can draw stronger connections between types of assessments and across the program because we use the at milestones within all of our didactic and clinical courses.” another professional program participant indicated: “it allows students to see that learning is a process rather than a discreet task. it also allows faculty members to step back from the details (i.e., can they perform a lachman’s [test]) and look at the learning process at a higher level (i.e., can they conduct an exam specific to a patient’s complaints).” lastly, one professional program participant described how the standardized structure of the rubric in the at milestones was valuable for their program in the following: we like the way the at milestones are set up as a rubric rather than a simple likert scale. we believe the rubric makes the evaluation process a bit more objective because the student, the preceptor, and the educator are able to see the criteria used to assign a score. it also facilitates discussions with students and allows us to help students create educational and clinical goals. frequency of use for the third identified theme, participants discussed the frequency of use of the at milestones across their programs (figure 4). some participants described implementing the at milestones only during matriculation and again at the end of the program. one participant from a professional program wrote: “we use the at milestones at the beginning and end of the program for athletic training students. they incorporate it within their own personal goals and development strategies.” one professional program participant described more frequent use of the at milestones: “we use the [at] milestones after our longer clinical rotations. our students complete 3 of these longer rotations throughout the program. we also use the tool at the end of each year as a summative evaluation for all of our students.” one participant from a post-professional program described even more frequent use of the at milestones, specifying they used the tool twice per clinical rotation to assess student progression. that participant wrote: “our preceptors complete the at milestones during every mid-rotation and 34% 46% 37% 66% matriculation/end of program yearly following a clinical rotation each semesterfigure 4. percentage of programs that use the at milestones at various timepoints throughout the program perceptions and use of the athletic training milestones in education: a report from the aate research network 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 end-of-rotation assessment for each student to track how the student is progressing and if remediation is needed.” discussion in the current study, we explored the perceptions and use of the at milestones among educators in athletic training. our participants represented multiple program types, and more than half indicated that they did not use or, in some cases, were not familiar with the at milestones. further, only a third indicated they were interested in using the at milestones in the future. for those participants who used the at milestones, 3 themes were identified during the analysis of our openended survey items. participants identified a variety of modes of use that included self-assessment, clinical experience performance, and course performance. the at milestones also added value to programs that used them by providing a continuum, contributing to their programmatic framework, and promoting a standardized structure. some participants also noted that they adapted the tool to meet the needs of their program better. lastly, the frequency of use of the at milestones varied throughout the curriculum for each program. some programs used them only at matriculation and program completion. others used them after each course, clinical rotation, semester, or year in the program. as our findings suggest, there is high variability in how often programs choose to use the at milestones within a curricular or clinical progression, and, as such, there is limited discussion to be had surrounding this theme until such a time that the at milestones are more readily used throughout at education. to date, there are no evidence-based recommendations that exist regarding how frequently the at milestones should be used to assess competence progression. while the at milestones were not originally designed for high-frequency use (i.e., weekly, monthly), it is difficult to establish the appropriate timeline for implementation. in medical education, the milestones are considered to be a complex educational intervention, which includes several interacting components.13 therefore, individuals interested in implementing the at milestones should appreciate the complexity of truly assessing competence progression and, in turn, develop an implementation plan based on the intended goals of the at milestones as a comprehensive tool to assess progression over the continuum of professional development and time. at milestone familiarity and awareness although our qualitative results indicated how the at milestones are used in athletic training education, a majority of our participants reported they did not use the at milestones at all. further, 15% of those who responded to our survey reported they were not at all familiar with the at milestones. this result is concerning. the at milestones were introduced over 5 years ago and have been available to athletic training programs since that time.4 however, our results suggested their widespread adoption and use have not yet been achieved. historically, pedagogical practices change very slowly and the implementation of new practices may be considered risky by educators.14 in such cases, the adoption of new practices may be overwhelming for educators, especially for practices that require a major overhaul of assessment methods and interpretation.14 given these results, we propose examining the adoption of the at milestones using the diffusion of innovation theory, which involves 4 components for the widespread adoption of innovative practices.15 specifically, the 4 components address the actual innovation, how education about the innovation is communicated to interested parties, the necessary time for adoption of the innovation, and the system or stakeholders the innovation is intended for.15 this theory specifies that the rate of adoption begins slowly with early adopters and that early adopters may influence the rate of perceptions and use of the athletic training milestones in education: a report from the aate research network 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 change in subsequent adopters.15 research suggests innovative practices in healthcare programs tend to be slowly adopted because of necessary changes in organizational culture.16 thus, at a minimum, adoption of the at milestones would require universal agreement across core faculty, associated and adjunct faculty, and preceptors. it would also require major modifications to programmatic assessment practices. as such, it is not surprising that there is not more widespread adoption of this tool. based on our study results, we hypothesize that the profession is still in the early stages of the adoption process of the at milestones. further, it is possible that education disruptions caused by the covid-19 pandemic, which impeded assessment practices and professional development opportunities, affected the adoption of the tool across educational programs in athletic training. therefore, to increase the adoption of the at milestones across athletic training education and practice, we should encourage the early adopters to provide clinical leadership and disseminate data that supports the use of the at milestones. we should also support the development of program-level infrastructure to migrate the at milestones into practice and provide additional resources and information to address and overcome the perceived risks associated with the adoption of innovative practices.15,16 some of the participants in our study who used the at milestones described using them to assess the competency of students. previous researchers3 defined competency as “a continuum of contemporary professional practice abilities that minimally indicates a provider can provide safe and reliable care on a consistent basis without harm to a patient and maximally indicates expertise in a given ability within clinical practice.” when considered this way, competence is not a binary achievement that one does or does not have; this concept is reflected in the scoring of the at milestones.4 although the at milestones can be an effective marker of students' or professionals' readiness for autonomous practice, we caution users from labeling learners as competent since the continuum of learning does not guarantee competence maintenance beyond skill acquisition and application, especially when the learner does not maintain their knowledge and professional practice ability throughout their career.1–3 if the goal of adopting the at milestones is to embrace competency-based education practices, the athletic training profession will need to unlearn the traditional numeric systems that often fail to align with competency-based education and the binary competency assessment models that have commonly been used for educational assessment. modes of use for the identified modes of use theme, the 3 categories of self-assessment, clinical experience performance, and course performance illustrated how programs use the at milestones. according to eva and regehr,17 self-assessment is a mechanism that healthcare providers use to recognize their strengths and weaknesses in clinical practice. successful self-assessment of weaknesses can provide clinicians with the ability to address areas of reduced competence in clinical practice and determine appropriate learning goals for future clinical development. successful self-assessment of strengths is also beneficial. having a better awareness of strengths allows clinicians to practice with greater confidence and establish appropriately challenging learning goals that advance clinical practice. further, effective self-assessment practices contribute to an individual’s overall selfefficacy and self-concept. more specifically, self-efficacy refers to an individual’s belief in their ability to manage a context-specific situation (e.g., an on-field cervical spine evaluation), whereas self-concept is the overall appraisal of one’s abilities across many dimensions (e.g., performing a musculoskeletal evaluation of the neck). because self-efficacy and self-concept are important aspects of the educational preparation of athletic trainers, using the at milestones to facilitate selfreflection in students may contribute to improvements in both. perceptions and use of the athletic training milestones in education: a report from the aate research network 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 participants of the current study also indicated they used the at milestones to measure student performance in clinical and didactic settings. more specifically, the at milestones were used to assess student/resident performance in athletic training clinical experiences (e.g., preceptor evaluation of a resident’s clinical performance) and in didactic courses (e.g., faculty evaluation of a student’s performance of skills related to a course or course assignment). this use of the at milestones is supported by the caate in their 2020 standards for professional athletic training programs,18 which identify multiple areas of use of the at milestones for overall assessment. the at milestones use a 6-level performance scale ranging from critical deficiencies to expert levels. within this framework, learning and progression over time can be assessed with serial application of the at milestones across a professional education program. this usage is especially valuable when considering current accreditation standard 15, which specifies: “a program’s athletic training clinical experiences and supplemental clinical experiences provide a logical progression of increasingly complex and autonomous patient-care and client-care experiences.”18 there is an expectation that programs facilitate progressively autonomous experiences, but recent findings suggest programs do not have effective measures for doing so.19 the at milestones offer such a tool to demonstrate each student’s progression over time and their incorporation of increasingly complex clinical skills. another benefit of using the at milestones for assessment is that they can be mapped directly to the 2020 caate core competencies.18 this particular usage could be beneficial for demonstrating each student’s knowledge and skill performance of curricular content while simultaneously providing evidence of programmatic compliance with accreditation standards. value added the value-added theme identified in the current study highlighted several aspects of the at milestones that were valuable to athletic training programs. first, the comprehensive nature of the at milestones provided a continuum of assessment from novice to expert practice. this continuum allowed students to see the trajectory of their growth during their professional education program. it also allowed them to assess current levels of performance and determine areas for future development. the at milestones also added value to the programmatic framework, likely because they are viewed as a more comprehensive, holistic, and global assessment tool. further, their developmental nature means they can be used for global assessment of student performance across the entirety of the program. as such, data from the at milestones could be used to make evidence-based decisions on program development and delivery that focus on improving student outcomes. this type of evidence also contributes to a program’s quality improvement efforts and may facilitate compliance with accreditation standards for program design and quality. additionally, the standardized nature of the at milestones provides an assessment tool that can be used in different ways (self, clinical, and didactic performances) while still maintaining its value as a global assessment. interestingly, although some programs valued the standardized structure of the at milestones, others identified a need to adapt them to fit their program better. for example, some adaptations involved altering the levels of performance, using a selection of competencies, or changing the competency descriptions. however, it is important to note that any adaptions or modifications to the at milestones, including the use of alternative scales or adjusting the criteria, could create a threat to the validity of the original tool.6 competency-based education has been a goal for many athletic training educators, but the profession has long lacked a comprehensive, athletic training-specific tool to support the achievement of this goal. with the validation and early adoption of the at milestones, athletic perceptions and use of the athletic training milestones in education: a report from the aate research network 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 trainers now have a valid evaluation instrument available to them that can be used throughout their professional careers to ensure they are continuing to seek clinical competence. limitations and future research as is true with all original inquiry, our findings should be interpreted with caution. because of the self-reported design of the study, we assumed that participants answered questions thoroughly and accurately. specifically, we employed this survey to explore the programmatic use of the at milestones. it is possible that faculty, preceptors, or clinicians affiliated with a program use the at milestones separately to evaluate athletic training students or residents, and that information would not have been captured in the current study. future research should aim to capture the successful use of the at milestones along the progression of athletic training professional and postprofessional education to aid others in adopting them. future research should also determine and establish best practices for using the at milestones effectively within athletic training education. lastly, as more programs adopt and use the at milestones, efforts should be made to create a universal data repository from which athletic training educational research questions might be answered. clinical application based on the time of availability of the at milestones and the findings of our study, athletic training education is likely still in the early phases of adopting the at milestones. early adopters of the at milestones should disseminate how the at milestones can be effectively used across the continuum of athletic training: from professional athletic training education to advanced practice to continuing professional development and growth. additionally, those considering adopting the at milestones should eliminate the credence of a binary assessment model and instead focus on the continuum of competence progression.3 athletic training educators using the at milestones within their respective programs highlighted the value they have added to their programs. participants identified using the at milestones in multiple modes, including self-assessment, didactic, and clinical assessments. our findings support the potential that the at milestones can be used programmatically in various valuable ways. doing so would likely result in the increased emphasis on the at milestones in a program’s framework and assessment plan and in demonstrating compliance with accreditation standards. since the at milestones have been validated and are being successfully used in athletic training education, athletic training educators looking for a useful assessment tool to address student progression on a continuum of competency should consider implementing the at milestones into their programmatic framework. references 1. mace kl, welch bacon ce. the future of health professions education: considerations for competency-based education in athletic training. athl train educ j. 2019;14(3):215-222. doi:10.4085/1403215 2. mace kl, welch bacon ce. athletic training educators’ knowledge and confidence about competency-based education. athl train educ j. 2018;13(4):302-308. doi:10.4085/1304302 3. welch bacon ce, cavallario jm, pike lacy am, walker se, eberman le. educators’ perceptions of characteristics that define athletic training student competence: a report from the aate research network. athl train educ j. 2022;17(3):241-249. doi:10.4085/1947-380x-21-088 4. athletic training milestones project. https://www.atmilestones.com/ accessed june 14, 2022 perceptions and use of the athletic training milestones in education: a report from the aate research network 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 5. nasca tj, philibert i, brigham t, flynn tc. the next gme accreditation system--rationale and benefits. n engl j med. 2012;366(11):1051-1056. doi: 10.1056/nejmsr1200117 6. welch bacon ce, anderson be, cavallario jm, van lunen bl, eberman le. content validation of the athletic training milestones: a report from the aate research network. j athl train. 2023;58(5):483487. doi: 10.4085/1062-6050-0332.22 7. hill ce, thompson bj, williams en. a guide to conducting consensual qualitative research. couns psychol. 1997;25(4):517-572. doi: 10.1177/0011000097254001 8. hill ce, knox s, thompson bj, williams en, hess sa, ladany n. consensual qualitative research: an update. j couns psychol. 2005;52(2):196-205. doi: 10.1037/0022-0167.52.2.196 9. williams rm, welch ce, parsons jt, valovich mcleod tc. athletic trainers’ familiarity with and perceptions of academic accommodations in secondary school athletes after sport-related concussion. j athl train. 2015;50(3):262-269. doi: 10.4085/1062-6050-49.3.81 10. office for human research protections (ohrp). the belmont report. accessed march 18, 2022. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/index.html 11. decieux jp, mergener a, neufang km, sischka p. implementation of the forced answering option within online surveys: do higher item response rates come at the expense of participation and answer quality? psihologija. 2015;48(4):311-326. 12. tong a, sainsbury p, craig j. consolidated criteria for reporting qualitative research (coreq): a 32item checklist for interviews and focus groups. int j qual health care. 2007;19(6):349-357. doi:10.1093/intqhc/mzm042 13. holmboe es, call s, ficalora rd. milestones and competency-based medical education in internal medicine. jama intern med. 2016;176(11):1601-1602. doi:10.1001/jamainternmed.2016.5556 14. le fevre dm. barriers to implementing pedagogical change: the role of teachers’ perceptions of risk. teaching and teacher education. 2014;38:56-64. doi: 10.1016/j.tate.2013.11.007 15. scott s, mcguire j. using diffusion of innovation theory to promote universally designed college instruction. international journal of teaching and learning in higher education. 2017;29(1):119-128. 16. bradley eh, webster tr, baker d, et al. translating research into practice: speeding the adoption of innovative health care programs. issue brief. 2004;(724):1-12. 17. eva kw, regehr g. self-assessment in the health professions: a reformulation and research agenda. acad med. 2005;80(10 suppl):s46-54. 18. commission on accreditation of athletic training education (caate). standards for the accreditation of professional athletic training programs. https://caate.net/pp-standards. published 2020. accessed august 12, 2020. 19. carlson be, young jp, neil er, barrett jl, eberman le. programmatic efforts to ease transition to practice through progressive autonomy. j athl train. 2024;19(1):51-61. https://doi.org/10.4085/1062-6050-013.23. abstract manuscript type validation case study 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 risk factors of medial tibial stress syndrome in active adolescents: a validation case series daniel delgado, dat, lat, atc*; matthew j. drescher, dat, lat, atc*; justin p. young, dat, lat, atc*; zachary k. winkelmann; phd, scat, atc†; matthew j. rivera, dat, lat, atc* *indiana state university, terre haute, in;†university of south carolina, columbia, sc abstract current literature reports that an increase in body mass index (bmi), navicular drop, ankle plantarflexion range of motion (rom), and hip external rotation rom are key modifiable risk factors in the development of medial tibial stress syndrome (mtss) in physically active adults. the purpose of this validation case series was to investigate these four measures as risk factors of mtss in adolescent athletes. in total, 100 cross country, volleyball, and/or basketball athletes (age = 15.89±1.31 years, 54 assigned female at birth) were included. the competitive sports season was the intervention in this case series and all athletes experienced 6 athlete-exposures per week. of the 100 athletes, 21% (n = 21/100) of participants developed mtss during their respective sports season. demographic data were analyzed using measures of central tendency. mean differences (md) between the mtss and nonmtss groups were calculated for the main outcome variables. a kruskal-wallis one-way analysis of variance was used to determine differences in main outcome variables between groups. there were no significant differences in bmi (p ≥ 0.42), navicular drop (p ≥ 0.27), active ankle plantarflexion rom (p ≥ 0.65), or active hip external rotation rom (p ≥ 0.77) between mtss and non-mtss groups. the md between groups were bmi = 0.22, navicular drop = 0.95mm, active ankle plantarflexion rom = -1.36°, and active hip external rotation rom = -0.40°. these results do not prospectively confirm adolescents who develop mtss have a significant increase in the risk factors described in the literature. therefore, more research should be performed to determine if the risk factors for mtss between adults and adolescents differ. content focus health care competence correspondence dr. daniel delgado, 567 n 5th st, terre haute, in 47802. e-mail: dan.delgado.atc@gmail.com full citation delgado d, drescher mj, young jp, winkelmann zk, rivera mj. risk factors of medial tibial stress syndrome in active adolescents: a validation case series. clin pract athl train. 2023;6(1): 13-20. https://doi.org/10.31622/2023/0006.01.3. submitted: may 13, 2021 accepted: march 24, 2022. article citation and summary hamstra-wright kl, bliven kc, bay c. risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. br j sports med. 2015;49(6):362-369. doi:10.1136/bjsports-2014-093462 article summary medial tibial stress syndrome (mtss), often referred to as “shin splints,” is described as an “exercise-induced, localized pain along the distal two thirds of the posterior-medial tibia,”1 and is a common musculoskeletal condition in those who are physically active.2-6 runners are particularly affected by mtss with an incidence rate as high as 13.6-20%.2,3 despite how common this condition is, there still is a lack of consensus within the literature about the etiology of the condition.2,3 multiple conjectures have been made about the anatomical source of the pain with myofascial strain, enthesopathy, periosteal inflammation, and bone stress reaction being the most widely accepted causes.7 our murky understanding of the involved tissue makes this condition difficult to treat and even more difficult to prevent. identifying risk factors for mtss could benefit a large proportion of those who are physically active, as it would provide clinicians with the necessary information to develop and implement risk reduction programming. developing this programming would help minimize the negative effects of the risk factors. mailto:dan.delgado.atc@gmail.com https://doi.org/10.31622/2023/0006.01.3 risk factors of medial tibial stress syndrome in active adolescents: a validation case series 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 a guiding systematic review and meta-analysis2 that identified risk factors for developing mtss in physically active individuals was selected for this case validation series. the authors of the review searched the database of abstracts of reviews of effects (dare) and the cochrane database of systematic reviews (cdsr) for systematic reviews pertaining to risk factors of mtss as well as the cochrane central register of controlled trials (central), medline (ovid sp), embase, and cinahl for studies meeting the inclusion criteria. studies were included in the review if they were original research, investigated risk factors associated with mtss, compared physically active individuals with and without mtss, were published in english, and were accessible, full papers, in peer-reviewed journals. after removing duplicates and investigations that did not align with the research question, a total of 21 original research articles were included and the following relevant data points were extracted: research design, study duration, participant selection, population, groups, mtss diagnosis, investigated risk factors, risk factor definitions, means, standardized deviations (sd), confidence intervals (ci), effect sizes, and odds ratios (or). this information was then classified into risk factor categories including arch height or angle, bmi, bone parameters, calcaneus and rearfoot position and displacement, calf girth, flexibility/rom, foot posture index, forefoot position, gait variables, leg angle and tibia angle, medical history and symptoms, ober’s test, strength, structure/alignment, training variables/fitness level, and demographic variables. the 21 included articles consisted of three cross-sectional, nine case-control, and nine prospective cohort studies. individuals with increased bmi (mean difference [md] = 0.79, 95% ci 0.38-1.20, p < 0.001, i2 = 0.00%), increased navicular drop (md = 1.19mm, 95% ci 0.54-1.84, p < 0.001, i2 = 40.19%), increased ankle plantarflexion rom (md = 5.94°, 95% ci 3.65-8.24, p < 0.001, i2 = 0.00%), and increased hip external rotation rom (md = 3.95°, 95% ci 1.78-6.13, p < 0.001, i2 = 0.00%) were found to be more likely to develop mtss. the increase in each of these four main outcome measures were deemed statistically significant when comparing physically active adults that did develop mtss to those that did not develop the condition. objective the purpose of this case validation series was to investigate these four main outcome measures as risk factors of mtss in secondary school (grades 9 to 12) athletes at the point-of-care. with this information, comparisons to previous literature that has investigated these risk factors can be made to allow for better recommendations for mtss prevention measures in the secondary school athlete patient population. patient population the clinical practice setting for this study included student-athletes at five secondary schools in rural indiana. in total, 100 athletes, 13 of which participated in more than one sport, were included. participant demographics can be found in table 1 with the mtss diagnoses. those who participated in more than one sport were observed during both sports seasons if they did not develop mtss during the first sport season. a breakdown of the number of participants by school and sex assigned at birth can be found in table 2. patients were included in this study if they were in high school and participated in cross country, volleyball, and/or basketball. individuals were included regardless of mtss history, however they had to be injury free at the time the risk factors were measured at the beginning of their respective sports season. intervention this case validation series followed the main findings from the guiding review which indicated that four main outcome measures were significantly different between those who developed mtss and those who did not. risk factors of medial tibial stress syndrome in active adolescents: a validation case series 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 in this case validation series, the athletic trainer(s) at each school calculated bmi (𝑘𝑘𝑘𝑘 ÷ 𝑚𝑚2) and measured navicular drop, ankle plantarflexion rom, and hip external rotation rom. both ankle plantarflexion and hip external rotation were measured actively. although bmi is not a great predictor of body mass, specifically body fat percentage in an athletic population, individuals with an increased bmi compared to controls are more likely to develop mtss.2 a bmi of 18.5-24.9 would be considered a “healthy” height-to-weight ratio, so an individual with a bmi greater than this may develop mtss because of the response of bones to loading. when tibial bowing or bending occurs, the load producing this bowing or bending stimulates periosteal activation, causing the tibia to become stronger to prevent bony overload.8,9 those with a higher bmi would be subject to a greater load and may require a more gradual and prolonged increase in activity levels to account for the slow, progressive process of osteogenesis that needs to occur to prevent the tibia from becoming injured due to overloading.2 navicular drop and arch height have been shown to be related to tibial internal rotation during running.2 having a more rigid arch, one that is not hypermobile allowing the navicular to drop significantly while weight bearing, is good because it allows for more tibial internal rotation.10,11 this may be one way the body is able to better absorb impact forces.2 on the other hand, individuals with a greater amount of navicular drop experience a decrease in arch height, or increased foot pronation, leading to less tibial table 1. participant demographics age (y) (mean±sd) 15.89±1.31 n mtss diagnosis n (%) sex assigned at birth (n) female male 54 46 10 (18.52%) 11 (23.91%) sport participation (n) cross country volleyball basketball 46 20 47 14 (30.43%) 0 (0%) 7 (14.89%) table 2. number of participants by school and sex assigned at birth males females total school 1 27 29 56 school 2 6 13 19 school 3 8 3 11 school 4 5 0 5 school 5 0 9 9 total 46 54 100* *of the 100 total participants, 13 participated in more than one sport (3 males, 10 females). figure 1. navicular drop. a) the navicular tuberosity is marked on the patient’s skin. b) next, the level of the navicular tuberosity is marked on a notecard while the patient is non-weightbearing. c) the patient is then asked to stand, and the level of the navicular tuberosity is marked on the notecard while the patient is weightbearing. the distance between the two markings on the notecard is then measured in millimeters (mm). risk factors of medial tibial stress syndrome in active adolescents: a validation case series 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 internal rotation and a decreased ability to absorb impact forces.16 having a navicular drop ≥10mm represents an overly pronated foot,12 meaning the tibia itself must absorb the majority of impact forces, predisposing individuals to mtss.16 the relationship between plantarflexion rom and the development of mtss has less evidence than the previous risk factors.2 researchers have hypothesized those with greater degrees of plantarflexion, of which the normative active rom is 50°,12 are more likely to land on their forefoot when running as opposed to landing on the rearfoot.4 this landing position may contribute to an increase in the amount of strain being placed on the posteromedial aspect of the tibia.13 however, there are currently no investigations that have corroborated this hypothesis. another possible explanation is that increased navicular drop and increased plantarflexion are interconnected. during the first half of the stance phase during running, foot pronation, which is a combination of ankle dorsiflexion, rearfoot eversion, and foot abduction, occurs.14 individuals with greater pronation, indicating increased navicular drop, may push through their first ray more forcefully during midstance, when the foot pronates to absorb impact forces.2 these greater push off forces can lead to a greater active rom in plantarflexion and therefore greater extensibility of the ankle dorsiflexors.2 increased extensibility of the anterior tibialis, a strong dorsiflexor which attaches to the base of the first ray, associated with greater plantarflexion rom, may influence navicular drop due to its proximity to the navicular bone.2 though these biomechanical connections can be make hypothetically, there remains a lack of substantial evidence to make these connections definitive, further demonstrating the need for screening and prevention. possibly more unclear than the connection between plantarflexion and mtss is the association between increased hip external rotation rom and mtss.2 the normative active rom for hip external rotation is 45°.12 hip external rotation rom greater than this could lead to excessive medial tibial loading; however, the same is true for decreased hip ranges of motion,4 as well as limited evidence suggesting greater internal rotation can lead to mtss.17 changes in the available degrees in various ranges of motion of the hip may result from anteversion or retroversion of the femoral neck,15 changing the orientation of the femur on the figure 2. active ankle plantarflexion rom measurement with goniometer a) starting position: the fulcrum of the goniometer is placed over the apex of the lateral malleolus, the stationary arm is aligned parallel to the axis of the fibula using the head of the fibula as a distal reference, and the moving arm is aligned parallel to the axis of the 5th metatarsal during movement. b) the patient is asked to plantarflex their ankle and the clinician ensures all parts of the goniometer remain correctly aligned. risk factors of medial tibial stress syndrome in active adolescents: a validation case series 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 tibia.2 another possible theory is that the total arc of rotation at the hip, meaning the total degrees of hip internal and external rotation combined, could influence tibial loading, though there is limited empirical evidence to make a concrete connection here.2 even so, more research should be conducted to identify the relationship between hip external rotation rom and ankle plantarflexion rom on the development of mtss. main findings participants of this case validation series were divided into two groups, mtss and non-mtss, based on the development of the condition. descriptive statistics were completed for both groups. measures of central tendency were used to analyze the demographic variables and main outcome measures. mean differences were calculated between the two groups. the groups were not normally distributed, so a kruskal-wallis one-way analysis of variance was used to determine differences. during their respective sport season, 21% (n = 21/100) of participants developed mtss. the supervising athletic trainer at their respective school used the following diagnostic criteria for mtss: injury must have been exercise-induced, pain must be localized, and pain must be along the distal two-thirds of the posteromedial tibia.1 the means and standard deviations for each main outcome variable by group can be found in table 3 with the normative values for the general population for comparison. the md between groups was calculated by subtracting the mean of those who did not develop mtss from those that did. the md of each of the measures were as follows: bmi = 0.22, navicular drop = 0.95mm, active ankle plantarflexion rom = -1.36°, and active hip external rotation rom = -0.40°. there were no significant differences in bmi (p ≥ 0.42), navicular drop (p ≥ 0.27), active ankle plantarflexion rom (p ≥ 0.65), or active hip external rotation rom (p ≥ 0.77) between participants who did and did not develop mtss. table 3. side-by-side comparison of the results to normative values between groups (mtss and non-mtss) normative values mtss group (n=21) non-mtss (n=79) bmi healthy = 18.5-24.9 22.36±4.35 (95% ci 20.50-24.22) 22.14±3.09 (95% ci 19.05-25.23) navicular drop normal ≤ 10mm 8.33±3.14 (95% ci 6.99-9.67mm) 7.38±3.63 (95% ci 6.58-8.18mm) active ankle plantarflexion rom 0-50° 55.24±9.54° (95% ci 51.16-59.32°) 56.59±10.75° (95% ci 54.23-58.96°) active hip external rotation rom 0-45° 33.98±7.30° (95% ci 30.85-37.10°) 34.38±9.91° (95% ci 32.19-36.57°) figure 3. active hip external rotation rom measurement with goniometer a) starting position: the fulcrum of the goniometer is placed over the middle of the patella, the stationary arm is aligned perpendicular to the floor or tabletop, and the moving arm is aligned parallel to the axis of the tibia during movement using the center of the talocrural joint as a distal reference. b) the patient is asked to externally rotate their hip and the clinician ensures all parts of the goniometer remain correctly aligned. risk factors of medial tibial stress syndrome in active adolescents: a validation case series 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 discussion the purpose of this validation case series was to investigate risk factors of mtss in an adolescent sporting population. identifying risk factors in this population would be a necessary step for the development and implementation of preventative training programs to reduce the incidence rate of this injury. the current investigation found no significant differences between the four main outcome measures between patients who developed mtss and those who did not. the average bmi of individuals in this study fell within the normative range (18.5-24.9) for both individuals who developed the condition and those who did not. similarly, the average navicular drop for both groups was between 7.38±3.63mm and 8.33±3.14mm for the non-mtss and mtss groups respectfully, which would be considered in the normative range below 10mm. overall, active ankle plantarflexion rom for both groups was approximately 5-7° greater than population normative values. however, since this finding was present in both groups, the difference between groups was not found to be significant. lastly, the average active hip external rotation rom for both groups was about 11° less than population normative values. though previous literature has suggested both increased and decreased hip ranges of motion could affect tibial loading,4 both those who developed mtss and those who did not develop mtss demonstrated a decrease in external rotation rom. in this study, there were some key limitations that need to be addressed in future research. this study included a small sample size (n = 100) and the patient population of this study was solely adolescent athletes between the ages of 13 and 18. adolescent athletes may have different anthropometric characteristics that predispose them to developing mtss when compared to adults. another limitation of this study was the use of rom measures as a surrogate for gait analysis. while rom theoretically influences biomechanics, an indepth biomechanical analysis should be utilized to more accurately identify these changes. in addition, this study was conducted during the covid-19 pandemic which saw sports teams regularly quarantine when an individual on a team tested positive for the virus. this may have had an effect on the number of individuals in the study who experienced mtss because the quarantine period created unusual rest periods throughout the sports season, where patients were not subjected to the same training regimen and decreased loading of the tibia. additionally, with the consistent changes in training load, we did not include training load and mileage ran for each participant. finally, when conducting a multi-site investigation at the point-of-care, coordination and collaboration are paramount for data collection. future studies should utilize larger sample sizes and investigate the differences between adolescents and adults who develop mtss from those that do not develop mtss. specifically, research should continue to investigate the influence of hip external rotation rom and running biomechanics. also, information related to training load and training intensity should be considered in future research on this topic, as previous investigations have shown that increased training load can predispose individuals to mtss. clinical bottom line adolescents with significantly greater bmi, navicular drop, active ankle plantarflexion rom, and/or active hip external rotation rom may not be more likely to develop mtss. more research should be performed with a larger sample size as well as to investigate if the risk factors for mtss between adults and adolescents differ. a reduction in the total number of adolescents experiencing mtss should also have a larger impact on the entire healthcare system, reducing the time and financial burden that is exacerbated treating preventable conditions. risk factors of medial tibial stress syndrome in active adolescents: a validation case series 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 acknowledgements thank you to dr. karina gonzalez, dr. grace mills, dr. andrew schweitzer, and kyrie potter for assisting in the data collection process. references 1. plisky ms, rauh mj, heiderscheit b, underwood fb, tank rt. medial tibial stress syndrome in high school cross-country runners: incidence and risk factors. j ortho sports phys ther. 2007;37(2):4047. https://doi.org/10.2519/jospt.2007.2343. 2. hamstra-wright kl, bliven kch, bay c. risk factors for medial tibial stress syndrome in physically active individuals such as runners and military personnel: a systematic review and meta-analysis. b j sports med. 2015;49(6):362-369. https://doi.org/10.1136/bjsports-2014-093462. 3. winkelmann zk, anderson d, games ke, eberman le. risk factors for medial tibial stress syndrome in active individuals: an evidence-based review. j athl train. 2016;51(12):1049-1052. https://doi.org/10.4085/1062-6050-51.12.13. 4. moen m, bongers t, bakker e, et al. risk factors and prognostic indicators for medial tibial stress syndrome. scand j med sci sports. 2012;22(1):34-39. https://doi.org/10.1111/j.16000838.2010.01144.x. 5. reinking mf, austin tm, richter rr, krieger mm. medial tibial stress syndrome in active individuals: a systematic review and meta-analysis of risk factors. sports health. 2017;9(3):252-261. https://doi.org/10.1177/1941738116673299. 6. yagi s, muneta t, sekiya i. incidence and risk factors for medial tibial stress syndrome and tibial stress fracture in high school runners. knee surg sports traumatol arthrosc. 2013;21(3):556-563. https://doi.org/10.1007/s00167-012-2160-x. 7. newman p, witchalls j, waddington g, adams r. risk factors associated with medial tibial stress syndrome in runners: a systematic review and meta-analysis. open access j sports med. 2013;4:229. https://doi.org/10.2147/oajsm.s39331. 8. beck br. tibial stress injuries. an aetiological review for the purposes of guiding management. sports med. 1998;26(4):265-279. https://doi.org/10.2165/00007256-199826040-00005. 9. judex s, gross ts, zernicke rf. strain gradients correlate with sites of exercise‐induced bone‐ forming surfaces in the adult skeleton. j bone miner res. 1997;12(10):1737-1745. https://doi.org/10.1359/jbmr.1997.12.10.1737. 10. eslami m, damavandi m, ferber r. association of navicular drop and selected lower-limb biomechanical measures during the stance phase of running. j appl biomech. 2014;30(2):250-254. https://doi.org/10.1123/jab.2011-0162 11. nigg bm, cole gk, nachbauer w. effects of arch height of the foot on angular motion of the lower extremities in running. j biomech. 1993;26(8):909-916. https://doi.org/10.1016/00219290(93)90053-h. 12. starkey c, brown sd. examination of orthopedic & athletic injuries. fa davis; 2015. 13. ekenman i, halvorsen k, westblad p, fellãnder-tsai l, rolf c. local bone deformation at two predominant sites for stress fractures of the tibia: an in vivo study. foot ankle int. 1998;19(7):479484. https://doi.org/10.1177/107110079801900711. 14. ferber r, hreljac a, kendall kd. suspected mechanisms in the cause of overuse running injuries: a clinical review. sports health. 2009;1(3):242-246. https://doi.org/10.1177/1941738109334272. https://doi.org/10.2519/jospt.2007.2343 https://doi.org/10.1136/bjsports-2014-093462 https://doi.org/10.4085/1062-6050-51.12.13 https://doi.org/10.1111/j.1600-0838.2010.01144.x https://doi.org/10.1111/j.1600-0838.2010.01144.x https://doi.org/10.1177/1941738116673299 https://doi.org/10.1007/s00167-012-2160-x https://doi.org/10.2147/oajsm.s39331 https://doi.org/10.2165/00007256-199826040-00005 https://doi.org/10.1359/jbmr.1997.12.10.1737 https://doi.org/10.1016/0021-9290(93)90053-h https://doi.org/10.1016/0021-9290(93)90053-h https://doi.org/10.1177/107110079801900711 https://doi.org/10.1177/1941738109334272 risk factors of medial tibial stress syndrome in active adolescents: a validation case series 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 1 – april 2023 15. whipple tj, eckhardt rb. the endurance paradox: bone health for the endurance athlete. routledge; 2016. 16. brody dm. techniques in the evaluation and treatment of the injured runner. orthop clin north am. 1982; 13: 541-558. 