Practice-based research networks, part II: a descriptive analysis of the athletic training practice-based research network in the secondary school setting

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Limited evidence exists regarding the assessment of single-item patient-reported outcomes when patients are medically cleared to return to sport after a lateral ankle sprain (LAS) injury.

OBJECTIVE

To evaluate self-reports of improvement in health status, pain, function, and disability at return to sport after an LAS.

DESIGN

Descriptive study.

SETTING

Sixty-nine athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 637 patients (males = 53.2%) who were diagnosed with an LAS, restricted from sport after injury, and subsequently medically cleared to return to sport within 60 days were included.

MAIN OUTCOME MEASURE(S)

Descriptive statistics were used to summarize scores for health status (Global Rating of Change), pain (Numeric Pain Rating Scale), function (Global Rating of Function), and disability (Global Rating of Disability). Mann-Whitney U tests were used to compare score differences between sexes. A Kaplan-Meier analysis was performed to provide a visual depiction of sex differences in the time to return to sport.

RESULTS

Most patients sustained an LAS injury while participating in basketball, football, or soccer and were cleared to return to sport 8 days after injury. More than two-thirds of patients reported a meaningful improvement in health status between the time of injury and return to sport. However, many noted deficits related to pain (65.1%), function (86.2%), or disability (35.8%) at return to sport. No differences were seen between males and females for pain (P = .90), function (P = .68), change in health status (P = .45), or disability (P = .21) at return to sport, although males returned to sport slightly sooner than females (P = .025).

CONCLUSIONS

Despite self-perceived improvements in health status since the time of injury, patients typically returned to sport with deficits in pain, function, and disability after an LAS. Patients may be returning to unrestricted sport participation before they feel their bodies have fully recovered from the injury.

Characterizing athletic healthcare: A perspective on methodological challenges, lessons learned, and paths forward

Recently, there has been an emphasis on collecting large datasets in the field of sports medicine. While there have been great advances in areas of sport performance and sport epidemiology, there have been fewer efforts dedicated to understanding the effectiveness and impact of athletic healthcare, including injury prevention programs and rehabilitation interventions provided at the point-of-care. In 2009, the Athletic Training Practice-Based Research Network (AT-PBRN) was launched to address this need, with the mission of improving the quality of care provided by athletic trainers. Unlike other research efforts in sports and medicine, such as sport epidemiology, there are fewer methodological best practices specifically related to clinical data in athletic healthcare. As a result, the AT-PBRN has encountered several methodological challenges during its tenure and has established guidelines based on various sources within the fields of sports and medicine to address these challenges. Therefore, the purpose of this perspective is to identify the challenges and describe strategies to address these challenges related to characterizing athletic healthcare using a large database. Specifically, challenges related to data entry (data quality and reliability) and data extraction and processing (data variability and missing data) will be discussed. Sharing challenges and perspectives on solutions for collecting and reporting on athletic healthcare data may facilitate a greater consistency in the approach used to collect, analyze, and report on clinical data in athletic healthcare, with the goal of improving patient outcomes and the quality of care provided by athletic trainers.

High School Athletes’ Health-Related Quality of Life Across Recovery After Sport-Related Concussion or Acute Ankle Injury: A Report From the Athletic Training Practice-Based Research Network

Background:

Evaluating adolescent athletes’ perceived health status after a sport-related injury can provide important direction for health promotion strategies and preparation for a successful return to play. Furthermore, comparing specific injury types regarding their impact on athletes' perspectives of their global and domain-specific health perceptions allows for a more detailed understanding of an athlete's experience while also providing avenues for targeted treatment strategies.

Purpose:

To compare health-related quality of life (HRQOL) between high school athletes who had sustained either a concussion or an acute ankle injury and compare how these injury types related to their global and domain-specific HRQOL across recovery.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Electronic medical records created by athletic trainers working in 32 high school facilities were examined, and records from 1749 patients who sustained either a sport-related concussion (n = 862) or ankle sprain (n = 887) were screened for inclusion. HRQOL was assessed by self-reported scores on the Pediatric Quality of Life Inventory (PedsQL) at 2 time points after injury (T₁ = 0-2 days; T₂ = 11-29 days). A 2-way group by time analysis of variance was conducted to examine differences in trajectories and disrupted areas of HRQOL.

Results:

Overall, 85 patient cases (46 concussion, 39 ankle sprain) fit the inclusion criteria. Each injury group exhibited improved global and domain-specific PedsQL scores between their 2 measured time points (P < .05), indicating recovery. However, domain-specific comparisons revealed that at T₂, patients who had sustained an ankle sprain reported significantly lower PedsQL physical functioning scores (78.3 ± 19.3 vs 86.2 ± 15.7 for concussion; P = .005), whereas patients who had sustained a concussion reported lower scores related to their school functioning (80.0 ± 20.0 vs 90.8 ± 12.7 for ankle sprain; P = .006).

Conclusion:

The study results indicated that in high school athletes, the trajectories and disrupted areas of HRQOL stemming from a sport-related injury may be influenced differentially when comparing concussions with ankle sprains.

