Chapter 1 - The Athletic Trainer as a Health Care Provider

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Early History
-Evidence suggests that coaches, physicians, and therapists existed in Greek and Roman civilizations.
-Athletic trainers came into existence in the late 19th century in intercollegiate and interscholaristic sports.
-Early treatments involved rubs, counter-irritants, home remedies, and poultices.
President Theodore Roosevelt
In 1905, he threatened to abolish football as a intercollegiate sport. This was due to 18 deaths and 159 serious injuries.
Earliest ATs
James Robinson: 1881 hired by Harvard
Michael Murphy: Track coach at Yale who provided athletic training services. Also worked at the University of Pennsylvania until his death in 1913.
Dr. Samuel E. Bilik
-Pre-med student at University of Illinois in 1914, and had a part-time job as an AT. (1.00 a day).
-"Father of Athletic Training"
-Author of "Athletic Training" and "The Trainer's Bible" (1917)
-Conducted seminars to other athletic trainers, eventually formed the Eastern Athletic Trainer's Association (District 1 and 2 today).
Charles and Frank Cramer
-In 1918, formed the Cramer Chemical Company - produced liniment for athletic teams.
-Publisheed the First Aider in 1933.
-Today, Cramer products continue to support athletic training profession. Major sponsor of the NATA and sponsors athletic training workshops.
Formation of NATA
1938-the first National Athletic Trainers Association (NATA) was formed by Cramer brothers and Bill Frey at the University of Iowa.
Rebirth-1950: After world war 2, June 1920 ATs met in Kansas City, Missouri and NATA has been in existence ever since.
Conference will be in Baltimore, Maryland - 2015
NATA
Today's organization is high structured.
Code of Ethics
Organized on state levels and NATA districts.
Membership and Gender Milestones in AT
AT was predominantly male profession until the mid-1990s.
Currently, women account for 48% of the ATCs.
Dotty Cohen: Indiana University Grad student who was the first NATA female member.
Marjorie J. Albohm, M.S., A.T.C., L.A.T: Past President of NATA. B.S. from Valparaiso Univ. and M.S. from Indiana State Univ.
Evolution of AT
Led to:
Recognition of Acts as healthcare providers.
Increased diversity of practice settings.
Passage of practice acts.
Third party reimbursement for ATs.
Constant revision and reform of AT education.
What is an AT?
A certified health care provider who collaborates with a physician.
What do ATs do?
Specialize in preventing, recognizing (clinical dx), managing (emergency care/therapuetic intervention), and rehabilitating injuries and medical conditions.

Function as a member of a healthcare team which also incorporates and involves a number of medical specialties.

Provide a critical link between the medical community and physically active individuals.
Settings of ATs
Colleges and Secondary schools: deals exclusively with an athletic population.

Variety of settings: professional sports, hospitals, clinics, industrial settings, military, equipment sales, and physician extenders.
Changing Face of AT Profession
40% of athletic trainers are employed in clinics, hospitals, industrial, and occupational settings.
Involved in NASCAR, performing arts, military, NASA, medical equipment and sales, law enforcement, and US government.
Resulted in changes in AT education.