17. burne sg, khan km, boudville pb, et al. risk factors associated with exertional medial tibial pain: a 12 month prospective clinical study. br j sports med. 2004;38(4):441-5. https://doi.org/10.1136%2fbjsm.2002.004499. https://doi.org/10.1136%2fbjsm.2002.004499 abstract manuscript type abstract presentation 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 southwest athletic trainers’ association free communications abstract presentations the following abstracts were accepted and presented at the 68th southwest athletic trainers’ association (swata) symposium, 2023. the association of vitamin d, bone mineral density, and injuries among acrobatics and tumbling athletes lee k, gallucci a, forsse j, cherpe de souza l, irvin l, boyer e, funderburk l: baylor university, waco, tx introduction: acrobatics and tumbling (a&t) is an emerging sport incorporating various elements of gymnastics and competitive cheerleading. anecdotal evidence suggests that the sport presents with high injury rates potentially due to the high impact nature of the activity. due to the potential aesthetic sport related concerns, bone mineral density and risk of injury presents a concern for patients, athletic trainers and stakeholders. increased understanding of the relationship between bone mineral density, serum vitamin d status, and injury incidence in a&t may be useful to athletic trainers, registered dietitians, and others working with these athletes. the objective of this study was to evaluate the relationship between bone mineral density, serum vitamin d, and injury among a&t student athletes. methods: cohort study at a ncaa division i university sponsored athletic department. forty-two participants on the active a&t roster consented to participate. average age was 19.69 ± 1.199 years. positional composition: 19 tops, 23 bases. serum vitamin d was analyzed at two timepoints 8 weeks apart. injury history data was collected between timepoints by team athletic trainer. routine dxas performed as standard of care. outcome measures included serum vitamin d (ng/ml), injury incidence, and bone mineral density (femur, lumbar spine). descriptive statistics were utilized in addition to t tests and anovas to determine if significant differences existed in injuries based on bone mineral density, or athletic position (i.e., top, base). poisson regressions were completed to analyze the relationship between bone mineral density and injuries. results: between week 1 and week 8, participants experienced a significant loss of vitamin d (6.093 ± 10.973, p<.001). average bone mineral density z score for the femur was 1.836 ± 0.842, and of the spine was 1.952 ± 0.999. bone mineral density of the spine was significantly greater in bases than tops, but no difference existed in the femur. there was no significant difference in injuries sustained based on bone mineral density of the femur or spine. clinical application: no significant differences were found in injuries related to differences in bone mineral density of the femur or lumbar spine. however, differences were found among bone mineral density by position group, with bases having higher bone mineral density in their spine than tops. this may be important due to the requirements of the base position compared to tops. although a direct relationship between serum vitamin d and high average bone mineral density was not identified, significant decreases in serum vitamin d and high average bone mineral density in the sample may provide interesting insight for healthcare providers working with a&t. athletic trainers, strength staff, and dietitians working with a&t should consider the impact of changes in serum vitamin d and activity when monitoring for factors related to injury. abstract presentation 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 attitudes toward implicit bias among ncaa medical support staff warner bj*, jacobsen ap†‡, decker m§, cage sa?: *grand canyon university, †ut health east texas, ‡the university of texas health science center at tyler, §the university of texas at arlington, ?the university of texas at tyler introduction: implicit biases are unconscious attitudes, emotions, or stereotypes that have the potential to negatively affect behaviors, actions, and decisions. recent research has shown that healthcare workers do not provide equitable care to patients from different demographics. when patients are receiving different levels of care, there is a potential for different patient-related outcomes. one of their first steps in many implicit bias interventions for healthcare professionals is identifying one’s implicit bias. the purpose of this study was to describe the attitudes toward implicit bias among non-athletic training healthcare professionals who provide care to collegiate student-athletes. methods: an electronic survey was sent to every national collegiate athletic association (ncaa) team physician, mental health care professional, and nutrition and dietetics professional whose email address was publicly available on their institution’s website (n = 623). a total of 116 (age = 40 ± 13 years, experience = 12 ± 11 years, 71 females, 45 males, 33 team physicians, 27 mental healthcare professionals, 56 nutrition and dietetics professionals) participants opened and completed the survey for a response rate of 18.6%. participants were asked to provide demographic information, including age, years of experience, gender identity, and race. following the demographics section, participants completed questions taken from the attitudes toward implicit bias instrument. pearson’s correlations were used to determine relationships between age, years of experience, and attitudes toward implicit bias. independent samples t-tests were performed to determine differences in attitudes toward implicit bias between races, gender identities, and professions with significance set at p < .05. results: the majority of participants (n = 109, 94.0%) agreed that implicit biases have the potential to impact patient care, and need to be addressed during education and professional development. there were no significant correlations between age or years of experience with attitudes toward implicit bias. females were significantly more likely to believe that implicit bias could impact patient care and needed to be addressed than males (t(114) = -3.068, p = .003). participants from racial minorities were significantly more likely to believe that implicit bias could impact patient care and needed to be addressed than white participants (t(114) = -2.131, p = .035). mental healthcare professionals were significantly more likely to believe that implicit bias could impact patient care and need to be addressed than team physicians (t(114) = -3.222, p = .002) or nutrition and dietetics professionals (t(114) = 3.017, p = .003). clinical application: despite some differences between groups, the overwhelming majority of healthcare professionals agreed that implicit bias has the potential to impact patient care and needs to be addressed. these findings suggest that ncaa healthcare professionals may be receptive to interventions designed to identify and address implicit biases. abstract presentation 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 does pressure from coaches affect the eating habits of male collegiate athletes? bynum c*, long m*: *abilene christian university introduction: research has shown that eating disorders tend to be most seen in females and athletes. the research on the prevalence of eating disorders in males is low compared to the research on females. this study examined male athletes at abilene christian university and determine if the pressure about weight from coaches and teammates could influence the eating habits of these athletes. the purpose of this study is to determine if pressure about weight from coaches or teammates affected eating habits of male collegiate athletes at a ncaa division 1 institution. methods: this study employed a cross-sectional survey design. participants included ncaa division i male student-athletes. the survey was sent out electronically to the participants via school email. the survey includes informed consent, demographic information (age, school classification, and ethnicity), and the questions from the weight pressures in sports scale in male athletes survey. a higher score for a question indicated that there are more weight-related pressures for that topic. this scale had instructions for how to calculate the total score for the different subscales. there was a total score, the coach/teammates subscale, and the appearance subscale. results: the score for the coach/teammate pressures subscale was 4.09 out of 6, the score for the appearance pressure subscale was 2.55 out of 6, and the total score with all the questions was a 3.32 out of 6. it was found that over half of the total score came from the coach/teammate pressure on the players. it was also shown that there was a higher score from the coach/teammate pressures compared to the appearance pressures. in each of the subscales, the coach /teammate subscale (α =0.87) and the appearance subscale (α = 0.84) included seven questions, so the total scale was made up of all 14 questions (α = 0.90). each question was scored on a six-point likert scale that ranges from 1 (never) to 6 (always). the total score was determined by adding up the scores for each question and then averaging that number by dividing it by 14. each subscale was totaled and divided by seven. the dependent variables were the coach/teammate subscale and the appearance subscale. translation to practice: the results indicate that the pressure from coaches can have an influence on their athletes' eating habits. while this can be an awkward topic, it is an important topic, especially for athletic trainers to keep in mind when working with athletes. when working with athletes on the daily, athletic trainers should make sure to check in with athletes who could possibly be struggling with disordered eating. knowing the signs and symptoms of disordered eating can lead to earlier interventions for student-athletes. abstract presentation 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 knowledge of and attitudes toward native american and first nations people among ncaa division i athletic trainers trail le*†, warner lk‡, warner bj§, decker m?, cage sa* : *the university of texas at tyler, †ut health east texas, ‡creighton university, §grand canyon university, ?the university of texas at arlington introduction: current literature shows that native americans people experience more health care disparities relative to other ethnic and racial groups. previous research has also shown that these healthcare disparities are present in pediatric and young adult native american populations. as healthcare professionals who will potentially treat these populations, it is important to understand the knowledge of and attitudes toward native americans people among athletic trainers. the purpose of this pilot study was to describe the knowledge of, and attitudes and opinions of national collegiate athletics association (ncaa) division i athletic trainers toward native americans. methods: an electronic survey (table 1) was sent to every ncaa division i athletic trainer whose email address was publicly available on their institution’s website (n = 3,016). a total of 253 (age = 34 ± 11 years, experience = 11 ± 10 years, 61 females, 42 males, 1 non-binary) athletic trainers opened and completed the survey. questions asked participants to provide demographic information, including age, years of experience, gender identity, race, and ethnicity. participants also completed questions related to comfort providing equitable care for native american patients, attitudes toward native americans and knowledge of contemporary, historical, and sports medicine issues specific to native americans. pearson’s correlations were used to determine relationships between age, years of experience, attitudes toward native americans, and knowledge of contemporary, historical, and sports medicine issues specific to native americans with significance set at p < .05. results: the majority of participants reported generally favorable attitudes toward native americans. there were significant, very weak negative correlations found between attitudes toward native americans and age (r(251) = -.258, p < .001) and years of experience (r(251) = -.223, p < .001). there were also significant, very weak positive correlations found between knowledge of native american sports medicine issues and age (r(251) = .275, p < .001) and years of experience (r(251) = .277, p < .001). when asked about providing equitable care for native american patients, 94.4% (n = 239) participants expressed some level of comfort with providing equitable care. however, participants had mean scores of 26.4% for knowledge of contemporary native american issues, 33.4% for knowledge of historical native american issues, and 64.6% for knowledge of sports medicine native american issues. clinical applications: while the majority of participants expressed generally favorable attitudes toward native americans people, there appears to be a gap between attitudes and knowledge of issues facing native american patients. professional masters in athletic training curricula and continuing education offerings should provide information about providing equitable healthcare for native american patients. table 1: knowledge of and attitudes toward native americans scale attitudes prompt answer choices 1. native americans tend to live in a way that is in tune with nature (e.g., live off the land, hunt for food, etc.) more than other americans* 2. native americans hold on to their traditions more than they should in this day and age.* 3. native americans tend to treat others with kindness. 4. native americans tend to work harder than most other racial groups. 5. native americans tend to be more spiritual than other social groups. a) strongly disagree b) disagree c) somewhat disagree d) somewhat agree e) agree f) strongly agree abstract presentation 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 6. native americans tend to be more cliquey than other minority groups.* 7. native americans have been treated poorly given their inherent worth as humans. 8. native americans should have more rights than they currently do given their status as the original americans. 9. using a native american as a mascot is acceptable with permission from the associated tribe. 10. using a native american as a mascot is acceptable without permission from the associated tribe.* contemporary issues (correct answers bolded) what percentage of the united states population is native american? a) 0.5% b) 0.9% c) 1.2% d) 1.5% how many federally recognized native american tribes are in the united states? a) 574 b) 484 c) 267 d) 654 which of the following tribes does not have a federally recognized reservation in the state of texas? a) apache b) tigua c) kickapoo d) alabama-coushatta how many native americans/native hawaiians were elected to the united states house of representatives in 2020? a) 1 b) 8 c) 6 d) 4 how many native american tribes have treaty rights to send non-voting delegates to the united states congress? a) 2 b) 4 c) 6 d) 7 historical issues (correct answers bolded) which of the following tribes is not part of the plains culture? a) crow b) blackfeet c) hopi d) comanche which of the following was not a primary crop grown by sedentary farming tribes in the southwest culture? a) corn b) carrots c) beans d) squash what housing structure was primarily used by the navajo tribe? a) teepee b) wigwam c) pueblo d) hogan before european contact, which region of the united states had the largest population? a) modern-day california b) modern-day texas c) modern-day florida d) modern-day new york abstract presentation 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 the ancestors of native americans are thought to have arrived in north america over _____ years ago. a) 6,000 b) 1,000 c) 12,000 d) 10,000 sports medicine issues (correct answers bolded) true or false: all native american tribes require consent from a medicine man for a sports medicine professional to provide care. a) true b) false which of the following native american tribes generally does not allow blood transfusions? a) navajo b) hopi c) mohawk d) seminole what percentage of native americans people use peyote for spiritual and medicinal purposes in modern society? a) 10% b) 20% c) 30% d) 40% which of these sports was invented by native american? a) football b) lacrosse c) golf d) tennis which native american olympian won the decathlon and pentathlon in 1912? a) billy mills b) jesse rinick c) jim thorpe d) andrew sockalexis abstract presentation 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 the effects of dry cupping therapy on touch pressure threshold in collegiate baseball players. cage sa*, peebles rl†‡, volpi jd†‡, trail le*†, warner bj§: the university of texas at tyler, †ut health east texas, ‡university of texas health science center at tyler, §grand canyon university introduction: cupping therapy is a therapeutic modality that uses negative pressures to achieve therapeutic benefits. various published studies report that cupping therapy decreases pain, increases range of motion, and improves blood flow. previous studies also report an effect on tissue tenderness. however, there do not appear to be any studies assessing the effects of cupping therapy on touch pressure threshold, which measures skin sensitivity. changes in touch pressure threshold may provide more information on the neurological effect cupping therapy has on treated tissues. the purpose of this study was to compare the effects of cupping therapy on touch pressure threshold with a control condition in collegiate baseball players. methods: we recruited and consented ten apparently healthy college baseball players (21.50 ± 1.18 yrs, 185.93 ± 6.21 cm, 89.16 ± 7.23 kg). subjects received treatment on the left side of their lower back while the right side of their lower back served as the control and received no treatment. touch pressure threshold, in grams of force measured by semmes-weinstein monofilaments, was the primary outcome measure. measurements were taken three times on the left side followed by three times on the right. the treatment site was prepared by applying coconut oil to the skin. one plastic pneumatic cup was applied to the left side, placed 5-cm lateral to the spinous process of the l4 vertebra. two pumps of air were withdrawn from the cup, and the cup was left in place for 20 minutes. following removal of the cup, touch pressure thresholds were taken for both sides again. a paired samples t-test was performed to determine if cupping therapy had a significant effect on touch pressure threshold, and an independent samples t-test was performed to determine differences in changes between the treatment site and control site, with significance set at p < .05. results: within group measures for touch pressure threshold produced significant increases post cupping therapy treatment (3.06 ± 0.50 to 3.73 ± 0.58 , p < .01). when compared with the control, cupping therapy resulted in a significant increase in touch pressure threshold (f(1,19)=10.902, p < .01). clinical application: cupping therapy applied for 20 minutes to the lower back appears to increase touch pressure threshold. this suggests that cupping therapy may influence cutaneous sensory nerves, in addition to the previously reported effects on treated tissues. further studies should be conducted to confirm the effect of cupping therapy touch pressure threshold. clinicians should use discretion when selecting a therapeutic modality if attempting to increase skin sensitivity. abstract presentation 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 acute management of an abdominal cavity perforation in a collegiate baseball pitcher: a case report. gallegos dm*†, jacobsen ap†‡, galbraith rm†‡, peebles rl†‡, warner bj§, cage sa*: *the university of texas at tyler, †ut health east texas, ‡university of texas health science center, §grand canyon university background: a 21-year-old male collegiate baseball player was performing warm up exercises when he tripped backwards onto one of the team’s pitching machines that had been laid on its side. upon falling backward, the patient sustained a puncture wound through the left buttock from one of the machine’s handles. unaware of the injury, the patient’s teammates lifted him off of the machine and retrieved the athletic trainer. evaluation revealed a deep wound with visible adipose tissue and musculature. at this time, the patient was immediately transported to the emergency department of the local hospital, and team physicians were informed to alert the hospital of the patient’s impending arrival. differential diagnosis: puncture wound of the left buttock, abdominal organ injury, anal laceration. treatment: upon arrival at the hospital the patient was admitted for evaluation. initial inspection of the wound revealed the anal sphincter was intact. a ct scan was ordered due to the possibility of perforation of the abdominal cavity. the ct scan revealed that the handle of the pitching machine had perforated the patient’s abdominal cavity to a depth of 14 cm. the handle traveled through the sciatic notch of the pelvis, anterior to the bowel and posterior to the bladder. during the penetration and subsequent removal, the handle did not come in contact with any blood vessels or nerves. while the ct scan showed evidence of the handle making contact with the bladder, the bladder was intact. the wound was then flushed and debrided, and closed with eight sutures. the patient was administered intravenous antibiotics while in the hospital. after performing a bowel movement and urinating, the patient was discharged the same day of admittance with a prescription for oral amoxicillin and hydrocodone. two days following the injury, the patient was evaluated by the team physician in clinic. evaluation found the wound to be healing well with no signs of infection. the team physician and athletic trainer reiterated the need to monitor for signs of infection, and reinforced the need to report any blood with bowel movements or urination. seven days post injury, the patient was re-evaluated by the trauma surgeon who had treated him in the hospital. the wound was continuing to heal well, and the patient was instructed to return at 14 days for suture removal. after the sutures were removed, the patient was allowed to begin progressing into light physical activity consisting of resistance band training and light throwing. 28 days post injury, the patient returned to full team activities, including full intensity practice and weight lifting. throughout the healing process, the patient experienced constipation no complications in the form of infection or issues with urination. uniqueness: the nature in which the patient was injured does not fit with a typical mechanism of injury found in sport. additionally, given the location of the injury the lack of neurovascular or organ damage is noteworthy. lastly, the patient did not require pelvic floor therapy to return to activity even though the handle of the pitching machine damaged the muscle wall of the abdomen. conclusions: when caring for an acute traumatic injury, timely and appropriate referral is paramount to ensuring optimal patient outcomes. emergency action plans should incorporate a chain of communication that includes the team physician in order to make sure that proper healthcare professionals are informed prior to the arrival of a patient. evaluation and reevaluation of healing injuries is critical to ensuring timely referral to therapy specialists if needed. abstract presentation 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 the impact of bracing on kinesiophobia and recovery in acl reconstruction patients: a case study valdecanas n*†, neelon k*, braunreiter k*†: *houston methodist sugar land orthopedics & sports medicine sugar land, tx, †fbisd stephen f. austin high school richmond, tx introduction: with 100,000 to 200,000 cases reported in the u.s. yearly, the anterior cruciate ligament (acl) is a commonly torn structure in the knee among contact and non-contact sports. as medical research on acl injuries grows, acl reconstruction (aclr) continues to be the preferred surgical intervention. due to extensive rehabilitation timeline requirements, aclr patients may face physical and psychosocial circumstances affecting their overall recovery. at any point in rehabilitation the patient may experience kinesiophobia, or an irrational fear relating to further injury from participation in physical movement, especially with return to running, jumping, and sports-specific programs. functional bracing has been an option for intervention to decrease fears of buckling and instability. however, they are argued to foster reliance, creating muscle atrophy and decreased knee extension velocity. as best evidence based practice develops on aclr patients and effective interventions, functional bracing is currently challenged as an assistance or hindrance to overall recovery. patient information: athlete is a 16-year-old softball catcher who underwent isolated bone patellar tendon bone acl reconstruction in june 2022. she not only experienced the physical complications of recovery, but also faced ongoing psychosocial factors from early to late stages of her rehabilitation. from fears of engaging in physical activity without her brace to the financial burdens of the equipment, the athlete poses a significant case regarding bracing use and kinesiophobia levels. interventions: post-surgery, the athlete was taken through a standard rehabilitation protocol focusing initially on extension mobilization and quadriceps activation with progressions. she received clearance from her physician to run and jump at 4 months and to begin softball-specific activity at 6 months. her physician instructed her to use the functional brace for running, jumping, and softball activity during the first season of play. at months 4, 6, and 10, the athlete completed hop testing and aclrsi measurements to track her progress in return to sport. to gradually prepare the athlete for softball catching, a deep knee flexion squat was also used to gauge her symptoms and abilities with therapeutic interventions. outcomes: while the athlete successfully returned to sport for softball hitting and as first baseman after 6-7 months, she continued to report psychosocial uncertainties that affected her performance. at 4 months, her baseline acl-rsi was 44.2%. with each re-evaluation, this score slowly progressed to 64.2% at 6 months and 82.5% at 10 months. additionally, her overall hop test outcome that allowed return to sport at 6 months was 91.6%. however, this score was achieved with her brace. the athletic trainer noted the athlete’s kinesiophobia with non-braced activity, so she was slowly weaned from functional brace outside of softball participation. at 10 months, hop testing was performed again without her brace with an overall score of 80%. clinical bottom line: functional bracing usage has been highly debated in acl reconstruction patients. while clinical practice has shifted away from using them, some clinicians and patients may prefer to use them in reintroduction of sports activity. although functional braces have shown to be disadvantageous in patient’s progressive tissue loading, comfortability, finances, and self-efficacy with long-term use, it is appreciable to consider the proprioceptive effects the external support may give patients with higher kinesiophobia levels when reintroducing running, jumping, and other sports activity. in doing so, the patients may address psychological hesitancies and build confidence in physical movements. however, it is crucial that if a functional brace is incorporated into therapeutic intervention, the rehabilitation team must work to wean the patient out of the brace to aid appropriate strength, neuromuscular control, and self-confidence in his or her abilities apart from the brace. use of blood flow restriction training with a collegiate baseball player following hook of the hamate excision abstract presentation 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 goza jp*, galbraith rm†‡, jacobsen ap†‡, warner bj§, cage sa?: *collin college, †ut health east texas, ‡university of texas health science center, §grand canyon university, ?the university of texas at tyler background: a 21-year-old male collegiate baseball player underwent successful excision of the hook of hamate of the left hand. following two weeks in a padded splint to allow for appropriate scar healing, the patient’s sutures were removed and rehabilitation was initiated. initial rehabilitation consisted of passive range of motion exercises progressing to active range of motion exercises. after one week of range of motion exercises and improvement of range of motion, resistance training with blood flow restriction was initiated. differential diagnosis: hook of the hamate excision. treatment: week 3: prior to beginning resistance training with blood flow restriction, grip strength was assessed using a handheld dynamometer. the average of the patient’s three trials for his surgery hand was 60.6 pounds. the average for the non-surgery hand was 145.8 pounds. the average resistance exercised consisted of theraputty gripping, resisted pronation and supination, and resisted wrist flexion and extension. all exercises were performed with 50% blood flow restriction for one set of 30 repetitions followed by three sets of 15 repetitions with 30 second breaks between repetitions and 60 second breaks between exercises. exercises were performed five days during the week. week 4: the average of the patient’s grip strength trials for his surgery hand was 82.4 pounds, and 144.5 pounds for his non-surgery hand. level of resistance for exercises was increased to tolerance with sets, repetitions and frequency remaining the same. week 5: the average of the patient’s grip strength trials for his surgery hand was 121.4 pounds, and 145.6 pounds for his non-surgery hand. level of resistance for exercises was increased again, and the patient began sport specific activities including hitting and catching. given the increase in sport specific activity, resistance training frequency was decreased to three times during the week. week 6: the average of the patient’s grip strength trials for his surgery hand was 130.8 pounds, and 145.2 pounds for his non-surgery hand. the patient returned to full participation in team activities, with a plan to continue therapeutic exercises three times a week. uniqueness: while the patient’s return to play following hamate excision was consistent with current literature, recent data has suggested that patients undergoing hook of the hamate excision experience a reduction in grip strength post-surgery. in this case, the patient improved his grip strength by 115.8% within four weeks of splint and suture removal. this case provides an example of a successful therapeutic exercise protocol for increasing grip strength using blood flow restriction following hook of the hamate excision. conclusions: when developing a therapeutic exercise protocol for a patient after injury or surgery, it is important to explore all possible options to ensure optimal patient outcomes. as this report describes only one hook of the hamate excision patient’s outcomes following therapeutic exercise with blood flow restriction, larger scale studies are necessary to provide more generalizable recommendations. abstract presentation 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 hook of the hamate fracture in a collegiate baseball player preceded by a hamate stress fracture parker hn*†, galbraith rm†‡, jacobsen ap†‡, hodges c†, warner bj§, cage sa*: *the university of texas at tyler, †ut health east texas, ‡university of texas health science center, §grand canyon university background: a 21-year-old male collegiate baseball player reported to the athletic training staff complaining of pain along the hypothenar eminence of the left hand. the patient’s pain was intensified when swinging a bat but remained constant even at rest. the patient reported symptoms beginning approximately three weeks prior to being evaluated by the athletic training staff, but delaying reporting symptoms in order to continue playing. physical exam revealed tenderness over the hook of the hamate and hypothenar eminence, decreased active wrist extension, decreased grip strength, and pain with resisted pronation and supination. at this time, the patient was removed from activities involving gripping or putting axial force on the wrist and referred to the team physicians. differential diagnosis: hook of the hamate fracture, triangular fibrocartilage complex injury, wrist flexor tendinopathy. treatment: day 2: initial exam by the team physician furthered the suspicion that the patient may have experienced a hook of the hamate fracture. x-rays were ordered for further evaluation, including a carpal tunnel view to evaluate the hook of the hamate. x-rays did not reveal a fracture, leading to the physician placing the patient in a volar wrist brace for two-weeks based on the tentative diagnosis of a hook of the hamate stress reaction. day 16: upon discontinuing the volar wrist brace, the patient attempted to return to activities, but experienced a similar magnitude of symptoms. at this time, the decision was made to obtain an mri to evaluate the patient’s hand further. day 18: upon receiving the results of the patient’s mri, it was determined that the patient had suffered a hook of the hamate fracture. the mri also revealed that the patient was suffering from a stress fracture of the hamate bone. the patient was then referred to an orthopedic hand surgeon for consultation. due to the nature of the patient’s health insurance, he was forced to return to his home state for his consultation. day 28: upon physical exam and review of the mri findings, the orthopedic surgeon suspected the patient had been predisposed to the hook of the hamate fracture due to the stress fracture in the hamate. the patient was consented for surgery, with the goal of excising the fractured portion of the hamate. day 29: the patient underwent successful surgery to excise the fractured portion of the hook of the hamate, and was discharged with instructions to follow up with the athletic training staff and team physician upon returning to his institution. uniqueness: the nature in which the patient was injured is typical of hook of the hamate fractures in baseball players. however, the presence of a stress fracture of the body of the hamate bone is an uncommon predisposition to a hook of the hamate fracture. stress fractures of the body of the hamate are not well described in the literature, making it an unlikely consideration when forming a differential diagnosis. furthermore, the patient’s health insurance status made timely diagnosis and treatment difficult. conclusions: when caring for a traumatic injury, early diagnosis is often critical to optimal patient outcomes. in the event a clinician is caring for a patient with restrictive health insurance, patient education on the potential ramifications of maintaining such an insurance plan is crucial. should a patient with a restrictive insurance plan suffer an injury warranting advanced diagnostic testing and therapeutics, clinicians must work to expedite access to care as quickly as possible. abstract presentation 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 twelfth rib avulsion fracture in a collegiate baseball pitcher: a case report. warner lk*, jacobsen ap†‡, galbraith rm†‡, hodges c†, warner bj§, cage sa?: *creighton university, †ut health east texas, ‡university of texas health science center, §grand canyon university, ?the university of texas at tyler background: a 21-year-old male collegiate baseball player reported to the athletic training staff after experiencing acute pain in his left side following throwing a pitch. the patient experienced immediate difficulty with active lateral flexion and trunk rotation. palpation revealed spasm and tenderness along the internal and external oblique muscle. the patient reported having subluxed a rib on a previous occasion. while the pain experienced was similar, the patient stated that there was more pain along the muscle bellies of the internal and external oblique muscles compared to the previous injury. no difficulties with breathing, bowel movements, or urination were reported. differential diagnosis: oblique strain, subluxated rib, intercostal cartilage irritation. treatment: at the time of the initial evaluation, the patient was diagnosed with a strained oblique. the patient was instructed to avoid vigorous physical activity, throwing, deep stretching, and any other painful activities until symptoms began to improve. the patient began a rehabilitation program centered around core and hip strengthening. treatment was initiated using cupping therapy and electrical stimulation following a week of relative rest and rehabilitation, the patient reported no improvement in pain or range of motion. at this time, the patient was referred to the team physician for diagnostic ultrasound. musculoskeletal ultrasound revealed edema consistent with a highgrade external oblique strain. given the amount of edema the patient had, the physician opted to postpone an mri until edema had begun to resolve. ten days after the previous evaluation, the patient was seen again in clinic to be consented for an mri. a second musculoskeletal ultrasound was performed, revealing a cortical disruption at the 12th rib. given the new finding, the physician ordered a ct scan for further evaluation. the ct scan confirmed an avulsion fracture of the distal aspect of the 12th rib as a result of the previous oblique strain. these findings provided context for the patient’s delay in decreased symptoms and healing. the patient continued relative rest and combined with treatment and rehabilitation for the following four weeks, at which point the fracture was confirmed to have healed. at this time, the patient began a return to throwing protocol, and was able to return to full activity with no complications. uniqueness: while avulsion fractures of the ribs have been previously reported in athletic populations, there appear to be no documented cases of an avulsion of the 12th rib. additionally, previous documented injuries have primarily involved the serratus anterior avulsing seventh through ninth ribs. conclusions: when providing care, clinicians must consider all patient reported signs and symptoms. in the event that a patient’s symptoms do not follow an anticipated progression, clinicians should use all available resources to obtain a diagnosis. evaluation and re-evaluation of patient progress is critical to ensure optimal outcomes following injury. abstract presentation 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 slowing it down: the impact of a core stabilization program of hypermobile sprinters spears, t* †, gonzalez-pons j †, debose j †: *houston methodist sugarland orthopedics & sports medicine sugarland, tx, † fort bend george bush high school richmond, tx background: low back pain (lbp) is a common complaint in sprinters, and it can present itself in many ways. one study published in 2019 surveyed 2539 runners; 22.6% of them reported lbp of some kind at least once within that year.5 lbp can occur in sprinters for many reasons. one study noted that muscle weakness, imbalance, and improper recruitment of hip and/or core musculature are a few sources of lbp in athletes.4 the aim of this study is to examine the effectiveness of a core stabilization program on athletes suffering from lumbar facet hypermobility. differential diagnosis: conditions that are typically prevalent in sprinters include but are not limited to: hypomobility, hypermobility, disc herniations, and spondylosis. treatment: lumbar hypermobility was the final diagnosis based on the patient’s presentation and characteristics. for the plan of care, stabilization exercises while incorporating sport-specific activities, manual therapy and patient education were initiated. evidence suggests that this program along with proper manual therapy techniques should begin to improve the patient’s symptoms over time.2 the manual therapy techniques included and were l3 segment gapping maneuver, paraspinal stripping, and a psoas release. manual therapy was to continue as needed throughout the patients’ rehab. uniqueness: patient is a 17-year-old male, 200-meter sprinter who showed up in the athletic training room with complaints of lbp that began after doing squats in the weight room at 165 lbs the previous day. patient complained of unilateral pain (7/10) left lower back that had gotten worse after sitting in class all day and reported being unable to participate in sprinting/jumping activities. patient demonstrated reproduction of symptoms with end range extension, left posterior quadrant test, palpation of l4 segment, and with prolonged static postures. he also showed hinge point at l4 with back extension and positive aberrant motion which leads to a high probability of having lumbar hypermobility. conclusion: following 5 treatment sessions over 10 days, the patient returned to his usual sport-like activities. upon discharge, the patient was pain-free with daily activities as well as with range of motion. this patient was instructed to continue with his home exercise program and was actively monitored for the following 2 weeks to ensure no relapses or setbacks to occur after treatment sessions concluded. this case demonstrated the positive effects of a core stabilization program, coupled with a manual therapy approach on sprinters who are suffering from a hypermobility issue of the lumbar spine. the patient was issued a personalized rehabilitation protocol that was followed carefully for two weeks, this program allowed us to see major improvements. the patient was able to recognize symptoms early enough for us to start making quick progress, and consistency allowed us to maintain progression over time. abstract presentation 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 the diagnosis, rehabilitation, and treatment of posterior impingement in a high school baseball pitcher tisdale k*†, *houston methodist orthopedics and sports medicine at the farm league spring, tx, †tomball high school tomball, tx introduction: posterior impingement, also known as internal impingement, is a type of secondary impingement that is caused by overuse and repetitive movements of the shoulder overhead during motions such as throwing, spiking, etc. a combination of shoulder abduction and external rotation produces impingement of the infraspinatus and/or of the supraspinatus against the posterior-superior glenoid. posterior impingement is common in overhead athletes, and this mechanism is usually seen during the cocking phase of throwing. someone suffering from posterior impingement may complain of posterior shoulder pain, posterior stiffness and decline in performance. patient information: in this case study, a 15year-old male high school baseball pitcher seeks medical help after dealing with posterior shoulder pain, elbow pain, and tingling in his elbow to 4th and 5th fingers for 3 weeks. the athlete complained of feeling weak while throwing. he states that does not recall doing anything specific to his shoulder, such as falling on it or subluxing/dislocating it. the pain is the highest during throwing and after throwing but eventually would cease as he rested. the symptoms he is experiencing are not isolated just from pitching but arise when throwing any ball. he also has pain from reaching overhead to grab things from shelves or stretching with his hands overhead. differential diagnoses include posterior impingement, slap tear, rotator cuff tendonitis, ucl tear, and cervical radiculopathy. these diagnoses have similar signs and symptoms, so the objective examination was important in determining the diagnosis. cervical radiculopathy was tested to rule in or out the paresthesia symptoms he was experiencing. posterior impingement was ruled in through location of pain and when he was getting pain. additionally, i tested multiple tests for the same condition to aid in ruling. intervention: the athlete was removed from participation to prevent further damage to structures and decrease pain and tingling symptoms. rehabilitation focused on shoulder stability, rotator cuff strength, serratus anterior strength, and proper scapulohumeral rhythm and throwing mechanics. posterior mobilizations, scapular framing, and scapular upward rotation mobilizations were utilized before exercises to help decrease pain and improve shoulder and scapular joint mobility, and soft tissue massages were done on the biceps, upper traps, forearm, rhomboids, and lats to help release tension. return to play protocol is broken up into phases. phase 1 is general stabilization and strengthening, phase ii is advanced stabilization and strengthening, phase iii is plyometrics, and phase iv is sport specific activities (return to throw). the athlete progressed through the program based off location of pain, type of pain, and change in symptoms. the throwing motion was also utilized to gauge progress. the goal for the athlete was to be able to return to strength and conditioning camp in 6 weeks. outcomes: the patient made progress through his program. he was re-tested on mmts for ir, er, flexion, and protraction, specifically the serratus anterior. he reported no pain through the first two weeks with any of the exercises. general muscles soreness is expected as he continued to increase strength gains. he has not been cleared to participate at this time, and he is currently continuing in phase ii. clinical bottom line: this case report demonstrates how posterior impingement goes beyond the shoulder musculature and glenohumeral joint. there are many impairments that can arise due to the impingement. muscle imbalances and improper scapulohumeral rhythm are expected in overhead athletes. one may note scapular dyskinesis as a sign of muscle imbalances often presented with posterior impingement. the current research harps on evaluation of the glenohumeral joint, scapulohumeral joint, and humeroulnar joint, including the cervical spine, and how to rule in and out their involvement. abstract presentation 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 a case study on treatment of subcoracoid impingement in an overhead athlete with manual therapy mennell m†, *, †: *houston methodist willowbook orthopedics & sports medicine spring, tx, †tomball memorial high school tomball, tx introduction: subcoracoid impingement of the shoulder is a condition that occurs when the tendons or soft tissues in the shoulder are compressed or pinched between the coracoid process and the humeral head. it is also suspected that subcoracoid impingement can occur when the humerus translates anteriorly, decreasing the subcoracoid space. this impingement can cause pain, inflammation, and limited mobility in the shoulder joint. all kinds of impingement are typically multifactorial, and have several areas that need to be addressed. the purpose of this case report is to examine the effects of therapeutic exercise as well as manual therapy on subcoracoid impingement in an overhead athlete. patient information: patient is a 16year-old third baseman who began seeking treatment for increased shoulder pain toward the end of a baseball game. patient reported sharp pain in the anterior aspect of his shoulder when throwing during the cocking phase. he reported pain during warm ups that gradually got worse throughout the game when throwing, and was unable to continue by the bottom of the 5th inning. he reports no neurological symptoms such as numbness or tingling. he reports no history of shoulder pain. differential diagnoses included subcoracoid impingement or rotator cuff strain. rotator cuff strain was ruled out as the rotator cuff muscles were strong and not painful, but subscapularis manual muscle testing was weak and painful along with positive impingement tests such as hawkins-kennedy test, o’brians test, and bear hug test. interventions: treatment options for subcoracoid impingement may include rest, physical therapy, anti-inflammatory medications, and in severe cases, surgery. the treatment for this patient included manual techniques along with therapeutic exercise over the course of about 6 weeks, followed by a return to throwing progression. manual techniques included soft tissue mobilization of the pecs as well as a poster glide of the shoulder. following manual therapy the patient would stretch internal and external rotation, and then complete a series of exercises targeting the subscapularis as well as overall rotator cuff strength. outcomes: once the patient was pain free and internal and external range of motion was normalized, he was cleared to begin a return to throwing progression with his coach. patient felt strength and range of motion improved and reported being ready to return to play. following the completion of the throwing progression the patient will be cleared to return to play as tolerated. patient discussed and agreed to continuing a maintenance program to be done 2-3 times a week either in the athletic training room or at home to maintain the strength needed to play baseball. clinical bottom line: overall this case met expectations of implementing a good posterior cuff strengthening therapeutic exercise plan along with introducing manual therapy to address subcoracoid impingement in an overhead athlete. based on the positive results of this treatment for this athlete, who had no shoulder injury prior, it would be interesting to see if introducing a posterior cuff strengthening program to overhead athletes as a warm up would prevent similar injuries in the future. abstract presentation 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 a case report of the evaluation and management of low back pain in a high school basketball player leveston, k*†, neelon k*, ephran e †: *houston methodist sugar land orthopedics and sports medicine sugar land, tx, †fort bend l.v. hightower high school missouri city, tx background: low back pain can be a tough injury to endure, especially in the growing high school athlete.3 lbp in a high school athlete can be caused by various factors, such as structural deformities, mobility deficits, and so much more. the majority of lbp in adolescents is nonspecific lbp, which is defined as lbp that does not cause systemic or structural changes.5 nonspecific lbp is often a result of other etiologies such as hypermobile or hypomobile segments of the spine, hip mobility deficits, gait, sleeping positions, or improper weightlifting form. differential diagnoses: other possible diagnoses of lbp in adolescents could be spondylolysis, spondylolisthesis, slipped vertebral apophysis, or fractures of the thoracolumbar spine.1 high school athletes who are diagnosed with hypermobilty of the lumbar spine can be treated conservatively by being prescribed stability exercises and manual techniques. treatment: a 17year-old male basketball player came to the athletic training room complaining of left lower back pain of 3 weeks. he reported pain with prolonged sitting, pain while getting dressed, and pain while lifting weights. the patient reported feeling this same type of pain during previous basketball seasons as well. the athlete did not seek treatment for his low back pain in the previous seasons as he reported it was intermittent. during examination, it was discovered that the patient had limited lumbar range of motion in left side bending and left rotation at end range. the patient also had an upslip of the left innominate and the left quadratus lumborum had increased muscle tone. a combination of manual techniques and strengthening of the hip and lower back muscles were used to improve the patient’s pain and stabilize the patient’s hypermobility at l4-l5. 