Principles of Athletic Training - A Guide to Evidence-Based Clinical Practice, William E. Prentice, McGraw-Hill, 16th Edition 2017-TLS.pdf

Principles of

ATHLETIC TRAINING A Guide to Evidence-Based Clinical Practice SIXTEENTH EDITION

William E. Prentice, PhD, ATC, PT, FNATA Professor, Coordinator Sports Medicine Program Department of Exercise and Sport Science The University of North Carolina at Chapel Hill Chapel Hill, North Carolina

PRINCIPLES OF ATHLETIC TRAINING: A GUIDE TO EVIDENCE-BASED CLINICAL PRACTICE, SIXTEENTH EDITION Published by McGraw-Hill Education, 2 Penn Plaza, New York, NY 10121. Copyright © 2017 by McGraw-Hill Education. All rights reserved. Printed in the United States of America. Previous editions © 2014, 2011, and 2009. No part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written consent of McGraw-Hill Education, including, but not limited to, in any network or other electronic storage or transmission, or broadcast for distance learning. Some ancillaries, including electronic and print components, may not be available to customers outside the United States. This book is printed on acid-free paper. 1 2 3 4 5 6 7 8 9 DOW 21 20 19 18 17 16 ISBN 978-1-259-82400-5 MHID 1-259-82400-4 Chief Product Officer, SVP Products & Markets: G. Scott Virkler Vice President, General Manager, Products & Markets: Marty Lange Managing Director: David Patterson Brand Manager: Penina Braffman, Jamie Laferrera Product Developer: Anthony McHugh Marketing Manager: Meredith Leo Director, Content Design & Delivery: Terri Scheisl Program Manager: Jennifer Shekleton Content Project Managers: Melissa M. Leick, George Theofanopoulos, Sandra Schnee Buyer: Laura Fuller Design: Studio Montage, Inc. Content Licensing Specialists: Lori Slattery Cover Image: © Science Photo Library / Alamy Stock Photo Design Elements: Clipboard: © Mcgraw-Hill Education Magnifying glass: © juliardi/Getty Images RF Compositor: MPS Limited Printer: R. R. Donnelley All credits appearing on page or at the end of the book are considered to be an extension of the copyright page. Library of Congress Cataloging-in-Publication Data Prentice, William E. Principles of athletic training : a guide to evidence-based clinical practice / William E. Prentice, PhD, ATC, PT, FNATA, professor, coordinator of Sports Medicine Program, Department of Exercise and Sport Science, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Sixteenth edition. | New York, NY : McGraw-Hill Education, [2017] | Subtitle changed from previous edition. | Includes bibliographical references and index. LCCN 2016040018 | ISBN 9781259824005 (alk. paper) LCSH: Athletic trainers. | Physical education and training. LCC RC1210 .A75 2017 | DDC 613.7—dc23 LC record available at https://lccn.loc.gov/2016040018 The Internet addresses listed in the text were accurate at the time of publication. The inclusion of a website does not indicate an endorsement by the authors or McGraw-Hill Education, and McGraw-Hill Education does not guarantee the accuracy of the information presented at these sites.

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Brief Contents PART I

Professional Development and Responsibilities 1 1 The Athletic Trainer as a Health Care Provider 2

12 On-the-Field Acute Care and Emergency Procedures 305 13 Off-the-Field Injury Evaluation 344 14 Infectious Diseases, Bloodborne Pathogens, and Universal Precautions 381 15 Using Therapeutic Modalities 397

2 Health Care Organization and Administration in Athletic Training 42

16 Using Therapeutic Exercise in Rehabilitation 430

3 Legal Concerns and Insurance Issues 75

17 Pharmacology, Drugs, and Sports 463

PART II

PART V

Risk Management 89

Musculoskeletal Conditions 505

4 Fitness and Conditioning Techniques 90

18 The Foot 506

5 Nutrition and Supplements 129

19 The Ankle and Lower Leg 545

6 Environmental Considerations 158

20 The Knee and Related Structures 581

7 Protective Equipment 184

21 The Thigh, Hip, Groin, and Pelvis 631

8 Wrapping and Taping 214

22 The Shoulder Complex 668 23 The Elbow 711

PART III

Pathology of Sports Injury 245 9 Mechanisms and Characteristics of Musculoskeletal and Nerve Trauma 246 10 Tissue Response to Injury 267