Cost and Treatment Characteristics of Sport-Related Knee Injuries Managed by Athletic Trainers: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Knee injuries are common during sport participation. However, little is known about the overall management and estimated direct costs of care associated with these injuries when under the care of athletic trainers.

OBJECTIVE

To describe the treatment characteristics and direct costs of care for athletic training services provided for patients with knee injuries.

DESIGN

Descriptive study.

SETTING

Ninety-five athletic training facilities across 24 states.

PATIENTS OR OTHER PARTICIPANTS

A total of 117 athletic trainers (females = 56.4%, age = 29.4 ± 8.7 years, years certified = 4.7 ± 6.0, years employed at site = 1.6 ± 4.1).

MAIN OUTCOME MEASURE(S)

Complete patient cases were identified using International Classification of Disease-10 diagnostic codes between 2009 and 2020. Summary statistics were calculated for patient demographics, treatment characteristics, and direct costs of care. Treatment characteristics included the type of athletic training service, duration, amount (eg, number of visits), and direct costs of care.

RESULTS

A total of 441 patient cases were included. The most common injuries reported were cruciate ligament sprain (18.1%, n = 80), medial collateral ligament sprain (15.4%, n = 68), and knee pain (14.1%, n = 62). Injuries occurred most frequently during football (35.4%, n = 156), basketball (14.7%, n = 65), and soccer (12.7%, n = 56). A total of 8484 athletic training services were recorded over 4254 visits, with therapeutic exercise (29.8%, n = 2530), hot or cold pack (25.8%, n = 2189), and therapeutic activities (11.2%, n = 954) being the most frequently reported services. The median duration of care was 23 days and number of visits was 8. The median total cost of care was $564 per injury and $73 per visit.

CONCLUSIONS

Patients with knee injuries demonstrated greater time loss than those with other lower extremity injuries. Thus, it is unsurprising that knee injuries were associated with a longer duration and higher cost of care than other lower extremity injuries such as ankle sprains. Future researchers should examine the effectiveness of common treatment strategies and aim to identify treatments that can reduce costs and improve patient outcomes.

Characteristics of Injuries Occurring During Cross-Country: A Report from the Athletic Training Practice-Based Research Network

CONTEXT

Cross-country is a popular sport activity, particularly in adolescent populations. Although epidemiologic investigations have provided insight into patient and injury characteristics associated with running injuries, little is known about how these injuries are managed at the point of care.

OBJECTIVE

To describe injury and treatment characteristics of injuries sustained during cross-country.

DESIGN

Cross-sectional study.

SETTING

High school athletic training clinics within the Athletic Training Practice-Based Research Network.

PATIENTS OR OTHER PARTICIPANTS

Patient cases were included if the patient was diagnosed with an injury that occurred during interscholastic cross-country participation. All patients received usual care by an athletic trainer.

MAIN OUTCOME MEASURE(S)

We used summary statistics to describe injury (sex, age, participation level, time of injury, mechanism of injury, body part, injury type, diagnosis) and treatment (type, amount, duration, number of services) characteristics.

RESULTS

Most cross-country injuries occurred to the lower extremity and were musculotendinous or ligamentous in nature. The most common injury types were sprain/strain (43.8%), tendinopathy (18.5%), and general pain (9.5%). Injured body parts and diagnoses were typically similar between sexes. The most frequently used treatment was therapeutic exercises or activities (28.7%), and patients received an average of 7.4 ± 17.4 total athletic training services during 5.5 ± 15.1 episodes of care over 27.8 ± 87.5 days.

CONCLUSIONS

Adolescent cross-country student-athletes frequently sustained non-time-loss injuries that required up to 1 month of treatment and management. These findings will generate awareness surrounding the role of athletic trainers in providing care for cross-country athletes.

Musculoskeletal Injury in Reserve Officers' Training Corps: A Report From the Athletic Training Practice-Based Research Network

Background:

Reserve Officers’ Training Corps (ROTC) cadets must meet the same physical standards as active duty military servicemembers and undergo organized physical training (PT). ROTC participation, like all physical activity, can result in training-related musculoskeletal injury (MSKI), and of course, cadets could sustain MSKI outside of ROTC. However, MSKI incidence in ROTC programs is largely unknown.

Purpose:

To describe patient and injury demographics of MSKI in 5 universities’ Army ROTC programs.

Study Design:

Descriptive epidemiology study.

Methods:

A retrospective chart review of electronic medical records was performed using the Athletic Training Practice-Based Research Network (AT-PBRN). Athletic trainers at 5 clinical practice sites within the AT-PBRN documented injury assessments via a web-based electronic medical record system. Medical records during the 2017-2018 and 2018-2019 academic years were used for analysis. Summary statistics were calculated for age, sex, height, body mass, military science year, training ability group, mechanism of injury, activity type associated with injury, anatomic location of injury, participation status, injury severity, and diagnosis.