6 after completing 12 rehab sessions over 4 weeks, the athlete was able to perform at his maximal level with no pain. the athlete’s asterisk signs, a squat and full court sprints, had significantly improved and no longer caused the athlete any pain. uniqueness: the athlete presented with lbp that was a result of a hyper mobile l4-l5 segment. the athlete’s age and activity levels were large factors in the athlete’s diagnoses. the athlete responded well to stability exercises, as well as manual techniques performed by the clinician. conclusion: this case shows that a combination of manual therapy and stabilization exercises are best to manage non-specific lbp.6 the patient responded well to attending rehab 3 times a week for 4 weeks and was able to perform at his maximum level with no pain. abstract presentation 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 low ferritin count in female collegiate soccer player presents as concussion nelson en*, pitcock td†, knoblauch mk*, harrison lj*: *university of houston, houston, tx, †rice university, houston, tx background: women’s soccer leads the national collegiate athletic association for having the highest number of concussions in female sports. common symptoms of concussion can include light headedness, headaches, and dizziness, but these symptoms are not exclusive to concussions. female athletes may experience nutritional deficits that can lead to a wide range of symptoms mimicking those commonly experienced with a concussion such as headaches, dizziness, and fatigue. the patient in this case is a 21year-old female soccer athlete who presented with sensitivity to light, light headedness, nausea, and fatigue after experiencing repeated ‘headers’ as well as a collision during a match. upon evaluation, she reported a long-standing history of hyperhidrosis, eating disorders, and migraines. the athletic trainer evaluated the patient for a concussion, but all results were within normal limits. as a precaution, the patient was removed from play and any further activity pending evaluation from the team physician. two days later, the patient was seen by the team physician who also ruled out a concussion and was cleared to return to play. nine days after the initial injury, the patient collided with an opponent while participating in a match. during halftime the patient complained of feeling ‘off’ but assumed it was due to dehydration. the athletic trainer treated the patient with water, a salt tablet, and electrolytes which relieved symptoms prior to the start of the second half of the competition. two minutes into the second half of the match the patient was removed from play due to dizziness, lightheadedness, headache, and nausea. the team physician referred the patient to the team’s concussion specialist. differential diagnosis: initial suspicions were centered around a concussion due to the collision sustained nine days prior. treatment: after examination, the concussion specialist ordered bloodwork. the blood panel revealed a low ferritin count, a protein responsible for iron storage. based on her blood panel, it was determined the low ferritin count secondary to hyperhidrosis was contributing to headaches, nausea, lightheadedness, and dizziness. the physician prescribed ferrous sulfate tablets to treat low levels of iron. the physician also recommended meetings with both the athletic trainer and registered dietitian for neck strengthening and meal planning. the registered dietician provided several food adjustments to incorporate higher levels of iron into the diet such as adding more leafy greens, proteins, and potatoes. she also advised the patient to keep a daily food and symptom log. the athlete was allowed to fully participate but was instructed to check in with the athletic trainer before and after any physical activity. after following the recommendations, the patient noted an immediate decrease in the severity and frequency of symptoms. she completed the season without any further incidents. uniqueness: nutritional deficits in female athletes are often missed due to high hormone intricacy and the lack of research on women. in this case symptoms caused by a low ferritin count mimicked those of a concussion. conclusion: the patient presented with a mechanism and symptoms that align with a concussion diagnosis. after ruling out a concussion, bloodwork confirmed a nutritional deficit which commonly presents with symptoms similar to a concussion. after changing her diet, the patient was able to resolve her symptoms. by collaborating with experts such as registered dieticians, athletic trainers can further their knowledge in the unique components of food and how important of a role it plays abstract presentation 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 athletic trainers in physician practice society free communications abstract presentations the following abstracts were accepted and presented at the 6th athletic trainers in the physician practice society annual conference in 2023. figure-8-reconstruction of posterior sternoclavicular joint dislocation 18 days post initial injury suri m, bunemann s: ochsner sports medicine institute, new orleans, la introduction: traumatic sternoclavicular joint injuries account for less than 3% of all traumatic joint injuries1. although rare, posterior dislocation of the sternoclavicular joint has the potential to be life-threatening due to the proximity of vital structures posterior to the manubrium. this injury typically requires a high-energy force applied through the joint2. sc dislocations become increasingly difficult to reduce after 24 hours, so timely diagnosis and treatment are important. glass et al. found mediastinal compression occurred 30% of the time with posterior dislocations. if left untreated, prolonged pressure on the superior mediastinum can cause erosion of the great vessels, tracheoesophageal fistula, brachial plexopathy and thoracic outlet syndrome1. an open reduction is indicated once a closed reduction has failed. case presentation: 74-yearold, caucasian male, who had a possible syncopal episode and fell onto a metal table from ground level sustaining a left posterior sternoclavicular dislocation. he was initially seen at the er at the region’s level 1 trauma center on 8/5/2022. his chief complaint was left clavicle pain with 10/10 pain on vas. xray were negative for left clavicle fracture and patient was released with a sling. he was referred from his primary care provider to a local orthopedist, who ordered a ct scan which showed a posterior sternoclavicular joint dislocation with the sternal end of clavicle imbedded in mediastinum. thirteen days post-injury closed reduction was attempted by an orthopedic trauma team at a local trauma hospital. follow up imaging showed persistent posterior dislocation. due to failed closed reduction. subsequently, an open reduction of the sternoclavicular joint was indicated. eighteen days post-injury, the patient underwent an open reduction of the left sternoclavicular joint with figure-of-8 reconstruction utilizing a semitendinosus allograft. a cardiovascular consult was obtained to assist with retro-manubrium dissection. a successful reconstruction of the sternoclavicular joint was achieved without adverse incident. discussion: this case illustrates the importance of accurate diagnosis and prompt treatment. posterior dislocations accompanied with symptoms of mediastinal compression can achieve satisfactory results with both closed and open procedures if the dislocation is reduced as close to the time of injury as possible. clinical practice recommendations: symptoms of mediastinal compression accompanied posterior dislocations 30% of the time although patients still achieve excellent to good results regardless in the choice of treatment. for patients treated by open reduction, the failure of an initial closed reduction resulted in the in functional outcomes no worse than for patients treated without an attempted closed reduction. based on the low number of reported open reduction cases in the literature, tenodesis, suture fixation and orif have the largest proportion of excellent/good results without frequently associated high-risk complications. k wire and pin fixation is associated with dangerous complications including wire and pin migration or breakage. abstract presentation 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 second victim syndrome and organizational support for healthcare providers: a scoping review petryszyn kr*, young jp*, neil er‡, benedict je†, eberman le*: *indiana state university, terre haute, indiana; ‡ temple university, philadelphia, pa; †henry ford health system, jackson, mi introduction: healthcare providers may experience critical incident, medical error, or other adverse patient events in their clinical practice. those that do encounter such events, may experience second victim syndrome (svs), a condition in which providers feel psychological, cognitive, or physical reactions rendering care in these instances. those with svs may experience symptoms such as anxiety, depression, or burnout. organizational support may mediate the impacts of svs after an adverse patient event. we conducted a scoping review to explore and synthesize the literature on the support strategies implemented by healthcare organizations in the united states, for healthcare providers, after adverse patient events. methods: the initial search strategy yielded 244 articles, 84 of which were removed for duplication. the 3-person review team completed title and abstract screening, reference screening, and full-text review, reaching 2-person consensus for article inclusion at each phase. to be included in analysis, studies had to have taken place in the united states, and had to include real or perceived outcomes of organizational support strategies for healthcare providers related to adverse patient events. during title and abstract screening, 144 articles did not meet inclusion criteria. the references of the remaining articles (n = 16) were screened and 6 articles were added to the review pool. twenty-two articles were included in the full text analysis, during which 16 articles were removed for not meeting the inclusion criteria. six articles were included in the final extraction and analysis. results: the studies included in the final analysis, assessed svs and organizational support across a variety of healthcare work settings and professions, using several strategies, both quantitative and qualitative, to measure provider experiences. the second victim experience and support tool (svest) (n = 2/6, 33.3%) and the medically induced trauma support services staff support survey (n = 2/6, 33.3%) were the most commonly used tools to measure svs experiences. our findings indicate that healthcare providers believe organizational support after adverse patient events was or would be beneficial for minimizing svs. despite the perception of its value, the frequency of perceived organizational support given to healthcare providers differed across studies, ranging from 43 – 94% of the participants believing they received some form of support. our findings also demonstrated a discrepancy in the types of support strategies healthcare providers preferred or desired after an adverse event, as the level of agreement differed between sampled populations. conclusion: healthcare providers believe support from their organization is important after experiencing an adverse patient event, but support strategies may not be universal. certain support strategies may be contextual, with potentially different preferences for support based on organization or profession. organizations should establish provider support systems for adverse events, but first need to assess provider preferences to implement the strategies most desired. that being said, little is known about the effectiveness of the discussed organizational support strategies, outside of their perceived value. athletic trainers in physician practice are situated among a variety of healthcare providers, all of whom are susceptible to svs. as organizations develop their support systems, they should consider the interprofessional nature of their staffs to aid in collective support following a crucial incident. abstract presentation 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 the impact of video-assisted education on knowledge and retention compared to paper education material nance km, drescher mj, eberman le, rivera mj: indiana state university, terre haute, in context: when educating patients, clinicians must be effective to assure patients understand their treatment plan and abide by such to achieve optimal outcomes. teaching methods that stimulate more than one sense more positively impact learning outcomes. the purpose of this study is to compare paper and video-assisted education at the point-of-care with the aim of changing patient education and local practice in a system for individuals undergoing total hip arthroplasties (thas). methods: we used a randomized cohort design to explore patient knowledge and retention and educational method at the point-of-care. we compared the current education method (paper) to video-assisted materials using pre and post-education surveys. both surveys included three demographic questions and a 10-item survey that covered the protocol for tha pre and post-operative care. the post-education survey included an additional three items regarding how often they referred to the material, perceived effectiveness, and accessibility. these questions were ranked on a likert scale (1 = strongly disagree to 5 = strongly agree) for perceived effectiveness and accessibility, and (1 = never to 5 = very often) for frequency of material referencing. the protocol items were graded on correctness, receiving one point for each correct answer or a zero an incorrect answer with a maximum score of 10. the tool was content validated by physicians in the clinic to ensure questions were accurate and aligned with the patient population. pre and post-surveys were collected approximately 1 month apart. patients were randomly assigned to their education group. in total, 12 participants (age = 70+11 years) were included in the analysis, 6 received paper education, and 6 video-assisted. the majority of patients identified as men (58%, n = 7), and achieved an annual salary of $35,100+26,163. demographic data and preand post-education surveys were analyzed using descriptive statistics. a wilcoxson signed rank test was used to compare pre and post-knowledge scores and education group. chi-squared analysis was calculated to determine the correlation of frequency of access, effectiveness, and accessibility and education group. results: the average preand post-survey scores were 7+1/10 and 7+1/10, respectively. there no significant difference between education group and post-survey scores (p > 0.05). there were no significant correlations between education group and frequency of use (p =.39), perceived effectiveness (p = .29), and accessibility (p =.55). conclusions: there was no differences in knowledge and retention between education materials. however, beyond the similar knowledge and retention scores, video-assisted material was found to be more accessible. due to this finding, the paper education material will be revised to assure patients are able to access these as well, as they are just as effective at sharing and retaining patient knowledge. other healthcare facilities should consider exploring various modes of education to determine which is most preferred and accessible to their patient population. abstract presentation 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 6 – issue 3s – january 2024 clinical athletic trainers decrease orthopedic physician clinical burden barloon, a. atc bcs-o, meadows, k. atc, pennuto, a, atc bcs-o, petrachaianan, k., glass, n., hogue, m., md: university of iowa hospitals and clinics, iowa city, iowa introduction/context: more than half of physicians in the united states are reporting symptoms of burnout. these symptoms lead to increased risk to patient safety and overall physician health. the use of certified athletic trainers (atcs) is increasing in popularity, especially in orthopedic clinics. atcs in the clinical setting have been shown to allow physicians to focus on patient care and less on clerical and documentation tasks. the goal of this study is to assess if atcs in the physician practice setting influence physician work-life integration, burnout, and work engagement. methods/intervention: approval obtained by irb at university of iowa. an observational, nonrandomized study with data collected from physicians at two time points, 6 months apart. this information included: overall quality of life question, two item burnout survey, work-life balance scale, and physician job satisfaction survey. in addition to data collected from physicians, monthly epic ™ signal data was collected and blinded by a research team member. each provider was divided by use of atc or no atc in clinic. these two groups were compared using independent, two-sample t-tests. analyses were performed using rstudio statistical software. results: clinics with atcs have decreased order contribution for providers as well as decreased portion of notes authored by provider. the average “in basket” time is significantly lower with atcs. additionally, providers who utilize atcs have significantly less time working in epic™ outside of clinical hours per person than those who do not. no significant difference was found between atc and no-atc groups in physician work-life balance, job satisfaction, or overall quality of life at time of initial survey and 6-month survey. there was noted to be decreased work engagement scores for those who use atcs. discussion: the use of atcs in physician practice is increasing in popularity with studies demonstrating decreased provider need for clerical and documentation tasks and increased time for providers to focus on patient care. it demonstrated lower amounts of time spent in epic ™ outside of clinical hours for those providers who utilize an atc. in addition to time outside clinical hours, our study found providers have decreased order input and documentation proportions with atcs. our study did not show any statistically significant differences in physician work-life balance, job satisfaction, or overall quality of life with use of atc or no atcs. clinical bottom line: in this study, the use of atcs in the orthopedic clinical setting demonstrated decreased amounts of time spent in emr software outside of clinical hours, decreased order input for physicians, and decreased documentation burden for physicians. manuscript type clinician expertise commentary 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors hollie walusz, ma, atc *; eric sauers, phd, atc, fnata†; mark laursen, ms, atc *; forrest pecha, ms, atc‡ *boston university, boston, ma; †a.t. still university, meza, az; ‡steamboat orthopaedic and spine institute, steamboat spring, co content focus vitality of the profession, health professions education correspondence 235 n billerica rd, tewksbury, ma 01876 e-mail: hjwalusz@bu.edu reference walusz h, sauers e, larsen m, pecha f. the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors. clin pract athl train. 2024;7(2): 5-11. https://doi.org/10.31622/2024/0007.02.2. author characteristics hollie walusz currently serves as a head athletic trainer for boston university and has served as the residency program director since 2016. she has been a preceptor for professional programs, faculty in a baccalaureate program and professional program, is affiliate faculty in a dat program, affiliate faculty in a neurology fellowship program, and is core faculty and program director for a commission on accreditation of athletic training education (caate)-accredited orthopedic residency program. she has seen the impact of the at milestones first-hand across all levels of at education as well as use for professional growth. hollie speaks nationally regarding the use of the at milestones in athletic training. additionally, hollie speaks nationally regarding residency and fellowship training as a catalyst to advance the profession. she serves as the chair of the residency and fellowship council for the caate and was previously the chair of the residency and fellowship standards committee for the caate. dr. eric l. sauers is a tenured full professor and dean of the college for healthy communities at a. t. still university in santa maria, california. he served the caate for 11 years in numerous roles, including as president, vice president, and commissioner. dr. sauers has published numerous peer-reviewed scientific articles and given numerous state, regional, national, and international presentations related to his research and scholarship. mark laursen currently serves as the residency and fellowship director for the caate and as an adjunct clinical associate professor at boston university. from 2008 until 2022, mark served boston university as the director of athletic training services and as a clinical associate professor in boston university's sargent college of health and rehabilitation sciences. forrest pecha serves as the clinical outreach director at steamboat orthopaedic and spine institute in steamboat springs, colorado, and medical coordinator for steamboat springs winter sports club. previously, he was the program director for the athletic training residency at both st. luke's sports medicine in boise, id and at emory sports medicine in atlanta, ga. forrest has served the profession through the caate, boc, and nata for over 20 years. he was one of the founders of athletic trainers in the physician practice society (atpps), past president of the atpps board of directors, and past commissioner for the caate. commentary background the development of the athletic training milestones (at milestones) ©1 (appendix 1) began as an effort to enhance and facilitate the assessment of learners in athletic training residency programs. however, during the development process, it became apparent that they could have much greater utility for the profession if they were developed to assess progressive clinical behaviors of learners, throughout the continuum of learning, from professional-level training through specialist and subspecialist training. the at milestones were developed to facilitate the observation and assessment of clinical behaviors across the six general core competencies adapted from the accreditation council for graduate medical education (acgme)2,3 and the https://doi.org/10.31622/2024/0007.02.2 the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 eight specialty areas identified by the commission on accreditation of athletic training education (caate).4 the authors designed the at milestones based closely upon the acgme milestones to provide a mechanism to allow mentors, peers, and other healthcare providers to assess an individual’s clinical behavior in one, more, or all of the competency areas. to date, the authors have completed the at milestones for all six acgme core competencies and five of the eight specialty areas. the specialty areas were developed in collaboration with clinicians who have specialty content expertise in one or more of the respective specialty areas. development the at milestones levels of progression were derived from the dreyfus model of skill acquisition. the dreyfus model is a five-stage model of skill acquisition frequently cited in the healthcare education literature that plots one’s progression through a series of five levels: novice, advanced beginner, competent, proficient, and expert.5 specifically, the model suggests that learners progress from rigid adherence to rules and procedures (novice) to a largely intuitive mode of operation that relies heavily on deep, implicit knowledge (expert). the acgme recommends this model for curriculum planning for residency training programs.6 the at milestones have adopted the institute of medicine criteria for quality care, which involves delivering safe, timely, effective, efficient, equitable, and patient-centered care (steep).7 the authors utilized the theoretical framework outlined by dreyfus and the acgme general competencies model, in which specific milestones have been developed for all medical specialties. in completing this work, the authors looked specifically at milestones from family medicine, internal medicine, physical medicine and rehabilitation, orthopaedic surgery, emergency medicine, and both orthopaedic sports and sports medicine specialties to develop and adapt specific milestone narratives for athletic training practice.8-14 this framework, in combination with the vision towards competency-based education (cbe) in medicine and competency-based developmental outcomes, led to the completion of the at milestones. cbe is a fundamentally flexible and outcome-centric educational framework that removes time-based constraints and focuses on the learner.15,16 cbe is an innovative advance in higher education that organizes content or delivery according to competencies, what a learner knows and can manage, and allows one to use experiences, skills, and knowledge to complete the training needed to pursue their goals.13 cbe in medical education, was an approach to designed to prepare physicians for practice that is fundamentally oriented to graduate outcome abilities and organized around competencies derived from an analysis of societal and patient needs.16 the at milestones expand on these efforts to identify and achieve outcomes for teaching and learning in athletic training. competency-based assessment is formative, aiming to monitor how one is learning, thinking, and applying knowledge.15 it is important to remember that competence is not fixed, and anyone can move forward or slide backward on the continuum based on how intentional the learner is in integrating the competencies into practice. one intentional addition to the at milestones was the inclusion of ‘critical deficiencies.’ not all medical specialties include this anchor in their milestones, but internal medicine does, and the authors considered their inclusion important for communicating to a learner what behaviors may negatively impact patient safety or represent unacceptable practice.17 perhaps one of the most valuable and unique features of the at milestones, compared to those developed in medicine and other healthcare professions, is the inclusion of milestones (observed behaviors) consistent with an early learner (levels 1 and 2), someone ready for unsupervised practice (level 3), someone who has completed specialty training (level 4), and aspirational behaviors emblematic of a clinical expert (level 5), which should represent the continuum of an athletic trainer’s career (table 1). significant time was spent the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 discussing what observed patient care behaviors were necessary for someone to complete a professional program and practice athletic training unsupervised (level 3). similarly, significant time was spent discussing the progression from generalist to specialist and how those behaviors should change with additional education and training (level 4). these discussions were not based on formal documents such as the caate standards or the boc practice analysis, but rather on the author's significant combined expertise in athletic training, healthcare, and education to represent a ‘preferred state.’ instead, they are independent of other prescribed expectations and seek to articulate a shared vision for highly competent athletic training practice to which we hope all educators and clinicians aspire. each competency and sub-competency, along with every milestone at every one of the five levels, is subject to scrutiny. over time, we hope that researchers and clinical specialists in each area may debate and challenge the assumptions within the at milestones and they will be iteratively enhanced through ongoing analysis. implementation formative and summative assessment alongside clear and constructive feedback are essential to a learner’s growth and development. traditional exams and checklists often miss the integral behaviors and assessment of skills encompassed within a comprehensive competency-based tool. kak, et al. found that written tests are probably the furthest from, and the weakest predictor of, actual job performance, whereas job samples are among the best predictors of job performance in healthcare.18 job samples, with periodic appraisals by supervisors, peers, and self, require both observation and evaluation and are used to infer competence.18 the goal of a formative assessment is to monitor learning and provide feedback that can be used to improve performance. studies have shown that programs that deeply invest in training, simulation, supervision, and frequent feedback may result in a marked shortening of training.19,20 the at milestones can be used in this manner via multiple established time points throughout a program and, subsequently, the clinical performance across the span of the clinician’s education or training, encompassing the entire continuum of learning. in our own use, we have found more meaningful assessments and subsequent debriefing sessions open a dialogue for forward progression and opportunities for the individual user. through the programmatic quality improvement process, feedback from faculty and learners alike have denoted the at milestones improve in the quality of formative feedback, establish transparent criteria that limits bias or confusion in scores because of established benchmarks, and provide a more accurate way to capture the totality of the learner’s transfer of knowledge, skills, and abilities to patient care and working within a healthcare system. in our experience, the at milestones have offered the faculty and learners easily identifiable criteria and thresholds for a given score, allowing for consistency of grading amongst users, and allows the program to tailor teaching and learning to the needs of each learner. leach described the treatment of the patient as an art, denoting the importance of finding harmony between biomedical knowledge, technology, and a patient-facing approach to healthcare to improve patient care.21 the at milestones allow for the assessment of clinical behaviors in an ongoing and consistent basis and allow for the development of individualized learner plans with specific examples of what one does well and areas of opportunity for growth as it relates to patient care across a broad spectrum of healthcare competencies. it is essential to use a summative assessment mechanism to evaluate learning so the program can feel confident that the learner has met the threshold expectation for the type of program they are progressing through (professional, residency, fellowship, doctoral) or for the time and space they are in relative to continuing professional development. by tying together foundational knowledge both scientifically and in the practice of athletic training, the at milestones allow for evaluation of one’s ability to apply all they have learned to the patient, quantify readiness to practice, and ultimately produce highly competent/proficient clinicians to meet the healthcare needs of the public. in addition, the capacity of the at milestones to facilitate the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 this summative assessment in athletic training education further implicates their use in both professional and post-professional athletic training education. we have also found that the at milestones can be used as a summative evaluation, providing both the learner and the program (or other relevant parties) clarity in expectations upon program completion. additionally, evidence supports the tool as having excellent content validity for the general competency milestones, indicating the at milestones can be used to assess an athletic trainer’s or athletic training student’s progression of independent knowledge, skill, and behavior acquisition.22 when implementing the at milestones, consideration should be given to how to best analyze, synthesize, and deliver information garnered from the tool in addition to training on how to use the tool, frequency of use, and selection of individuals performing the assessment. in physician education, milestones are typically used every 3-6 months,2,3 so it is important to use the tool in conjunction with other measures to supplement multisource feedback. the orthopedic residency and neurology fellowship programs at boston university use the tool in multiple ways across four time points. it first serves as a training tool on expectations of foundational core competencies and specialty competencies within the residency and fellowship programs upon hire. it is then used for self-assessment as a mode of exposure to and training of the tool early in the program for formative discussions. this is followed by self-assessment, peer assessment, and clinical faculty assessment at both mid-experience (for formative feedback) and end of the experience as a summative assessment tool. the final element is to determine who is doing the assessment. it is important to develop a clinical competency committee (ccc) made up of those who mentor and observe the learner’s practice and behaviors in a clinical capacity on an ongoing and consistent basis.23 depending on the size of the learner groups being assessed, the literature suggests the ccc be a minimum of 3 individuals, but ideally made up of 5 to 7 people.23 the role of the members of the ccc is to create accountability that graduates will provide safe, high-quality care to patients and maintain the standards of the healthcare system. value detailed and immediate feedback to healthcare providers about their competence helps them learn and improve performance.18 the primary authors of the at milestones believe that they are a valuable tool to assess and provide feedback about progressive clinical behaviors to ensure competence at graduation from a professional program and upon completion of specialty or subspecialty training. regardless of where an individual is within their professional development, the at milestones provide explicit examples of clinical competence at increasing levels, including aspirational milestones, for every competency area. in this way, the authors have also found that the at milestones are useful to practicing athletic trainers for self-assessment and reflection on one’s growth and continued professional development. the at milestones have been found to have content validity22 and serve as a feasible assessment24 across a broad spectrum of education. the at milestones have also recently been used to assess didactic components of a doctor of athletic training (dat) program, for learning activities such as quality improvement projects and case presentations. there is also preliminary evidence of the use of the at milestones in professional education.24 future work examining the value of the at milestones in different types of programs and for various purposes is warranted. however, a significant benefit of the at milestones is that they are based on the same theoretical model as the medical milestones, which have a rich and growing research base to support their use.25 perhaps more importantly, the at milestones serve as a reflective tool that can help capture where the athletic trainer has started and identify their current depth and breadth of knowledge, skills, attitudes, and behaviors in each of the respective competencies and sub-competencies. in this sense, the tool can subsequently provide a map of what the learner needs to continue to grow and develop in a particular the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 area. the narrative descriptors within each performance level outline a framework of observable behaviors and other attributes required to build individualized professional growth plans. these narratives can help guide planning and continuing development along the continuum and progression of learning throughout one’s career. multiple studies cite the importance of self-reflection,26-28 so using that in conjunction with valid feedback is a sound approach to building a plan for continued professional growth and to amplify learning. by providing a tool for assessing progress and defining global athletic training competencies within the healthcare system, we believe that educators can be aided in producing competent and proficient clinicians who can better treat the public and subsequently advance the athletic training profession. we, as clinical educators, should all strive to be lifelong learners who are able to ensure we, too, are continually developing our clinical expertise. the at milestones provide added value to the profession in the form of a valid instrument to assess competence and growth both within athletic training education and across the continuum of professional practice, ultimately advancing and promoting growth and change in the profession. references 1. athletic training milestones project. at milestones website. https://www.atmilestones.com. 2018 © 2. accreditation council for graduate medical education. milestones resources. https://www.acgme.org/milestones/resources 3. accreditation council for graduate medical education. the milestones guidebook. https://www.acgme.org/globalassets/milestonesguidebook.pdf 4. caate approved residency specialty areas. caate website. https://caate.net/programs/residencyfellowship 5. dreyfus and dreyfus. a five-stage model of the mental activities involved in directed skill acquisition. unpublished report, university of california, berkely, 1980. 6. batalden p, leach d, swing s, dreyfus h, dreyfus s. general competencies and accreditation in graduate medical education. health aff. 2002;21(5):103-111. doi:10.1377/hlthaff.21.5.103 7. six domains of healthcare quality. agency for healthcare research and quality. https://www.ahrq.gov/talkingquality/measures/six-domains.html 8. accreditation council for graduate medical education. milestones resources. family medicine milestones. https://www.acgme.org/globalassets/pdfs/milestones/familymedicinemilestones.pdf 9. accreditation council for graduate medical education. milestones resources. internal medicine milestones. https://www.acgme.org/globalassets/pdfs/milestones/internalmedicinemilestones.pdf 10. accreditation council for graduate medical education. milestones resources. orthopaedic sports medicine milestones. https://www.acgme.org/globalassets/pdfs/milestones/orthopaedicsportsmedicinemilestones.pdf 11. accreditation council for graduate medical education. milestones resources. sports medicine milestones. https://www.acgme.org/globalassets/pdfs/milestones/sportsmedicinemilestones.pdf 12. accreditation council for graduate medical education. milestones resources. physical medicine and rehabilitation milestones. https://www.acgme.org/globalassets/pdfs/milestones/pmrmilestones.pdf 13. accreditation council for graduate medical education. milestones resources. emergency medicine milestones. https://www.acgme.org/globalassets/pdfs/milestones/emergencymedicinemilestones.pdf 14. accreditation council for graduate medical education. milestones resources. orthopaedic surgery milestones. https://www.acgme.org/globalassets/pdfs/milestones/orthopaedicsurgerymilestones.pdf https://www.atmilestones.com/ https://www.acgme.org/milestones/resources https://www.acgme.org/globalassets/milestonesguidebook.pdf https://caate.net/programs/residency-fellowship https://caate.net/programs/residency-fellowship https://www.ahrq.gov/talkingquality/measures/six-domains.html https://www.acgme.org/globalassets/pdfs/milestones/familymedicinemilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/internalmedicinemilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/orthopaedicsportsmedicinemilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/sportsmedicinemilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/pmrmilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/emergencymedicinemilestones.pdf https://www.acgme.org/globalassets/pdfs/milestones/orthopaedicsurgerymilestones.pdf the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 15. mace kl, bacon cew. the future of health professions education: considerations for competencybased education in athletic training. athl train educ j. 2019;14(3):215-222. doi:10.4085/1403215 16. frank jr, mungroo r, ahmad y, wang m, de rossi s, horsley t. toward a definition of competencybased education in medicine: a systematic review of published definitions. med teach. 2010;32(8):631-637. doi:10.3109/0142159x.2010.500898 17. kinnear b, bensman r, held j, o’toole j, schauer d, warm e. critical deficiency ratings in milestone assessment: a review and case study. acad med. 2017;92(6):820. doi:10.1097/acm.0000000000001383 18. kak n, burkhalter b, cooper ma. measuring the competence of healthcare providers. oper res issue pap. 2001;2(1):1-28. 19. ten cate o, hart d, ankel f, et al. entrustment decision making in clinical training. acad med. 2016;91(2):191. doi:10.1097/acm.0000000000001044 20. ten cate o. a primer on entrustable professional activities. korean j med educ. 2018;30(1):1-10. doi:10.3946/kjme.2018.76 21. leach dc. changing education to improve patient care. postgrad med j. 2008;84(994):437-441. doi:10.1136/qhc.100054 22. welch bacon ce, anderson be, cavallario jm, van lunen bl, eberman le. content validation of the athletic training milestones: a report from the association for athletic training education research network. j athl train. 2023;58(5):483-487. doi:10.4085/1062-6050-0332.22 23. accreditation council for graduate medical education. clinical competency committee guidebook. https://www.acgme.org/globalassets/acgmeclinicalcompetencycommitteeguidebook.pdf 24. welch bacon ce, anderson be, cavallario jm, van lunen bl, eberman le. perceptions and use of the athletic training milestones in education: a report from the aate research network. clin pract athl train. 2024;7(2): 11-26. https://doi.org/10.31622/2024/0007.02.3. 25. accreditation council for graduate medical education. research and reports. https://www.acgme.org/milestones/research/ 26. koshy k, limb c, gundogan b, whitehurst k, jafree dj. reflective practice in health care and how to reflect effectively. ijs oncol. 