PART IV

Management Skills 285 11 Psychosocial Intervention for Sports Injuries and Illnesses 286

24 The Forearm, Wrist, Hand, and Fingers 734 25 The Spine 767

PART VI

General Medical Conditions 823 26 The Head, Face, Eyes, Ears, Nose, and Throat 824 27 The Thorax and Abdomen 860 28 Skin Disorders 893 29 Additional General Medical Conditions 926

iii

Appendix A Addresses of Professional Sports Medicine Organizations 949 Appendix B NATA Position, Official, Consensus, and Support Statements 951 Appendix C Sports Medicine–Related Journals 953 Appendix D Sample Résumé 954 Appendix E NATA Code of Ethics 955

Brief Contents

Appendix F Manual Muscle Tests 956 Appendix G Goniometric Measurements of Range of Motion 960 Glossary 964 Index 968 Suggested Supplies 984 Conversions 987

Contents Preface x Applications at a Glance xvii

Collecting Injury Data 68 Summary 71

Chapter 3 Legal Concerns and Insurance PART I

Professional Development and Responsibilities 1

Issues 75 Legal Concerns for the Athletic Trainer 76 Insurance Considerations 79 Third-Party Reimbursement 82 Summary 86

Chapter 1 The Athletic Trainer as a Health Care Provider 2 Historical Perspectives 3 Sports Medicine and Athletic Training 4 Employment Settings for the Athletic Trainer 7 Roles and Responsibilities of the Athletic Trainer 14 Professional Responsibilities of the Athletic Trainer 19 Referring the Patient to Other Medical and Nonmedical Support Services and Personnel 29 Recognition and Accreditation of the Athletic Trainer as an Allied Health Care Professional 33 Requirements for Certification as an Athletic Trainer 35 State Regulation of the Athletic Trainer 36 Future Directions for the Athletic Trainer 37 Summary 38

Chapter 2 Health Care Organization and Administration in Athletic Training 42 Establishing a System for Athletic Training Health Care 43 Issues Specific to Athletic Training Program Operation in the Secondary-School, College, or University Setting 43 Issues Specific to Athletic Training Program Operation in the Clinic, Hospital, Corporate, or Industrial Setting 52 Record Keeping 56 Computers, Tablets, and Smartphones as Tools for the Athletic Trainer 67

PART II

Risk Management 89 Chapter 4 Fitness and Conditioning Techniques 90 The Relationship between Athletic Trainers and Strength and Conditioning Coaches 91 Principles of Conditioning 91 Warm-Up and Cool-Down 92 Cardiorespiratory Endurance 93 The Importance of Muscular Strength, Endurance, and Power 100 Improving and Maintaining Flexibility 113 Fitness Assessment 122 Periodization in Conditioning 122 Summary 124

Chapter 5 Nutrition and Supplements 129 Nutrition Basics 130 Energy Sources 131 Regulator Nutrients 133 Nutrient Requirements and Recommendations 136 Food Labels 137 Myplate 137 Dietary Supplements 138 Eating and Drinking Practices 142 Body Composition and Weight Control 147 Disordered Eating 152 Summary 154

Chapter 6 Environmental Considerations 158 Hyperthermia 159 Hypothermia 171 Altitude Sickness 173 Overexposure to Sun 174 Lightning Safety 175 Air Pollution 176 Circadian Dysrhythmia (Jet Lag) 178 Synthetic Turf 179 Summary 179

Chapter 7 Protective Equipment 184 Safety Standards for Sports Equipment and Facilities 185 Legal Concerns in Using Protective Equipment 185 Equipment Reconditioning and Recertification 185 Using Off-the-Shelf versus Custom Protective Equipment 186 Head Protection 187 Face Protection 192 Neck Protection 195 Trunk and Thorax Protection 195 Lower-Extremity Protective Equipment 199 Elbow, Wrist, and Hand Protection 206 Construction of Protective and Supportive Devices 207 Summary 210

Chapter 8 Wrapping and Taping 214 Wrapping 215 Nonelastic and Elastic Adhesive Taping 223 Common Taping Procedures 226 Kinesio Taping 240 Summary 242

Chapter 10 Tissue Response to Injury 267 The Healing Process 268 Soft-Tissue Healing 273 Bone Healing 276 Pain 278 Summary 282