Results:

A total of 364 unique injuries were documented. Cadets in the most advanced fitness group (Alpha; n = 148/364) and in their third year of training (n = 97/364) presented with the most injuries. Injuries most commonly occurred during PT (n = 165/364). Insidious onset (n = 146/364) and noncontact (n = 115/364) mechanisms of injury were prevalent. The most frequent anatomic location of injury was the knee (n = 71/364) followed by the ankle (n = 57/364). General sprain/strain was the most frequent International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code reported (n = 34/364).

Conclusion:

The knee was the most frequent location of MSKI in ROTC participants, and most MSKIs had insidious onset. Cadets with higher injury frequency were high achieving (Alpha) and in a critical time point in ROTC (military science year 3). The majority of MSKIs can be attributed to ROTC training, with PT being the most frequent activity associated with injury. Civilian health care providers, from whom ROTC cadets will most likely seek medical attention, need to be aware of ROTC physical demands as well as the characteristics of training-related injuries.

The Impact of a Previous Ankle Injury on Current Health-Related Quality of Life in College Athletes

CONTEXT

There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL).

OBJECTIVE

To determine the impact of a previous ankle injury on current HRQOL in college athletes.

DESIGN

Cross-sectional study.

SETTING

Athletic training clinics.

PARTICIPANTS

A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143).

MAIN OUTCOME MEASURES

Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12).

METHODS

A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12.

RESULTS

No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males.

CONCLUSIONS

Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients' region-specific function as well as aspects of their HRQOL.

Point-of-Care Clinical Trials in Sports Medicine Research: Identifying Effective Treatment Interventions Through Comparative Effectiveness Research

CONTEXT

Recently, calls to conduct comparative effectiveness research (CER) in athletic training to better support patient care decisions have been circulated. Traditional research methods (eg, randomized controlled trials [RCTs], observational studies) may be ill suited for CER. Thus, innovative research methods are needed to support CER efforts.

OBJECTIVES

To discuss the limitations of traditional research designs in CER studies, describe a novel methodologic approach called the point-of-care clinical trial (POC-CT), and highlight components of the POC-CT (eg, incorporation of an electronic medical record [EMR], Bayesian adaptive feature) that allow investigators to conduct scientifically rigorous studies at the point of care.

DESCRIPTION

Practical concerns (eg, high costs and limited generalizability of RCTs, the inability to control for bias in observational studies) may stall CER efforts in athletic training. In short, the aim of the POC-CT is to embed a randomized pragmatic trial into routine care; thus, patients are randomized to minimize potential bias, but the study is conducted at the point of care to limit cost and improve the generalizability of the findings. Furthermore, the POC-CT uses an EMR to replace much of the infrastructure associated with a traditional RCT (eg, research team, patient and clinician reminders) and a Bayesian adaptive feature to help limit the number of patients needed for the study. Together, the EMR and Bayesian adaptive feature can improve the overall feasibility of the study and preserve the typical clinical experiences of the patient and clinician.

CLINICAL ADVANTAGES

The POC-CT includes the basic tenets of practice-based research because studies are conducted at the point of care, in real-life settings, and during routine clinical practice. If implemented effectively, the POC-CT can be seamlessly integrated into daily clinical practice, allowing investigators to establish patient-reported evidence that may be quickly applied to patient care decisions. This design appears to be a promising approach for CER investigations and may help establish a "learning health care system" in the sports medicine community.

Athletic Trainers' Practice Patterns Regarding Medical Documentation

CONTEXT

Medical documentation is a required component of patient care in all health care professions.

OBJECTIVE

To evaluate athletic trainers' perceived behaviors toward, barriers to, and confidence in their medical documentation.

DESIGN

Cross-sectional study.

SETTING

Web-based survey.

PATIENTS OR OTHER PARTICIPANTS

We purchased a list of randomly selected e-mails from the National Athletic Trainers' Association. Of the 9578 participants, 1150 accessed our questionnaire (12.0% access rate), 1053 completed at least 1 portion, and 904 completed the questionnaire in its entirety (85.8% completion rate). Of the participants, 60.1% (n = 569/947) were female, 66.6% (n = 632/949) held a master's degree, 39.3% (n = 414/1053) worked in a collegiate or university setting, and 36.1% (n = 381/1053) worked in a secondary school setting.

MAIN OUTCOME MEASURE(S)

We used a 31-item questionnaire with demographics (12 items), medical documentation behaviors (16 items), barriers (2 items), and perceptions (1 multipart item) sections. The questionnaire explored athletic trainers' behaviors as well as confidence in, comfort with, and concerns about their documentation practices (Cronbach α = 0.887). We used descriptive statistics to identify characteristics of central tendency (mean, standard deviation, mode, frequency).

RESULTS

Participants always (45.7%, n = 478/1046) or very frequently (39.0%, n = 408/1046) used a double documentation system consisting of electronic and paper records (50.4%, n = 523/1038). They most often documented to provide legal protection (86.8%, n = 914/1053), because it is a legal obligation (79.1%, n = 833/1053), or to track patient progress (83.9%, n = 883/1053). The most frequently cited barriers to medical documentation were time (76.5%, n = 806/1053), managing too many patients (51.9%, n = 547/1053), technological concerns (17.2%, n = 181/1053), and software limitations (17.2%, n = 181/1053). Respondents believed they were competent, comfortable, and confident in their documentation practices.