2017;2(6):e20. doi:10.1097/ij9.0000000000000020 27. winkel af, yingling s, jones aa, nicholson j. reflection as a learning tool in graduate medical education: a systematic review. j grad med educ. 2017;9(4):430-439. doi:10.4300/jgme-d-1600500.1 28. carraccio c, englander r, gilhooly j, et al. building a framework of entrustable professional activities, supported by competencies and milestones, to bridge the educational continuum. acad med. 2017;92(3):324. doi:10.1097/acm.0000000000001141 29. carraccio cl, benson bj, nixon lj, derstine pl. from the educational bench to the clinical bedside: translating the dreyfus developmental model to the learning of clinical skills. acad med. 2008;83(8):761. doi:10.1097/acm.0b013e31817eb632 30. meier ah, gruessner a, cooney rn. using the acgme milestones for resident self-evaluation and faculty engagement. j surg educ. 2016;73(6):e150-e157. doi:10.1016/j.jsurg.2016.09.001 31. nodine t r. how did we get here? a brief history of competency-based higher education in the united states. j competency-based educ. 2016;1(1):5-11. doi:10.1002/cbe2.1004 32. park ys, zar fa, norcini jj, tekian a. competency evaluations in the next accreditation system: contributing to guidelines and implications. teach learn med. 2016;28(2):135-145. doi:10.1080/10401334.2016.1146607 https://www.acgme.org/globalassets/acgmeclinicalcompetencycommitteeguidebook.pdf https://doi.org/10.31622/2024/0007.02.3 the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 33. potts jr. assessment of competence: the accreditation council for graduate medical education/residency review committee perspective. surg clin. 2016;96(1):15-24. doi:10.1016/j.suc.2015.08.008 the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors appendix 1: athletic training milestones template. the diagram below presents the standardized structure for each competency, sub-competency, and milestone with interpretations for each of the six levels of performance. in addition, each sub-competency is cross-referenced back to a specific acgme sub-competency in parentheses after the sub-competency is stated. for each assessment period (defined by the end-user), an individual’s performance on the milestones for each sub-competency will be indicated by: • selecting the level of milestones that best describes the individual’s performance in relation to the milestones or, • selecting the “critical deficiencies” option general competency (e.g., medical knowledge): sub-competency stated (reference to corresponding acgme milestone) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) behaviors are not within the spectrum of developing competence significant deficiency in learner performance what are the expectations for a beginning learner? what are the milestones for a learner who has advanced beyond beginner, but is not performing at a level sufficient for unsupervised practice? what should the learner be able to do well at this point in their training? what does a graduate of a professional program look like? what additional knowledge, skills, and attitudes have they obtained? are they ready for boc certification? what does a graduating resident look like? what additional knowledge, skills, and attitudes have they obtained? are they ready for specialty certification? what does clinical expertise look like? what are stretch goals to encourage continued progression towards mastery? ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: selecting a response box in the middle of a level implies that milestones in that level and in lower levels have been substantially demonstrated. selecting a response box on the line in between levels indicates that milestones in lower levels have been substantially demonstrated as well as some milestones in the higher level(s). the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. table 2: athletic training milestones. general competencies: patient-care and procedural skills athletic trainers must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. patient-care and procedural skills (pc-1): patient-centered care: responds to each patient’s unique characteristics, needs, and goals. (internal medicine prof-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 aspirational is insensitive to differences related to culture, ethnicity, gender identify, race, age, and religion in the patient/caregiver encounter is unwilling to modify care plan to account for a patient’s unique characteristics, needs, and goals is sensitive to and has basic awareness of differences related to culture, ethnicity, gender identify, race, age, and religion in the patient/caregiver encounter requires assistance to modify care plan to account for a patient’s unique characteristics, needs, and goals seeks to fully understand each patients unique characteristics, needs and goals based upon culture, ethnicity, gender identify, religion, and personal preference modifies care plan to account for a patient’s unique characteristics, needs, and goals with partial success recognizes and accounts for the unique characteristics and needs of the patient/caregiver appropriately modifies care plan to account for patient’s unique characteristics, needs, and goals role models professional interactions to negotiate differences related to a patient’s unique characteristics or needs role models consistent respect for patient’s unique characteristics, needs, and goals develops best practice guidelines for professional interactions to negotiate differences related to a patient’s unique characteristics, needs, and goals develops organizational policies and education to support respect for patient’s unique characteristics, needs, and goals ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient-care and procedural skills (pc-2): patient-centered care: demonstrates humanism and cultural competency. (family medicine prof-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 aspirational fails to demonstrate appropriate compassion, respect, and empathy has difficulty recognizing the impact of culture on health and health behaviors exhibits resistance to improving cultural competence consistently demonstrates compassion, respect, and empathy recognizes impact of culture on health and health behaviors displays a consistent attitude and behavior that conveys acceptance of diverse individuals and groups, including diversity in gender, age, culture, race, religion, disabilities, sexual orientation, and gender identity elicits cultural factors from patients and families that impact health and health behaviors in the context of the biopsychosocial model identifies own cultural framework that may impact patient interactions and decision-making incorporates patients’ beliefs, values, and cultural practices in patient care plans identifies health inequities and social determinants of health and their impact on individual and family health anticipates and develops a shared understanding of needs and desires with patients and families; works in partnership to meet those needs demonstrates leadership in cultural competence, understanding of health disparities, and social determinants of health advocates for the rights of vulnerable patients / patient populations recognizes and addresses lack of patientcenteredness in colleagues/peers develops organizational policies and education to support the application of these principles in the practice of athletic training generates and disseminates new knowledge in humanism and cultural competence ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient-care and procedural skills (pc-3): diagnosis and management: gathers and synthesizes essential and accurate information to define each patient’s clinical problem(s). (internal medicine pc-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) does not collect accurate historical data does not use physical exam to confirm history relies exclusively on documentation of others to generate own database or differential diagnosis fails to recognize patients’ central clinical problems fails to recognize potentially life threating problems inconsistently able to acquire accurate historical information in an organized fashion does not perform an appropriately thorough physical exam or misses key physical exam findings does not seek or is overly reliant on secondary data inconsistently recognizes patients’ central clinical problem or differential diagnoses consistently acquires accurate and relevant histories from patients seeks and obtains data from secondary sources when needed consistently performs accurate and appropriately thorough physical exams uses collected data to define a patient’s central clinical problem(s) acquires accurate histories from patients in an efficient, prioritized and hypothesisdriven fashion performs accurate physical exams that are targeted to the patient’s complaints synthesizes data to generate a prioritized differential diagnosis and problem list effectively uses history and physical examination skills to minimize the need for further diagnostic testing obtains relevant historical subtleties, including sensitive information that informs the differential diagnosis identifies subtle or unusual physical exam findings efficiently utilizes all sources of secondary data to inform differential diagnosis role models and teaches the effective use of history and physical examination skills to minimize the need for further diagnostic testing publishes clinical case reports on unique clinical problems collaborates in practicebased research efforts to gather, aggregate, and synthesize patient data to enhance diagnostic and management efforts generates and disseminates new knowledge pertaining to diagnoses and management ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient-care and procedural skills (pc-4): diagnosis and management: physical examination (systems-based examination adapted for health condition and contextual factors). (physical medicine and rehabilitation pc-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to perform a thorough physical examination fails to seek feedback or guidance on the accuracy and thoroughness of physical examination performs physical examination procedures that are contraindicated and create increased patient discomfort or risk performs a general physical exam requires prompting to perform a thorough physical examination including all necessary elements (e.g., medical, neurologic) performs a physical exam that assists in functional assessment (e.g., may include balance, gait, cognition, neurologic, or musculoskeletal assessments) performs excessive physical examination using unwarranted techniques begins to identify normal and pathologic findings performs a relevant, accurate comprehensive disorder-specific physical exam modifies exam to accommodate the patient’s impairments and minimize discomfort efficiently performs a hypothesis-driven and targeted physical exam that drives clinical decision making across a spectrum of ages, impairments, and clinical settings efficiently performs a hypothesis-driven and targeted physical exam that drives clinical decision making for complex cases identifies and correctly interprets subtle or atypical physical findings rapidly focuses on the presenting problem and elicits key information from the exam in a prioritized and efficient fashion models and teaches exam skills in complex patients efficiently produces a focused and prioritized physical examination accounting for rare conditions streamlines physical examination for maximal cost effectiveness and minimal patient burden ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient-care and procedural skills (pc-5): diagnosis and management: diagnostic evaluation. (physical medicine and rehabilitation pc-3) this includes: • differential diagnosis of primary and secondary conditions • appropriate studies (e.g., laboratory, imaging, neuropsychological) • functional assessments critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to develop an appropriate list of differential diagnoses uncertain of which diagnostic studies are appropriate for common medical conditions fails to recognize when medical referral is necessary identifies appropriate diagnostic studies for common medical conditions identifies reasonable diagnosis for common medical conditions produces a differential diagnosis for common medical conditions recommends appropriate diagnostic studies for common medical conditions inconsistently interprets diagnostic study results develops a comprehensive differential diagnosis, including less common conditions orders appropriate diagnostic studies for common medical conditions appropriately prioritizes the sequence and urgency of diagnostic testing correctly interprets diagnostic study results and appropriately pursues further testing or specialist input appropriately integrates functional assessment measures into overall evaluation efficiently produces a focused and prioritized differential diagnosis across a spectrum of ages and impairments and for complex conditions orders diagnostic testing based on cost effectiveness and likelihood that results will influence clinical management efficiently produces a focused and prioritized differential diagnosis accounting for rare conditions streamlines testing for maximal cost effectiveness and minimal patient burden ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. comments: patient-care and procedural skills (pc-6): diagnosis and management: develops and implements comprehensive management plan for each patient. (internal medicine pc-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) care plans are consistently inappropriate or inaccurate does not react to situations that require urgent or emergent care does not seek additional guidance when needed inconsistently develops an appropriate care plan inconsistently seeks additional guidance when needed recognizes patients requiring urgent or emergent care seeks additional guidance and/or consultation as appropriate consistently develops and implements appropriate care plan appropriately modifies care plans based on patient’s clinical course, additional data, and patient preferences recognizes patient presentations that deviate from common patterns and require complex decision-making manages complex acute and chronic patients role models and teaches complex and patientcentered care develops customized, prioritized care plans for the most complex patients, incorporating diagnostic uncertainty and cost effectiveness principles serves as a regional consultant for complex patients ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient-care and procedural skills (pc-7): diagnosis and management: manages patients with progressive responsibility and independence. (internal medicine pc-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) cannot advance beyond the need for direct supervision in the delivery of patient care cannot manage patients who require urgent or emergent care does not assume responsibility for patient management decisions requires direct supervision to ensure patient safety and quality care provides inconsistent preventative care inconsistently provides comprehensive care for single or multiple diagnoses requires indirect supervision to ensure safety and quality care provides appropriate preventive care provides comprehensive care for single or multiple diagnoses under supervision, provides appropriate care for medically complex patients initiates management plans for urgent or emergent care independently manages patients who have a broad spectrum of clinical disorders including undifferentiated syndromes seeks additional guidance and/or consultation as appropriate appropriately manages situations requiring urgent or emergent care manages unusual, rare or complex disorders effectively supervises the management decisions of the athletic health care team serves as a preceptor capable of recognizing and assessing milestone achievement in athletic training students and residents recognizes and promotes clinical expertise in peers and implements policy to ensure patients are seen by appropriate members of the team serves as a clinical care leader supervising multiple clinicians in a coordinated, teambased manner contributes to the development and refinement of models of education that promote progressive responsibility and independence ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. patient care and procedural skills the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. this individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. medical knowledge athletic trainers must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological, and socialbehavioral sciences, as well as the application of this knowledge to patient care. medical knowledge (mk-1): demonstrates medical knowledge of sufficient breadth and depth to practice athletic training. (family medicine mk-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to demonstrate the capacity for medical knowledge improvement fails to self-reflect and recognize personal limitations in medical knowledge demonstrates the capacity to improve medical knowledge through targeted study uses the commission on accreditation of athletic training education (caate) curricular content and board of certification (boc) maintenance of competence framework to further guide his or her education demonstrates capacity to assess and act on personal learning needs demonstrates appropriate medical knowledge to care for both individual patients and patient populations recognizes the limitations of their medical knowledge and a willingness to continue to advance their medical knowledge across their career passes the boc examination successfully completes a caate accredited residency program passes a board of athletic training specialties (bats) specialty examination collaborates to produce clinical pathways and engage in practice-based research to inform best practices for patient care demonstrates life-long learning through continual self-assessment and continuing education focused on maintenance of contemporary medical knowledge generates and disseminates new medical knowledge leads the development of clinical pathways for the delivery of high quality, affordable health care coordinates practicebased research to inform best practices for patient care ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. medical knowledge (mk-2): knowledge of diagnostic testing and procedures. (internal medicine mk-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) lacks foundational knowledge to apply diagnostic testing and procedures to patient care chooses inappropriate diagnostic tests or procedures that place the patient at risk or pose a safety hazard uncertain of which diagnostic tests and procedures are appropriate understands which diagnostic tests and procedures to perform, but can not adequately explain why does not understand the concepts of pre-test probability and test performance characteristics inconsistently interprets basic diagnostic test accurately needs assistance to understand the concepts of pre-test probability and test performance characteristics minimally understands the rationale and risks associated with common procedures consistently interprets basic diagnostic tests accurately understands the concepts of pre-test probability and test performance characteristics fully understand the rationale and risks associated with common procedures interprets complex diagnostic tests accurately anticipates and accounts for pitfalls and biases when interpreting diagnostic tests and procedures teaches the rationale and risks associated with common procedures and anticipates potential complications when performing procedures introduces innovation in diagnostic testing and procedures in athletic training pursues knowledge of new and emerging diagnostic tests and procedures ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. medical knowledge (mk-3): basic sciences of athletic training, including biology, chemistry, physics, psychology, anatomy, physiology, statistics, research design, epidemiology, pathophysiology, biomechanics and pathomechanics, exercise physiology, nutrition, pharmacology. (sports medicine mk-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 aspirational lacks appropriate foundational knowledge in the basic sciences knowledge is limited to traditional athletic populations (e.g., college and secondary school aged) without appropriate understanding of anatomy and physiology across the lifespan demonstrates knowledge of the basic sciences of athletic training demonstrates knowledge of anatomy and physiology related to growth, development, and aging demonstrates knowledge of basic sciences applied to athletic training in patients of all ages demonstrates basic science knowledge foundational to prevention, rehabilitation, and management synthesizes scientific knowledge in managing common medical conditions integrates basic and clinical science knowledge of pathophysiology, tissue healing, and treatment interventions in returnto-activity decisions demonstrates knowledge of factors associated with risk of injury, including age, gender, and disability demonstrates both basic science and clinical knowledge of the details of tissue healing and cellular physiology across the lifespan in selecting treatment options synthesizes and applies scientific knowledge in complex medical conditions possesses the scientific, socioeconomic, and behavioral knowledge required to successfully incorporate basic and clinical science to diagnose and treat uncommon, ambiguous, and complex conditions generates and disseminates new basic science knowledge introduces innovation from the basic sciences to advance athletic training possesses the scientific socioeconomic and behavioral knowledge required to successfully incorporate basic and clinical science to diagnose and treat uncommon, ambiguous, and complex conditions ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. medical knowledge the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. practice-based learning and improvement athletic trainers must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. practice-based learning and improvement (pbli-1): evidence-based practice: locates, appraises, and assimilates evidence from scientific studies related to the patients’ health problems. (family medicine pbli-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) unable to locate appropriate evidence related to the patients’ health problems to help direct care unable to categorize and interpret the strength of a research study describes basic concepts in clinical epidemiology, biostatistics, and clinical reasoning categorizes the design of a research study identifies pros and cons of various study designs, associated types of bias, and patient-centered outcomes formulates a searchable question from a clinical question evaluates evidencebased point-of-care resources applies a set of critical appraisal criteria to different types of research, including synopses of original research findings, systematic reviews and meta-analyses, and clinical practice guidelines critically evaluates information from others, including colleagues, experts, and sales representatives, as well as patient-delivered information incorporates principles of evidence-based care and information mastery into clinical practice roles models evidencebased practice and information mastery techniques holds peers accountable to practice in an evidencebased manner identify important clinical questions and information gaps engages in implementation science to support the rapid dissemination and adoption of evidence into clinical practice develops and/or implements evidencebased practice guidelines to improve system performance develops organizational policies and education to support the implementation of evidence-based practice ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. practice-based learning and improvement (pbli-2): quality improvement: improves systems in which the athletic trainer provides care. (family medicine pbli-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to recognize the key steeep (safe, timely, effective, efficient, equitable, patient-centered) elements of quality health care unable to accurately describe the system of care in which they are working unable to identify quality gaps in their own health systems understands the key elements of quality health care (steeep) recognizes the importance of measuring the end results of health care in order to adequately assess health care quality begins to identify potential gaps in quality care recognizes inefficiencies, inequities, variation, and quality gaps in health care delivery identifies potential gaps in quality care and identifies potential contributing factors within the system recognizes the importance of developing quality improvement teams assesses available health care outcomes data to compare their results to expected results within the system uses a systematic improvement method (e.g., plan-do-study act [pdsa] cycle) to address an identified area of improvement compares care provided by self and practice to internal and external standards, identifies areas for improvement, and implements change in their practice. establishes protocols for continuous review and comparison of practice procedures and outcomes and implementing changes to address areas needing improvement uses an organized method, such as a registry, to assess and manage population health performs multi-cycle quality improvement initiatives to improve health care quality role models continuous quality improvement of personal practice, as well as larger health systems or complex projects, using advanced methodologies and skill sets generates and disseminates new knowledge to advance effective strategies for improving systems in which athletic trainers provide care ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. practice-based learning and improvement (pbli-3): quality improvement: learns and improves via performance audit. (internal medicine pbli-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) disregards own clinical performance data demonstrates no inclination to participate in or even consider the results of quality improvement efforts limited awareness of or desire to analyze own clinical performance data nominally participates in a quality improvement projects not familiar with the principles, techniques, or importance of quality improvement analyzes own clinical performance data and identifies opportunities for improvement participates in a quality improvement project understands common principles and techniques of quality improvement and appreciates the responsibility to assess and improve care analyzes own clinical performance data and actively works to improve performance actively engages in quality improvement initiatives demonstrates the ability to apply common principles and techniques of quality improvement to improve care actively monitors clinical performance through various data sources leads quality improvement projects utilizes common principles and techniques of quality improvement to continuously improve care demonstrates professional leadership in promoting performance audits for quality improvement using clinical data monitoring generates and disseminates new knowledge to advance performance audits for quality improvement using clinical data monitoring ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. practice-based learning and improvement (pbli-4): quality improvement: monitors practice with a goal for improvement. (internal medicine pbli-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) unwilling to self-reflect upon one’s practice or performance not concerned with opportunities for learning and selfimprovement inconsistently selfreflects upon one’s practice or performance and inconsistently acts upon those reflections misses opportunities for learning and self improvement regularly self-reflects upon one’s practice or performance and identifies areas to improve practice inconsistently acts upon opportunities for learning and selfimprovement recognizes the value of critical reviews and morbidity and mortality conferences (m and ms) for learning and selfimprovement regularly self-reflects upon one’s practice or performance and maximizes practice improvement recognizes sub-optimal practice or performance as an opportunity for learning and selfimprovement actively engages in critical reviews and morbidity and mortality conferences (m and ms) to support learning and improvement in self and others role models self-reflective practice and monitoring practice improvement holds peers accountable for failures to recognize opportunities for improvement leads critical reviews and morbidity and mortality conferences (m and ms) to support learning and self-improvement in others demonstrates professional leadership regarding self-reflective practice and monitoring practice performance generates and disseminates new knowledge to advance self-reflective practice and monitoring practice performance ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. practice-based learning and improvement the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. interpersonal and communication skills athletic trainers must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. interpersonal and communication skills (ics-1): communicates effectively with patients and caregivers. (internal medicine ics-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) ignores patient preferences for plan of care makes no attempt to engage patient in shared decisionmaking routinely engages in antagonistic or counter-therapeutic relationships with patients and caregivers engages patients in discussions of care plans and respects patient preferences when offered by the patient, but does not actively solicit preferences attempts to develop therapeutic relationships with patients and caregivers but is often unsuccessful defers difficult or ambiguous conversations to others engages patients in shared decision making in uncomplicated conversations requires assistance facilitating discussions in difficult or ambiguous conversations requires guidance or assistance to engage in communication with persons of different socioeconomic and cultural backgrounds identifies and incorporates patient preference in shared decision making across a wide variety of patient care conversations quickly establishes a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds incorporates patientspecific preferences into plan of care role models effective communication and development of therapeutic relationships in both routine and challenging situations models culturally competent communication and establishes therapeutic relationships with persons of diverse socioeconomic backgrounds demonstrates professional leadership in promoting effective communication with patients and caregivers generates and disseminates new knowledge to advance effective communication with patients and caregivers ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. interpersonal and communication skills (ics-2): communicates effectively with patients, families, stakeholders, and the public. (family medicine c-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) demonstrates disrespectful communication with patients, families, stakeholders, or the public fails to recognize physical, cultural, psychological, and social barriers to communication unable to establish rapport and facilitate patient-centered information exchange recognizes that respectful communication is important to quality care identifies physical, cultural, psychological, and social barriers to communication uses the medical interview to establish rapport and facilitate patient-centered information exchange matches modality of communication to patient needs, health literacy, and context organizes information to be shared with patients and families participates in lifealtering discussions and delivery of bad news negotiates a visit agenda with the patient, and uses active and reflective listening to guide the visit educates and counsels patients and families in disease management and health promotion skills engages patients’ perspectives in shared decision making recognizes non-verbal cues and uses nonverbal communication skills in patient encounters effectively communicates difficult information, such as life-altering discussions, delivery of bad news, acknowledgement of errors, and during episodes of crisis role models patientcenteredness and integrates all aspects of patient care to meet patients’ needs role models effective communication with patients, families, stakeholders, and the public engages community partners to educate the public demonstrates professional leadership in promoting effective communication with patients, families, stakeholders, and the public generates and disseminates new knowledge to advance effective communication with patients, families, stakeholders, and the public ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. interpersonal and communication skills (ics-3): communicates effectively in interprofessional teams. (internal medicine ics-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) utilizes communication strategies that hamper collaboration and teamwork verbal and/or nonverbal behaviors disrupt effective collaboration with team members uses unidirectional communication that fails to utilize the wisdom of the team resists offers of collaborative input exhibits defensive behaviors within the health care team inconsistently engages in collaborative communication with appropriate members of the team inconsistently employs verbal, non-verbal, and written communication strategies that facilitate collaborative care consistently and actively engages in collaborative communication with all members of the team verbal, non-verbal, and written communication consistently acts to facilitate collaboration with the team to enhance patient care role models and teaches collaborative communication with the health care team to enhance patient care, even in challenging settings and with conflicting team member options demonstrates professional leadership in promoting effective communication in interprofessional teams generates and disseminates new knowledge to advance effective communication in interprofessional teams ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. interpersonal and communication skills (ics-4): health information technology: appropriate utilization and completion of health records. (internal medicine ics-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) health records are absent or missing significant portions of important clinical data health records are disorganized and inaccurate health records are not completed in a timely manner privacy of health records is not adequately maintained fails to recognize the criticality of appropriate utilization and completion of health records health records are organized and accurate but are superficial and miss key data or fail to communicate clinical reasoning health records are completed in a timely manner privacy of health records is of prime importance health records are organized, accurate, comprehensive, and effectively communicate clinical reasoning health records are succinct, relevant, and patient specific health records are organized and complete from patient intake to discharge, documenting all patient interactions, a thorough history and physical examination, daily treatment notes, referrals, and discharge summary health records capture patient-rated outcomes health records adhere to all state and federal guidelines health records serve as a primary means of data collection and aggregation for the ongoing assessment of quality of care role models and teaches importance of organized, accurate and comprehensive health records that are succinct and patient specific demonstrates professional leadership in promoting the appropriate utilization and completion of health records generates and disseminates new knowledge to advance appropriate utilization and completion of health records ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. interpersonal and communication skills the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. professionalism athletic trainers must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. professionalism (prof-1): completes a process of professionalization. (family medicine prof-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) demonstrates lack of professionalism places personal values ahead of professional values fails to exhibit appropriate honesty, integrity, and respect to patients and team members defines professionalism knows the basic principles of medical ethics recognizes that conflicting personal and professional values exist demonstrates honesty, integrity, and respect to patients and team members recognizes own conflicting personal and professional values knows institutional and governmental regulations for the practice of athletic training recognizes that athletic trainers have an obligation to selfdiscipline and to selfregulate engages in selfinitiated pursuit of excellence embraces the professional responsibilities of being an athletic trainer practices to the full scope of education and training and formal privileging within a health system demonstrates leadership and mentorship in applying shared standards and ethical principles, including the priority of responsiveness to patient needs above self-interest across the health care team develops institutional and organizational strategies to protect and maintain these principles demonstrates professional leadership in promoting professionalism with patients and caregivers generates and disseminates new knowledge to advance effective strategies for instilling professionalization in others ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. professionalism (prof-2): has professional and respectful interactions with patients, caregivers, members of the interprofessional team, and stakeholders. (internal medicine prof-1) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) lacks empathy and compassion for patients and caregivers disrespectful in interactions with patients, caregivers, members of the interprofessional team, and stakeholders sacrifices patient needs in favor of own self-interest blatantly disregards respect for patient privacy and autonomy inconsistently demonstrates empathy, compassion, and respect for patients and caregivers inconsistently demonstrates responsiveness to patients’ and caregivers’ needs in an appropriate fashion inconsistently considers patient privacy and autonomy consistently respectful in interactions with patients, caregivers, and members of the interprofessional team, even in challenging situations is available and responsive to needs and concerns of patients, caregivers, and members of the interprofessional team to ensure safe and effective care emphasizes patient privacy and autonomy in all interactions demonstrates empathy, compassion, and respect to patients and caregivers in all situations anticipates, advocates for, and proactively works to meet the needs of patients and caregivers demonstrates a responsiveness to patient needs that supersedes selfinterest positively acknowledges input of members of the interprofessional team and incorporates that input into plan of care as appropriate role models compassion, empathy, and respect for patients and caregivers role models appropriate anticipation and advocacy for patient and caregiver needs fosters collegiality that promotes a high-functioning interprofessional team teaches others regarding maintaining patient privacy and respecting patient autonomy demonstrates professional leadership in promoting professionalism with patients, caregivers, members of the interprofessional team, and stakeholders generates and disseminates new knowledge to advance effective strategies for professionalism with patients, caregivers, members of the interprofessional team, and stakeholders ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. professionalism (prof-3): demonstrates professional conduct and accountability. (internal medicine prof-2 and family medicine prof-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) is unreliable in completing patient care responsibilities or assigned administrative tasks shuns responsibilities expected of an athletic training professional completes most assigned tasks in a timely manner but may need multiple reminders or other support accepts professional responsibility only when assigned or mandatory documents and reports clinical and administrative information truthfully maintains patient confidentiality attends to responsibilities and completes duties as required identifies appropriate channels to report unprofessional behavior recognizes professionalism lapses in self and others completes assigned professional responsibilities without the need for reminders consistently recognizes limits of knowledge and asks for assistance presents themselves in a respectful and professional manner completes administrative and patient care tasks in a timely manner in accordance with local practice and/or policy reports professionalism lapses using appropriate reporting procedures willingness to assume professional responsibility regardless of the situation or consequences prioritizes multiple competing demands in order to complete tasks and responsibilities in a timely and effective manner role models prioritizing multiple competing demands in order to complete tasks and responsibilities in a timely and effective manner assists others to improve their ability to prioritize multiple, competing tasks negotiates professional lapses of the athletic health care team exhibits self-awareness, self-management, social awareness, and relationship management helps implement organizational policies to sustain athletic training as a profession models professional conduct placing the needs of each patient above self-interest demonstrates the highest degree of professional conduct and accountability that others seek to emulate ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. professionalism (prof-4): exhibits integrity and ethical behavior in professional conduct. (internal medicine prof-4 modified) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) dishonest in clinical interactions, documentation, research, or scholarly activity refuses to be accountable for personal actions does not adhere to basic ethical principles blatantly disregards formal policies or procedures honest in clinical interactions, documentation, research, and scholarly activity. requires oversight for professional actions has a basic understanding of ethical principles, formal policies and procedures, and does not intentionally disregard them demonstrates accountability for the care of patients adheres to ethical principles for documentation, follows formal policies and procedures, acknowledges and limits conflict of interest, and upholds ethical expectations of research and scholarly activity begins to reflect on personal professional conduct honest and forthright in clinical interactions, documentation, research, and scholarly activity demonstrates integrity, honesty, and accountability to patients, society and the profession identifies and responds appropriately to lapses of professional conduct among peer group actively manages challenging ethical dilemmas and conflicts of interest regularly reflects on personal professional conduct assists others in adhering to ethical principles and behaviors including integrity, honesty, and professional responsibility role models integrity, honesty, accountability, and professional conduct in all aspects of professional life demonstrates professional leadership in promoting integrity and ethical behavior in professional conduct generates and disseminates new knowledge to advance integrity and ethical behavior in professional conduct ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. professionalism the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice athletic trainers must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. systems-based practice (sbp-1): patient safety: recognizes system error and advocates for system improvement. (internal medicine spb-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) ignores a risk for error within the system that may impact the care of a patient ignores feedback and is unwilling to change behavior in order to reduce the risk for error does not recognize the potential for system error makes decisions that could lead to error which are otherwise corrected by the system or supervision resistant to feedback about decisions that may lead to error or otherwise cause harm recognizes the potential for error within the system identifies obvious or critical causes of error and notifies supervisor accordingly recognizes the potential risk for error in the immediate system and takes necessary steps to mitigate that risk willing to receive feedback about decisions that may lead to error or otherwise cause harm identifies systemic causes of medical error and navigates them to provide safe patient care activates formal system resources to investigate and mitigate real or potential medical error reflects upon and learns from own critical incidents that may lead to medical error advocates for system leadership to formally engage in quality assurance and quality improvement activities advocates for safe patient care and optimal patient care systems teaches others regarding the importance of recognizing and mitigating system error demonstrates professional leadership in promoting patient safety generates and disseminates new knowledge to advance effective strategies for promoting patient safety viewed as a leader in identifying and advocating for the prevention of medical error ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice (sbp-2): patient safety: emphasizes patient safety. (family medicine spb-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) ignores medical errors fails to understand that medical errors vary widely across settings and between providers ignores the importance of teambased care in ensuring patient safety understands that medical errors affect patient health and safety and that their occurrence varies across settings and between providers understands that effective team-based care plays a role in patient safety recognizes medical errors when they occur, including those that do not have adverse outcomes understands the mechanisms that cause medical errors understands and follows protocols to promote patient safety and prevent medical error participates in effective and safe hand-offs and transitions of care uses current methods of analysis to identify individual and system causes of medical errors common to athletic training develops individual improvement plan and participates in system improvement plans that promote patient safety and prevent medical errors performs effective and safe hand-offs and transitions of care consistently engages in self-directed and practice improvement activities that seek to identify and address medical errors and patient safety in daily practice fosters adherence to patient care protocols amongst team members that enhance patient safety and prevent medical errors leads self-directed and system improvement activities that seek to continuously anticipate, identify, and prevent medical errors to improve patient safety in all practice settings, including the development, use, and promotion of patient care protocols and other tools ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice (sbp-3): cost-effectiveness: identifies forces that impact the cost of health care, and advocates for, and practices cost-effective care. (internal medicine sbp-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) ignores cost issues in the provision of care demonstrates no effort to overcome barriers to costeffective care lacks awareness of external factors (e.g., socio-economic, cultural, literacy, insurance status) that impact the cost of health care and the role that external stakeholders (e.g., providers, suppliers, financers, purchasers) have on the cost of care recognizes the costs associated with the provision of athletic training services, even when they aren’t being billed for / reimbursed recognizes that external factors influence a patient’s utilization of health care and may act as barriers to costeffective care possesses an incomplete understanding of costawareness principles for a population of patients (e.g., screening