Do not just provide medical care to athletes or those injured during physical activities.
Becoming more aligned as a clinical healthcare profession.
As profession evolves, so does AT education: requires term changes.
-Patients and clients versus athletes
-Athletic clinic or facility versus athletic training room
-Athletic trainers NOT trainers
Employment Settings
Becoming increasingly diverse.
Clinics and Hospitals
Physician Extenders
Industrial
Occupational
Corporate
Colleges or Universities
Secondary Schools
School Districts
Professional Sports
Amateur/Recreational/Youth Sports
Performing Arts
Military and Law Enforcement
Health and Fitness Clubs
The Adolescent Athlete
Focuses on organized competition in sports.
A number of sociological issues involved: How old or when should a child begin training?
Skeletal maturity presents some challenges with respect to healthcare.
Physically and emotional adolescents can not be managed the same way as adults.
ATs must be aware of patterns of growth and development.
The Aging Athlete
Physiological and performance capability changes over time. Function will increase and decrease depending on point in lifecycle.
May be result of both biological and sociological effects.
High levels of physiological function can be maintained through active lifestyle. The impact on long-term health benefits have been documented.
Before Beginning Exercise Program
Exercise program should be gradual and progressive as long as no unusual signs or symptoms develop.
Individuals over age 40 should have a physical and exercise testing before engaging in an exercise program.
The Occupational Athlete
Occupations, industrial, or worker "athlete" are involved in strenuous, demanding or repetitive physical activity. May result in accidents and injury.
Involves: Instruction on ergonomic techniques to avoid injury associated with physical demand of job responsibilities. Intervention when injuries arise: correcting mechanics, faulty postures, strength deficits, lack of flexibility.
Injury prevention is still critical.
Roles and Responsibility of ATs
Unique: Athletic Trainer deals with the patient and injury from its inception until the athlete returns to full competition.
Five Practice Domain
Injury/Illness prevention & wellness protection
Clinical evaluation and diagnosis
Immediate & emergency care
Treatment & rehabilitation
Organizational and professional health and well-being
Injury/Illness Prevention & Wellness Protection
Ensure Safe Environment
Conduct Pre-participation Physicals
Develop Training and Conditioning Programs
Select and Fit Proctective Equipment Properly
Explaining Important Diet and Lifestyle Choices
Ensure Appropriate Medication Use While Discouraging Substance Abuse
Clinical Evaluation and Diagnosis
Recognize Nature and Extent of Injury
Involves Both On and Off-field Evaluation Skills and Techniques
Understand Pathology of Injuries and Illnesses
Referring to Medical Care
Referring to Supportive Services
Immediate and Emergency Care
Administration of Appropriate First Aid and Emergency Medical Care (CPR, AED)
Activation of Emergency Action Plans (EAP)
Treatment and Rehabilitation
Design Preventative Training Systems
Rehabilitation Program Design
Supervising Rehabilitation Programs
Incorporation of Therapeutic Modalities and Exercises
Offering Psychosocial Intervention
Organizational and Professional Health and Well-Being
Record Keeping
Ordering Supplies and Equipment
Establishing policies and Procedures for Operation of and AT Program
Supervising Personnel
Personal Qualities of ATs
Stamina and Ability to Adapt
Empathy
Sense of Humor
Communication
Intellectual Curiosity
Ethical Practice
Professional Memberships
AT and Athlete
Injured patient is the main concern.
All decisions impact the patient.
Injured patient must always be informed: Be made aware of how, when, and why that dictates the course of injury rehabilitation.

Patient must be educated about injury prevention and management.
Instructions should be provided regarding training and conditioning.
Inform the patient to listen to his or her body in order to prevent injuries.