PART IV

Management Skills 285 Chapter 11 Psychosocial Intervention for Sports Injuries and Illnesses 286 The Psychological Response to Injury 287 The Athlete and the Sociological Response to Injury 288 Predictors of Injury 290 Reacting to Athletes With Injuries 293 Psychological Factors in the Rehabilitation Process 294 Psychological Skills Training Techniques 296 Mental Disorders 299 Summary 301

Chapter 12 On-the-Field Acute Care and Emergency Procedures 305 The Emergency Action Plan 306 Principles of On-the-Field Injury Assessment 309 The Primary Survey 309 The Secondary Survey 321 Protective Equipment Removal 328 Moving and Transporting the Injured Patient 333 Proper Fit and Use of The Crutch or Cane 337 Summary 340

Chapter 13 Off-the-Field Injury PART III

Pathology of Sports Injury 245 Chapter 9 Mechanisms and Characteristics of Musculoskeletal and Nerve Trauma 246 Mechanical Injury 247 Musculotendinous Unit Injuries 249 Synovial Joint Injuries 253 Bone Injuries 257 Nerve Trauma 262 Body Mechanics and Injury Susceptibility 263 Summary 263

Contents

Evaluation 344 Basic Knowledge Requirements 345 The Off-The-Field Injury Evaluation Process 348 Functional Screening Tests 358 Using the Best Available Evidence in Clinical Decision Making 363 Progress Evaluations 366 Clinical Evaluation and Diagnosis 367 Documenting Injury Evaluation Information 367 Additional Diagnostic Tests Used by a Physician 371 Ergonomic Risk Assessment (ERA) 377 Summary 378

Chapter 14 Infectious Diseases, Bloodborne Pathogens, and Universal Precautions 381 Infectious Diseases 382 Bloodborne Pathogens 385 Universal Precautions In An Athletic Environment 391 Summary 394

Chapter 15 Using Therapeutic Modalities 397 Legal Concerns 398 Classification of Therapeutic Modalities 398 Thermal Conductive Energy Modalities 398 Electrical Energy Modalities 406 Electromagnetic Energy Modalities 411 Sound Energy Modalities 413 Mechanical Energy Modalities 416 Modalities Not Commonly Used by Athletic Trainers 424 Recording Therapeutic Modality Treatments 425 Safety in Using Therapeutic Modalities 426 Evidence-Based Data Regarding Therapeutic Modality Use 426 Summary 427

Chapter 16 Using Therapeutic Exercise in Rehabilitation 430 The Athletic Trainer’s Approach to Rehabilitation 431 Therapeutic Exercise versus Conditioning Exercise 431 Sudden Physical Inactivity and Injury Immobilization 432 Major Components of a Rehabilitation Program 433 Developing a Rehabilitation Plan 440 Additional Approaches to Therapeutic Exercise in Rehabilitation 443 Purchasing and Maintaining Therapeutic Exercise Equipment 458 Summary 458

Chapter 17 Pharmacology, Drugs, andSports 463 What Is A Drug? 464 Pharmacokinetics 464 Legal Concerns in Administering Versus Dispensing Drugs 466 Selected Therapeutic Drugs 470 Drugs That Can Increase the Rate of Heat Illness 483

Protocols For Using over-the-Counter Medications 483 Substance Abuse Among Athletes 489 Drug Testing in Athletes 496 Summary 500

PART V

Musculoskeletal Conditions 505 Chapter 18 The Foot 506 Foot Anatomy 507 Functional Anatomy and Foot Biomechanics 514 Prevention of Foot Injuries 517 Foot Assessment 519 Recognition and Management of Specific Injuries 522 Foot Rehabilitation 536 Summary 542

Chapter 19 The Ankle and Lower Leg 545 Anatomy of The Ankle and Lower Leg 546 Functional Anatomy 551 Preventing Injury to the Ankle and Lower Leg 551 Assessing the Ankle and Lower Leg 553 Recognition of Specific Injuries 556 Rehabilitation Techniques for the Ankle and Lower Leg 571 Summary 577

Chapter 20 The Knee and Related Structures 581 Anatomy of The Knee 582 Functional Anatomy 588 Assessing the Knee Joint 589 Prevention of Knee Injuries 603 Recognition and Management of Specific Injuries 604 Knee Joint Rehabilitation 621 Summary 626