tests) does not consider limited health care resources regarding diagnostic or therapeutic interventions consistently works to address patient specific barriers to cost-effective care advocates for costconscious utilization of resources incorporates costawareness principles into standard clinical judgments and decisionmaking, including screening tests minimizes costs associated with unnecessary diagnostic and therapeutic tests teaches patients and healthcare team members to recognize and address common barriers to costeffective care and appropriate utilization of resources actively participates in initiatives and care delivery models designed to overcome or mitigate barriers to cost-effective high quality care demonstrates professional leadership in promoting costeffective athletic training services generates and disseminates new knowledge to advance cost-effective athletic training services develops best practice guidelines for the provision of costeffective care develops organizational policies and education to support costeffective care ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice (sbp-4): interprofessional teams: works effectively within an interprofessional team. (internal medicine sbp-1; level 1 from family medicine sbp-4) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) refuses to recognize the contributions of other interprofessional team members frustrates team members with inefficiency and errors disregards need for communication at time of transition does not respond to request of caregivers in other delivery systems understands that quality patient care requires coordination and teamwork, and participates as a respectful and effective team member identifies roles of other team members but does not recognize how/when to utilize them as resources frequently requires reminders from team to complete athletic training responsibilities inefficient transitions of care lead to unnecessary expense or risk to a patient (e.g., duplication of tests, reinjury) understands the roles and responsibilities of all team members but uses them ineffectively participates in team discussions when required but does not actively seek input from other team members communication with future caregivers is present but with lapses in pertinent or timely information understands the roles and responsibilities of and effectively partners with, all members of the team actively engages in team meetings and collaborative decisionmaking proactively communicates with past and future care givers to ensure continuity of care integrates all members of the team into the care of patients, such that each is able to maximize their skills in the care of the patient viewed by other team members as a leader in the delivery of high quality care coordinates care within and across health delivery systems to optimize patient safety, increase efficiency, and ensure high quality patient outcomes anticipates needs of patient, caregivers, and future care providers and takes appropriate steps to address those needs demonstrates professional leadership in promoting safe and effective transitions of care within and across health delivery systems as part an interprofessional team generates and disseminates new knowledge to advance interprofessional teambased care ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice (sbp-5): advocates for individual and community health. (family medicine sbp-3) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) refuses to recognize social context and environmental impact on individual and community health ignores how a community’s public policy decisions affect individual and community health recognizes social context and environment, and how a community’s public policy decisions affect individual and community health recognizes that athletic trainers can impact community health lists ways in which community characteristics and resources affect the health of patients and communities identifies specific community characteristic that impact specific patients’ health understands the process of conducting a community strengths and needs assessment collaborates with other athletic training practices/systems, public health, and communitybased organizations to educate the public, guide policies, and implement and evaluate community initiatives role models active involvement in community education and policy change to improve health of patient and communities demonstrates professional leadership in community education and policy change to improve health of patient and communities generates and disseminates new knowledge in community education and policy change to improve health of patient and communities ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice (sbp-6): health information technology: utilizes technology to optimize communication. (family medicine c-4) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to recognize the effects of technology on information exchange and the athletic trainer/patient relationship ignores the ethical and legal implications of using technology to communicate in health care recognizes effects of technology on information exchange and the athletic trainer/patient relationship recognizes the ethical and legal implications of using technology to communicate in health care ensures that clinical and administrative documentation is timely, complete, and accurate maintains key patientspecific databases, such as problem lists, medications, health maintenance, chronic disease registries effectively and ethically uses technology in a manner which enhances communication and does not interfere with the appropriate interaction with the patient ensures transitions of care are accurately documented, and optimizes communication across systems and continuums of care stays current with technology to improve communication with patients, other providers, and systems uses comprehensive multi-media communication strategies to enhance patient care uses technology to optimize continuity care of patients and transitions of care uses technology to adapt systems for improving communication with patients, other providers, and systems demonstrates professional leadership in utilizing technology to optimize communication generates and disseminates new knowledge in utilizing technology to optimize communication ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. systems-based practice the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. specialty competencies: orthopaedics athletic trainers must demonstrate the ability to conduct an appropriate diagnostic evaluation to define each patient’s clinical problem and to effectively manage increasingly complex patient problems. orthopaedics (ortho-1): diagnostic evaluation: gathers and synthesizes essential and accurate information (history, physical exam, lab work, imaging studies, neuropsychological testing, functional assessment measures, etc.) to define each patient’s clinical problem(s). critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to identify appropriate diagnostic tests fails to accurately identify appropriate differential diagnoses fails to identify deviations from the normal course of orthopaedic conditions perform a relevant patient history performs a basic physical examination recognizes normal movement patterns demonstrates knowledge of common orthopaedic conditions demonstrates both basic science and clinical knowledge of the details of tissue healing and cellular physiology across the lifespan performs a regional orthopaedic exam with appropriate diagnostic selective tissue tests recognize source of abnormal movement patterns and structures applies clinical rules for diagnostics (such as ottawa ankle, canadian c-spine) demonstrates knowledge of factors associated with risk of injury, including, age, gender, and disability accurately and efficiently diagnoses common, noncomplex, orthopaedic conditions recognizes the need for and recommends appropriate plain films/radiographs accurately interprets plain films/radiographs appropriately prioritizes the urgency and sequencing of diagnostic testing utilizes clusters of diagnostic tests and evaluates complex conditions with or without comorbidities and recognizes atypical presentations recognizes appropriate differentials that include nonorthopaedic conditions that present as orthopaedic conditions recommends and interprets advanced orthopaedic imaging, such as msus, mri, and ct educates others to improve their orthopaedic diagnostic evaluation knowledge and skills efficiently produces a focused and prioritized orthopaedic examination accounting for rare conditions serves as a consultant for rare and/or complex orthopaedic patients demonstrates professional leadership in orthopaedic diagnostic evaluation generates and disseminates new knowledge to advance orthopaedic diagnostic evaluation ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. orthopaedics (ortho-2): management: effectively manages patients with increasingly complex orthopaedic conditions. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) inappropriate management places patient at risk care plans are consistently inappropriate or inaccurate fails to refer when appropriate fails to measure the end-results of care fails to inform patient of long-term health consequences participates in patient management being conducted by other appropriately qualified providers demonstrates knowledge of basic care plans for common orthopaedic conditions inconsistently develops an appropriate care plan participates in patient education regarding the nature of their condition and corresponding care plan synthesizes information gathered to guide patient care consistently develops appropriate care plan protects patient from further injury and understands the implications of activity on recovery time performs patient education regarding their condition and corresponding care plan initiates management plans for urgent or emergent care demonstrates knowledge of treatment options of operative and nonoperative management of orthopaedic conditions effectively manages common, non-complex orthopaedic conditions appropriately modifies care plans based on patient’s clinical course, additional data, and patient preferences performs patient education regarding long-term consequences of orthopaedic conditions appropriately applies criteria for safe return to activity and participation appropriately manages situations requiring urgent or emergent care recognizes complications in operative and nonoperative management of orthopaedic conditions effectively manages complex orthopaedic conditions with or without co-morbidities develops customized, prioritized care plans for the most complex patients, incorporating diagnostic uncertainty and cost effectiveness principles patient advocate for maximizing long-term health-related quality of life (hrqol) care plan extends beyond return to safe activity to maximize participation educates others to improve their orthopaedic management knowledge and skills demonstrates knowledge of controversies in operative and nonoperative management of orthopaedic conditions effectively manages rare conditions serves as a consultant for rare and/or complex orthopaedic patients demonstrates professional leadership in orthopaedic management generates and disseminates new knowledge to advance orthopaedic management develops best practice guidelines for developing orthopaedic care plans ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. orthopaedics the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. behavioral health athletic trainers must demonstrate the ability to appropriately assess and recognize each patient’s clinical problem and to effectively manage behavioral health problems. behavioral health (bh-1): assessment and recognition of conditions, that include, but are not limited to, suicidal ideation, depression, anxiety disorder, psychosis, mania, eating disorders, and attention deficit disorders. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to recognize behavioral health concerns in patients fails to recognize an at-risk or in crisis patient fails to intervene on behalf of an at-risk or in crisis patient fails to identify appropriate assessment measures fails to identify deviations from the normal course of behavioral health conditions demonstrates knowledge of common behavioral health conditions performs a relevant patient history identifies common characteristics of at risk or in crisis patients inconsistently seeks additional guidance when needed identifies common behavioral health conditions identifies at risk patients and populations recognizes appropriate behavioral responses to life events recognizes the need to intervene on behalf of an at-risk or in crisis patient seeks additional guidance, consultation and/or referral as appropriate recognizes the need for and recommends appropriate behavioral health assessments demonstrates both basic science and clinical knowledge of behavioral health conditions accurately interprets behavioral health assessments accurately identifies common, non-complex, behavioral health conditions establishes a network of behavioral health professionals recognizes complex conditions with or without co-morbidities, and atypical presentations accurately identifies at-risk populations and is able to intervene early in the process recognizes different presentations, sequelae, and prognoses of behavioral health conditions across the lifespan appropriately prioritizes the urgency and sequencing of behavioral health assessments educates others to improve their behavioral health knowledge and skills serves as a consultant for complex behavioral health patients demonstrates professional leadership in behavioral health generates and disseminates new knowledge to advance behavioral health ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. behavioral health (bh-2): management: effectively manages patients with behavioral health conditions. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to recognize need for referral fails to refer when appropriate inappropriate management places patient at further risk or in crisis activates emergency action plan in a suspected behavioral health crisis participates in patient management being conducted by other appropriately qualified providers adheres to all institutional/facility behavioral health policies demonstrates knowledge of basic care plans for common behavioral health conditions recognizes when referral is needed and when a situation is emergent/non-emergent understands when an individualized behavioral health care team needs to be developed performs patient education regarding behavioral health conditions initiates and recommends appropriate management plans for urgent or emergent care of behavioral health conditions is an active member of the behavioral health care team synthesizes information gathered to guide patient care effectively manages common, non-complex behavioral health conditions communicates with care team and participates in the implementation of the care plan appropriately manages situations requiring urgent or emergent care recognizes common complications in behavioral health conditions able to educate patients and stakeholders of at-risk populations on prevention and long-term consequences of behavioral health conditions develops and implements behavioral health eap and other policies governing behavioral health conditions demonstrates knowledge of the use of psychotropic medications and their interactions and side effects manages day-to-day considerations for behavioral health patients patient advocate for maximizing long-term health-related quality of life (hrqol) educates others to improve their knowledge and skills in managing behavioral health conditions within a patient population, identify individual and group behavioral health needs and develops more advanced behavioral health policies (e.g., team policy, individual contracts) serves as a consultant for management of behavioral health conditions demonstrates professional leadership in management of behavioral health conditions generates and disseminates new knowledge to advance the management of behavioral health conditions develops best practice guidelines for the management of behavioral health conditions ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. behavioral health the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. he/she is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patientcentered care.  _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. pediatrics athletic trainers must demonstrate the ability to conduct an appropriate diagnostic evaluation to define each pediatric patient’s clinical problem and to effectively manage increasingly complex pediatric patient problems. pediatrics (peds-1): diagnostic evaluation: gathers and synthesizes essential and accurate information (history, physical exam, lab work, imaging studies, neuropsychological testing, and functional assessments) to define each pediatric patient’s clinical problem(s). critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to identify conditions unique to the pediatric patient fails to identify appropriate pediatric diagnostic tests fails to accurately identify appropriate differential diagnoses for the pediatric patient fails to identify deviations from the normal course of pediatric conditions perform a relevant patient history including growth and developmental milestones performs a basic physical examination demonstrates knowledge of common pediatric conditions demonstrates clinical knowledge of pediatric growth and development demonstrates knowledge of basic science of tissue healing, cellular physiology, and physis physiology in pediatrics applies clinical rules for diagnostics (such as pediatric ottawa ankle, pecarn head trauma rules, canadian c-spine) demonstrates knowledge of factors associated with risk of injury, including, age, gender, and disability performs a regional pediatric orthopaedic exam with knowledge of the growth plate locations and appropriate diagnostic tests accurately diagnoses common, non-complex, pediatric conditions accurately recommends and interprets appropriate plain films/radiographs, recognizing the importance of comparison views to evaluate physis injury recognizes appropriate pediatric differentials that include asthma, diabetes (type 1 and 2), anaphylaxis, syncope, congenital and acquired heart disease, exercise, dehydration, supplements, and medication side effects appropriately prioritizes the urgency and sequencing of diagnostic testing utilizes clusters of diagnostic tests and evaluates complex conditions with or without comorbidities, and recognizes atypical presentations recognizes appropriate differentials that include nonorthopaedic conditions that present as orthopaedic conditions in the pediatric patient respects cumulative radiation effects in pediatric patients and recommends and interprets advanced pediatric orthopaedic imaging, such as msk us, mri, and ct educates others to improve their pediatric diagnostic evaluation knowledge and skills efficiently produces a focused and prioritized pediatric examination accounting for rare conditions serves as a consultant for rare and/or complex pediatric patients demonstrates professional leadership in pediatric diagnostic evaluation generates and disseminates new knowledge to advance pediatric diagnostic evaluation ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. comments: pediatrics (peds-2): management: effectively manages pediatric patients with increasingly complex conditions. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) inappropriate management places patient at risk care plans are consistently inappropriate or inaccurate fails to refer when appropriate fails to measure the end-results of care fails to inform patient and family/caregiver of long-term health consequences participates in pediatric patient management being conducted by other appropriately qualified providers demonstrates knowledge of basic care plans for common pediatric conditions inconsistently develops an appropriate care plan participates in pediatric patient and family/caregiver education regarding the nature of their condition and corresponding care plan synthesizes information gathered to guide pediatric patient care consistently develops appropriate care plan protects pediatric patient from further injury and understands the implications of activity, overuse injury, and physis injury on recovery time performs pediatric patient and family/caregiver education regarding their condition and corresponding care plan demonstrates knowledge of treatment options of operative and nonoperative management of pediatric conditions effectively manages common, non-complex pediatric conditions appropriately modifies care plans based on patient’s clinical course, additional data, and patient and family/caregiver preferences educates family and patient regarding long-term consequences of pediatric conditions appropriately applies criteria for safe return to activity and participation appropriately manages situations requiring urgent or emergent care recognizes complications in operative and nonoperative management of pediatric conditions educates patient and family regarding medication side effects (prescribed, otc, and supplements). effectively manages complex pediatric conditions with or without co-morbidities such as asthma, allergy, diabetes, heart disease, seizures etc. develops customized, prioritized care plans for the most complex patients, incorporating diagnostic uncertainty and cost effectiveness principles care plan extends beyond return to safe activity to maximize participation and long term health educates others to improve their pediatric patient management knowledge and skills demonstrates knowledge of controversies in operative and non-operative management of pediatric conditions effectively manages rare conditions serves as a consultant for rare and/or complex pediatric patients demonstrates professional leadership in pediatric condition management generates and disseminates new knowledge to advance pediatric condition management develops best practice guidelines for developing pediatric condition care plans the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: pediatrics the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in their education and training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. primary care athletic trainers must demonstrate the ability to conduct an appropriate diagnostic evaluation to define each patient’s clinical problem and to manage increasingly complex primary care problems. primary care (pc-1): diagnostics: medical issues across all systems (e.g., circulatory, pulmonary, nervous, psychologic, digestive, endocrine, musculoskeletal, immune, reproductive, integumentary, lymphatic, urinary). (sports medicine mk-2) critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) failure to understand patients personal healthcare needs (comprehensive medicine) fails to identify knowledge of systems involved based on patient presentation fails to identify deviations from the normal course of systems functioning demonstrates general knowledge of personal healthcare needs across all systems able to identify pertinent information to guide patient care demonstrates knowledge of pathophysiology of common medical conditions identifies appropriate history and symptomatology of common conditions identifies relationships between involved systems in common medical conditions demonstrates knowledge of diagnostic testing to evaluate medical conditions demonstrates both basic science and clinical knowledge of the details of disease process and natural course of illness recognizes the need and selects appropriate diagnostic studies used to evaluate common medical conditions (e.g., ekg, pulmonary function test, laboratory results, phq2, radiographs, vestibular oculomotor motor screen) correctly interprets diagnostic study results and appropriately pursues further testing or specialist input synthesizes knowledge of condition(s) and effect on system(s), and vice versa, to develop differential diagnoses. accurately and efficiently diagnoses common, noncomplex, medical conditions appropriately prioritizes the urgency and sequencing of diagnostic testing recommends and interprets advanced diagnostic studies used to evaluate common and complex medical conditions utilizes clusters of diagnostic tests and evaluates complex conditions with or without comorbidities, and recognizes atypical presentations integrates knowledge of conditions (common and complex), systems, and interactions to arrive at diagnosis educates others to improve their primary care diagnostic evaluation, knowledge, and skills publishes peer-reviewed scientific work related to medical issues possesses the scientific, socioeconomic, and behavioral knowledge required to diagnose and treat uncommon, ambiguous, and complex medical conditions efficiently produces a focused and prioritized general medical examination accounting for rare conditions serves as a consultant for rare and/or complex primary care patients generates and disseminates new knowledge to advance primary care diagnostic evaluation ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. primary care (pc-2): management: effectively manages patients with increasingly complex medical conditions. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) fails to intervene correctly with patients personal healthcare needs inappropriate management places patient at risk care plans are consistently inappropriate or inaccurate fails to refer when appropriate fails to measure the end-results of care fails to inform patient of long-term health consequences participates in patient management being conducted by other appropriately qualified providers demonstrates knowledge of basic care plans for common general medical conditions inconsistently develops an appropriate care plan participates in patient education regarding the nature of their condition and corresponding care plan demonstrates knowledge of the role of medications and substances recognizes the need for urgent care synthesizes information gathered to guide patient care develops appropriate care plans protects patient from further injury and understands the implications of activity on recovery time performs patient education regarding their condition and corresponding care demonstrates knowledge of treatment options of operative and non-operative management of medical conditions identifies common medication and substance use and misuse appropriately manages situations requiring urgent care accurately and efficiently manages patients with common, non-complex, medical conditions identifies and recommends appropriate consultation and/or referral of patients with medical conditions demonstrates knowledge of activity and participation guidelines for common medical conditions appropriately modifies plan of care based on clinical course and individual risk factors recognizes complication in operative and nonoperative management of medical conditions recognizes appropriate medication and substance use for specific conditions and identifies multiple drug interactions implements advanced interventions for situations requiring urgent care effectively manages uncommon and/or complex medical conditions with or without co-morbidities demonstrates knowledge of activity and participation guidelines for complex medical conditions recommends appropriate medication(s) based on clinical course and individual risk factors identifies common signs and symptoms of medication and/or substance abuse educates others to improve their medical management knowledge and skills effectively manages rare medical conditions serves as a consultant for rare and/or complex primary care patients collaborates with other experts to advance medical management demonstrates professional leadership in primary care management generates and disseminates new knowledge to advance primary care management develops best practice guidelines for developing primary care plans ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. comments: primary care the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care.  _____ yes _____ no _____ conditional on improvement rehabilitation athletic trainers must demonstrate the ability to conduct an appropriate assessment to define each patient’s clinical problem and to implement the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. effective rehabilitation strategies for increasingly complex patient problems. rehabilitation (r-1): diagnostic evaluation: gathers and synthesizes essential and accurate information (history, physical exam, lab work, imaging studies, neuropsychological testing, functional assessment measures, etc.) to define each patient’s clinical problem(s). critical deficiencies level 1 level 2 level 3 (ready for unsupervised practices) level 4 (ready for advanced practice) level 5 (aspirational) fails to identify appropriate diagnostic tests fails to accurately identify appropriate differential diagnoses fails to re-assess at appropriate intervals fails to identify deviations from the normal course of care perform a relevant patient history performs a basic physical examination assesses the patient perspective including goals & values recognizes normal movement patterns demonstrates knowledge of body systems and basic pathology demonstrates both basic science and clinical knowledge of tissue healing and cellular physiology across the lifespan identifies precautions and contraindications to rehabilitation assesses patient’s overall health-related quality of life identifies abnormal and adaptive movement patterns recognizes need to reassess based on healing and function demonstrates knowledge of factors associated with risk of injury and disease, including age, gender and disability recognizes the need for and recommends appropriate diagnostic tests (e.g., labs, imaging) accurately interprets diagnostic tests recognizes the impact of specific conditions on the whole person (e.g., psychologic, physiologic) recognize source of abnormal and adaptive movement patterns and structures appropriately prioritizes the urgency and sequencing of diagnostic testing utilizes clusters of diagnostic tests and evaluates complex conditions with or without comorbidities, and recognizes atypical presentations demonstrates ability to analyze abnormal movement patterns and identify causation educates others to improve their rehabilitation diagnostic evaluation knowledge and skills efficiently produces a focused and prioritized rehabilitative examination accounting for rare conditions serves as a consultant for rare and/or complex rehabilitation patients demonstrates professional leadership in rehabilitative diagnostic evaluation generates and disseminates new knowledge to advance rehabilitative diagnostic evaluation ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ comments: the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. rehabilitation (r-2): management: effectively manages the rehabilitation of patients with increasingly complex conditions. critical deficiencies level 1 level 2 level 3 (ready for unsupervised practice) level 4 (ready for advanced practice) level 5 (aspirational) inappropriate management places patient at risk care plans are consistently inappropriate or inaccurate fails to identify appropriate patient progress fails to refer when appropriate fails to measure the end-results of care fails to inform patient of long-term health consequences participates in patient management being conducted by other appropriately qualified providers demonstrates knowledge of basic rehabilitation principles participates in patient education regarding the nature of their condition and corresponding care plan describes basic impairments, activity limitations, and participation restrictions resulting from disease or injury synthesizes information gathered to guide patient care consistently develops appropriate care plan protects patient from further injury and understands the implications of activity on recovery time addresses foundational movement dysfunction as part of intervention implements systemsbased rehabilitation strategies identify when referral to others will expedite care performs patient education regarding their condition and corresponding care plan effectively manages common, non-complex conditions appropriately modifies care plans based on patient’s clinical course, additional data (e.g., pros, cros), and patient preferences performs patient education regarding long-term consequences of injury or disease appropriately applies criteria for safe return to activity and participation prescribes commonly used assistive and adaptive devices and strategies considers the whole person (e.g., psychologic, physiologic) in the care plan effectively manages uncommon and/or complex patient conditions with or without co-morbidities develops customized, prioritized care plans for the most complex patients, incorporating diagnostic uncertainty and cost effectiveness principles patient advocate for maximizing long-term health-related quality of life (hrqol) care plan extends beyond return to safe activity to maximize participation effectively manages the whole person (e.g., psychologic, physiologic) effectively leads or directs interdisciplinary care team educates others to improve their rehabilitation management, knowledge and skills effectively manages patients with rare conditions serves as a consultant for rare and/or complex rehabilitation cases demonstrates professional leadership in rehabilitation management generates and disseminates new knowledge to advance rehabilitation management develops best practice guidelines for developing rehabilitation care plans ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ the development, implementation, and value of the athletic training milestones for assessing progressive clinical behaviors copyright © 2018-2023 all rights reserved. the copyright owners grant third parties the right to use the athletic training milestones on a non-exclusive basis for educational purposes. rehabilitation the individual is demonstrating satisfactory development of the knowledge, skill, and attitudes/behaviors needed to advance in training. the individual is demonstrating a learning trajectory that anticipates the achievement of competency for unsupervised practice (or advanced practice for residency programs) that includes the delivery of safe, timely, effective, efficient, equitable, and patient-centered care. _____ yes _____ no _____ conditional on improvement comments: manuscript 225 final_final_hw.pdf manuscript 225 appendix 1 .pdf manuscript type clinician expertise commentary 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 standardized patient evaluation tool: a valid measure of the core competencies lindsey e. eberman phd, lat, atc* & jessica edler nye phd, lat, atc** *indiana state university, terre haute, in **grand view university, des moines, ia content focus health professions education correspondence 567 n 5th street, dat suite, room a-10, terre haute, in 47809 e-mail: lindsey.eberman@indstate.edu twitter: na. reference eberman le, edler nye j. standardized patient evaluation tool: a valid measure of the core competencies. clin pract athl train. 2024;7(2):26-34. https://doi.org/10.31622/2024/0007.02.4. author characteristics dr. lindsey eberman is the program director for the post-professional doctorate in athletic training, bachelors degree in leadership and professional development, and doctor of philosophy in instructional leadership at indiana state university. she earned her bachelors degree from northeastern university in boston, ma and her post-professional masters in advanced athletic training and doctorate in curriculum and instruction from florida international university in miami, fl. dr. eberman is an expert in pedagogy and assessment. dr. eberman has been recognized with the several awards recognizing her commitment to teaching, scholarship, and service to the profession at the local, state, regional, and national level. she facilitates doctoral student scholarship that improves the practice of athletic training and maintains a robust research agenda of her own amassing over 200 published manuscripts. dr. jessica edler nye is an associate professor and program director of the master of science in athletic training at grand view university. she earned her bachelors degree from central college and her post-professional masters and doctorate in curriculum and instruction from indiana state university. dr. edler nye is an expert in pedagogy and assessment. commentary in 2017, dr. jessica edler nye and i had the opportunity to develop and validate a standardized patient evaluation tool (spet) (appendix a) to measure the institute of medicine’s healthcare core competencies using a delphi-panel review process.1 although these core competencies (table 1)2 have historically existed in the commission on accreditation of athletic training education (caate) post-professional program standards and, until recently, the residency standards, they have also now been added to the professional education standards. there is also a crosswalk available between these core competencies and the at milestones, which were developed from the acgme core competencies (table 2).3 the spet was developed because no high-quality mechanism existed to measure these outcomes, and as the program director of a caate-accredited post-professional doctor of athletic training (dat) program, it was my responsibility to ensure we were using a valid measure in our standardized patient encounters (spes) to show that program graduates were, in fact, advanced practice clinicians upon graduation. to establish validity, we first created five cases, representative of all the core competencies, each with a primary focus of one of the core competencies (case 1: patient-centered care, case 2: interprofessional and collaborative practice, case 3: evidence-based practice, case 4: quality improvement, case 5: healthcare informatics). we then used a panel of 22 experts to conduct a 4-round delphi panel review to establish consensus on the content validity of the spet and its ability to apply to the sp cases. we established consensus on the evaluative criteria as appropriate (mean=3.6±0.6 out of 4, 65% strongly agree) and its use across https://doi.org/10.31622/2024/0007.02.4 standardized patient evaluation tool: a valid measure of the core competencies 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 the spes to evaluate the healthcare core competencies (mean=3.5±0.8 out of 4, 65% strongly agree) (table 3). experts indicated, through the delphi-panel process, that quality improvement and healthcare informatics may be difficult to assess during a single spe. we also worked to establish reliability but learned that more advanced training was necessary to ensure raters are consistently scoring learners. to create spes for the raters to evaluate, we implemented six different continuing professional development sessions, which were eligible for continuing education units and consisted of a 45-minute interactive lecture, a maximum 30-minute spe that was video recorded, and a 15minute group debriefing session. we then trained three independent raters (30-minutes) on the spet and its evaluative criteria and asked them to review the spes (n=41). we established moderate reliability for the overall performance score (icc=0.641) and each of the specific competencies demonstrated variable reliability (icc: patient-centered care=0.778; interprofessional and collaborative practice=0.581; evidence-based practice=0.274; quality improvement=0.390; healthcare informatics=0.232). the raters also stated that there was limited opportunity to assess quality improvement and healthcare informatics during the spes. after establishing the spet, the dat program has implemented the tool over 1000 times as part of its clinical education curricula. this includes an initial spe to establish baseline performance, and an additional 4 spes at the end of each semester, with a culminating progressive spe experience (3 encounters with one patient case [onset to discharge]). this curricula also includes 4 virtual spes, which use only 2 individual competencies and the overall performance measure instead of the entire tool. upon enrolling students in the newlyaccredited masters in athletic training (mat) program at indiana state, we also began integrating the spet into their spe evaluations, with broad use of the tool consistently across semesters in the program. the lessons learned from the regular use of the tool across both programs are that foundational training, as well as continued maintenance, are necessary to ensure accuracy. as dat faculty, we meet once per semester to watch 1 to 2 spes, score them, calculate inter-rater reliability, and then discuss. we also have an established bias checklist to help with repeated use of the spet when we are evaluating multiple encounters in a row. when new evaluators are introduced to the team, we do preliminary training and integration into virtual (formative) spes first before integrating them into the evaluative spes, with feedback provided to new evaluators throughout this process. in addition to training evaluators, we also provide performance feedback to the learners. for each encounter, they receive a copy of their spet, a checklist of behaviors performed (consistent with simulation best practices), and a summary of how the core competencies, including how quality improvement and healthcare informatics could be integrated into the encounter. the summary outlines competent performance for that case. in both the mat and dat programs, we have learned that it is critical to train the learner in interpreting the results and responding to the feedback. historically in athletic training education, we have misused the terms competent and proficient, and interchanged competency and proficiency. moreover, the board of certification examination and program graduation add additional elements of confusion around competence. these missteps and misunderstandings make it difficult for learners to comprehend the behavior expectations around entering and continuing competence in the profession. in addition, competence is a continuum, not a “place achieved after investing time and effort.” competence ebbs and flows due to use and disuse and a more complete understanding of the construct is critical for learners to embrace, so that they can use the feedback for self-improvement. the spet is a staple tool in our post-professional, caate-accredited dat program and helps us document performance across 6 semesters. we remind learners regularly that is not uncommon for competence to be fluid, especially when you don’t consistently apply the core competencies in practice. therefore, it is not atypical for students to see drastic improvements in patient-centered care between the first and second standardized patient evaluation tool: a valid measure of the core competencies 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 semester, but in the third, when the focus is on interprofessional and collaborative practice, they may slip back into past behaviors. however, the ultimate goal is that the learners are demonstrating competent to proficient behavior in all core competency areas upon graduation. references 1. eberman le, edler jr. developing, validating and establishing reliability of a standardized patient evaluation tool to measure healthcare core competency. j athl train. 2020;55(6):s-240. doi:10.4085/1062-6050-55.6s.s-1 2. the core competencies needed for health care professionals. institute of medicine. health professions education: a bridge to quality. washington, dc: the national academies press, 2003. 3. sauers el, laursen rm, pecha f. walusz hj. the athletic training milestones. https://www.atmilestones.com/milestones.html. accessed on april 24, 2024. https://www.atmilestones.com/milestones.html standardized patient evaluation tool: a valid measure of the core competencies 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 table 1. healthcare core competencies (iom) core competency description provide patientcentered care − identify, respect, and care about patients’ differences, values, preferences, and expressed needs − relieve pain and suffering − coordinate continuous care − listen to, clearly inform, communicate with, and educate patients − share decision making and management − continuously advocate disease prevention, wellness, and promotion of healthy lifestyles, including a focus on population health work in interdisciplinary teams − cooperate, collaborate, communicate, and integrate care in teams to ensure that care is continuous and reliable employ evidencebased practice − integrate best research with clinical expertise and patient values for optimum care, and participate in learning and research activities to the extent feasible apply quality improvement − identify errors and hazards in care − understand and implement basic safety design principles, such as standardization and simplification − continually understand and measure quality of care in terms of structure, process, and outcomes in relation to patient and community needs − design and test interventions to change processes and systems of care, with the objective of improving quality utilize informatics − communicate, manage knowledge, mitigate error, and support decision making using information technology standardized patient evaluation tool: a valid measure of the core competencies 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 table 2. caate core competency to at milestone crosswalk caate core competency at milestones general competencies & sub-competencies patient-centered care patient-care and procedural skills (sub-competencies 1,2) interpersonal and communication skills (sub-competencies 1,2) interprofessional practice and education patient-care and procedural skills (sub-competency 7) interpersonal and communication skills (sub-competency 3) professionalism (sub-competency 2) systems-based practice (sub-competencies 1-4) evidence-based practice practice-based learning and improvement (sub-competency 1) medical knowledge (sub-competency 3) quality improvement practice-based learning and improvement (sub-competencies 2-4) systems-based practice (sub-competencies 1-4) health care informatics interpersonal and communication skills (sub-competency 4) systems-based practice )sub-competency 6) professionalism professionalism (sub-competencies 1-4) standardized patient evaluation tool: a valid measure of the core competencies 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 table 3. delphi panelists perceptions about spet evaluative criteria representing the core competencies case 1 case 2 case 3 case 4 case 5 patient-centered care 3.9 ± 0.3 3.8 ± 0.4 3.8 ± 0.4 3.9 ± 0.2 4.0 ± 0.0 interprofessional and collaborative practice 3.5 ± 0.6 3.2 ± 0.7 3.9 ± 0.3 3.3 ± 0.7 3.2 ± 0.6 evidence-based practice 3.7 ± 0.5 3.9 ± 0.3 3.6 ± 0.6 3.7 ± 0.5 3.7 ± 0.5 quality improvement 3.5 ± 0.6 3.3 ± 0.8 3.2 ± 0.7 3.4 ± 0.7 3.4 ± 0.7 healthcare informatics 3.6 ± 0.6 3.2 ± 0.6 3.4 ± 0.5 3.3 ± 0.7 3.1 ± 0.7 likert scale: 1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree clinician expertise commentary 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 appendix a. standardized patient evaluation tool (spet) evaluative criteria:  critically deficient – these learner behaviors are not within the spectrum of developing competence. instead they indicate significant deficiencies in performance.  