AT, physician, and coaches must be aware and inform parents of Health Insurance Portability and Accountability Act (HIPAA): Regulates dissemination of health information. Protects patient's privacy and limits the people who could gain access to medical records.
AT and Parents
ATs must keep parents informed, particularly in the secondary school setting: injury management and prevention.
The parents decision regarding healthcare must be primary consideration.
Insurance plans may dictate care: Selection of physician.
AT and Team Physician
AT works under direct supervision of physician.
Physician assumes a number of roles: Serves to advise and supervise ATC.
Physician and the AT must be able to work together. Have similar philosophical opinions regarding injury management. Helps to minimize discrepancies and inconsistencies.
Physician is responsible for compiling medical histories and conducting physical exams. Pre-participation screenings.
Diagnosing injury.
Deciding on disqualifications. Decisions regarding athlete's ability to participate based on medical knowledge and psychophysiological demands of sport.
Attending practice and games.
Commitment to sports and athlete.
Potentially serve as the academic program medical director: Coordinates and guides medical aspects of program. Provides input into educational content and provides programmatic instruction.
AT and the Coach
It is the responsibility of coaches to clearly understand the limits of their ability to function as a health care provider in the state where they are employed.
All coaches should be certified in CPR, AED, and first aid.
Referring the Patient
The AT must be aware of available medical and non-medical personnel. Patient may require special treatment outside of the traditional sports medicine team.
Must be aware of community based services and various insurance plans. Typically the AT and Team physician will consult on the particular matter and refer accordingly.
Support Health Services and Personnel
Physicians, Dentist, Podiatrist, Nurse, Physician's Assistance, Physical Therapist, Occupational Therapist, Massage Therapist, Ophthalmologist, Dermatologist, Gynecologist, Exercise Physiologist, Biomechanist, Nutritionist, Sport Psychologist, Coaches, Strength and Conditioning Specialist, Social Worker, Neurologist, Emergency Medical Technician, and Osteopath
Growth of Professional Sports Medicine Organizations
International Federation of Sports Medicine (1928)
American Academy of Family Physicians (1947)
National Athletic Trainers Association (1950)
American College of Sports Medicine (1954)
American Orthopedic Society of Sports Medicine (1972)
National Strength and Conditioning Association (1978)
American Academy of Pediatrics, Sports Committee (1979)
Sports Physical Therapy Section of APTA (1981)
NCAA Committee on Competitive Safeguards and Medical Aspects of Sports (1985)
National Academy of Sports Medicine (1987)
National Athletic Trainers Association (NATA)
Formed in the 1950s.
Mission is to: To enhance the quality of health care for athletes and those engaged in physical activity, and to advance the profession of athletic training through education and research in the prevention, evaluation, management, and rehabilitation of injuries.
The NATA now has 35,000 members world-wide.
Also helps to disseminate "Best Practice" information by sharing research.
National Academy of Sports Medicine
Founded in 1987 by physicians, physical therapists, and fitness professionals.
It focuses on the development, refinement, and implementation of educational programs for fitness, performance, and sports medicine professionals. More than 100,000 members and partners in 80 countries.
Sharing Research and Clinical Evidence to Improve Healthcare
Information sources through which to share and create consistent, efficient, and current healthcare practices.
Position Statements
Formal statements related to specific topic areas that have been developed by experts in AT. (Provide direct impact on standards of professional practice).
Emergency Planning in Athletics
Exertional Heat Illnesses
Fluid Replacement in Athletics
Head Down Contact and Spearing in Tackle Football
Management of Asthma in Athletes
Official Statements
Issued by the NATA to address a specific issue that may be affecting the professional practice of AT or patient healthcare practices.
Not intended to change professional practice.
Consensus Statements
Comprehensive report that is completed through an extensive research process along with various professional organizations.
Can create an immediate impact in the ATC's standard of professional practice. Appropriate medical care for secondary-school age athletes. Inter-association Task Force on Exertional Heat Illnesses.
Support Statements
An organization may receive a public comment, related to the practice of another profession.
Peer-Reviewed Journal Publications
Journal of Athletic Training
Athletic Training Education Journal
Recognition of AT
June 1990: The American Medical Association (AMA) officially recognized athletic training as an allied health profession.
External Accreditation
Committee on Allied Health Education and Accreditation (CAHEA) was charged with responsibility of developing essentials and guidelines for academic programs to use in preparation of individuals for entry into profession through the Joint Review Committee on Athletic Training (JRC-AT).
June 1994-CAHEA dissolved and replaced immediately by Commission on Accreditation of Allied Health Education Programs (CAAHEP). Recognized as an accreditation agency for allied health education programs by the U.S. Department of Education.
Entry level college and university athletic training education programs at both undergraduate and graduate levels were accredited by CAAHEP through 2005.
In 2003, JRC-AT became an independent accrediting agency. It would accredit AT education programs without involvement of CAAHEP. It officially became the Committee for Accreditation of Athletic Training Education (CAATE) in 2006. CAATE was officially recognized by CHEA in 2007. It is a private onprofit organization that coordinates accreditation activity in the US. Recognition by CHEA puts CAATE on the same level as other national accreditors, such as CAAHEP.
Athletic Training education programs are accredited through CAATE: 2006. All accredited programs must: Complete an extensive accreditation self-study review. On-campus accreditation site visit by external reviewers very 5/10 years.,
Advanced graduate AT education programs are designed for those that are already certified ATCs.
December 2013: Recommended professional training for ATs should occur at the Master's Degree level.
AT Education
1997: Education Council was established to dictate the course of the educational preparation for the athletic training student.
Focus has shifted to competency-based education at the entry level.
Education Council has significantly expanded and reorganized the clinical competencies and proficiencies.
AT Education Competencies
Evidence-Based Practice
Prevention & Health Promotion
Clinical Examination & Diagnosis
Acute Care of Injury & Illness
Therapeutic Interventions
Psychosocial Strategies & Referrals
Healthcare Administration
Professional Development & Responsibilities
Foundational Behaviors of Professional Practice