Chapter 21 The Thigh, Hip, Groin, and Pelvis 631 Anatomy of the Thigh 632 Functional Anatomy of the Thigh 634 Assessment of the Thigh 635 Prevention of Injuries to the Thigh, Hip, Groin, and Pelvic Region 636 Recognition and Management of Thigh Injuries 636

Contents

vii

Anatomy of the Hip, Groin, and Pelvic Region 640 Functional Anatomy of the Hip, Groin, and Pelvic Region 645 Assessment of the Hip, Groin, and Pelvis 646 Recognition and Management of Specific Hip, Groin, and Pelvic Injuries 652 Thigh and Hip Rehabilitation Techniques 660 Summary 665

Chapter 22 The Shoulder Complex 668 Anatomy of The Shoulder 669 Functional Anatomy 676 Prevention of Shoulder Injuries 677 Assessment of The Shoulder Complex 677 Recognition and Management of Specific Injuries 685 Throwing Mechanics 697 Rehabilitation of the Shoulder Complex 699 Summary 706

Chapter 23 The Elbow 711 Anatomy of the Elbow Joint 712 Functional Anatomy 716 Assessment of the Elbow 717 Recognition and Management of Injuries tothe Elbow 720 Rehabilitation of the Elbow 728 Summary 731

Chapter 24 The Forearm, Wrist, Hand, and Fingers 734 Anatomy of the Forearm 735 Assessment of the Forearm 735 Recognition and Management of Injuries to the Forearm 739 Anatomy of the Wrist, Hand, and Fingers 741 Assessment of the Wrist, Hand, and Fingers 744 Recognition and Management of Injuries to the Wrist, Hand, and Fingers 748 Rehabilitation of Injuries to the Forearm, Wrist, Hand, and Fingers 759 Summary 764

Chapter 25 The Spine 767 Anatomy of The Spine 768 Functional Anatomy 775 Prevention of Injuries to the Spine 777 Assessment of the Spine 778 Recognition and Management of Specific Injuries and Conditions 792 Rehabilitation Techniques for the Neck 808 Rehabilitation Techniques for the Low Back 810 Summary 817 viii

Contents

PART VI

General Medical Conditions 823 Chapter 26 The Head, Face, Eyes, Ears, Nose, and Throat 824 Prevention of Injuries to the Head, Face, Eyes, Ears, Nose, and Throat 825 The Head 825 The Face 842 Dental Injuries 845 Nasal Injuries 847 Ear Injuries 848 Eye Injuries 850 Throat Injuries 856 Summary 856

Chapter 27 The Thorax and Abdomen 860 Anatomy of the Thorax 861 Anatomy of the Abdomen 863 Prevention of Injuries to the Thorax and Abdomen 869 Assessment of the Thorax and Abdomen 871 Recognition and Management of Specific Injuries and Conditions of the Thoracic Region 875 Recognition and Management of Specific Injuries and Conditions of The Abdomen 881 Injuries and Conditions Related to the Digestive System 883 Summary 890

Chapter 28 Skin Disorders 893 Skin Anatomy and Function 894 Skin Lesions Defined 895 Skin Trauma 897 Bacterial Infections 906 Fungal Infections 910 Viral Infections 913 Allergic, Thermal, and Chemical Skin Reactions 916 Infestation and Bites 918 Other Skin Conditions 921 Summary 923

Chapter 29 Additional General Medical Conditions 926 The Role of the Immune System 927 Viral Infections 927 Respiratory Conditions 930 Muscular System Disorders 933 Nervous System Disorders 933 Blood and Lymph Disorders 934 Endocrine System Disorders 936 Seizure Disorders 937

Hypertension (High Blood Pressure) 938 Cancer 938 Sexually Transmitted Diseases (STDs) 939 Menstrual Irregularities and the Female Reproductive System 941 Summary 945

Appendixes Appendix A Addresses of Professional Sports Medicine Organizations 949 Appendix B NATA Position, Official, Consensus, and Support Statements 951

Appendix C Sports Medicine–Related Journals 953 Appendix D Sample Résumé 954 Appendix E NATA Code of Ethics 955 Appendix F Manual Muscle Tests 956 Appendix G Goniometric Measurements of Range of Motion 960 Glossary 964 Index 968 Suggested Supplies 984 Conversions 987