novice – a novice has a basic understanding of the knowledge and skill and applies the information within a specific set of rules or steps that they have learned. skills are applied as taught, although typically without efficiency. critical thinking is limited or not present. understanding, deciding, and the outcomes are free of the context in which they are being applied.  advanced beginner – an advanced beginner has begun to develop a framework for the application of knowledge and skills. he or she begins to recognize situational aspects and applies appropriate skills. practice efficiency is minimally evident, and critical thinking is implemented at certain points of the encounter. the advanced beginner demonstrates, to a degree, that their understanding and decision-making are contextual, but they do not experience personal responsibility for the situation.  competent – a competent clinician is able to identify situational aspects that are important and those that can be ignored, making understanding and decision-making easier. the clinician practices in an efficient manner and critical thinking is present throughout the encounter. skill application is appropriate. the competent clinician demonstrates that their understanding and decision-making are contextual and that they take personal responsibility for the outcome of the situation.  proficient – a proficient clinician identifies goals of the encounter early in the process and is able to critically apply skills and knowledge in an efficient manner. the proficient clinician uses intuition and prior experiences to develop practice patterns and critical thinking, versus traditional rule following.  expert – an expert is able to determine what needs to be achieved and they also immediately see a path to achieving the specific goal. evidence of efficient clinical practice with critical thinking application is demonstrated throughout the encounter. decision-making is intuitive. an expert is involved and committed to the understanding, decision-making, and outcomes of the situation. standardized patient evaluation tool: a valid measure of the core competencies 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 critically deficient novice advanced beginner competent proficient expert provide care that is patient-centered patient-centered care includes sharing the responsibility of decision making with the patient. the clinician communicates with the patient in a fully open manner and also takes into account the patient’s individuality, emotional needs, values, and life issues. work in interdisciplinary teams working in interdisciplinary teams requires understanding about other team members’ expertise, background, knowledge/values, roles and processes to work collaboratively. the clinician works to ensure that accurate and timely information is shared with the patients/families and other providers, customizes care, ensures continuity of care between providers using a shared language. the clinician plays an active role in resolving conflicts with other members of the team. employ evidence-based practice evidence-based practice refers to the integration of best research evidence, clinical expertise, and patient values in decision making. the clinician demonstrates the ability to identify and interpret best evidence and the ability to integrate the evidence to guide clinical practice decisions, with respect for patient values. standardized patient evaluation tool: a valid measure of the core competencies 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 2 july 2024 critically deficient novice advanced beginner competent proficient expert apply principles of quality improvement quality improvement refers to a continual process to understand and measure the quality of care by analyzing the structure, process, and outcomes of a healthcare unit. the clinician systematically acts to identify errors and areas for improvement in care and the health status of the patient(s). utilize informatics informatics is the application of technology systems to solve problems and answer questions in healthcare. the clinician uses data from patientpractitioner interactions and available electronic resources (internal and external databases and the internet) to find information, make decisions, mitigate error, and communicate with patients and other providers while securing data and ensuring ethical and legal practices are followed. the clinician is able to assess the veracity of the data and the data sources before making decisions and implementing practices. overall impression please use the above evaluative criteria to describe the behaviors consistent with the learner’s performance during this patient encounter. this should align with scoring of the aforementioned healthcare competencies. comments: manuscript type abstract presentation 1 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 mid-atlantic athletic trainers’ association (maata) free communications abstract presentations the following abstracts were accepted and presented at the 2024 maata annual meeting in virgina beach, va. athletic trainers’ attitudes towards concussion biomarkers and their future use in concussion diagnosis allen jm, mccormick t, swindell kgs, campbell t: old dominion university, norfolk va context: currently, concussions are diagnosed using subjective criteria that typically require baseline measurements to be considered accurate. in some cases, symptoms may not be immediately evident following a brain injury. recently, studies have begun analyzing the possibility of using biomarkers as a means of objectively diagnosing concussions. however, more research and information on biomarkers are required before implementation of diagnostic methods are possible; therefore, the purpose of our study was to explore and analyze current practicing athletic trainers’ attitudes toward the future implementation of concussion biomarkers in clinical practices. methods: a phenomenological qualitative research design was used to gather information regarding attitudes of athletic trainers toward the future implementation of biomarkers in clinical practices. participants were recruited from a previous survey-based study through the national athletic trainers’ association (nata) research survey service. a total of 11 athletic trainers (five female, six male) were interviewed via zoom. semi-structured interviews were conducted by the lead researcher until data saturation occurred. data analysis was guided by consensual qualitative research tradition processes broken down into five cycles. the 4-person research team reached consensus on common themes and subthemes. each member of the research team then focused analyzing their respective theme for the results. results: the 4th theme, attitude about biomarker use, primarily focuses on analyzing how athletic trainers feel about the use of concussion biomarkers in their future practice and how they compare to current diagnostic methods. the sub-categories for this theme included “towards its future use in general,” “compared to gold standard,” and “feasibility at current site.” all participants expressed a desire or need for the future implementation of objective concussion diagnostic methods. conclusions: considering the research is still relatively new, current practicing athletic trainers have little knowledge on what they are and how they can be used; however, all participants agreed that with more research, using biomarkers for concussion diagnosis could prove to be a promising objective measure. participants expressed the future implementation of biomarkers would enhance concussion diagnosis. abstract presentation 2 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 measuring psychological readiness with the shoulder instability-return to sport after injury scale in athletes with traumatic shoulder dislocations: a critically appraised topic arnett ha, moore k, winkelmann zk, miller h, fraley al: university of south carolina, columbia, sc focused clinical question: how can using the shoulder return to sport after injury (si-rsi) scale to measure mental readiness in athletes after a shoulder injury improve return-to-play protocol? data sources: in september 2023, a computerized search of pubmed for evidence was completed. the search terms were fear of reinjury or psychological readiness, kinesiophobia, confidence, and return to play or return to sport, or rtp. the search was limited to studies published between 2018 and 2023. study selection: the inclusion criteria consisted of studies that used the si-rsi to measure fear during return to play and shoulder injuries that required surgery. the criteria were written in english and performed using an observational or experimental design. studies were excluded if the patients did not play sports preoperatively. data extraction: outcomes included quantitative evidence of si-rsi scores to identify a connection between sirsi scores and the athlete’s decision to return to play. one study took a cohort-study approach, one used a cross-sectional approach, and the third used a retrospective comparative cohort study. all three used the sirsi to analyze mental preparedness before return to play. summary measures: all three studies used the si-rsi to measure psychological readiness before return to play. two studies compared the si-rsi score with the subjective shoulder value (ssv). these two studies had a mean si-rsi score of 68.9±22.0 and 41.5±21.9 with a p-value of p<0.0001. evidence appraisal: all three studies were evaluated using the strobe critical appraisal checklist. search results: the computerized search returned 534 studies, 46 of which were included based on inclusion criteria, eight of which were included based on title, and three articles that met the exclusion criteria were kept for review. data synthesis: two of the included studies concluded that patients who returned to sport passed the si-rsi benchmark of 56 73.1% and 81.4% of the time. one study revealed that participants who returned to sport scored higher on the reinjury fear and risk subscale 42.2±23 compared to those who did not return 27.3±16 (p<0.05) even if they didn’t pass the benchmark. evidence quality: the strobe critical appraisal checklist resulted in a score of 17/22 for the crosssectional study and retrospective comparative cohort study and 18/22 for the cohort study. points were removed for not including statistical analysis, bias, funding, and an explanation for the loss of participants. conclusion: the strength of recommendation taxonomy checklist concluded a level c recommendation because of the consistent rating of level 3 evidence across all three studies. moderate evidence suggests that the si-rsi helps evaluate psychological readiness before returning to play after a shoulder dislocation. clinically, this may limit the recurrence of shoulder dislocations by requiring athletes to pass the si-rsi benchmark of 56. abstract presentation 3 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 consistency in patient-reported outcomes survey response beck me, johnson j, garrett wz, lavender c, hewett te, konz sm: marshall university, huntington, wv context: patients returning from acl or other knee injuries must be physically ready to return to activity and mentally. patient-reported outcome measures are important means to evaluate the level of patient readiness. many healthcare providers utilize multiple surveys as part of their intake process to determine current status. the distribution of multiple surveys related to one joint may be problematic. a question of completeness and consistency among participants is a limitation of most measures. the purpose of this study was 1) to determine the level at which people will persist in multiple surveys and 2) to determine the consistency in participant response across questions repeated across surveys, similar questions, or movement patterns. methods: the study design for this research was a qualitative survey of a convenient sample. participants were recruited via their university, asking for participation in the study. the survey was distributed through the host’s school email system, and qualtrics hosted the survey. to be included in the study, participants had to be either a student, faculty, or staff member of the university. the study included general demographic information (age, gender, ethnicity, and history of injury or pain in the knee) and four knee-related quality-of-life surveys, which included the anterior cruciate ligament return to sport after injury (acl-rsi) scale, international knee documentation committee (ikdc), knee injury and osteoarthritis outcomes scores (koos), and lysholm knee scoring scale. ran interclass correlation coefficient to determine cronbach’s alpha. significance was set at the 0.05 level. results: the number of participants who consented to participate in this survey was 663. of these 663 participants, only 292 (45.34%) completed all 4 surveys. a total of 152 (22.93%) participants stopped after the demographics, 85 (12.82%) completed at least 1 survey, 84 (12.67%) completed at least 2 surveys, and 15 (2.26%) completed at least 3 surveys. seventy percent of participants complained of knee injury or pain and 27% occurred more than 5 years ago. response consistency was seen with question looking at confidence in knee (icc .869, 95% ci 845 to .891), confidence to perform (icc .94, , 95% ci .927 to .951), locking and catching in the knee (icc .479, , 95% ci .374 to .570), stairs (icc .93, 95% ci .917 to .942), kneeling (icc .885, 95% ci .856 to .909), squatting (icc .895, 95% ci .873, .915), and sitting (icc .731, 95% ci .676, .788). conclusion: these results support response consistency across the four surveys. survey compliance overall was low, but because it did not impact the consistency of responses, using one survey encompassing questions from all four surveys might increase survey compliance while still gathering sufficient information. abstract presentation 4 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 reliability and validity of the iphone to measure hip internal and external rotation blatz jl*, cattano, nm†, kreschollek, hg†: †west chester university of pennsylvania, west chester, pa. *atrium health wake forest baptist, winston-salem, nc. context: clinicians use a traditional goniometer or a quick visual estimate to measure range of motion (rom) in patients, these methods can be time consuming or inaccurate. the purpose of this study is to assess the reliability and validity of the iphone measure app to measure hip internal rotation (ir) and external rotation (er). methods: 20 participants were recruited; they were physically active and aged 18-28 years old. hip ir and er was measured prone with the subject on a table. the measures were taken three times and bilaterally for each, then recorded. the rom was measured by 2 student clinicians using the iphone measure app, and one clinician using the traditional goniometer. the clinician using the goniometer is a certified athletic trainer, preceptor, and professor that has taught students how to use this tool. intraclass correlation coefficients (iccs), coefficients of variation (cv) and standard error of measurement (sem) were utilized to assess reliability. to assess validity of the smartphone application against the bubble inclinometer intraclass correlation coefficients were utilized. results: there was excellent reliability for ir (icc=.992) and excellent for er (icc=.988). the iphone measure app interrater reliability in ir was excellent (icc = .993), and er interrater reliability was excellent (icc = .990). the iphone when compared to the goniometer in ir had excellent validity (icc= .983-.989). the validity of the iphone compared to the goniometer in er was excellent (icc=.972-.983). conclusions: smartphones, specifically iphones are often very accessible for clinicians and could be a great tool to quickly and easily measure joint rom. clinicians should be consistent with their choice of rom measure and avoid switching back and forth with one specific measure or one patient. abstract presentation 5 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 how comorbidity with adhd impacts on neurocognitive performance in adolescents after sportrelated concussions: a scoping review chiba t, emerson dm: university of south carolina, columbia, sc context: the number of sport-related concussions (srcs) is higher in adolescents than in other age groups and accounts for 32% of concussions. athletes with attention-deficit hyperactivity disorder (adhd) have a higher risk of previous history of concussion and future concussion risk compared with those without adhd. people with adhd present lower baseline scores of neurocognitive performances compared with those without adhd. neurocognitive deficits after src lead to increase risk of musculoskeletal injuries or another concussion after return to play (rtp) and affect rtp process. there is no consensus regarding the management of srcs for those with adhd. this scoping review aims to provide the currently available evidence regarding how adhd impacts neurocognitive test performance after sustaining srcs in adolescent athletes. methods: a scoping review of literature published in english was conducted in february 2024 using google scholar. key terms included “adolescent,” “athlete,” “sport-related concussion,” “adhd,” “neurocognitive test,” and “impact test.” articles were excluded if they were systematic reviews or meta-analyses and included participants with a history of brain surgery or meningitis due to the influence on neurocognitive performance. articles written in english and including adolescent populations were inclusion criteria. the search yielded 11 studies for possible inclusion. of these, three were included based on inclusion criteria. results: all neurocognitive performance was measured using the impact test. one study showed that among the 4 compositions of the neurocognitive test, verbal memory (adhd: 72.1±16.60, control: 79.1±13.40) and visual motor speed (29.9±8.60, 35.3±8.30) were significantly decreased (p<0.01) post-src in those with adhd compared with those without adhd. another study found among those with adhd not taking medication, both verbal memory (0.87(0.67-1.06), 0.68 (0.64-0.71)) was and reaction time (1.25 (0.831.66), 0.96 (0.90-1.01)) was showed significantly greater standard deviation from the baseline(p<0.05) compared with individuals without adhd. finally, verbal memory (82.8 ± 12.80, 86.9 ± 10.66), visual memory (73.0±14.17, 77.8±12.76), and visual motor (36.0±7.28, 38.5±7.07) were significantly decreased and reaction time (0.63±0.10, 0.60±0.10) was significantly increased (p<0.01) in patients with adhd. conclusions: as a neurodevelopment disorder, adhd results in an individual having trouble paying attention (e.g., listening, following through on instructions, being distracted, and organizing) and/or being hyperactive (e.g., difficulty waiting, fidgeting). existing research shows adolescent athletes with adhd tend to have worse neurocognitive test and symptom performance following acute srcs compared with those without adhd. clinicians must evaluate the baseline assessment for this population and create a relationship among parents, coaches, school nurses, and teachers to discuss care plans that may be unique for adhd patients. considering the number of adolescent athletes with adhd and the potential impact of src among this population, the amount of research on recovery and return to learning challenges is lacking. abstract presentation 6 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 changes in neural excitability following 6-week of balance training in individuals with chronic ankle instability chung sh, freeman j, gray j, mccann rs: old dominion university, norfolk va context: individuals with chronic ankle instability (cai) often struggle with balance issues due to changes in the central nervous system (cns). specifically, difficulties in modulating spinal reflexive excitability and enhancing corticospinal excitability contribute to poor balance, indicating challenges in transferring control to supraspinal centers. a recent study found that a single session of balance training could positively impact the cns, improving spinal reflexive excitability modulation and corticospinal excitability in cai patients. however, there is limited research on the effects of long-term balance training on neural excitability in cai individuals. therefore, this study aimed to investigate the effects of a 6-week balance training program on spinal reflexive excitability modulation, corticospinal excitability, and balance performance in cai individuals. methods: 28 participants with cai (f:16, m:12, 22.5±2.8yrs, 171.1±9.0cm, 77.3±19.6kg) were randomly assigned to the balance training group (bal) or control group (con). we assessed their spinal reflexive excitability modulation using hoffmann-reflex (h-reflex) testing in prone and single-limb stance positions. corticospinal excitability was measured during single-leg balance using transcranial magnetic stimulation (tms), assessing motor evoked potential (mep), active motor threshold (amt), and cortical silent period (csp). balance function was evaluated by performing single-leg balance on a force plate to measure center of pressure (cop) variables. the bal group underwent a 6-week progressive balance training program, engaging in sessions three times a week for 20-30 minutes each. training comprised static (singleleg stance with eyes open and closed) and dynamic exercises (hop and stabilization, hop and reaching). statistical analysis utilized separate 2x2 mixed-model analysis of variances (anova) to examine the interaction effect of group (bal and con) x time (baseline and post-training) on each variable. cohen's d effect sizes were calculated to determine the significance of differences, with significance set at p<0.05. results: there was a significant group x time interaction in csp (f=19.63, p=0.01). a large effect size (d=0.49[0.25, 1.20]) suggested that csp was significantly shorter at post-testing (72.4±30.4) in bal when compared to baseline (100.7±38.8). furthermore, a significant group x time interaction was present for modulation of spinal reflexive excitability (f=8.06, p = 0.01). there was a moderate effect size (d =.88, [0.08, 1.63]) indicating that post-testing (44.0±21.8) spinal reflexive excitability modulation was greater than the result of baseline (29.5±35.2) in bal. conclusions: balance training resulted in a decrease in cortical silent period (csp), indicating enhanced corticospinal excitability among individuals with cai. it was also observed that spinal reflexive excitability modulation was improved after balance training. the balance-related neurosignature of individuals with cai might be restored with 6-week of balance training. clinically, these alterations following balance training could suggest why balance training has been successful in preventing recurrent ankle sprains as well as improving balance performance in individuals with cai. abstract presentation 7 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 chronic neck pain, vasculopathy, and pre-syncope in a young adult: a type 4 case study crane tn, moore k, field a, fraley al: university of south carolina, columbia, sc background: the patient is a 23-year-old college female presenting with chronic cervicalgia, bilateral upper extremity neurovascular symptoms, and insidious pre-syncope episodes over the past 3.5 years. upper extremity neurovascular symptoms include bilateral numbness and tingling into the hands and bilateral throbbing arm pain originating proximal to the elbow and traveling to the fingers, which worsens with cervical rotation bilaterally. the patient has experienced 10 episodes of pre-syncope lasting less than 30 seconds that occur with cervical flexion, extension, or bilateral rotation. pre-syncope symptoms include lightheadedness, blurry vision, increased neck/arm pain, headache, and malaise. upon clinical evaluation, no obvious deformity, discoloration, or swelling of the cervical spine were present. the patient was tender to palpation on c2-c5 spinous processes. cervical range of motion (rom) was within normal limits; a deficit of 15 degrees was present for right cervical rotation. cervical manual muscle testing (mmt) were all 5/5, with pain in the posterior cervical spine during rom and mmt of cervical flexion, extension, and bilateral rotation. positive findings were reported with cervical distraction, vertebral artery (bilaterally), allen’s (bilaterally), and adson’s (bilaterally) special tests. neurological assessment identified horizontal maltracking of the eyes, causing lightheadedness and headaches. all other components of a cranial nerve assessment and upper quarter screen were normal. differential diagnosis: differential diagnoses include herniated disk, nerve root compression, brachial plexus pathology, spondylosis, vertebral fracture, vertebral osseous lesions, vascular stenosis and/or occlusion, and thoracic outlet syndrome (tos). treatment: the patient was evaluated by her primary care physician, followed by a sports chiropractor, spine physiatrist, general orthopedist, spine orthopedist, physical therapist, vascular surgeon, and neurologist. when one provider could not make a definitive diagnosis or an intervention failed, the patient was referred to the next provider. multiple differential diagnoses were ruled out via diagnostic imaging and laboratory results, including radiographs, mri, and spect-ct of the cervical spine, brain, upper extremity, and chest ct angiogram. the patient received a diagnostic bilateral upper extremity duplex ultrasound, which revealed mild arterial pressure variability with maneuvers. imaging of the cervical spine revealed signs of spondylosis and tos. initial treatment included sports chiropractic care, rehabilitation, and tizanidine prescription. limited pain relief from the 2 interventions resulted in the patient undergoing 2 occipital nerve blocks and 3 radiofrequency ablation procedures performed by the spine physiatrist. the patient attended physical therapy for 3 months where she followed a cervical spine and tos protocol and failed to notice meaningful change in symptomology. uniqueness: this case is unique as there was no specific mechanism of injury. diagnostic imaging and laboratory tests have resulted in no significant positive findings, making diagnosis challenging. the spine orthopedist, vascular surgeon, and neurologist cannot explain the medical link between pre-syncope in combination with cervicalgia and neurovascular symptoms. the cumulation of the patient’s symptoms has impacted her activities of daily living (adl) and quality of life (qol), such as difficulty completing schoolwork, lack of adequate sleep, heightened fear of driving, and increased anxiety. she feels stressed and overwhelmed by the time demand of medical services, the complexity of the health insurance process, and cost of services. conclusion: the patient required extensive medical evaluations and interventions from multiple healthcare providers, which is still on-going. her experiences over the last 3.5 years negatively impacted her adls, qol, and overall mental status, which resulted in the patient feeling discouraged, frustrated, and alone. in patients who present with chronic signs and symptoms, especially when there is not a definitive diagnosis, it is important for athletic trainers to remain diligent in providing patientcentered care. athletic trainers must continue to advocate and remain knowledgeable about additional healthcare providers or resources that can be a part of the patient’s care plan. abstract presentation 8 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 figure 1. abstract presentation 9 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 single limb postural control throughout a collegiate football season custer l, tomasi s, lima j, rieland a: towson university, towson md context: it is estimated that college football players sustain an average of 3 subconcussive blows to the head per game. limited research has demonstrated that collegiate football players present with decreased static postural control, as measured using the balance error scoring system, at the end of season compared to baseline. interestingly, neurocognitive test scores in collegiate football players were not found to differ preseason, midseason and postseason. authors hypothesized that using neurocognitive tests may not have been sensitive enough to detect the effects of the subconcussive impacts. force plate data provides valid information of postural control. the purpose of this study was to evaluate static postural control throughout a collegiate football season in players who had sustained no known concussion throughout a season. methods: this case series consisted of 45 volunteers from a division i collegiate football team (age = 20.55 ± 1.50 years, height = 183.22 ± 7.24 cm, weight = 99.42 ± 21.88 kg) with no known concussion at time of first data collection visit. participants completed three data collection visits (early season, mid-season, end-of-season). at each visit, participants completed three successful 30-second trials of single limb, eyes closed balance on a force plate. the following center of pressure (cop) force plate outcomes were analyzed: cop sway in the mediolateral (ml sway) and anteroposterior (ap sway) directions, cop pathlength, cop maximum path velocity, and 95% ellipse. for each outcome, a repeated measures anova was conducted to compare means over time. post hoc t-tests were used for those differences that were found to be significant. a significance level was set a priori at p ≤ .05. results: significant differences were found for cop sway in ap (f2,129 = 4.28, p = .017) and ml (f2,129 = 10.66, p < .001) directions. for both measures, postural control was worse at end-of-season (cop ap sway = 0.08 ± 0.37; cop ml sway = 0.071 ± 0.45) compared to early season (cop ap sway = 0.319 ± 0.46; cop ml sway = 0.556 ± 0.67). there were no differences between early season and midseason and no differences between midseason and end-ofseason. there were no statistical differences between cop pathlength (f2,129 = 0.32, p = .730), cop maximum path velocity (f2,129 = 0.33, p = 0.72), or 95% ellipse (f2,129 = 1.739, p = .182). conclusions: our results show inconclusive postural control differences in non-concussed football athletes throughout a season. further analysis of our participants is planned to determine if playing time may impact balance during a season. at this time, it does not appear that a football season has an impact cognitive function as measured via static postural control. abstract presentation 10 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 injury prevention programs: factors that effect if a coach uses injury prevention programs deguzman a, martinez jc: old dominion university, norfolk, va context: the purpose of this study was to determine how coaches view injury prevention programs (ipp) and how this affects their decision to implement an ipp with their team. the more information gained on a coach’s influence to implement an injury prevention program for their team, the more athletic trainers can understand and educate on the importance of injury prevention programs. methods: design: cross-sectional setting: web-based survey target population: youth sport coaches dependent variable: coaches beliefs on ipps independent variable: willingness to implement an ipp. youth sport coaches were surveyed on their attitudes and beliefs about injury prevention programs. all questions used a five-point likert scale (5=strongly agree, 1=strongly disagree for questions on willingness or 5=very important, 1= not important). questions on willingness to implement an ipp were dichotomized (4-5=yes, 1-3= no). as a response of “3” indicates “neither agree nor disagree” responses of “3” were considered “no” since they could not be considered agreement. statistical analyses were performed using spss (version 28; ibm corporation, armonk, ny) and the α level set a priori at p ≤ .05. a pearson χ2 test of association was used to identify any significant (p<0.05) differences in coaches’ responses between sport (basketball and soccer). if no association was observed, chi-square tests were performed on the coaches as one group. any categorical variables that displayed an expected count below five were omitted from this analysis. ethics approval was obtained from university x’s irb (irb #x12-116). results: 150 coaches (sport: basketball=76 soccer =74, sex: female=34, male=116 age=42+11) completed the survey. coaches who indicated they plan to implement an ipp next season reported finding it of higher importance to prevent sport-related injuries (χ2(2, n=138)=8.831, p=0.012), prevent acl injuries (χ2(2, n=137)=13.826, p<.001) and say it was “very important” to use an injury prevention program to prevent injury (χ2(2, n=135)=32.505, p<.001) than coaches who said they do not plan to implement an ipp with their team in the upcoming season. conclusions: youth sports coaches who find it important to prevent sport-related injuries to the lower extremity and, more specifically, acl injuries are more likely to use injury prevention programs. a vast majority of coaches do not utilize ipps and find them of lesser importance. education on the importance of these programs for coaches to help their teams reduce injury risk and rates at the youth sport level is warranted to help close this gap and increase coaches’ knowledge of injury prevention programs. abstract presentation 11 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 effects of passive heat interventions on a person’s active heat acclimatization: a critically appraised topic dickstein si, emerson dm, fraley al: university of south carolina, columbia, sc focused clinical question: does implementing a month-long passive heat protocol in a sauna affect a person’s active heat acclimatization by decreasing average heart rate (hr), decreasing internal body temperature, and increasing skin temperature (tsk)? data sources: a comprehensive search was conducted in september 2023 through pubmed. the search terms used were passive heat therapy, heat acclimatization, and hypoxia. manuscripts were limited to those published within the last 5 years. study selection: inclusion criteria consisted of physically active participants, measures of hr and body temperature, and randomizedcontrolled trials and crossover studies using saunas as a passive heat intervention. exclusion criteria consisted of systematic reviews, meta-analyses, case studies, individuals with cardiovascular disease or any other underlying health conditions, animal studies, and the use of water-profused suits. data extraction: studies measured hr, internal body temperature, and tsk as outcomes of heat acclimatization. body temperature was measured via an infrared thermometer (skin) and an oral mucosa test (internal). hr was measured by hr monitors and electrocardiograph (ecg). summary measures: intra-group data was determined with the wilcoxon test for paired samples in both groups. evidence appraisal: all 3 studies were analyzed using the pedro scale to identify threats to internal validity. search results: the computerized search returned 21 studies. eighteen studies were excluded because they did not use saunas, did not match study design, and did not include physically active participants. data synthesis: one study found a decrease in average hr (123.68 vs. 106.89, p<0.05), no increase in internal body temperature (37.43°c vs. 37.42°c, p=0.002), and an increase in tsk (36.92°c vs. 37.74°c, p=0.005) at higher sauna temperatures (42°c) from session 1 to session 9. however, another study found varying results with internal and tsk at both higher and lower temperatures. the third study did not find any significant difference in hr, body temperature, and tsk between the control and sauna groups (p>0.05). evidence quality: each study was assessed using the pedro scale, losing points for not blinding participants and experimenters (7/11, 6.5/11, and 7/11). conclusions: the strength of recommendation taxonomy yields b evidence due to inconsistency in study findings, suggesting moderate evidence that passive heat interventions can improve someone's active heat acclimatization over a month-long period. having a healthy hr contributes to adequate blood flow to the extremities. in addition, having an increase in tsk while exercising in a hot environment can increase sweat rate which enhances the thermoregulatory response. an efficient thermoregulatory system can help inhibit inflammation markers in the cells, thus limiting the chance of developing hypoxia. a decrease in a person’s hr and internal body temperature attributes to effective heat acclimatization. additional research can focus on at-risk populations, using tsk patches, and hydration levels which play a vital role in thermoregulation. abstract presentation 12 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 anaerobic capacity and lower body strength deficits related to thermal protective gear in rural volunteer firefighters diggins j, shagena r, patrick t, catanese a, pacinelli l, durst j: frostburg state university, frostburg, maryland context: firefighting is a dangerous job with occupational hazards, strenuous shifts, and increased work related fatigue that contributes to risk of injury. the weight of thermal protective gear (tpg) may increase neuromuscular challenges while on-duty. the purpose of this study was to investigate the influence of tpg on volunteer firefighters’ anaerobic and lower body strength performance. methods: nine healthy males (mean±sd: age= 41±9.3 years; ungeared body mass= 96.47 ± 14.51kg; ungeared height=181.67 ± 4.48cm; vff experience 8 years) participated in a cross-sectional correlation study during three visits to a university research laboratory. participants’ tpg included thermal pants, jacket, boots, and a standardized helmet and self-contained breathing apparatus (scba) with respirator. lower extremity aerobic fitness capacity was assessed using the timed up and go (tug) test. a forward-facing (f) and perpendicular facing (p) start positions were utilized. lower extremity strength was assessed using a five repetition sit to stand (sts) measured with a linear displacement accelerometer. all tests were performed with and without tpg. statistical analyses to determine performance differences between the ungeared and geared conditions were conducted using paired sample t-test for tug and sts. pearson’s coefficient correlations were conducted to determine relationships between geared and ungeared sts performance variables. results: geared tug-p times were significantly slower than ug tug-p and demonstrated a large effect size (p=<0.001, d= -2.07). no significant difference was identified between geared and ungeared tug-f performance (p<0.120, d=-0.42). with sts performance, the geared condition was significant only regarding velocity and total time variables. geared peak velocity, geared average velocity, and geared averaged peak velocity values were all significantly less than ungeared and demonstrated a large effect size (p=<0.001, d = 1.58; p=0.001, d = 1.43; p=0.001, d = 1.44, respectively). finally, geared total time sts performance was significantly longer than ungeared and demonstrated a large effect size (p=0.004, d = -1.17). the ungeared sts strength variables exhibited positive, significant relationships with geared condition strength variables (ug-average power & gaverage power, r= .325, p<.001; ugaverage power & gaverage peak power, r= .898, p<.001; ug-average power & gaverage peak force, r= .937, p<.001; ug-average power & gpeak power, r= .856, p<.003; ug-average power & gaverage peak force, r= .948, p<.001). conclusions: wearing tpg negatively affected anaerobic capacity and rapid strength compared to ungeared trials. task completion times were significantly longer with gear compared to ungeared. regarding strength, geared peak power and force correlated with ungeared average power. the additional weight from the tpg may cause the firefighter to exert more effort compared to the effort needed when ungeared. this decline in maximal and rapid strength and anaerobic capacity while geared simulates what the firefighter may encounter during fire rescue situations. abstract presentation 13 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 effects of sex hormones and the menstrual cycle on knee joint laxity in physically active females: a critically appraised topic eicher, ae, gage, rj, park-braswell, k; liberty university, lynchburg, va clinical scenario: in recent years, females have exhibited increased physical activity and sport participation than ever before. recent studies have identified a rising incidence rate of acl injuries and indicate that the risk of acl tears is greater in females than males. knee laxity and physiological variation in women during the menstrual cycle have demonstrated increased ligament laxity, therefore, varying hormone concentrations may contribute to changes in ligamentous mechanical properties. despite these findings, it remains unclear whether fluctuating sex hormone concentrations directly correlate to measurable changes in knee laxity. clinical question: how do fluctuations in sex hormones throughout the menstruation cycle impact knee joint laxity among physically active females? data sources: a computerized search of electronic databases was completed. search terms used to guide the search include sex hormones, knee joint laxity, and physically active females. study selection: the literature search yielded 51 total studies of which four adequately met inclusion and exclusion criteria. selected studies explored the influence of sex hormones on knee laxity in physically active females with regular menstrual cycles and no use of contraceptives. data extraction: observed outcome measures include analyzing hormone and measuring knee laxity throughout the menstrual cycle. summary measures: across the four studies, anterior knee laxity was observed during ovulation (4.71mm ± 0.86). two of the four studies revealed estradiol peaks during ovulation (187.27 pg/ml ± 27.26), while the remaining 2 studies found highest estradiol concentrations during the luteal phase (176.24 pg/ml ± 79.91). evidence appraisal: the critical appraisal skills program (casp) and oxford center for evidence based medicine (ocebm) were utilized to appraise the quality of evidence included. search results: databases including pubmed, ebsco host, medline, and cinahl, were systematically searched for relevant studies. initially, 51 studies were identified, with 12 duplicates removed. following screening, 14 remained for further eligibility assessment. after thorough evaluation, four studies were selected for this critically appraised topic. data synthesis: two studies utilized a 95% confidence interval to examine changes in knee laxity concerning fluctuations in hormone levels within subjects. evidence quality: reviewed manuscripts exhibit inconsistency in outcome measures and limited significance to enhance patient-centered evidence. summary of key findings: each study analyzed hormone concentration levels through blood draws and measured knee laxity using the kt-2000 arthrometer. increased anterior knee laxity was observed during ovulation in two studies. two of the four studies revealed peak estrogen levels during ovulation, while the remaining two studies found peak estrogen concentrations during the luteal phase. clinical bottom line: based upon the included studies, there is compelling evidence to suggest that sex hormone fluctuations across the menstruation cycle can impact the magnitude of knee laxity in physically active females. abstract presentation 14 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 conflict management in athletic training: the influence of organizational culture emerson cc: kansas state university, manhattan, ks context: athletic trainers (ats) face conflict within the social ecosystem of the organizations in which they practice and arises due to incompatibility of goals and interests. within athletic departments, the ats’ role to advocate for health and safety often comes at odds with an organizational culture directed towards maximizing performance and winning. ats are often evaluated by dominant and powerful members of organizations who may not understand or respect the at’s role. the purpose of this study was to examine the experience of managing conflict as an at within the culture of athletics. methods: this qualitative study explored experiences of conflict management through the perspectives of at managers. at managers hold positions which allow them to observe and facilitate conflict management in a variety of settings and with a range of personalities. an interview guide was developed based on conflict management and leadership literature and reviewed by an expert in organizational leadership. eleven at managers (7 males, 4 females; years certified=17.9±8.2; years as manager=7±4.9) participated in two 1-hour videoconference interviews, which were recorded then transcribed via an online transcription platform. for this study, the ats’ worksites (i.e., high school, college, recreational) were considered, not the healthcare organizations which employed the ats. member checks were performed to confirm accuracy, ensure clarity and intention, and offer the opportunity to provide additional information. transcripts were analyzed through an inductive process, including descriptive, values, and versus coding strategies. codes were clustered and thematized through a phenomenologically informed process. results: managers identified that the goals of conflict management were to ensure athlete safety and reach mutual understanding. three organizational factors acted as barriers or facilitators, ultimately influencing the work environment: 1) contextual factors, 2) conflict culture, and 3) health and safety culture. contextual factors increased the perceived stakes of ats’ decisions to remove athletes from play and led to emotionally charged conflicts. decisions involving important games (i.e., playoffs), star players, implications on college recruitment, and schools with a history of athletic success were more likely to be met with emotional conflict. the college setting was considered more challenging for ats than high school and recreational sports, involving more politics, higher perceived stakes, and higher stress. conflict culture, the extent to which conflict and norms promoting productive conflict is accepted, complicated ats’ ability to manage conflict. politics led to power dynamics, which favored the opinions of coaches and administrators over ats. some organizations accepted antagonistic and aggressive behaviors from coaches and administrators while expecting unwavering professionalism from ats. ats who were able to identify and navigate politics were considered better able to manage conflict. health and safety culture, the extent to which health and safety is valued within an organization, was marked by the knowledge of— and respect for—the at’s role. policies and procedures as well as support from administrators which granted ats medical decision-making authority prevented and mitigated conflict. excessive negative elements of conflict culture, health and safety culture, and contextual factors led to a negative work environment, marked by a lack of respect for the at and pressure to clear athletes prematurely. managers observed higher at turnover in organizations with negative environments. conclusions: ats’ ability to effectively manage conflict and ensure athlete safety is influenced by the organizational culture in which they practice. conflict culture, health and safety culture, and contextual factors influenced ats’ experience with conflict management. negative elements of culture were related to poor work environments and increased at turnover. ats should be aware of organizational factors which influence conflict and employ strategies to effectively navigate these factors to improve their workplace experience and maintain athlete safety. abstract presentation 15 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 effects of concussion history on risk taking behaviors in collegiate athletes formey k, campbell tr: old dominion university, norfolk, virginia context: according to the literature, in the united states there are an estimated 1.6 to 3.8 million sportrelated concussions annually with over 10,000 concussions among national collegiate athletic association (ncaa) student-athletes1. the annual incidence of medically diagnosed pediatric concussions increased from 34 per 10,000 persons in 2003 to 150 per 10,000 persons in 20132. there has been an increase in research studied on the physiological mechanisms and causes of concussions among people of all ages with sports participation being the etiology of about half of all pediatric concussions2. concussions occur from excessive forces being applied to the skull resulting in a temporary or permanent injury to the brain leading to impairments of the neurological system3. this can result in decreased cognitive functioning, impaired decisionmaking abilities, poor judgement, and impulsive thoughts which influences risk-taking behaviors3. student athletes with increased sensation-seeking behaviors could be at risk for failing to disclose a concussion, impact their safety, and result in decreased care post-injury4. risk-taking behaviors can be categorized as financial, social, legal, physical, and psychological5. however, the engagement in risky behaviors is subjective and based on individual circumstances and concussion history. purpose: to compare risk-taking behaviors in men’s and women’s division i basketball players using a previously validated risk-taking questionnaire (rt18)5. methods: as part of annual baseline concussion testing, participants completed a basic medical history questionnaire and rt-18 questionnaire. the rt-18 is a brief 18-item survey using “yes/no” questions to evaluate individuals’ risk-taking behaviors and perceptions of risk. once completed, all data was exported to ibm spss statistics v.28.0 for analysis. a mann-whitney u test was used to characterize the data and compare risk taking behaviors and perceptions of risk between two groups – those with a history of concussion and those without. results: a total of 29 ncaa division i basketball players (male=15, female=14) completed the rt-18 questionnaire and medical history form. of the 29 players, 31% (n=9) reported a previous history of at least one concussion. there was no significant difference in risk-taking between those with concussion history (m=18.67) and those without (m=13.35) as indicated by performance on the rt-18, u=57.00, z=-1.57, p=.117. conclusions: concussions are severe life-threatening injuries, and the research supports increased prevalence amongst male and female ncaa athletes. the results from this study demonstrate that risk-taking behaviors are unrelated to a history of concussion, however this data is dependent on truthful reporting of concussion injury. clinicians should encourage timely reporting of symptoms and remain knowledge about the signs of an unreported concussion to provide immediate treatment and decrease the potential risk of an adverse event. abstract presentation 16 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 orientation using standardized patients increases athletic training student communication effectiveness when transitioning to clinical education experiences frye jl*, belbey ma†, armstrong kj*: *james madison university, harrisonburg, va, †new mexico state university, las cruces, nm context: transitioning from didactic to clinical education is overwhelming for novice athletic training students. the change in the learning environment often causes anxiousness as students get acquainted with the clinical site, preceptor expectations, and demonstrating clinical skills during patient care. learning to communicate provides additional challenges as students must convey information to their patients, practice active listening, relay patient information to their preceptor, and possibly navigate conflict management. simulation-based orientations have been effective in other healthcare professions to ease this transition; however, it has not been examined in professional athletic training students. methods: the study used a convenience sample of 17 first-year athletic training students (3 men, 14 women, age=22.59±0.99) enrolled in a caate-accredited professional master’s program. students had completed one didactic semester in the program and were preparing to transition to clinical education. a two-day simulated-based orientation was completed prior to beginning their first clinical education experience. orientation was designed to introduce the role of clinical education, define student roles and responsibilities, examine how to navigate clinical learning, review policies and procedures, review clinical skills, and practice effective communication. the orientation delivery framework included lectures, facilitated discussion, clinical skill practice, 3 standardized patient (sp) encounters, and two facilitated debrief sessions (one debrief immediately following the orientation and a second debrief two weeks after orientation). a 15 item preand post-orientation communication confidence survey was completed. eight questions evaluated confidence communicating with a preceptor, seven questions evaluated confidence communicating with patients. descriptive statistics were calculated for all survey items. paired samples t-tests were used to compare preand post-orientation communication confidence ratings. alpha levels were set at 0.05. a semi-structured debrief guide was stimulated self-reflection during the two debriefs. qualitative analysis of respondents’ comments was completed using interpretive coding. results: a paired sample t-test revealed that students’ confidence significantly improved in communicating with preceptors (t=3. 