"People" components of the profession:
Recognizing the primary focus of practice should be the patient.
Understanding that competent health care requires a team approach.
Being aware of legal elements of practice.
Practicing Ethically.
Advancing the knowledge base in AT.
Appreciate cultural diversity.
Being an advocate and model for the AT profession.
The Patient
Recognize sources of conflict that can impact the patient's health.
Know and apply commonly accepted standards for patient confidentially (HIPPA).
Provide the best health care available for the patient.
Advocate for the needs of the patient.
Team Approach
Recognize the unique skills and abilities of other health care professionals.
Understand the scope of practice for other health care professionals.
Understand and execute duties within the identified scope of practice for ATs.
Include the patient (and family when appropriate) in decision making process.
Demonstrate the ability with others in effecting positive patient outcomes.
Legal Practice
Practice AT in a legally competent manner.
Recognize the need to document compliance with the laws that govern AT.
Understand the consequences of violating laws that govern AT.
Ethical Practice
Understand and comply with the NATA's Code of Ethics and the BOC's Standards of Practice.
Understand the consequences of violating them.
Understand and comply with other codes of ethics as applicable: GSU's Student Code of Conduct.
Advance Knowledge
Critically examine the body of knowledge in AT and related fields.
Use evidence-based practice as a foundation for delivery of care.
Understand the connection between continuing education and improvement of AT practice.
Promote the value of research and scholarship in AT.
Disseminate new knowledge in AT to fellow ATs, other healthcare professionals, and others as necessary.
Cultural Competence
Understand cultural differences of patients' attitudes and behaviors toward health care.
Demonstrate knowledge, attitudes, behaviors, and skills necessary to achieve optional health outcomes for diverse patient populations and be able to work with diverse populations and in diverse working environment.
Professionalism
Be an advocate for the profession.
Demonstrate honesty and integrity.
Exhibit compassion and empathy.
Demonstrate effective interpersonal communication skills.
Requirements for Certification
Students must earn a degree (bachelor's or master's) from an accredited AT curriculum. Must have extensive background in formal academic preparation and supervised practical experience.
In the future, AT will be moving to an entry level master;s.
Upon meeting the educational guidelines applicants are eligible to sit for the examination. Exam is computer based and assesses the 5 domains.
Upon passing the certification exam=BOC certification as an AT. Credential of ATC.
BOC certification is a prerequisite for licensure in most states.
History of BOC Certification Exam
First exam conducted in 1969.
Evolved into 3-part exam: Written, written simulation, and practical.
2007: Implemented to a 3-part computerized testing format. 175 scored and unscored (experimental) items including: stand-alone multiple choice, stand-alone alternative items (drag and drop, text-based simulation, multi-select, hot spot, etc.).
Focused testlets: 5 item focused testlet consists of a scenario followed by 5 key/critical questions related to that scenario. Each focused testlet may include multiple-choice questions and/or any of the previously described alternative item types.
Maintaining Certification
ATs must obtain 75 continuing education hours in medically related education (every three years).
Attending symposiums, workshops seminars.
Serving as a speaker or panelist.
Participating in the USOC program.
Authoring a research article: authoring/editing a textbook.
Completing post-graduate work.
Online and mail-in home study courses.
CEU's are no longer awarded for CPR/First Aid an AT must stay current during reporting period.
Main Purpose for CEU's
To encourage ATs to obtain current professional development information.
To explore new knowledge in specific areas.
To master new AT related skills and techniques.
To expand approaches to effective AT.
To further develop professional judgement.
To conduct professional practice in an ethical and appropriate manner.
Practicing as an AT (national level)
BOC: Regulatory board for the ATC on a national level. Validates who is competent to practice as an AT.
BOC role delineation study (5-7 years). 5 domains which delineate major responsibilities performed by the ATC.
BOC standards of professional practice: Help the public understand the type and level of care from an ATC. Guide the ATC to effectively evaluate their level of patient care. Assist the ATC to understand his/her roles and responsibilities.
Practicing as an AT (state level)
At the state level practicing as an AT is regulated in the form of: Licensure and Certification
Licensure
Limits practice of AT to those who have met minimal requirements established by a state licensing board.
Limits the number of individuals who can perform functions related to AT as dictated by the practice act.
Most restrictive of all forms of regulation.
GA has licensure.
Certification
Does not restrict using the title of AT to those certified by the state.
Can restrict performance of AT functions to only those individuals who are certified.
Pennsylvania has certification.
No regulation: Alaska and California.
Registration
Before an individual can practice AT he or she must register in that state.
Individual has paid a fee for being placed on an existing list of practitioners but says nothing about competency.
Exemption
State recognized that an AT performs similar functions to other licensed professions (Physical Therapy), yet still allows them to practice AT despite the fact that they do not comply with the practice acts of other regulated professions.
Evidence-based Practice
Making decisions about the clinical care of individual patients based on the current best available evidence in the professional literature.
Failure to engage could jeopardize patient care.
Five Steps to Evidence-based Practice
Develop clinical question
Search literature
Appraise evidence
Apply evidence
Assess outcomes
Develop a Clinical Question
Utilizes the PICO format
Patient (problems or conditions)
Intervention (possible treatment options)
Comparison (alternatives that might be used in the intervention)
Outcome (what you want the patient to achieve)
Search the Literature
Using key words to assemble a comprehensive assessment of available literature.
Evaluate the Strength of Evidence
Type of study versus quality of evidence.
Must critically evaluate and rate the evidence.
Apply the Evidence into Practice
Intergrating evidence with patient needs and values.
Bridging barriers between research evidence and clinical decisions to ensure optimal care.
Assess the Outcome
Determining effectiveness:
Outcoming assessment measures - condition-oriented evidence and patient-oriented evidence (perceptions, experience, patient-centered goals).
Disbablement Model:
Evaluates functional loss due to impairment and impacr on quality of life.
Comprehensive assessment.
Patient reported outcomes.
Global ratings of change.
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