Contents

Preface PHILOSOPHY Since the first edition of Principles of Athletic Training was published in 1963, the profession of athletic training has experienced amazing growth, not only in numbers but also in the associated body of knowledge. During all those years and in fifteen previous editions, the authors of this text, Daniel Arnheim, John Klafs, and now Bill Prentice, have taken it as a personal responsibility to provide the reader with the most current clinical information in athletic training and sports medicine. It has always been based on the most current research evidence and, consequently, it has endured as one of the preeminent textbooks for athletic training students and professionals for more than 50 years. The text is designed to lead the student from general foundations to specific concepts relative to injury prevention, evaluation, management, and rehabilitation. As with other health care professions, the gold standard for athletic trainers is to make decisions about the clinical care of individual patients based on the current best available evidence in the professional literature to achieve the most optimal patient outcomes. It has always been important for this text to address all of the competencies and clinical proficiencies that the profession has identified as critical relative to both the education of our students and to the practice of athletic training. The changes, updates, and additions to this sixteenth edition are a reflection of my commitment and passion toward continuing Dan Arnheim’s and John Klafs’s tradition.

THE ATHLETIC TRAINER AS A HEALTH CARE PROVIDER Over the years since the origins of the athletic training profession in the 1930s, the majority of athletic trainers have been employed at colleges and universities, and in secondary schools, providing services almost exclusively to an athletic population. Historically, this work environment has been referred to as the “traditional setting” for employment for athletic trainers. During the past decade, the role of the athletic trainer has gradually evolved into one that is unquestionably more aligned with that of a health care provider. Today, more than 40percent of certified athletic trainers are employed in clinics and hospitals or in industrial and occupational settings, working under the direction of a physician as physician extenders. Although many athletic trainers continue to work in colleges, universities, and secondary schools, others can be found working as health care providers in all kinds of professional sports, including rodeo and NASCAR; in performing arts and the entertainment industry; in medical x

equipment sales and support; in the military; with law enforcement departments; and with government agencies, including NASA, the U.S. Senate, and the Pentagon. This expansion of potential employment settings has forced the profession not only to change the methods by which health care is delivered to a variety of patient populations but also to change athletic training education programs to teach and/or establish professional competencies and proficiencies that are universal to all settings. Depending on the employment settings in which they work, athletic trainers no longer provide health care only to athletes, nor do they only provide health care to individuals who are injured as a result of physical activity. Thus, the athletic trainer is more closely aligned with other allied health professionals, and athletic training has gained recognition as a clinical health care profession.

WHO IS IT WRITTEN FOR? Principles of Athletic Training: A Guide to EvidenceBased Clinical Practice should be used by athletic trainers in courses concerned with the scientific, evidence-based, and clinical foundations of athletic training and sports medicine. Practicing athletic trainers, physical therapists, and other health care professionals involved with physically active individuals will also find this text valuable.

CONTENT ORGANIZATION The 29 chapters in the sixteenth edition are organized into six sections: Professional Development and Responsibilities, Risk Management, Pathology of Sports Injury, Management Skills, Musculoskeletal Conditions, and General Medical Conditions. As in previous editions, developing the sixteenth edition included serious consideration and incorporation of suggestions made by students, as well as detailed feedback from reviewers and other respected authorities in the field. Consequently, this sixteenth edition reflects the major dynamic trends in the field of athletic training and sports medicine. Furthermore, it is my hope that this newest edition will help prepare students to become competent health care professionals who will continue to enhance the ongoing advancement of the athletic training profession. In addition to the inclusion of material that focuses on evidence-based practice, this newest edition continues to undergo changes in content. The changes and additions are reflective of the ever-increasing body of knowledge that is expanding the scope of practice for the athletic trainer. Throughout the text, information relevant to athletic trainers working in a variety of employment settings is included. As is the case for those working in secondary

schools and colleges or universities, athletic trainers working in clinical, hospital, corporate, or industrial settings must be competent in preventing and recognizing injuries, and supervising injury rehabilitation programs. However, staff athletic trainers working in these settings treat and rehabilitate a wider range of patients both in terms of age and physical condition. The athletic trainer may provide care to pediatric, adolescent, young adult, adult, and geriatric patients. Patients may have physical ailments that may or may not be related to physical activity.