CONCLUSIONS

We were able to evaluate the generalizability of previous research while adding to the understanding of the behaviors toward, barriers to, and perceptions about medical documentation. We confirmed that time and patient load affected the ability to perform high-quality medical documentation.

Patient, Injury, Assessment, and Treatment Characteristics and Return-to-Play Timelines After Sport-Related Concussion: An Investigation from the Athletic Training Practice-Based Research Network

OBJECTIVES

To describe the patient, injury, assessment and treatment characteristics, as well as return-to-play timelines and clinical findings at discharge for adolescent patients after sport-related concussion.

DESIGN

Retrospective analysis of electronic medical records.

SETTING

Athletic training facilities of secondary school members of the Athletic Training Practice-Based Research Network (AT-PBRN).

PATIENTS

In total, 1886 patient records were reviewed. [1204 (63.8%) male, 682 (36.2%) female, age = 15.3 ± 1.9 years, height = 169.5 ± 13.5 cm, mass = 70.3 ± 17.0 kg]. Patients were diagnosed with a concussion by an athletic trainer or team/directing physician.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Descriptive analysis of patient, injury, assessment, treatment, and participation status characteristics, as well as discharge information.

RESULTS

Injury demographic forms were completed for 1886 concussion cases. A concussion-specific evaluation form was completed for 55.9% (n = 1054) of cases. Treatment documentation was completed on 829 patients (44.0% of initial documented cases). Discharge forms were completed for 750 patients (40.0% of initial documented cases). Most cases were coded as 850.9-Concussion (85.5%, n = 642) and occurred during an in-season game (49.4%, n = 308). Time lost from competition was 24.9 ± 39.9 days.

CONCLUSIONS

Most concussion cases documented in this study were not on-field emergencies, as indicated by their normal clinical examinations and the lack of immediate referral to an emergency department. However, certain aspects of the clinical examination were often not assessed during the initial evaluation. These findings describe concussion assessment and recovery in adolescents and reinforce the need for a standardized approach to concussion assessment and appropriate documentation.

Use of Patient-Reported Outcome Measures in Athletic Training: Common Measures, Selection Considerations, and Practical Barriers

CONTEXT

Current evidence suggests that a low percentage of athletic trainers (ATs) routinely use patient-reported outcome measures (PROMs). An understanding of the perceptions of ATs who use (AT-USE) and who do not use (AT-NON) PROMs as well as any differences due to demographic characteristics (eg, use for patient care or research, job setting, highest education level) may help facilitate the use of PROMs in athletic training.

OBJECTIVE

To describe commonly used PROMs by AT-USE, the criteria by which AT-USE select PROMs, and reasons for non-use by AT-NON.

DESIGN

Cross-sectional study.

SETTING

Online survey.

PATIENTS OR OTHER PARTICIPANTS

A convenience sample of 1784 ATs (response rate = 10.7% [1784/17972]; completion rate = 92.2% [1784/1935]) who worked in a variety of settings.

MAIN OUTCOME MEASURE(S)

Participants completed an anonymous electronic online survey. Descriptive statistics were used to describe commonly used PROMs, PROM selection criteria, and reasons for PROM non-use.

RESULTS

Participants were classified as AT-USE (n = 370, 20.7%) or AT-NON (n = 1414, 79.3%). For the AT-USE group, the most common type of PROMs used were specific (eg, region, joint; n = 328, 88.6%), followed by single-item (n = 258, 69.7%) and generic (n = 232, 62.7%). Overall, the PROMs most frequently endorsed by the AT-USE group were the Numeric Pain Rating Scale (n = 128, 34.6%); Lower Extremity Functional Scale (n = 108, 29.2%); Disability of the Arm, Shoulder and Hand (n = 96, 25.9%); Owestry Disability Index (n = 80, 21.6%); and Foot and Ankle Ability Measure (n = 78, 21.1%). The most important criteria reported by AT-USE for selecting PROMs were that the measure was valid and reliable, easy for patients to understand, and easy for clinicians to understand and interpret. Common reasons for non-use were that PROMs were too time consuming for the clinician, too time consuming for the patient, and more effort than they were worth.

CONCLUSIONS

The Numeric Pain Rating Scale; Lower Extremity Functional Scale; Disability of the Arm, Shoulder and Hand; Owestry Disability Index; and Foot and Ankle Ability Measure were the PROMs most commonly endorsed by AT-USE and should be considered for athletic training use. To further facilitate the use of PROMs in athletic training, future authors should identify strategies to address organizational and time-constraint obstacles. Interpretation of our study findings may require caution due to a relatively low response rate and because "routine use" was not operationalized.