697, df=14, p < 0. 001) and communicating with patients (t= 2. 344, df=14, p<0. 017) after participating in simulation-based orientation. three themes were established from debrief data, including (1) improved communication, (2) improved clinical skills, and (3) role clarity. participants expressed improved confidence to present patients to their preceptors and to perform evaluations. orientation improved confidence in clinical skill application through skill review yet students described apprehension when new skills were presented. students grew in their role clarity and felt more confident to ask questions and to express day-to-day concerns and preferences with their preceptors. conclusions: a simulation-based orientation was effective at improving professional at students’ communication skills. at educators should focus on orientation strategies designed to prepare students for their transition from didactic to clinical education. orientations that include simulations or standardized patients and facilitated debrief help ease the transition to clinical education. abstract presentation 17 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 presentation of bilateral acetabular labral tears in a collegiate women’s lacrosse player: a level 3 clinical case study giannelli w, herraiz k, mercer a, farmer s, lisman p: towson university, towson, md background: the hip and groin injury rate in female collegiate lacrosse players has been reported to be 35.06 per 100,000 athlete exposures yet the frequency of acetabular labral tears (atl) remains unclear. sports which involve repeated bouts of running in combination with frequent twisting and pivoting motions, have been suggested to have a higher prevalence rate of alt. this level 3 case study will discuss the unique presentation of bilateral alts in a female collegiate lacrosse player. patient: patient is a 19-year-old division i collegiate women’s lacrosse player who first presented with pain in her left hip while at home during summer break. the patient could not recall a specific moi and was initially evaluated and treated by a physical therapist. since symptoms persisted, she was referred to a sports medicine physician who prescribed diagnostic imaging. findings revealed a cam pincer lesion on the femoral head accompanied with an alt. upon returning to campus, the patient reported to the athletic training clinic complaining of left hip pain and instability after practice involving cutting, sprinting, and high-volume exercises. the patient outlined the previous months to the team athletic trainer, who performed an additional evaluation on her left hip. the athletic trainer developed a rehabilitation plan that centered on pain control and increasing stability while permitting the athlete to play as tolerated with certain limitations. four weeks after, the patient began complaining of pain in her right hip. despite having full strength and rom, she underwent an mri on her right hip, which revealed an alt. following this new diagnosis, the patient was removed from practice until she met with the orthopedic surgeon. at this meeting, the physician discussed both non-operative and operative treatment options. ultimately, the patient opted for surgery which occurred 3 months following her initial presentation to the athletic training clinic. the patient continued rehabilitation for roughly 4 weeks until the first surgery, an arthroscopic acetabuloplasty of her left hip. six weeks later, the patient underwent an arthroscopy with correction of impingement of her right hip. intervention or treatment: following the initial injury presentation (left hip), the patient’s rehabilitation program focused on strengthening the gluteal and abdominal muscle groups. upon return to campus, the team athletic trainer developed an approach centered on pain control and increasing stability which allowed the patient to participate in practice as tolerated. following the diagnosis of a right hip alt, conservative and operative interventions were presented. the patient opted for surgery and underwent separate procedures for her left and right hips. outcomes or other comparisons: despite having bilateral hip labral tears, the patient maintained a high level of strength and function. during the 4 months between her initial diagnosis (left hip) and discovery of alt in her right hip, the patient participated in all strength and conditioning sessions and limited field work. in the weight room, she scored in the top 2% of all her teammates across the three lower body test lifts: front squat, hex bar deadlift, and romanian deadlift. conclusions: recent evidence has reported the use of both conservative and operative management for patients diagnosed with alts, with accompanying symptomatic femoroacetabular impingement (fai) being a primary reason for surgery. in this case, the patient was symptomatic in both hips with presence of fai in the left. consequently, the athlete opted for surgical intervention to both hips, spaced six weeks apart. clinical bottom line: athletes diagnosed with an alt with fai may still present with optimal lower body strength, making the decision for treatment more challenging. in these cases, it is important that the sports medicine team discuss all options with the athlete so an appropriate management plan can be instituted. abstract presentation 18 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 anxiety and depression amongst female athletes golden, dp, obmann, re, moore, em: university of virginia, charlottesville, va context: anxiety (categorized by a feeling of fear, dread, and uneasiness) and depression (mood disorder causing feelings of persistent sadness and loss of interest in things an individual once loved) are two major mental health disorders effecting females considerably who participate in sport. females are more likely to present with anxiety (55-60%)1 and depression (1.844 times)2 compared to males. the purpose of this study was to examine the prevalence between mental health comorbidities (anxiety and depression), across female athletes aged 18-40. methods: an anonymous survey was distributed via snowball sampling using social media. demographic data, generalized anxiety disorder-7 (gad-7), validated for use as a screening tool and severity measure across various settings and populations,3 and beck depression inventory-ii (bdi-ii), with high reliability (0.83-0.96)4 were utilized. analyses were conducted using spss with an alpha level set at p < 0.05. power calculation indicated a sample size of 84 participants. frequencies and proportions were determined. female athletes (n= 96, age: 22.47 ± 4.38 years, height 165.41 ± 7.51 cm, weight 64.15 ± 9.12 kg, bmi 23.48 ± 3.23) who were exercising for ≥5 days a week in an organized sport (i.e., clubs, teams, recreational), with total exercise volume of at least 8 hours per week met inclusion criteria. results: a total of 96 out of 109 participants completed the survey (88.1% completion rate). some participants did not complete all questions, however for the gad-7 and bdi-ii, only those who completed those specific sections in full were used for analysis (gad-7, n=90, bdi-ii, n=80). of those, 58.9% (n= 53/90) of participants were categorized as meeting clinically meaningful values of anxiety using the gad-7. less than 1% of participants reported taking anti-anxiety medication. 39.8% (n=30/80) of participants were categorized as having clinically meaningful values of depression and only 18.2% (n=8/80) of participants reported taking anti-depressant medication. 10 (11.1%) participants yielded severe anxiety scores and 6 (7.2%) scored severe depression. to note, 34.4% (n=31/90) presented with a comorbidity of both anxiety and depression. the majority (74%, n=71/96) of our population were collegiate athletes. conclusions: while our results are congruent with elevated anxiety and depression in female athlete populations, early identification (screening tools) and interventions are essential for a holistic landscape of the physical and mental health among female athletes. clinicians should be prepared and equipped to recognize as well as assist with mental health comorbidities for quality patient centered treatment plans. abstract presentation 19 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 external pressures on injured athletes’ and their effects on mental health and return to play graham a, johnson j: marshall university, huntington, wv context: student athletes face many challenges in and out of their sport. along with practicing and playing to their best ability, they have to worry about keeping up with schooling. once a player is hurt and out of play, they add the pressure of getting back into play on their plate. along with their own internal pressure, athletes may experience pressure from outside sources. these sources could include friends, family, coaches, and parental guardians. external pressures could play a role in how an athlete returns to play. this research can help us understand whether the external pressures end up causing the athlete more mental, emotional, or physical harm with re-injury. the purpose of this study is to determine whether the injured athletes feel any external pressure to return to play before they fully heal and if the external pressure affects their mental health. methods: participants were recruited by the university asking for their participation in this study. the survey was distributed through the university’s mass email system and was hosted by qualtrics. to be included in this survey the participants must be a student or facility member of the university. participants must also have participated in a high school or collegiate sport and have sustained an injury that put them out of play. the survey included general demographic information (age, gender, race, education, what sport they played, and what injury they sustained). the survey also included questions regarding the external pressures the athlete experienced during their injury. these external pressures include parent/guardian, coaches, and friends. results: 91 participants consented to do the survey. out of those 91 participants, 41 (45.05%) did not complete the survey. this survey is done on a scale from strongly disagree to strongly agree. out of the 50 participants that completed the survey, 29 (58%) stated that they felt external pressure during their time of recovery. 30 (60%) of participants stated that during their recovery their mental health declined. when asked if the external pressure the participants felt caused them to return to play before they were mentally ready 15 (30%) agreed, 10 (20%) neither agreed nor disagreed, and 25 (50%) agreed. 25 (50%) agreed that they pushed through pain and other symptoms because of external pressures. conclusions: the study found that during the injury most athletes experienced external pressures and a decrease in mental health. out of the 91 participants who consented to the survey only 50 (54.94%) completed the survey. this could be due to some athletes not experiencing an injury that put them out of play. determining which external pressures contribute to decreased health will increase the awareness of mental health in student athletes related to injury. abstract presentation 20 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 interdisciplinary approach to management of an l4/l5 disc herniation in a collegiate football player: a type 3 case study janush c, meriwether a, tillman m, hash s, cherry k, lisman p: towson university, towson, maryland background: the rate for low back injuries in collegiate football players has been reported as 2.70 per 10,000 athlete exposures with lumbar disc herniations (ldh) accounting for roughly 8% of these injuries. in athletic populations, the decision of surgical versus conservative management for ldh can present a unique challenge to the clinician and patient given an patient’s concern for return to play with minimal time loss. this type 3 case study will discuss the non-operative management of an l4/l5 disc herniation in a collegiate football player and highlight the interdisciplinary team approach that allowed the athlete to play an entire competitive season without limitations. patient: in january 2023, a 21-year-old male division i collegiate football player (long-snapper) presented to the athletic training facility with lower back pain, which radiated down his left leg. no specific moi was reported. both lower back and radicular pain were reported to increase during prolonged sitting and standing up from a seated position, as well as lowering into a sportspecific position. the patient was evaluated by the team physician and referred for diagnostic imaging. the mri revealed an l4 and l5 paracentral disc bulge with increased narrowing of the vertebral foramen. intervention: following diagnosis, the patient was cleared by the team physician to continue football-related activities as tolerated. the sports medicine team developed a management approach for this patient which included consults from a pain management physician and spine surgeon, rehabilitation sessions three times a week with a physical therapist, daily rehab and pain management sessions with the athletic training staff, weekly treatment from a chiropractor, and scheduled check-ins with team physician. physical therapy sessions focused on increasing abdominal strength and stability. exercises included supine alternating upper and lower extremity lifts with dumbbells, hip hinges, hamstring curls with physioball, quadruped resisted hip extension, and standing lumbar extension. the athletic training staff implemented daily treatments which included the following: lumbar heat pack in combination with electrical stimulation, si joint mobilizations, piriformis release and stretching, and hip realignment. additional therapeutic exercises performed twice weekly with the athletic trainer included quadruped fire hydrants, walking lunges, and pallof marches. weekly chiropractic care centered on mechanical lumbar traction and mild adjustment. all rehabilitation exercises were performed prior to practice while cryotherapy was provided following activity. lastly, the patient was directed to take otc nsaids as needed for pain, and received an epidural corticosteroid injection prior to the fall season. outcomes and other comparisons: given the patient’s position (special team’s long snapper) and limited plays per game, the patient was given the option for conservative treatment in effort to play the entire fall season and delay surgery to season’s end. the patient opted for this conservative approach and received a comprehensive interdisciplinary management plan that allowed him to play the entire season without time loss. conclusions: the election for surgical versus conservative management of ldh is often dependent on injury timing, patient symptoms, and the sport demands the athlete is returning to. in this case, the patient was a collegiate football player (long-snapper) who elected for conservative treatment. the interdisciplinary team, comprised of athletic trainers, physical therapists, a chiropractor, and team physician, worked together to develop a comprehensive management plan that allowed the patient to continue play throughout the competitive season. upon completion of the fall season, the patient underwent microdiscectomy surgery to address his ldh. clinical bottom line: this case highlights the benefits of an interdisciplinary team-based approach to injury management for a collegiate football player diagnosed with a ldh. since all members of the interdisciplinary sports medicine team have important roles in optimizing patient outcomes following injury, it is important for athletic trainers to consider this approach. abstract presentation 21 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 image 1: mri lateral view image 2: mri transverse view abstract presentation 22 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 mole or melanoma: knowing your abcde’s may save your life! knaul, jh: riverside health system, newport news, va background: skin cancer is the most common type of cancer in the united states. one in five americans will be diagnosed with skin cancer in their lifetime, or about 9500/day. research indicates that nonmelanoma skin cancer (nmsc), including basal cell carcinoma (bcc) and squamous cell carcinoma (scc), affects more than 3 million americans a year. more than 1 million americans are living with melanoma, nearly 200,000 cases of melanoma were diagnosed in 2022 with about 98,000 being invasive and 100,000 being noninvasive (in situ). the average age of diagnosis is 65. melanoma rates in the us have been rising rapidly over the past 30 years, doubling between 1982 and 2011, but trends vary by age. in 2018, the centers for disease control (cdc) reported 8,199 people died from melanoma. by making sun safety a habit, people can avoid sunburns and reduce the risk of melanoma. patient: 47-year-old, caucasian male with red hair, who spends a significant amount of time outside working as an athletic trainer. he had a history of blistering sunburns as a child, mostly on shoulders, nose and ears. he previously has had 4 suspicious lesions removed on head and back. the patient has bi-annual skin checks performed at a dermatologist’s office. during his 8/1/2023 skin check, a small suspicious lesion was noted on his left jaw line, just inferior to his ear and posterior to the angle of the mandible. patient was not aware of the lesion. the lesion was excised and sent for testing (see images below). differential diagnosis: squamous cell carcinoma, basal cell carcinoma, invasive melanoma, non-invasive melanoma. treatment: on august 6, 2023 results showed melanoma in situ (non-invasive). the dermatologist referred patient to a second dermatology procedure, a slow mohs procedure, which was scheduled for september 18, 2023. results the next day showed melanoma in situ at site 1 (located posterior to left ear lobe). a second slow mohs procedure was performed the following day (9/20/2023) with results on 9/21/2023 showing no additional melanoma present. outcome/comparison: a slow mohs procedure is a staged surgical excision used to precisely remove skin cancer while trying to save as much normal healthy skin around it. the tissue is processed in the mohs method to allow a pathologist to examine 100% of the margins and allow the surgeon to “trace” the roots. the procedure went as expected and the outcome was considered very good, with continued follow ups every 4 months for the first year, then back to 6 months thereafter. conclusion: this case illustrates the need for regular skin checks and appropriate skin care for all people who spend a significant time in the sun. learning what to look for as an individual can help to identify an irregular mole and know when a referral to a dermatologist is required. suspicious changes to pigmented areas should be monitored and evaluated using the mnemonic abcde: a – asymmetry what is the shape? b – border what do the contours look like? c – color how many colors? d – dimension what size? e – evolution have you noticed a recent change in one of the above? clinical bottom line: athletic trainers, like any outdoor athlete, have the potential for significant uv exposure. sun protection should include sunscreen, protective clothing and behavioral changes, including regular skin checks. outdoor winter sports are just as susceptible to uv exposure as outdoor summer sports. abstract presentation 23 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 figure 1 abstract presentation 24 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 specific barriers to athletic trainers’ familiarity with and attitudes toward concussion biomarkers: a phenomenological qualitative study mccormick, te, allen, jm, swindell, kgs, campbell, tr: old dominion university, norfolk, va context: the diagnosis of concussions is largely reliant on subjective information in conjunction with objective measures that might not be the most valid and/or reliable. there is now new research being performed evaluating the use of biological indicators, or biomarkers in the diagnosis and management of concussion. however, the amount of knowledge about biomarkers among athletic trainers is unknown. additionally, the barriers preventing ats from using such biomarkers has yet to be studied. therefore, the purpose of this study is to examine athletic trainers’ familiarity with and their attitude towards concussion biomarkers, while evaluating specific barriers preventing their use in current clinical practices. methods: the design of this study was a phenomenological qualitative research design. the participants for this study were recruited from a previous survey-based study in which participants were recruited through the national athletic trainer’s association (nata) research survey service. additionally, social media and snowball sampling were used to increase recruitment efforts. from this, there were several participants that stated they would be willing to participate in follow-up research. then, a total of 11 participants, all of which were certified athletic trainers, comprised of five females and six males, were chosen at random to be part of the research. data was collected via zoom (zoom video communications. version 5.13. san jose, ca: yuan, eric; 2022) interviews. all participants were asked the same nine questions by the same interviewer. the interviews were converted from speech to text transcripts, which were then reviewed by three additional researchers. following that review, the participants were sent their transcripts to make any changes and/or provide clarifications. the final step was to go through each transcript as a research group and code each line by a theme and subcategory. results: there were four themes total that were found within the transcripts. each theme had at least two subcategories. the specific theme that is the focus of this presentation is “barriers specific to biomarker use”. within this theme, there were four subcategories, which were setting/population specific, resources, training, and cost. the order in which they are listed is from most lines coded to the least. there were 70 total words/phrases coded under setting/population specific, 59 under resources, 34 under training, and 21 under cost. conclusions: based on the results, it can be concluded that the amount of knowledge varies among athletic trainers, but most participants have a broad idea about what biomarkers are. it can also be concluded that athletic trainers see the potential of biomarker use but have concerns due to the various barriers discussed. overall, athletic trainers need to see improvements in budgets, specific training, and more specific resources to effectively implement biomarkers into their concussion diagnosis and management practices. many of the participants expressed concerns regarding not having the appropriate setting for such tools to be implemented, like a secondary school that does not typically have a large budget for the sports medicine department, as well as the appropriate and/or supportive stakeholders. add in the gray areas about the resources that are needed to implement biomarkers and what the process would look like, as well as what training outside of athletic training would be, and athletic trainers feel left in the dark. while they have a generally positive view on the future of biomarkers, they do not know how it would come to fruition with these barriers. abstract presentation 25 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 non-operative management of distal and proximal interphalangeal fractures without excessive sport removal newhouse og, johnson, j: marshall university, huntington, wv background: intra-articular fracturs of the distal interphalangeal (dip) and proximal interphalangeal (pip) joints occur primarily from impacted shear force. with continued participation, fractures have a high possibility of nonunion or malunion. while accounting for patients’ requests may not always be possible, extreme modification of activity may permit their requests. patient: the patient is a college-aged female volleyball athlete who plays in the front row. the initial report showed a fracture of the right fifth phalange from incomplete range of motion (rom), swelling, and bruising after an impacted shear force was placed on her finger from a block. she was referred to have an x-ray. the initial x-ray showed a displaced bony mallet fracture of the distal phalanx and a comminuted intra-articular volar radial fracture of the middle phalanx. intervention: the initial plan was to restrict movement of dip with intermittent pip motion. the athlete participated in modified practice ten days after initial injury with a splint that extended dip and flexed pip. the day following, the hand specialist stated that there was no need for surgery as the proximal fracture was stable and the distal fracture was not warranting surgery yet. surgical intervention would have been more effective in the long-term, yet she expressed concerns about not having surgery as well, because she did not want to be removed from her sport for a long period of time. following this, the pip was to be in full extension at all times with no clearance to play and active assisted rom of pip needed to be performed every two hours. the 2nd week follow-up x-ray shows distal phalanx is healing and middle phalanx fracture is incomplete, she is clear for return-to-play (rtp) with conditions of no blocking with injured hand and alumafoam splint with buddy tape. active assisted rom rehabilitation process begins and a stax splint is worn on dip joint at night. the 4th week post injury, another x-ray is performed showing distal phalanx mallet fracture has widened slightly and there is healing on middle phalanx. she continues to splint in practice with modification of it being a curved splint and stax splint when outside of practice including during sleep. following this, she started to have pain in metacarpal phalangeal joint and “pitch count style” was implemented to limit stress on her finger of twenty-eight attempts of hits per day with no blocking of right hand. in the 7th week since initial injury, the x-ray showed healing of distal fracture with incomplete but stable fracture of middle phalanx with no change in alignment and incomplete remodeling. without the complete removal of play, the athlete was able to finish her final season in volleyball without permanent injury. outcomes: at 7 weeks since initial injury, the x-ray showed healing of distal fracture with incomplete but stable fracture of middle phalanx. at 19 weeks post-injury, she still has mild pain, swelling, and stiffness, but the finger is functional. she is cleared to return to normal activities, with low probability of reinjury. conclusion: the injury is a displaced bony mallet fracture of the distal phalanx and a comminuted intraarticular volar radial fracture of the middle phalanx. in the nineteen-week time period, she was minimally removed from sport with the implementation of extreme modification of activity per the athlete’s request. clinical bottom line: this case shows the importance of her sport to her as an athlete and the modification techniques implemented by her healthcare team to allow continued participation safely. in cases similar, accounting for patient requests with precautionary measures allows for continued participation without surgical intervention. by furthering research in modifications of activity, surgical intervention and removal of play has greater potential to be eliminated. abstract presentation 26 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 abstract presentation 27 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 platelet-rich-plasma injections vs. corticosteroid injections in the reduction of pain for patients with frozen shoulder: a critically appraised topic pendleton al, dombrowski mr, bonser rj dat, lat, atc, coots jg edd, lat, atc: liberty university, lynchburg, virginia focused clinical question: is a platelet-rich plasma or a corticosteroid injection better for relieving pain for patients with frozen shoulder pathologies? data sources: to identify relevant research papers, boolean searches were conducted on google scholar, cinahl ultimate, medline ultimate, and sportdiscus databases from september 14th through september 25th, 2023. key terms used were corticosteroid (cs) injection, platelet-rich-plasma (prp) injection, frozen shoulder, and adhesive capsulitis. study selection: the inclusion criteria were: articles published from 2018-2023, randomized control trials comparing prp and cs injections, and studies that used visual analog scale (vas). additionally, each article selected summarized outcome measures in a table. data extraction: a vas score was used as the main outcome measure for all three articles. participants in each study were assessed pre-injection for prp and cs injections for their pain levels. all articles collected vas scores until 12 weeks post-injection and 2 studies continued to monitor patient pain levels through 24 weeks. summary measures: for statistical analyses, all studies included used a pvalue of < 0.05 to determine statistical significance. p-values and mean vas scores are used to compare articles within this cat. evidence appraisal: the pedro scale was used to appraise the quality of evidence included. search results: three articles were selected for use in this cat from the 15 articles that were screened. this process is outlined in figure 1. data synthesis: in the study by gupta et al., the mean vas scores for prp-injection were as follows: 67.4 (pre-injection), 43.23 (12 weeks), and 14.33 (24 weeks). the mean vas scores for the cs-injection were 69.63 (pre-injection), 31.83 (12 weeks), and 31.63 (24 weeks). statistical significance was found between groups at both 12 (p=0.0001) and 24 weeks (p=0.0001). in the study by shahzad et al., the mean prp-injection vas scores were 8.9 (pre-injection) and 0.85 (12 weeks). the cs-injection had mean vas scores of 9.5 (pre-injection) and 2.3 (12 weeks). statistical significance was found with a p-value of 0.004. the third study by somisetty et al., recorded mean prp-injection vas scores of 8.5 (pre-injection), 2 (12 weeks) and 1 (24 weeks). the mean vas scores for the cs-injection were 8 (preinjection), 3 (12 weeks), and 2 (24 weeks). statistical significance was found at 12 and 24 weeks (p=0.0011). evidence quality: results of article appraisal using the pedro scale as follows: 8/10, 7/10, and 7/10. all articles lacked blinding of the participants and the therapist who administered the treatment. two articles lacked blinding of the assessors as well. conclusions: the purpose of this report was to compile the known evidence regarding the effect of prp and cs injections on frozen shoulder. grade a evidence found that prp injections had significantly decreased vas scores compared to cs for long-term results. evidence was inconclusive for short-term benefits. future research should be conducted to determine the best treatment for immediate relief. abstract presentation 28 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 from: page mj, mckenzie je, bossuyt pm, boutron i, hoffmann tc, mulrow cd, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021;372:n71. doi: 10.1136/bmj.n71 for more information, visit: http://www.prisma-statement.org/ http://www.prisma-statement.org/ abstract presentation 29 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 cyclops lesion in a collegiate men’s lacrosse player: a type 4 clinical case study powers k*, moen r*, siarkas g*, tamberrino k†, lisman p*: towson university, towson, md*, loyola university, baltimore, md† background: in late july 2023, a 20-year-old male division i lacrosse player reported to the athletic training clinic with pain, swelling, and an inability to fully extend his left knee. evaluation revealed an extension deficit of 5 – 10° during active range of motion (rom). the patient had previously undergone a double-bundle procedure to repair a torn anterior cruciate ligament (acl) in his left knee in november 2022. following this surgery, the patient completed a standard but conservative acl reconstruction (aclr) rehabilitation program as prescribed by the sports medicine team but switched to a light strength training regimen on his own during summer break. upon return to campus, the patient reported he had experienced lingering pain, swelling, and lack of full knee motion. notably, the patient had a previous acl injury in his contralateral knee and underwent single-bundle aclr prior to beginning his collegiate career. following this first surgery, the patient was discovered to have a cyclops lesion on the patellar tendon graft and underwent operative excision to remove the lesion. given his present symptoms, extension deficit, and previous history, the patient was given a platelet-rich plasma (prp) injection for his symptoms that paused his strength training program. as symptoms lingered, the patient was referred to the team physician who prescribed diagnostic imaging. mri findings revealed the presence of a cyclops lesion on the anterolateral aspect of the tibial insertion site of the acl graft. differential diagnosis: radial tear of the meniscus, chronic injury of the distal acl, excessive joint effusion, cyclops lesion. treatment: prior to the onset of postoperative symptoms following aclr rehabilitation for his left knee, the patient performed little to no rehabilitation or exercise. upon discovery of the cyclops lesion, the sports medicine team determined that surgery was required and delayed further rehabilitation until operative treatment was performed. in september 2023, the patient underwent left knee arthroscopy for debridement of the surrounding structures and excision of the cyclops lesion. following this surgery, the patient completed a rehabilitation program that mimicked that of an accelerated aclr rehabilitation plan and returned to play within two months of the cyclops lesion removal. uniqueness: cyclops lesions refer to fibrous nodules composed of granulated tissue that often present in front of a graft following aclr. the novelty of this present case is specific to the rarity of this condition, the presence of symptoms, and the athlete’s prior injury history (cyclops lesion following aclr of right knee). prior reports indicate that cyclops lesions present in only 1 – 10% of all aclrs, and only 2 – 10% of these cases are symptomatic. the patient presented with a loss of knee extension and pain with activity (e.g., running), findings consistent with prior research of symptomatic cases. roughly 90% of cyclops lesion cases are diagnosed within six months following aclr. in this case, the patient presented with increased symptoms and an extension deficit roughly eight months following aclr. lastly, and related to the aclr surgical approach, the incidence of cyclops lesions has been found to be greater following double-bundle graft reconstruction in comparison to single-bundle and hamstring graft aclr. the patient reported having undergone a single-bundle aclr for his prior acl injury (pre-college), yet he underwent a double-bundle procedure for his right knee. notably, the patient was diagnosed with cyclops lesions following both procedures. conclusion: although the incidence of cyclops lesions is rare and few are symptomatic, it can be a cause of pain and restricted motion weeks to months following aclr. in cases where a patient presents with increasing pain and an extension deficit several months following aclr, the athletic trainer should consider the potential involvement of a cyclops lesion. abstract presentation 30 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 influence of thermal protective gear on rural volunteer firefighter postural stability shagen e, patrick j, catanese a, glascoe b, pacinelli l, durst j: frostburg state university, frostburg, maryland context: firefighting is a physically demanding job. the ability to maintain and appropriately adjust postural stability is vital for the safety of firefighters, as they navigate through unpredictable terrain in various rescue situations while wearing restrictive equipment. the weight and design of thermal protective gear (tpg) may alter weight distribution causing changes to the center of gravity or restrict movement. the need for firefighters to maintain postural stability is essential for preventing falls onduty. the purpose of this study was to assess the influence of tpg on rural volunteer firefighter (vff) postural stability. methods: nine healthy males (mean±sd: age= 41±9.3 years; ungeared body mass= 96.47 ± 14.51kg; ungeared height=181.67 ± 4.48cm; vff experience 8 years) participated in a crosssectional correlation study during three visits to a university research laboratory. the tpg in this investigation included thermal pants, jacket, boots, and a standardized helmet and self-contained breathing apparatus (scba) with respirator. postural stability was assessed with and without tpg using a multiaxial device consisting of a dynamic, spring-loaded platform. assessments consisted of 3, 30s trials with participants attempting to maintain a single leg stance on the right leg, with two conditions, eyes open (eo) then eyes closed (ec). during assessment, the multiaxial stability platform started in a locked position then progressively released to 50% of the device’s available dynamic capacity. statistical analysis to determine performance differences between the ungeared and geared conditions were conducted using paired sample t-tests and pearson’s coefficient correlations to evaluate relationships between ungeared and geared condition performance. level of significance was determined as 𝛼𝛼 ≤ 0.05. results: tpg added an average 25.63kg additional weight to participants (mean±sd geared weight= 122.09±15.47kg). there was a significant difference between ungeared and geared eo anterior-posterior index (api) (p=0.03) that presented with a large effect size (d: -0.73). a significant difference between ungeared and geared ec overall stability index (osi) with a moderately large effect size was also found (p=0.032, d: 0.72). overall stability index and api demonstrated a positive, significant correlation in the geared condition with eo (r=0.822-0.975, p=<.001-.008), while osi and api for the ungeared eo condition exhibited moderate to strong significant, positive relations (r= 0.576-0.780, p=<.001-.013). conclusions: the results of this study indicate a strong relationship between geared conditions and higher index scores. wearing tpg while eo negatively affected balance compared to ungeared trials. the influence of ec significantly decreased postural stability with tpg. the correlations identified between api and osi affirm that osi is a composite score with anterior-posterior sway as an influential factor. the additional weight from the tpg may complicate postural stability capacity of volunteer firefighters, especially in the absence of clear visual input which is often encountered during fire rescue situations. abstract presentation 31 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 weighted ball programs and medial elbow injury in youth baseball pitchers sobolewski m, pritchard k: shenandoah university, winchester, va introduction: weighted ball programs have been proven to increase pitching velocity, however a combination of poor musculature and body mechanics with increased elbow valgus can heighten the incidence of medial elbow overuse injuries in the youth population. clinical question: can youth baseball pitchers who use weighted ball programs increase their pitching velocity without causing an increased risk of medial elbow injury? methods: the literature was explored to discover studies that investigated medial elbow injuries using weighted ball programs in youth baseball pitchers. articles included weighted ball programs as an intervention, kinetics/injury mechanics, youth elbow injuries, and prevention of overuse injuries. studies were excluded if athletes were over 18 years old, collegiate or professional athletes, or other treatment methods were used. five key studies were ultimately selected in this critical appraisal. results: in reinold et al, the experimental group underwent a 6-week weighted ball program and displayed a statistically significant 1 m/s increase in the training group representing a 3.3% increase in ball speed. there were 4 elbow injuries in this group (24%) that required medical intervention. in okoroha et al, medial elbow torque increased by 0.92 nm, arm speed decreased 8.52 rpm, and pitch velocity decreased 2.0 mph per 1oz increase in ball weight. moore et al illustrated when throwing the 3oz baseball, the pitchers decreased