WHAT IS NEW IN THIS EDITION? This latest edition of Principles of Athletic Training: A Guide to Evidence-Based Clinical Practice continues to evolve in concert with the profession. Historically, the authors have tried diligently to stay on the cutting edge of the athletic training profession with regard not only to presenting a comprehensive and ever expanding body of knowledge but also with the latest techniques of delivering educational content to students. Most evident in this edition is the replacement of many of the older photos, and the addition of new photos to better illustrate the injuries, conditions, or clinical techniques described in the text. In addition to the hard copy of this text, the author has created an online library of approximately 1,400 instructional videos that clearly demonstrate specific clinical techniques, injury evaluation skills, rehabilitative exercises, and manual therapy skills that are used by experienced athletic trainers. There is also an online eBook version of this text that will facilitate direct access to the instructional videos from within the body of the text.

CHAPTER-BY-CHAPTER ADDITIONS One of the objectives throughout this text has been to incorporate the best available evidence to support the recommendations being made relative to patient care. The strength of those recommendations (SoR) based on the NATA Position, Official, and Consensus statements is identified within the text and can easily be found next to the reference where appropriate. For the special tests presented in Chapters 18 to 25, the specificity, sensitivity, and positive and negative likelihood ratios are included wherever possible to show the usefulness and diagnostic accuracy of each of those tests based on the best available evidence in the literature.

Chapter 1 • • • •

Added information on the Youth Sport Safety Alliance and their Secondary School Student Athletes Bill of Rights Added new information on the athletic trainer’s role in managing athletes with disabilities Updated the information on rating the levels of evidence and the strength of recommendations Expanded the section on patient-related outcome measures

• • •

Added new table listing the outcome measures most often used by sports medicine professionals Added information on the CAATE decision to establish the entry-level degree for professional practice for athletic trainers at the masters level Update Board of Certification requirements for certification and continuing education

Chapter 2 • • • •

Added new information on establishing a crisis management plan Updated information on electronic medical records Reorganized, expanded, and updated the information on pre-participation exams Replaced old versions with new updated medical history and physical examination forms

Chapter 3 • • •

Clarified information on negligence Added new information and a focus box explaining the Affordable Care Act Replaced outdated form with a new StudentAthlete Insurance Information form

Chapter 4 • • • •

Updated information on newest guidelines and recommendations for continuous training relative to intensity of the activity Updated information on high-intensity interval training Updated information on fartlek training Updated information on weight-bearing exercises

Chapter 5 • • • • •

Updated new 2016 Food label Updated information on vegetarian diets Updated the calorie table for fast foods Added new section on Dual Energy X-ray Absorptiometry (DXA) Added new information on binge eating disorder

Chapter 6 • • • •

Updated NCAA-mandated guidelines for acclimatization in preseason football practices Updated revised information from the NATA 2015 position statement on exertional heat illness Changed classification of hyponatremia, which is no longer classified as an exertional heat illness Updated information on lightning safety

Chapter 7 • • •

Updated table on equipment regulatory agencies Updated information on the selection and fitting of the newest available football helmets Included updated information on the effectiveness of soccer headgear Preface

Chapter 8 •

Updated the information on the effectiveness of using ankle braces versus ankle taping

Chapter 9 • •

Updated information on the cause of muscle cramps Revised information on tendinopathies to clarify the differences between tendinitis and tendinosis

Chapter 10 •

Revised and clarified information on the gate control theory of pain management

Chapter 11 • •

Updated information on mental disorders Updated the keys for referring patients with mental disorders for further care

Chapter 12 • • • • •

Added new information on medical “time-outs” Reorganized and updated new 2015 guidelines for CPR Added new acronym POLICE and updated discussion of acute care for musculoskeletal injuries Added new inter-association recommendations for removal of facemask, helmet, and shoulder pads Added new recommendation for treating patients with suspected cervical spine injuries, including immobilization and placing the patient on a spineboard, scoop stretcher, or vacuum mattress

Chapter 13 • • •

• •

Reorganized the order of topic presentation throughout to create a more logical flow of information Added a new discussion and photos of various functional screening tests Added a new discussion on applying the best available evidence in clinical decision making, including sensitivity, specificity, likelihood ratios, and more. Updated information and replaced all of the photos for various imaging techniques Added new information on refractometers