Fundamentals of Sports Analytics

Recently, the importance of statistics and analytics in sports has increased. This review describes measures of sports injury and fundamentals of sports injury research with a brief overview of some of the emerging measures of sports performance. We describe research study designs that can be used to identify risk factors for injury, injury surveillance programs, and common measures of injury risk and association. Finally, we describe measures of physical performance and training and considerations for using these measures. This review provides sports medicine clinicians with an understanding of current research measures and considerations for designing sports injury research studies.

Future Strategies to Enhance Patient Care Documentation Among Athletic Trainers: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  High-quality patient care documentation is an essential component of any health care professional's daily practice. Whereas athletic trainers (ATs) recognize the importance of patient care documentation, several barriers may prevent them from producing high-quality patient care documentation.

OBJECTIVE

  To explore beneficial strategies and techniques that ATs perceived would enhance the quality of patient care documentation in the secondary school setting.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

  Ten ATs who were members of the Athletic Training Practice-Based Research Network and employed in the secondary school setting were interviewed (4 men, 6 women with 7.1 ± 7.8 years of athletic training experience).

DATA COLLECTION AND ANALYSIS

  An individual telephone interview was conducted with each participant. Once transcribed, data were analyzed into common themes and categories per the consensual qualitative research tradition. Trustworthiness of the data was achieved through triangulation strategies: (1) the inclusion of multiple researchers to ensure accuracy and representativeness of the data and (2) participant member checking.

RESULTS

  Participants identified several documentation strategies they perceived would be helpful to improve the quality of patient care documentation, including mode and consistency of documentation and the need for a standardized process as well as the need for system standardization. In addition, participants discussed the need for more education on patient care documentation. Specifically, they identified ways of learning and strategies for future education to enhance patient care documentation across the profession.

CONCLUSIONS

  As athletic training continues to evolve, it is crucial that ATs are well educated on how to produce high-quality patient care documentation as a part of routine practice. Continuing professional development opportunities are needed to promote lifelong learning in the area of patient care documentation.

Athletic Training Service Characteristics for Patients With Ankle Sprains Sustained During High School Athletics

CONTEXT

Limited information exists on the amount and type of care provided by athletic trainers (ATs) treating athletes who sustained ankle sprains in the high school setting.

OBJECTIVE

To describe AT services provided for patients with ankle sprains injured in high school athletics.

DESIGN

Descriptive epidemiology study.

SETTING

Athletic training facility (ATF) visits and AT services collected from 147 high schools in 26 states.

PATIENTS OR OTHER PARTICIPANTS

High school student-athletes participating in 13 boys' and 14 girls' sports who sustained a diagnosed ankle sprain during the 2011-2012 through 2013-2014 academic years. The ATs documented 3213 ankle sprains.

MAIN OUTCOME MEASURE(S)

Number of ATF visits and individual AT services and mean ATF visits (per injury) and AT services (per injury) were calculated by sport and for time-loss injuries (participation-restriction time of at least 24 hours) and non-time-loss injuries (participation-restriction time <24 hours).

RESULTS

During the 3-year period, 19 925 ATF visits were reported, with an average of 6 (interquartile range = 1-7) ATF visits per ankle sprain. Most ATF visits were for non-time-loss injuries (65.1%). Football accounted for the largest proportions of ankle sprains (27.3%) and ATF visits (35.0%). In total, 71 404 AT services were provided for ankle sprains. Therapeutic activities or exercise were the most common AT services (47.4%), followed by neuromuscular reeducation (16.6%), strapping (14.2%), and modalities (11.5%). An average of 22 (interquartile range = 4-28) AT services were reported per ankle sprain. The average number of AT services per injury was higher among patients with time-loss than non-time-loss injuries (35 versus 19; P < .001).

CONCLUSIONS

The ATs provided a variety of services to treat high school athletes who had sustained ankle sprains, including therapeutic exercises and neuromuscular reeducation, which were supported by research. However, ATs should consider using manual therapy (use supported by grade B evidence) and therapeutic exercise more (use supported by grade A evidence).

Quality Improvement in Athletic Health Care

CONTEXT

  Quality improvement (QI) is a health care concept that ensures patients receive high-quality (safe, timely, effective, efficient, equitable, patient-centered) and affordable care. Despite its importance, the application of QI in athletic health care has been limited.

OBJECTIVES

  To describe the need for and define QI in health care, to describe how to measure quality in health care, and to present a QI case in athletic training.

DESCRIPTION

  As the athletic training profession continues to grow, a widespread engagement in QI efforts is necessary to establish the value of athletic training services for the patients that we serve. A review of the importance of QI in health care, historical perspectives of QI, tools to drive QI efforts, and examples of common QI initiatives is presented to assist clinicians in better understanding the value of QI for advancing athletic health care and the profession. Clinical and Research Advantages:  By engaging clinicians in strategies to measure outcomes and improve their patient care services, QI practice can help athletic trainers provide high-quality and affordable care to patients.

Rankings of High School Sports Injury Rates Differ Based on Time Loss Assessments

OBJECTIVE

To examine how injury definition inclusiveness affects the rank order of injury rates in 27 high school (HS) sports.