their elbow varus torque compared to the 5oz baseball. mahure et al indicated that the incidence of ucl reconstruction surgeries is expected to increase remarkably for those between 15-19 years old through 2025. translation to practice: research supports the use of weighted ball programs to increase pitch velocity, but more evidence is needed to detect how this influences injury rate. weighted ball programs should be approached with caution and utilize proper coaching to decrease incidence of medial elbow injuries in youth athletes. abstract presentation 32 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 presentation of an accessory navicular bone in a collegiate women’s field hockey player: a type 3 clinical case study sutker n, franco j, mallory k, hansberger b, lisman p: towson university, towson, maryland background: the accessory navicular is an extra bone located posterior and medial to the navicular tuberosity. the prevalence of accessory navicular has been reported to be 4 21% in the general population though this anatomical variant may often be overlooked during differential diagnosis. this case presents a female collegiate field hockey patient that was initially diagnosed with a midfoot sprain but was later determined to have an accessory navicular bone which required surgical removal. patient: a 19year-old female division i collegiate field hockey patient presented to the athletic training clinic with pain in her left medial foot. the patient could not recall a specific moi and reported noticing the pain after an in-season game. patient had no previous injury history to her left foot or ankle. physical examination revealed mild edema over the left navicular bone with point tenderness on the navicular, medial cuneiform, and the anterior aspect of the deltoid ligament complex. pain was reported with eversion during active and passive rom. mmt of the peroneus longus and brevis, and anterior tibialis revealed 5/5 strength; posterior tibialis and peroneal tertius measured 4/5 strength. further evaluation revealed navicular pain during metatarsal glides (1st and 2nd), kleiger’s, and eversion talar tilt tests. results for the calcaneal bump and lower leg compression squeeze tests were negative. intervention & treatment: the patient was treated for a midfoot sprain and permitted to participate in sport-related activities as tolerated. initial therapy focused on pain and edema control and strengthening the muscles of the foot and ankle. prior to sport activity, a donut pad was placed over the navicular and a modified teardrop low dye arch tape was applied. at 3 weeks post-injury, the patient reported increased pain that was now present after sport-related activities and during the toe-off phase of walking. additionally, the patient reported pain in her left achilles tendon and stated she purposely altered her running gait to decrease impact on her medial foot. over the next 2 weeks, rehabilitation was modified to include soft tissue therapy consisting of dry needling over the achilles tendon and midfoot area and instrument assisted soft tissue mobilization to the posterior lower leg. additionally, a joint decision was made by the team physician, athletic trainer, coach, and patient to allow the patient to continue play throughout the remainder of the season as tolerated. management would include continued rehabilitation and taping prior to activity, and administration of a walking boot which was to be worn at the start each week as needed. activity modification included having the patient routinely complete non-impact conditioning in place of practice to maximize her health for end-of-week game play. diagnostic imaging taken at 8 weeks post-injury revealed an os supranaviculare, which would require surgical excision. following the season, the patient underwent a modified kidner procedure to remove the accessory navicular. outcomes or other comparison: due to increasing pain and unresponsiveness to conservative treatment, the patient was discovered to have an accessory navicular bone. however, the injury management plan was successful in permitting the patient to play the entire competitive season as tolerated. conclusion: in this case, the patient originally presented with findings consistent with a medial midfoot sprain though the presence of an accessory navicular bone would ultimately be discovered. following the season, the patient underwent a modified kidner procedure to remove the accessory navicular bone. clinical bottom line: symptomatic accessory naviculars have been reported to occur more frequently in young, active women though diagnosis is often missed or delayed. in cases where a patient presents with medial midfoot pain with no specific moi, and is unresponsive to therapeutic treatment, the athletic trainer should consider the potential involvement of an accessory navicular. abstract presentation 33 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 treatment timeline figures: abstract presentation 34 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 a qualitative study evaluating athletic trainers’ self-perceived knowledge and knowledge acquisition of concussion biomarkers swindell kgs, mccormick t, allen jm, campbell tr: old dominion university, norfolk, va context: rapid movement of the brain caused by a concussion can damage brain cells and create chemical changes within the brain, which may cause lasting neurological, cognitive, and behavioral symptoms. it is suggested that following a trauma, biomarkers can be released which may be useful in accurately diagnosing concussions. potential biomarkers being studied include β-amyloid peptide 42 [aβ42], s100 calcium-binding protein b [s100b], glial fibrillation acidic protein [gfab], microtubuleassociated protein 2 [map2], and 2’,3’-cyclic-nucleotide 3'phosphodiesterase [cnpase]. this study focuses on evaluating at knowledge and awareness of biomarkers, with sub-analyses evaluating ats’ perception of current knowledge of biomarkers, and the acquisition of current knowledge of biomarkers. these themes are derived from a larger study, titled, “athletic trainers familiarity with and their attitudes towards concussion biomarkers: a qualitative study.” methods: a phenomenological qualitative research design was used where 1 researcher separately interviewed the participants with the same series of 9 questions. participants were recruited from the national athletic trainer’s association (nata) research survey service, snowball sampling, and social media recruitment. interviews were conducted remotely using zoom (zoom video communications. version 5.13 san jose, ca: yuan, eric; 2022) where the speech was converted into text, via zoom’s automatic transcription. there were 11 participants, all are certified ats from a variety of settings, with 5 females and 6 males. the study process involved data analysis through a consensual qualitative research traditional process broken down into five cycles, which created a codebook. for this study, the codes being used are from theme 1 and are codes 1a and 1b. results: out of the 11 participants, 3 of them indicated no prior knowledge of biomarkers and their use in relation to concussions, due to lack of being exposed to biomarkers and lack of necessity to research them due to their work setting, with 2 university and 1 secondary school settings. five participants indicated minimal prior knowledge, with 1 occupational, 2 secondary school, and 2 university settings. they acquired their knowledge through research, attending conferences, and by word of mouth. they stated that they did not have a large amount of knowledge due to their work environments, are established with their concussion diagnosis/management practices, and it not in discussion in their respective settings. one participant, at a secondary school, indicated a decent amount of prior knowledge and stated that they acquired their knowledge through their research. two participants indicated a considerable amount of prior knowledge and stated that they acquired their knowledge at work, 1 military/university/research and 1 research. conclusion: this study concluded that the majority of the participants have minimal prior knowledge of biomarkers and their use with concussions. the majority did not receive any formal training or education on biomarkers and gained their knowledge through their efforts. biomarkers are not a current discussion in the majority of work settings of ats due to a variety of obstacles. due to lack of knowledge, formal training, and education, it would be difficult to implement biomarkers in relation to concussions in the athletic training field in the near future. with further research on this topic, conducting more studies similar to this one, and providing opportunities for formal education and training to ats, implementation of biomarkers for concussion diagnosis and treatment in the athletic training field may be possible in the future. abstract presentation 35 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 the food environment of female athletes attending historically black colleges and universities: a qualitative study on the dimensions of food access and nutrition uriegas na, winkelmann zk, emerson dm, ortaglia a, torres-mcgehee tm: university of south carolina, columbia, sc context: student-athletes are a subset of college students who face additional stressors related to the demands of their sport and academic workload. the food choices of student-athletes may be influenced by the unique food environment they are in. further challenges may present for historically black colleges and universities (hbcus) student-athletes as their institutions tend to be in low food access areas. we aimed to assess food security and explore the lived experiences of hbcu female student-athletes surrounding their food environment and ability to access food based on the five dimensions of food access: availability, accessibility, affordability, accommodation, and acceptability. methods: this qualitative study used a semistructured interview protocol derived from quantitative data to explore the lived experiences of 10 hbcu female athletes (age = 19 ± 1 years) living in on-campus dormitories. participants answered the us department of agriculture six-item short form of the food security survey module as part of the interview. participants were recruited after completing a quantitative study examining energy needs and availability. interviews lasted approximately 30 minutes and were recorded and transcribed verbatim using virtual transcription services as part of a web-based conferencing platform. data were analyzed by three coders using the consensual qualitative research tradition. trustworthiness was established using member checking, multi-analyst triangulation, and external auditing. results: food security status varied across participants, resulting in an even split (50/50) between food security and food insecurity. four domains emerged from the interviews: 1) on-campus living, 2) personal, 3) convenience, and 4) nutritional awareness. the participants shared available food sources on campus and within their community and the challenges of living in an on-campus dormitory with limited resources to make their meals, something they wished they could do more of. they discussed that while having various food sources, at times, it is not what they would like to eat; it may not look appealing to them, or they may perceive the food as unhealthy. participants detailed timing conflicts as a challenge to fuel properly and rely on quick options such as frozen meals and snacks on the go to fuel during the day. following the quantitative study, athletes reflected on their nutritional habits and detailed an understanding they do not fuel appropriately for the activities they engage in. additionally, female athletes reported having some form of nutritional knowledge sources in the past, but these were typically informal conversations before their enrollment at their current institution. conclusion: although hbcu female student-athletes have options at school and in their community, our findings suggest they may require modifications based on timing and schedules to meet their needs. hbcu administrators, athletic trainers, and coaches should collaborate with the athletes to explore community resources and public benefits such as supplemental nutrition assistance program (snap) benefits and food banks, update antiquated dorm policies, and provide nutritional education resources specific to their needs. abstract presentation 36 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 an investigation of lower extremity injuries in soccer athletes related to their playing environment whitlock ak, francis k, maloney h, lapole c, anders b, garrett wz, & konz sm: marshall university, huntington, wv context: the goal of this study was to investigate a connection between cleat type, surface type, and increased lower extremity injury rates in soccer athletes. our hypothesis was that the cleat model, surface type, and facility affected the lower extremity injury rate among soccer athletes. methods: a review of survey results distributed to the male and female soccer from an ncaa d-i program was completed. the survey investigated athlete injury history related to the specific shoe worn and the field surface information where the injury occurred. measures of central tendency were calculated. data was analyzed using a correlation analysis with the alpha level set at 0.05. results: twenty-one athletes completed the survey. of the participants, 13 were between the ages of 18 and 20, while seven were between the ages of 21 and 23. females were 52.38% of the respondents, while 42.86% were men. the breakdown in the type of cleat worn by the athletes is as follows: nike mercurials (9), nike phantoms (4), nike tiempos (6), and nike premier (1). out of 50 possible respondents, 21 were completed (42%). of the 21 respondents, 13 (61.9%) reported a soccer-related injury last season. athletes reported 10 acute injuries and 4 chronic injuries lasting longer than 6 months. the direct mechanism of injury saw 9 non-contact mechanisms, while 5 suffered a contact injury. nineteen injuries occurred in practice, and 8 were during a game. injuries occurred more frequently at home (11 or 52.38%) during practice (10). injuries occurred more frequently on artificial turf (52.38%) than on natural grass (14.28%). the multiple linear regression analysis reported no significant findings. conclusions: our study investigated the relationship between cleat type, surface type, and increased lower extremity injury rates in soccer athletes. we rejected our hypothesis based on the statistical analysis as our results found no connection to an increased lower extremity injury rate despite the cleat worn or surface. our results contradict other published research indicating a correlation between cleat type, surface type, and lower extremity injury rates. studies demonstrated lower extremity injury rates increase daily by 16% on artificial turf (old-generation and new-generation) with increased ankle and foot injuries. natural and artificial surfaces are guilty of increased hip and knee injury, with females having a significant increase in anterior cruciate ligament injury risk playing on natural grass. a limitation of our study was the small number of participants, which affected the findings. the response rate was at a lower level than hoped. abstract presentation 37 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 caffeine consumption on sports performance measures in college athletes: a critically appraised topic wills ja, fraley al: university of south carolina, columbia, sc focused clinical question: how does caffeine (caf) consumption affect sports performance measures in healthy college athletes? data sources: in december 2023, pubmed was utilized to search key terms, including collegiate athlete, caffeine, and performance measures. a publication time frame from 2013-2023 was established. study selections: inclusion criteria consisted of studies investigating collegiate athletes ingesting caf and its impact on anaerobic, agility, and speed performance measures. exclusion criteria consisted of participants with current injuries and ingredients consumed in addition to caf. data extraction: outcomes included sports performance measures such as: vertical jump test, 60and 100-meter time trials, reaction time, maximum voluntary isometric contractions (mvic), and anaerobic muscle endurance through the submaximal voluntary isometric contractions fatigue protocol (t lim). summary measures: statistical analyses were performed utilizing non-parametric kruskal-wallis tests, paired-sample t-tests, and analyses of variance (anovas). evidence appraisal: all included studies were randomized-controlled trials. quality of evidence was assessed using the pedro critical appraisal checklist. search results: the computerized search resulted in 42 studies. thirty-seven were excluded due to not being published within the past 10 years. the remaining 5 met all inclusion criteria. data synthesis: all included studies supported that caf has a positive effect on sports performance measures. one study found that reaction time was faster after consumption of a caf supplement in comparison to placebo (pl) (caf: +0.4 to 7.5%; pl: -1.4 to 1.4%, p<0.5). another study found that reaction time was significantly faster (p<0.01) with caf dosages of 1.56 mg·kg−1 (1.5 (0.7±0.02 s), 3.0 (0.71±0.02 s), and 6.0 mg·kg−1 (0.69+0.02 s) compared to placebo (0.73±0.02 s). the third study established that up to 6 mg/kg of caf significantly increased mvic (male: ↑5.1%; female: ↑6.7%, p<0.05) and t lim (male: ↑16.6%; female: ↑14.4%). the fourth study measured explosive lower body power, finding higher doses of caf, from 3 to 6 mg/kg, significantly improved vertical jump height (57.00±6.38 vs. 60.33±5.51, p<0.001). the last study measured speed with a 60and 100meter sprint; caf intake significantly decreased sprint time by 0.14 seconds in 100-meter test (caf: 11.26±0.33 s, pl: 11.40±0.39 s; p = 0.007). the 60-meter sprint time was also decreased compared to the placebo (caf: 7.03±0.17 s; pl: 7.12±0.20 s; p=0.002). evidence quality: articles received 8/11, 9/11, 9/11, 11/11, and 9/11 on the pedro scale. lost points were due to a lack of establishing eligibility criteria, lack of random allocation to groups, not concealing allocation, and lack of assessor blinding. conclusion: there is a moderate amount of evidence indicating that caf intake can positively affect various athletic performance measures in the collegiate athlete population. these findings indicate a strength of recommendation a due to the high quality, consistent, and patient-oriented results. further research should examine additional advantages and disadvantages of caf consumption on sports performance. abstract presentation 38 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 southwest athletic trainers’ association free communications abstract presentations the following abstracts were accepted and presented at the 69th southwest athletic trainers’ association (swata) symposium, 2024. individual goal and velocity based throwing program for collegiate baseball pitchers with medial elbow injuries. trail le*†, cline jm‡, jacobsen ap†§, warner bj?, cage sa*: *the university of texas at tyler, tyler, tx; †ut health east texas, tyler, tx; ‡azalea orthopedics, tyler, tx; §university of texas health science center at tyler, tyler, tx; ?grand canyon university, phoenix, az background: a 22-year-old male collegiate baseball pitcher experienced sudden pain in the medial left elbow following feeling a pop when pitching. the pitcher was removed from the competition and was evaluated with a point-of-care ultrasound at the conclusion of the competition. ultrasound revealed an intact ulnar collateral ligament (ucl) and no edema. differential diagnosis: ucl sprain, wrist flexor strain treatment: the patient was referred to a primary care sports medicine physician for further evaluation. the physician found no tenderness or laxity at the ucl and ordered an mri arthrogram for further diagnostic information. mri revealed a grade ii flexor digitorum superficialis strain. after consultation with the physician and athletic trainer, a return-to-play protocol involving a platelet-rich plasma (prp) injection, therapeutic exercise, individual goal, and velocity-based interval throwing program was agreed upon. 20 days following injury, the patient received an ultrasound-guided prp injection at the site of injury. 24 days following injury, the patient achieved a full range of motion after the injection. as such, the patient began isometric exercises. 26 days after injury, the patient began resistance exercise for the forearm extensors, flexors, pronators, supinators, and finger intrinsics with blood flow restriction. prior to beginning the interval throwing program, the pitcher met with the athletic trainer to discuss individualized goals and milestones with the pitcher’s input being taken into account. 31 days after injury, the patient began the individual goal and velocity-based throwing program shown in table 1. 52 days after injury, the patient was able to successfully return to competitive pitching without complication. uniqueness: while the flexor strains at the elbow are common injuries among baseball pitchers, the majority of throwing programs are distance based rather than velocity based. additionally, many of these programs have been shown in previous research to be generic, and even arbitrary in some cases. this case details the use of an individual goal and velocity-based interval throwing program to progress a pitcher back to competition. by adding in individualized goals set by the patient, there was an opportunity to give the patient a greater sense of agency in his return to play process. additionally, the velocity-based aspect of the program allowed objective data to dictate progression to the next phase of the throwing program. conclusions: when attempting to return of an overhead throwing athlete to participation, it is important to incorporate individualized goals and objective measures of performance. doing so has the potential to increase patient compliance and provides a more measurable means of progressing to the next phase of return to play. as diligent clinicians, athletic trainers should assess and reassess any return-to-play protocol a patient is completing to ensure optimal outcomes. abstract presentation 39 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 table 1. individual goal and velocity based throwing program timeframe throws percentage of max velocity (84 mph) target velocity day 1-3 2x20 70% 59-61 mph day 4 1x20 70% 59-61 mph day 5 2x20 1x10 70% 75% 59-61 mph 63-65 mph day 6 & 7 2x20 75% 63-65 mph day 7 rest rest rest day 8 & 9 2x20 1x10 75% 85% 63-65 mph 72-74 mph day 10 1x20 85% 72-74 mph day 11 preparation preparation preparation day 12 1x20 80% bullpen (89 mph max) 71-83 mph day 13 recovery recovery recovery day 14 rest rest rest day 15 & 16 2x20 90% 76-78 mph day 17 preparation preparation preparation day 18 1x20 90% bullpen (89 mph max) 80-82 mph day 19 recovery recovery recovery day 20 rest rest rest day 22 preparation preparation preparation day 23 competition competition competition day 33 & 34 3x20 90% 81-87 mph abstract presentation 40 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 continuing education seminar’s impact on knowledge and retention among athletic trainers. brandon warner*†, gill d†, shultz s†, karper w†, cage sa§: *grand canyon university, phoenix, az; †university of north carolina – greensboro, greensboro, nc; §the university of texas at tyler, tyler, tx context: the athletic training profession requires continuing education (ce) to maintain their national practice credential. recent research has shown healthcare professionals to have knowledge and skill declines postcontinuing education courses. even with the ce mandate and available research, there is little evidence on the effectiveness of continuing education in the profession of athletic training. there is also a lack of research on the impact of a ce seminar assessing behavior change post-seminar. therefore, the purpose of this study is to determine the impact of an educational seminar on participant knowledge gain, knowledge retention, and reported use of es for pain management. methods: an electronic survey was sent to preceptors at a caate accredited institution and recipients were encouraged to use snowball recruiting. a total of 48 certified athletic trainers, from two samples, with an average of seven years of experience, started this study. a web-based survey assessed educational history, current use, perceived and actual knowledge of electrical stimulation. participants attended a 1.5-hour seminar and completed surveys pre-seminar, postseminar, and at one-month follow-up. basic descriptive statistics were calculated for all responses and scores. paired t-tests were used to assess changes over time on knowledge, with significance set at p < .05. independent samples t-testing, with levene’s test for equality of variance and means, was performed to ensure samples could be pooled. related-samples wilcoxon signed rank test was used to assess differences between usage for acute and post-operative pain. results: a total of 41 participants completed the postseminar survey and 30 of those completed the one-month follow-up survey (62.5% response rate). most (82.9%, n = 34) participants rated the seminar as excellent. participants (n = 41) demonstrated a significant improvement in perceived (t(40) = 7.03, p < .001) and actual knowledge scores (t(40)= 5.08, p < .001) post-seminar. those who completed the one-month follow-up survey (n=30) demonstrated a significant increase in perceived knowledge (t(29)= 5.11, p < .001) post-seminar. perceived knowledge scores decreased significantly on the one-month follow-up survey (t(29)= 3.17, p = .004) but remained significantly higher than pre-seminar (t(29)= 3.13, p = .004). the participants also demonstrated a significant increase in actual knowledge post-seminar (t(29)= 3.03, p = .003) and remained significantly higher than preseminar at the one-month follow-up surveys (t(29)= 3.69, p < .001). the frequency of use for electrical stimulation showed no significant difference for acute pain (z = -.816, p = .414) or post-operative pain usage (z = -.465, p = .642). conclusion: these findings suggest that the presentation was effective for improving both perceived and actual knowledge scores in athletic trainers and was well received by the participants. the seminar was not effective for increasing the use of electrical stimulation in the sample. abstract presentation 41 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 myositis ossificans in a female sprinter with the sickle cell trait quintana rl, menjivar m, goyen c, knoblauch m: university of houston; houston, tx background: sickle cell trait (sct) is associated with an increase in muscle breakdown after strenuous exercise due to improper blood flow to active muscles. evidence suggests that individuals with sct can increase muscle breakdown during exercise by as much as 54%. this case outlines a 21-year-old african collegiate sprinter with sct who reported feeling a “pop” in her right hamstring that caused her to stop running mid-race. she reported that no pain was associated with the “pop” but was scared by the sensation. evaluations of strength and range of motion were all unremarkable and there were no palpable deformities. she continued in her sport for 3 months until she suffered a similar injury on the left hamstring, again with an unremarkable evaluation. because of a history of hamstring strains, she was referred to the team physician, where inflammation and a hardened nodule on the earlier-injured right hamstring led to ordering of bilateral magnetic resonance imaging (mri). differential diagnosis: hamstring strain, avulsion injury, hamstring tendinitis, adductor strain, and myositis ossificans were suspected. treatment: the mri revealed bilateral grade 2 hamstring strains with evidence of prior ruptures in the mid-belly of the right hamstring, along with myositis ossificans (mo) and hematoma. the hematoma was aspirated, and the athlete began a rehabilitation protocol to get her back to running activity. however, after 2 months, the athlete was referred for a 2nd mri due to an inability to sprint at full speed without pain. this mri revealed that the mo and strain were still present, warranting a platelet-rich-plasma (prp) injection to improve healing. following the injection, the athlete returned to running for 3 months; however, she was unable to fully sprint without pain. a subsequent ultrasound showed that the mo had grown, and the decision was made to surgically remove the mo, followed by a rehabilitation program centered around restrengthening the hamstring. after 4 months of this program and running with the athletic trainer, she returned to practicing with the team. a month following the athlete’s return to sport, she felt a “pop” in her right quadricep while performing a reverse lunge. she was referred to the team physician, where a 3rd mri scan was ordered. this scan revealed a grade 2 strain in her rectus femoris with the presence of mo. this 2nd incidence of mo led to a consideration by her team athletic trainer that sct might be a contributing factor to its development. taking this into account, a prp injection was administered to the quadriceps with the intent that the calcium deposits would resorb. the athlete began restrengthening exercises and a running progression that involved the use of an alter-g treadmill, coupled with ample rest and hydration periods to combat a potential sickling event. within 3 months from the prp, she was able to fully compete. uniqueness: there is scant research on myositis ossificans for athletes with sct. the athlete in this case had repetitive tissue damage and the presence of mo, which may be related to muscle breakdown as a result of harboring sct. furthermore, this athlete did not initially present with common symptoms of a hamstring strain such as immediate pain, swelling, tenderness, palpable defect, and loss of function. the subsequent calcification that occurred in the rectus femoris created a potential link for mo and sct given the 2nd incidence in a short time. conclusion: this case describes a 21-year-old african sprinter with sct, and multiple incidences of mo. establishing if a link exists between mo and sct could help provide better care for athletes harboring the sct gene. abstract presentation 42 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 esophageal candidiasis in a baseball athlete fitzgerald a*, carvino n†, knoblauch m*, harrison l*: *university of houston, houston, tx, †rice university, houston, tx background: candidiasis is a yeast-based fungal infection often found in immunocompromised individuals, that can produce white patches, redness or soreness in the mouth, xerostomia, loss of taste, pain with eating and swallowing, and angular cheilitis. the patient in this case is a 21-yearold male baseball player who presented to the athletic trainer (at) with flu-like symptoms such as fever, cough, body aches, shortness of breath, and chills. the at referred the patient to the team physician, who prescribed zithromax five days after the onset of symptoms for bronchitis. there was no improvement after two days, so a medrol pack was prescribed to alleviate shortness of breath. three days later, the patient went to the emergency department (ed) complaining of vomiting after the consumption of food for the last 24 hours and hemoptysis. a computed tomography (ct) angiogram of the patient’s chest was ordered but imagining was unremarkable. he was discharged the same day with a prescription for acetaminophen, codeine-guaifenesin, and ondansetron. two days later, he reported to the team physician with complaints of stomach pain, dark urine, dark stools, coughing, and vomiting. he was prescribed zofran with codeine syrup to alleviate vomiting. the next day, he returned to the ed complaining of vomiting after the consumption of fluids, stomach pain, and dark stool. the physician ordered a non-contrast ct scan of the patient’s abdomen and pelvis, which was unremarkable. he was discharged the same day with a prescription for famotidine, promethazine, and sucralfate. three days later he was referred to a gastroenterologist (gi). the gi admitted the patient into the hospital to undergo an esophagogastroduodenoscopy (egd) due to the loss of 20 pounds in two weeks. differential diagnosis: initial suspicions included upper respiratory infection, bronchitis, or peptic ulcer. treatment: the egd discovered that the patient had a diaphragmatic hernia and a candidiasis fungal infection inside of the esophagus. the patient was prescribed an anti-fungal medication and discharged after three days. within a few days, the patient was able to tolerate eating and drinking. caution had to be taken when introducing foods back into his diet, as he was at risk for developing refeeding syndrome, a potentially fatal shift in the fluids and electrolytes that occurs in malnourished patients receiving artificial refeeding. the patient consulted with a registered dietician (rd) who prescribed a multivitamin, 100mg of thiamine, and recommended a high carbohydrate and protein diet. two weeks after the patient was discharged, he was cleared by the at and rd to begin the return-to-play (rtp) protocol. the rtp protocol introduced activities such as riding a stationary bike and weightlifting workouts. once light activities were tolerable, he started incorporating baseball-specific activities such as hitting, tossing, and base-running. the patient made a full recovery and returned to sport 3 months after the egd procedure. uniqueness: candidiasis in the esophagus is typically seen in individuals with a weakened immune system, such as those living with human immunodeficiency virus/acquired immunodeficiency syndrome and those who have cancers such as leukemia and lymphoma. since esophageal candidiasis is unique in a healthy population, there is not a protocol to follow when returning to activity. in this case, the at treated the patient’s rtp similarly to the covid-19 rtp protocol, which focuses on light activity and slowly progresses as the patient can tolerate. conclusion: the case outlines a 21-year-old baseball player who suffered from an esophageal candidiasis infection. understanding the symptoms of candidiasis as well as how to avoid refeeding syndrome was imperative to treating this patient. the patient in this case was able to make a full recovery and returned to baseball as normal. citation accuracy of scholarly journal articles in sports medicine abstract presentation 43 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 warner lk*, trail le†‡, warner bj§, cage sa*: *creighton university, omaha, ne; †the university of texas at tyler, tyler, tx; ‡ut health east texas, tyler, tx; §grand canyon university, phoenix, az context: previous research has expounded on the importance of accurate use of references in scholarly manuscripts. a thorough and appropriate use of references allows authors to validate and lend credence to the position they are attempting to take on their subject matter. reference errors have been well documented in multiple scholarly journals covering healthcare topics. to date, there does not appear to be a description of the accuracy of reference lists in sports medicine scholarly journal articles. therefore, the purpose of this study was to describe the rate of reference errors in sports medicine literature. methods: we examined four peer-reviewed sports medicine journals: journal of athletic training (jat), athletic training education journal (atej), clinical practice in athletic training (clinat), and journal of sports medicine and allied health sciences (jsmahs). we randomly selected 10 issues each from jat and atej, and five issues each from clinat and jsmahs. this resulted in 262 articles, containing a total of 8,686 references being reviewed. each citation was checked for grammar errors, as well as errors in the provided doi number when applicable. measures of central tendency (means, frequencies, and standard deviation) were calculated where applicable. results: 13.7% (n=36) of articles had minor reference errors, and 3.1% (n=8) of articles had major reference errors. overall, jat presented with the fewest average citation errors per article compared with the other journals evaluated (jat = 0.05 ± 0.22; atej = 0.10 ± 0.30; clinat = 0.24 ± 0.50; jsmahs = 0.88 ± 1.18). clinat and jsmahs were the only journals that featured the regular reporting of doi numbers for citations. while 13.1% (n=202) doi numbers in clinat (3.52 ± 3.55 doi errors per article) and jsmahs (2.69 ± 4.25 doi errors per article) did not take the investigators to the corresponding article, a number of these errors appeared to be due to the number not having a linked webpage from the host journal. conclusion: while each scholarly journal evaluated contained at least some articles with minor or major reference errors, the relative number of errors was similar or lower than those found in scholarly journals in other healthcare professions. fields including general surgery, neurosurgery, and nursing have all documented concerns related to citation accuracy in scholarly journals related to their area of study. as such, these findings are not an issue faced exclusively by athletic training and sports medicine professionals. errors in references appear to be an issue for sports medicine scholarly publications. while the rate of error appears to be similar or better than other healthcare fields, there is still a need to improve reference accuracy in sports medicine scholarly writing. abstract presentation 44 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 the analysis of ground kinematics in tie-down ropers watts m, chelette a, sandford j, mata k: stephen f. austin state university, nacogdoches, tx context: tie-down roping, an event in rodeo, occurs when the athlete ropes a calf while on horseback, quickly dismounts from the horse and ties three legs of the calf together. injuries to the knee and lower body have occurred with athletes in the tie-down roping event. previous research with college rodeo athletes has shown the knee to be the most frequently injured area of the body. the athlete’s lower body movements during the dismount from the horse may increase the risk of injury to the knee. however, these movements have not been previously studied in the tie-down roping event. the purpose of this pilot study is to examine the lower body movements of college rodeo athletes during a practice tie-down roping run. methods: two male tie-down athletes were recruited from local college teams for this pilot study. all participants were screened for musculoskeletal injuries and provided informed consent. movella awinda inertial measurement units (imu) were used to analyze joint kinematics over three trials of the tie-down roping event. sensors were secured to the posterior pelvis, lateral thigh, and medial shank under the subject’s jeans and on top of the foot inside the boot. movella analyze pro software and a custom matlab script were utilized to deduce the hip and knee joint angles at the time of contact and for the following 100ms. the results of three trials for each subject were averaged and the average of all subjects is reported. results: left foot ground contact always occurred before right foot ground contact. hip flexion was 39° ± 15 in the right and 22° ± 3 in the left at ground contact. both hip angles reduced by 7° toward extension over the next 100ms. knee flexion was 38° ± 5 in the right and 31° ± 20 in the left at ground contact. knee angle reduced by 10° over the next 100ms in the right but remained stable (within 1°) over the next 100ms for the left. the knee was slightly adducted at ground contact for the right -.2° ± 7 and -.2° ± 3 left knee. conclusion: these results suggest that hip and knee flexion of tie down roping athletes is insufficient to absorb ground forces during contact with the ground. however, tie down roping athletes are able to maintain a neutral lateral knee angle during ground contact. understanding the lower body movements during the ground mechanics portion of a tiedown roping run can contribute to the development of strength and injury prevention programs for the athletes. abstract presentation 45 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 enhancing cultural competency in sports medicine resident and fellowship physicians through the coming out star exercise. cage sa*, jacobsen ap†‡, wang a†‡, gallegos dm*†, warner bj§: the university of texas at tyler, tyler, tx †ut health east texas, tyler, tx; ‡university of texas health science center at tyler, tyler, tx; §grand canyon university, phoenix, az context: previous studies have reported that lesbian, gay, bisexual, transgender, queer, intersex, and asexual (lgbtqia) healthcare providers and student-athletes encounter difficulties in their work or competition settings. numerous medical professional associations have published statements affirming their commitment to providing equitable healthcare for patients from the lgbtqia community. however, there is a paucity of research related to building cultural competency among healthcare professionals with regards to lgbtqia patients. the purpose of this study was to describe the effects of the coming out star exercise on giving sports medicine track resident and fellowship physicians a better understanding of the challenges faced by lgbtqia patients. methods: we recruited twelve physicians completing the sports medicine track for their residency or fellowship (30 ± 3 years old, 6 females, 6 males). participants took part in the coming out star exercise as part of their employee orientation. the exercise consisted of participants selecting a colored star and writing the name of a close friend, a family member, a community they were involved with, a job they wanted, and their life goals on the points of the star. the exercise leader then informed them that they would be read a series of scenarios as if they were a member of the lgbtqia community who had recently come out to the people around them. each colored star resulted in different consequences for each scenario. upon completing the exercise, participants were led through a discussion on their experiences with the exercise, and on the importance of cultural competence for healthcare providers. following the discussion, participants were asked to fill out a survey on the impact the exercise had on their understanding of the challenges that face members of the lgbtqia community on a scale of 1 (strongly disagree) to 6 (strongly agree). a paired sample t-test was performed to determine if the exercise had a significant effect on participants’ understanding of the challenges that face members of the lgbtqia community with significance set at p < .05. results: following the coming out star exercise, participants reported an increase in appreciation for the challenges faced by members of the lgbtqia community (4.58 ± 0.40 to 5.67 ± 0.14, p < .01). additionally, all participants agreed that the coming out star exercise gave them new perspective on the importance of empathy in patient care (5.67 ± 0.49). conclusion: the coming out star exercise appeared to give resident and fellow physicians an increased understanding of the challenges faced by the lgbtqia community. this suggests that the exercise may be a valuable component of employee training designed to improve delivery of equitable healthcare. further studies should be conducted to determine the long-term impact of the coming out star exercise. abstract presentation 46 copyright © by indiana state university clinical practice in athletic training all rights reserved. issn online 2577-8188 volume 7 – issue 3s september 2024 use of an external dynamic arm stabilizer in a collegiate baseball player with valgus extension overload: a case report. goza jp*, jacobsen ap†‡, hodges c†‡, warner bj§, frizzell b†, cage sa?: *collin college, †ut health east texas, ‡university of texas health science center, §grand canyon university, ?the university of texas at tyler background: a 21-year-old, male, collegiate baseball player reported to the athletic training staff complaining of pain along the posteromedial aspect of the right elbow. the patient reported a previous history of a grade i ulnar collateral ligament sprain that had been rehabilitated until he was able to return to full pain free activities. the patient could not recall a specific mechanism of injury. physical examination revealed a loss of terminal elbow extension, and pain along the posteromedial aspect of the elbow. the patient reported no neurological symptoms during or after throwing. valgus stress, milking, and posterolateral rotary drawer tests were all negative for pain or laxity. differential diagnosis: triceps tendinopathy, osteophyte, ulnar collateral ligament sprain, ulnar nerve irritation. treatment: the patient began treatment and rehabilitation with a working diagnosis of triceps tendinopathy. the rehabilitation protocol consisted for forearm and elbow resistance exercises with 50% blood flow restriction. treatment consisted of cupping therapy and dry needling to address adhesions in the triceps muscle belly. following two weeks of treatment, the patient reported no significant improvement in symptoms. at this time, the patient was referred to the team physician for further evaluation. point of care ultrasound findings were consistent with valgus extension overload, leading to the patient discontinuing throwing while continuing rehabilitation and treatment. 10 days after discontinuing throwing, the patient was experiencing no pain when moving suddenly into terminal elbow extension. at this time, the patient began a return to throwing program while wearing an external dynamic arm stabilizer (k2 sleeve, kinetic arm, chamblee, ga) as pictured in. over the next two months, the patient progressed his throwing program in terms of frequency, volume, and intensity, while continuing to hit and field with no limitations. at the end of the two-month period, the patient was able to return to full team activities without the external dynamic arm stabilizer. uniqueness: while valgus extension overload has been described in the currently available literature, the overall prevalence is unknown. this appears to be the first case study describing the use of an external dynamic arm stabilizer during rehabilitation for a baseball player suffering from valgus extension overload. while surgery may be indicated for valgus extension overload presenting with prolonged symptoms, current surgical outcomes are mixed. this places an increased emphasis on exhausting all nonoperative interventions prior to surgery. conclusions: while there is a need for further research, this case describes the use of an external dynamic arm stabilizer in a baseball player to allow the patient to throw with reduced discomfort during the return to play process. when caring for patients with musculoskeletal injuries, it is crucial to exhaust all nonoperative interventions prior to recommending surgery. further research is needed to determine the magnitude of effect for the use of an external dynamic arm stabilizer for decreasing forces at the elbow. 