The Athletic Trainer

Regulation

Graduation from an accredited professional program is a requisite to sit for the Board of Certification, Inc. (BOC) examination as an entry-level AT. The “ATC” designation indicates that a person has passed the BOC examination, which serves as the common examination for individual states that issue the practice credential, typically “LAT” or “AT.” Although most states have licensure for professional practice, some states regulate practice via Registration or State Certification ( Table 30.2 ). As of 2017 California is the only state that does not have any sort of state regulation of AT practice. Although the language of these practice acts is broad, a commonality is that ATs work collaboratively with and/or under a physician's direction.

Injury Prevention and Health Promotion

The basis of injury prevention and risk management is ensuring the individual's physical readiness to participate in strenuous activity, ensuring a safe playing/work environment, and developing and implementing EAPs. Another form of injury prevention is ensuring the safe return to activity after an injury has been sustained. Lastly, ATs spend significant time educating patients before, during, and after injury and illness.

Using both written health questionnaire and physical examination, the preparticipation physical examination identifies a person's physical readiness to engage in selected activities. During a routine preparticipation physical examination, the patient's and patient's family medical history are analyzed, and a review of systems and regional examinations are performed. In addition, baseline testing such as concussion testing and strength and range of motion (ROM) assessments may be conducted.

ATs work with physicians, administrators, and attorneys to develop EAPs. The EAP describes the standard of care and the procedures to follow in the event of foreseeable emergent situations (e.g., cardiac arrest, cervical spine injury), inclement weather (e.g., heat or lightning), or other possible venue-specific contingencies.

Patient education is the most encompassing method of injury prevention and risk management. When working with high school–aged patients (or younger), patient education also includes the athlete's parent(s) or legal guardian. The AT is often the primary source for information regarding concussions, heat illness, sickle cell trait, and nutritional and hydration needs. This role also extends to bridging the gap between the patient, the patient's family, and the physician regarding the potential outcomes of surgery or other interventions for an injury or illness (and, likewise, the possible consequences of not following the physician's advice). Because ATs tend to see their patients on a frequent (sometimes daily) basis, they serve as a valuable resource for answering questions that may arise during the patient's treatment.

Clinical Diagnosis and Immediate Care

The immediate (on-field) examination first rules out life- or limb-threatening conditions, fractures, or dislocations. The on-field examination ultimately culminates in the decision about how to remove the athlete from the playing field (e.g., assisted or unassisted) and whether the condition requires that the patient be immediately transported to a hospital for emergency care.

The clinical examination relies on obtaining a medical history and performing a functional assessment, inspection, palpation, and assessment of joint and muscle function to form a differential diagnosis. Joint-specific stress tests, selective tissue tests, and, when applicable, neurologic and vascular tests are used to rule in or rule out various pathologies, resulting in a working clinical diagnosis. The AT triages the patient and determines if a referral is indicated. Once a diagnosis has been established, the AT may consult with the physician to determine the appropriate course of care ( Fig. 30.1 ).

Immediate and Emergent Care

In cases in which the findings of the acute (i.e., immediately following the injury) clinical examination and diagnosis indicate that the patient requires emergent care and/or direct transportation to a medical facility, the AT leads (or provides assistance during) the process. The scheme of the on-field examination follows the principle of ruling out life-threatening conditions and conditions that jeopardize the integrity of the extremity and then performing a more finite musculoskeletal examination. In equipment-intensive sports such as football and hockey, the player's protective equipment may hinder the examination process.

Even before arriving at the scene, the AT begins the triage (i.e., the primary assessment of airway, breathing, and circulation, shock, severe bleeding, and spinal injury). If the athlete is experiencing cardiorespiratory compromise, life support is begun. If this initial screen is negative, the athlete's level of consciousness is ascertained. If the athlete is unconscious (or if a cervical spine injury is indicated), the AT stabilizes the cervical spine and leads the process of immobilizing the patient on a spine board. The AT is often the only person on site to make the return-to-play (RTP) determination, which is particularly important in the case of concussion management. ATs are well educated in the diagnosis and management of concussion, along with RTP criteria.

The on-field orthopaedic examination is more rote than a clinical examination. Although its underlying purpose is to determine if assistance is needed to transport the athlete to the sideline or directly to a medical facility (and, if so, the transportation method required), it is also the best opportunity to identify joint stability before a muscle spasm sets in. The focus is on the immediate history of the injury (primarily the mechanism), inspection and palpation for gross deformity, and determination of active ROM. Although exceptions occur, in general only uniplanar stress tests are performed on the field; selective tissue tests are reserved for a more controlled examination environment.

ATs are well educated regarding transportation techniques, ranging from spine boarding to manually assisted transport. When appropriate, the AT will apply an appropriate protective device and/or fit the patient with crutches to ensure safe ambulation.

Therapeutic Interventions

Therapeutic intervention includes therapeutic modalities, manual therapy, and therapeutic exercise to return the patient to the desired level of function. In a more athletic population, the primary emphasis is on reducing participation restrictions. However, the athletic training philosophy tends to yield interventions that are more aggressive than those used with the general population. Although the protocols used are aggressive, the goal is to return the patient to activity safely and in the shortest time possible. Identification of the relative and absolute contraindications and precautions to intervention techniques is embedded in the patient examination.

Some therapeutic modalities, such as ice, moist heat, electrical stimulation, and therapeutic ultrasound, are passive devices used to regulate the physiologic response to trauma. Other modalities such as traction or compression are used to cause physical changes in the tissues. Typically, therapeutic modalities are used to allow active exercise or manual therapy to be performed.

Manual therapies include massage, myofascial release, augmented soft tissue mobilization, and joint mobilization ( Fig. 30.2 ). These therapies are augmented by passive, active-assisted, active, and resisted ROM exercises. Once strength and ROM are restored, a functional progression relative to the body part that involves appropriate strengthening, proprioceptive activities, and activity-specific skills is implemented.

Prescription, over-the-counter, and herbal supplements are commonly used by athletes and other physically active persons. ATs understand the influence of pharmacologic approaches in the management of acute and chronic injury and disease and recognize the potential ramifications for patient care.