DESIGN

The National Athletic Treatment, Injury and Outcomes Network (NATION) used certified athletic trainers (ATs) to collect injury and athlete-exposure (AE) data in practices and competitions for 27 HS sports during the 2011/2012 to 2013/2014 academic years. Time loss (TL) injuries resulted in ≥24 hours of participation restriction. Nontime loss (NTL) injuries resulted in <24 hours of participation restriction.

SETTING

Aggregate injury and exposure data collected from 27 HS sports.

PARTICIPANTS

High school student-athletes.

INTERVENTIONS

Sports injury data from the National Athletic Treatment, Injury and Outcomes Network.

MAIN OUTCOME MEASURES

Time loss and TL + NTL injury rates were calculated. Sport-specific rates were placed in rank order, stratified by gender.

RESULTS

Most of the 47 014 injuries reported were NTL (82.8%). Among boys' sports, TL injury rates were greatest in football (3.27/1000AE) and wrestling (2.43/1000AE); TL + NTL injury rates were greatest also in football (15.29/1000AE) and wrestling (11.62/1000AE). Among girls' sports, TL injury rates were greatest in soccer (1.97/1000AE) and basketball (1.76/1000AE); TL + NTL injury rates were greatest in field hockey and lacrosse (both 11.32/1000AE).

CONCLUSIONS

The rank order of injury rates and the resulting injury prevention priorities may depend on injury definition inclusiveness, particularly in female HS sports.

Athletic Trainers' Reasons for and Mechanics of Documenting Patient Care: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  Documenting patient care is an important responsibility of athletic trainers (ATs). However, little is known about ATs' reasons for documenting patient care and the mechanics of completing documentation tasks.

OBJECTIVE

  To understand ATs' perceptions about reasons for and the mechanics of patient care documentation.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews with Athletic Training Practice-Based Research Network members.

PATIENTS OR OTHER PARTICIPANTS

  Ten ATs employed in the secondary school setting (age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) were recruited using a criterion-based sampling technique. Participants were Athletic Training Practice-Based Research Network members who used the Clinical Outcomes Research Education for Athletic Trainers electronic medical record system and practiced in 6 states.

DATA COLLECTION AND ANALYSIS

  We used the consensual qualitative research tradition. One investigator conducted individual telephone interviews with each participant. Data collection was considered complete after the research team determined that data saturation was reached. Interviews were transcribed verbatim and independently analyzed by 4 research team members following the process of open, axial, and selective coding. After independently categorizing interview responses into categories and themes, the members of the research team developed a consensus codebook, reanalyzed all interviews, and came to a final agreement on the findings. Trustworthiness was established through multiple-analyst triangulation and member checking.

RESULTS

  Participants identified 3 reasons for documenting patient care: communication, monitoring patient care, and legal implications. Four subcategories emerged from the mechanics-of-documentation theme: location, time of day, length of time, and criteria for documenting. The ATs described different criteria for documenting patient care, ranging from documenting every injury in the same manner to documenting time-loss and follow-up injuries differently.

CONCLUSIONS

  Whereas ATs recognized individual mechanisms that enabled them to document patient care, they may need more guidance on the appropriate criteria for documenting various patient care encounters and strategies to help them document more effectively.

Athletic Trainers' Perceptions of and Barriers to Patient Care Documentation: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

  For the practice characteristics of the services athletic trainers (ATs) provide to be identified, all ATs must complete high-quality patient care documentation. However, little is known about ATs' perceptions of patient care documentation or the potential barriers they may encounter while trying to ensure high-quality documentation.

OBJECTIVE

  To explore ATs' perceptions of and barriers to patient care documentation via the Clinical Outcomes Research Education for Athletic Trainers (CORE-AT) electronic medical record system in the secondary school setting.

DESIGN

  Qualitative study.

SETTING

  Individual telephone interviews.

PATIENTS OR OTHER PARTICIPANTS

  We interviewed 10 ATs (4 men, 6 women; age = 32.6 ± 11.4 years, athletic training experience = 7.1 ± 7.8 years) who were members of the Athletic Training Practice-Based Research Network (AT-PBRN) and employed in the secondary school setting.

DATA COLLECTION AND ANALYSIS

  We conducted an individual interview with each participant. After transcription of the interviews, the data were analyzed into common themes and categories following the consensual qualitative research tradition. Data triangulation occurred through member checking and multiple researchers to ensure accuracy during data analysis.

RESULTS

  Participants revealed several perceptions of patient care documentation, consisting of quality, expectations and accountability, priority, incentive, and culture of the secondary school setting. In addition, we identified barriers to quality patient care documentation: lack of time, lack of accountability for documenting patient care, inadequate facility resources, and lack of personnel. Participants discussed the volume of patients as a unique challenge in the secondary school setting.

CONCLUSIONS

  Whereas ATs perceived patient care documentation as important, several practical barriers may inhibit their ability to complete high-quality documentation of the services they provide. Effective strategies to improve the quality of patient care documentation among ATs are needed to ensure that their value, particularly in the secondary school setting, is accurately characterized.