Chapter 14 • •

Updated the most current information regarding the immune system Updated the most recent worldwide and U.S. statistics in HIV and AIDS

Chapter 15 • • • xii

Updated the section on shortwave diathermy Added new discussion of dry needling technique Replaced most of the pictures with updated photos of the latest therapeutic modality devices Preface

Chapter 16 • • • •

Added new information on the mental aspects of dealing with the stress of rehabilitating an injury Updated information on the Graston technique Added new information on structural integration Added new information on postural restoration

Chapter 17 • •

Updated the table of the list of drug classifications and definitions Updated the athletic trainers guide to frequently used drugs

Chapter 18 • • • •

Introduced the concept of the “core” in the foot Clarified the functions of absorption and propulsion in the foot as they apply to pronation and supination Added new special tests: Mulder’s test and the Dorsiflexion-Eversion test Updated information on using orthotics to enhance foot control

Chapter 19 • • • •

Added new special test for the ankle: the Cotton test. Added clinical prediction rules for the ankle joint Updated information on the most recent management and rehabilitation techniques for ankle sprains Emphasized the importance of balance training in patients with chronic ankle instability

Chapter 20 • • • •

Added clinical prediction rules for the knee Updated information on shoe types and the relationship to knee injuries Updated most recent information on the mechanisms that cause injuries to the ACL Updated information on the most current strategies for preventing knee injuries

Chapter 21 • •

•

Updated information about the mechanism and treatment of hamstring injuries Added additional special test for the hip including: flexion-internal rotation test, scour test, patellar-pubic percussion test, resisted hip abduction test, and Craig’s test Added new clinical prediction rules for the hip

Chapter 22 • •

Added new special test: the Rent test Added new clinical prediction rules for the shoulder

Chapter 23 • • •

Added new special tests: the elbow-extension test and moving valgus stress test Updated etiology for ulnar collateral ligament injury Updated information on medial and lateral epicondylitis

Chapter 24 • •

Added clinical prediction rule for carpal tunnel syndrome Updated and replaced the majority of the photos

Chapter 25 • •

Added new tests: Stork test, Gillet test, Gaenslen’s test, thigh thrust rest, sacral thrust test, and prone instability test Added clinical prediction rules for the spine

Chapter 26 • • •

Updated the ever-changing information on prevention, assessment, and management of concussion Added the latest version of the Sport Concussion Assessment Tool 3 (SCAT3) Updated information where appropriate on facial, dental, eye, ear, and nasal injuries

Chapter 28 •

Replaced almost all of the photos depicting the various types of skin diseases and disorders

Chapters 27 and 29 •

Updated both chapters with the latest medical information on organs and body systems, general medical conditions to help the athletic trainer with recognition, management, and referral decisions

INSTRUCTOR RESOURCES These resources include invaluable information to accompany the sixteenth edition of Principles of Athletic Training, including key terminology, lecture outlines, and worksheets with the accompanying answer keys. It also integrates the text with image clips. These components can be accessed via the Instructor Resources tab within Connect®.

Test Bank The test bank includes approximately 2,000 examination questions. Each chapter contains true-false, multiple choice, and completion test questions. The worksheets in each chapter also include a separate test bank of matching, short-answer, listing, essay, and personal or injury

assessment questions that can be used as self-testing tools for students or as additional sources for examination questions.

Computerized Test Bank McGraw-Hill’s EZ Test is a flexible and easy-to-use electronic testing program. The program allows instructors to create tests from book specific items. It accommodates a wide range of question types and instructors may add their own questions. Multiple versions of the test can be created, and any test can be exported for use with course management systems such as WebCT, BlackBoard, or PageOut. The program is available for Windows and Macintosh environments.

PowerPoint Presentation A comprehensive and extensively illustrated PowerPoint presentation accompanies this text for use in classroom discussion. The PowerPoint presentation may also be converted to outlines and given to students as a handout. You can easily download the PowerPoint presentation from the Instructor Resources tab in Connect®.

Instructional Videos Instructional videos are available on Connect® for Principles of Athletic Training. These visual aids are designed to illustrate key concepts, promote critical thinking, and engage students on the most relevant topics in athletic training.