Sports Injury Surveillance Systems: A Review of Methods and Data Quality

BACKGROUND AND AIMS

Data from sports injury surveillance systems are a prerequisite to the development and evaluation of injury prevention strategies. This review aimed to identify ongoing sports injury surveillance systems and determine whether there are gaps in our understanding of injuries in certain sport settings. A secondary aim was to determine which of the included surveillance systems have evaluated the quality of their data, a key factor in determining their usefulness.

METHODS

A systematic search was carried out to identify (1) publications presenting methodological details of sports injury surveillance systems within clubs and organisations; and (2) publications describing quality evaluations and the quality of data from these systems. Data extracted included methodological details of the surveillance systems, methods used to evaluate data quality, and results of these evaluations.

RESULTS

Following literature search and review, a total of 15 sports injury surveillance systems were identified. Data relevant to each aim were summarised descriptively. Most systems were found to exist within professional and elite sports. Publications concerning data quality were identified for seven (47%) systems. Validation of system data through comparison with alternate sources has been undertaken for only four systems (27%).

CONCLUSIONS

This review identified a shortage of ongoing injury surveillance data from amateur and community sport settings and limited information about the quality of data in professional and elite settings. More surveillance systems are needed across a range of sport settings, as are standards for data quality reporting. These efforts will enable better monitoring of sports injury trends and the development of sports safety strategies.

Athletic Training Services During Daily Patient Encounters: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Athletic training services such as taping, wrapping, and stretching are common during routine care but rarely captured in traditional patient documentation. These clinical data are vital when determining appropriate medical coverage and demonstrating the value and worth of athletic trainers (ATs).

OBJECTIVE

To analyze clinical data from daily encounter forms within the Athletic Training Practice-Based Research Network (AT-PBRN).

DESIGN

Descriptive study.

SETTING

Secondary school athletic training clinics.

PATIENTS OR OTHER PARTICIPANTS

Adolescent patients (n = 4888; age = 16.3 ± 1.4 years) seeking care from ATs.

MAIN OUTCOME MEASURE(S)

We used Web-based electronic medical records from December 1, 2009, to July 1, 2015, to obtain patient characteristics via deidentified data. Descriptive data regarding practice characteristics from patient encounter forms were analyzed and reported as percentages and frequencies.

RESULTS

A total of 36 245 patient encounters (mean = 7.5 ± 11.6 encounters per patient) were recorded. Football, basketball, soccer, track, and volleyball accounted for 85.1% of all encounters. Most encounters were for preventive services (48.8%, n = 22 329), followed by care for a current injury (37.2%, n = 17 027) and care for a new injury (13.9%, n = 6368). Of the preventive encounters, taping (52.7%) was the most common service provided, followed by ice- or hot-pack application (25.4%) and treatment (9.6%). Taping (28.7%) was also the most common service for current injuries, followed by treatment (26.7%) and ice- or hot-pack application (26.2%).

CONCLUSIONS

Our findings highlight the unique role of ATs as health care providers who provide substantial preventive services to their patients. Further, these results represent one of the first attempts to describe athletic training services related to nontime-loss injuries, emphasizing the significant role that ATs play in the health care of secondary school athletes. These findings should help clinicians and administrators make more informed decisions regarding appropriate medical coverage.

High School Football Injury Rates and Services by Athletic Trainer Employment Status

CONTEXT

Reported injury rates and services in sports injury surveillance may be influenced by the employment setting of the certified athletic trainers (ATs) reporting these data.

OBJECTIVE

To determine whether injury rates and the average number of AT services per injury in high school football varied by AT employment status.

DESIGN

Cross-sectional study.

SETTING

We used data from the National Athletic Treatment, Injury and Outcomes Network and surveyed ATs about their employment setting.

PATIENTS OR OTHER PARTICIPANTS

Forty-four responding ATs (37.9% of all National Athletic Treatment, Injury and Outcomes Network participants) worked at high schools with football programs and were included in this study. Fourteen ATs were full-time employees of the high school, and 30 ATs were employed as outreach ATs (i.e., full-time and part-time ATs from nearby clinics, hospitals, and graduate school programs).

MAIN OUTCOME MEASURE(S)

We calculated injury rates per 1000 athlete-exposures and average number of AT services per injury.

RESULTS

Reported injury rates and services per injury were greater among full-time school employees compared with outreach ATs. However, injury rates did not differ when restricted to time-loss injuries only.

CONCLUSIONS

Our findings suggest that ATs who are full-time school employees may be able to identify and care for more patients with injuries.

Methods and Descriptive Epidemiology of Services Provided by Athletic Trainers in High Schools: The National Athletic Treatment, Injury and Outcomes Network Study

CONTEXT

Research is limited on the extent and nature of the care provided by athletic trainers (ATs) to student-athletes in the high school setting.

OBJECTIVE

To describe the methods of the National Athletic Treatment, Injury and Outcomes Network (NATION) project and provide the descriptive epidemiology of AT services for injury care in 27 high school sports.

DESIGN

Descriptive epidemiology study.

SETTING

Athletic training room (ATR) visits and AT services data collected in 147 high schools from 26 states.

PATIENTS OR OTHER PARTICIPANTS

High school student-athletes participating in 13 boys' sports and 14 girls' sports during the 2011-2012 through 2013-2014 academic years.

MAIN OUTCOME MEASURE(S)

The number of ATR visits and individual AT services, as well as the mean number of ATR visits (per injury) and AT services (per injury and ATR visit) were calculated by sport and for time-loss (TL) and non-time-loss (NTL) injuries.

RESULTS

Over the 3-year period, 210 773 ATR visits and 557 381 AT services were reported for 50 604 injuries. Most ATR visits (70%) were for NTL injuries. Common AT services were therapeutic activities or exercise (45.4%), modalities (18.6%), and AT evaluation and reevaluation (15.9%), with an average of 4.17 ± 6.52 ATR visits and 11.01 ± 22.86 AT services per injury. Compared with NTL injuries, patients with TL injuries accrued more ATR visits (7.76 versus 3.47; P < .001) and AT services (18.60 versus 9.56; P < .001) per injury. An average of 2.24 ± 1.33 AT services were reported per ATR visit. Compared with TL injuries, NTL injuries had a larger average number of AT services per ATR visit (2.28 versus 2.05; P < .001).

CONCLUSIONS

These findings highlight the broad spectrum of care provided by ATs to high school student-athletes and demonstrate that patients with NTL injuries require substantial amounts of AT services.

Injury and treatment characteristics of sport-specific injuries sustained in interscholastic athletics: a report from the athletic training practice-based research network

Background:

The inclusion of clinical practice factors, beyond epidemiologic data, may help guide medical coverage and care decisions.

Hypothesis:

Trends in injury and treatment characteristics of sport-specific injuries sustained by secondary school athletes will differ based on sport.

Study Design:

Retrospective analysis of electronic patient records.

Level of evidence:

Level 4.

Methods:

Participants consisted of 3302 boys and 2293 girls who were diagnosed with a sport-related injury or condition during the study years. Injury (sport, body part, diagnosis via ICD-9 codes) and treatment (type, amount, and duration of care) characteristics were grouped by sport and reported using summary statistics.

Results:

Most injuries and treatments occurred in football, girls’ soccer, basketball, volleyball, and track and field. Sprain or strain of the ankle, knee, and thigh/hip/groin and concussion were the most commonly documented injuries across sports. The injury pattern for boys’ wrestling differed from other sports and included sprain or strain of the elbow and neck and general medical skin conditions. The most frequently reported service was athletic training evaluation/reevaluation treatment, followed by hot/cold pack, therapeutic exercise, manual therapy techniques, electrical stimulation, and strapping of lower extremity joints. Most sports required 4 to 5 services per injury. With the exception of boys’ soccer and girls’ softball, duration of care ranged from 10 to 14 days. Girls’ soccer and girls’ and boys’ track and field reported the longest durations of care.

Conclusion:

Injury and treatment characteristics are generally comparable across sports, suggesting that secondary school athletic trainers may diagnose and treat similar injuries regardless of sport.

Clinical Relevance:

Subtle sport trends, including skin conditions associated with boys’ wrestling and longer duration of care for girls’ soccer, are important to note when discussing appropriate medical coverage and care.

Practice-based research networks, part I: clinical laboratories to generate and translate research findings into effective patient care

CONTEXT

To improve patient care, athletic training clinicians and researchers should work together to translate research findings into clinical practice. Problems with patient care observed in clinical practice should be translated into research frameworks, where they can be studied. Practice-based research networks (PBRNs) provide a compelling model for linking clinicians and researchers so they can conduct translational research to improve patient care.

OBJECTIVE

To describe (1) the translational research model, (2) practice-based research as a mechanism for translating research findings into clinical practice, (3) the PBRN model and infrastructure, (4) the research potential using the PBRN model, and (5) protection of human participants in PBRN research.

DESCRIPTION

Translational research is the process of transforming research findings into health behavior that ultimately serves the public and attempts to bridge the gap between research and clinical practice. Practice-based research represents the final step in the translational research continuum and describes research conducted by providers in clinical practices. The PBRNs are characterized by an organizational framework that transcends a single site or study and serves as the clinical research "laboratory" for conducting comparative-effectiveness studies using patient-oriented measures. The PBRN approach to research has many benefits, including enhanced generalizability of results, pooling of resources, rapid patient recruitment, and collaborative opportunities. However, multisite research also brings challenges related to the protection of human participants and institutional review board oversight. CLINICAL AND RESEARCH ADVANTAGES: Athletic training studies frequently include relatively few participants and, consequently, are able to detect only large effects. The incidence of injury at a single site is sufficiently low that gathering enough data to adequately power a treatment study may take many years. Collaborative efforts across diverse clinical practice environments can yield larger patient samples to overcome the limitations inherent in single-site research efforts.