Connect® for Principles of Athletic Training. Connect is an online learning system composed of interactive exercises and assessments, like those that appear on the new Board of Certification exam. Videos, animations, and other multimedia features enable students to visualize complicated concepts and practice skills. All of the activities are automatically graded and can be submitted to the instructor’s grade book. For more information, visit connect.mheducation.com Connect® for Principles of Athletic Training was developed by Amanda Benson, PhD, ATC, from Louisiana State University, and Linda Bobo, PhD, ATC, from Stephen F. Austin Slate University, and has been updated for the new edition. Connect® is a Web-based assignment and assessment platform that gives students the means to better connect with their coursework, their instructors, and the important concepts that they need to know for success now and in the future. Students can practice important skills at their own pace and on their own schedule, receive instant feedback on their work, and track performance on key activities. With Connect®, students get 24/7 online access to an eBook—an online edition of the text—to aid them in successfully completing their work, wherever and whenever they choose. With Connect®, instructors can deliver assignments, graphing questions, quizzes, and tests easily online. Preface

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Acknowledgments I would like to express my sincere appreciation to my Developmental Editor, Gary O’Brien who, as always, has provided invaluable guidance throughout the development of this edition. In truth, Gary should share authorship with me on this project. Through his efforts he has demonstrated ownership and a personal investment in making this text the best it can be. His input, patience with me, and dedication to this project has been indispensable and I truly respect his opinions and direction on all of our projects. I would be hard pressed to complete any of our projects without his help. For this revision, instead of having a reviewer take on the daunting and time-consuming task of reviewing all 29 chapters of this 1,000+ page text, I identified specific individuals who have distinguished themselves as content experts to review a specific chapter or, in some cases, chapters related to their area of expertise. These reviewers have provided critical, constructive, detailed comments and suggestions relative to the existing content in each chapter based on the most current and best available evidence in the professional literature. They have also offered suggestions for specific updates or additions that needed to be made and identified material that was no longer supported by the available evidence. I cannot thank them enough for being part of this revision process. I sincerely appreciate their interest and commitment in helping to continue the legacy of this book as an important resource in the education of our students. Bruce Baldwin, OD, PhD University of North Carolina at Chapel Hill Joel Beam EdD, ATC University of North Florida Helen Binkley, PhD, ATC Middle Tennessee State University Damien Clement, PhD, ATC West Virginia University Lindsay Distefano, PhD, ATC University of Connecticut Doug Halverson, MA, ATC University of North Carolina at Chapel Hill Michael Higgins, PhD, ATC, PT Towson University Kim Jones, MD University of North Carolina at Chapel Hill Lisa Jutte, PhD, ATC Xavier University Kristin Kuchera, PhD, ATC University of North Carolina at Chapel Hill James “Mick” Lynch, MD Florida Southern University xvi

Jill Manners, EdD, ATC Western Carolina University Janis Matson, MA University of North Carolina at Chapel Hill Patrick McKeon, PhD, ATC Ithaca College Johna Mihalik, PhD, ATC University of North Carolina at Chapel Hill Jennifer O’Donoghue, PhD, ATC North Carolina State University Barbara Osborne, JD University of North Carolina at Chapel Hill Sakiko Oyama, PhD, ATC University of Texas San Antonio Jody Padua, OT Occupational Therapy Consultant-Chapel Hill Kathryn Pietrosimone, PhD University of North Carolina at Chapel Hill Eric Rivera, DDS University of North Carolina at Chapel Hill Christine Rosenbloom, PhD, RD Nutrition Consultant- Atlanta Georgia Amy Sauls, PharmD University of North Carolina at Chapel Hill Jason Scibek, PhD, ATC Duquesne University Jay Scifers, DsPT, ATC, PT Moravian College Carrie Shearer, MS, PT, ATC University of North Carolina at Chapel Hill Abbie Smith-Ryan, PhD University of North Carolina at Chapel Hill Erik Swartz, PhD, ATC University of New Hampshire Tim Uhl, PhD, ATC, PT University of Kentucky Erik Wikstrom, PhD, ATC University of North Carolina at Chapel Hill Gary Wilkerson, PhD, ATC University of Tennessee at Chattanooga Steve Zinder, PhD, ATC University of South Florida Finally, I want to thank my wife, Tena, and our sons, Brian and Zach, for their enduring support and encouragement. They constantly help me to keep my perspective on both my professional and personal life. William E. Prentice

Applications at a Glance Key National Athletic Trainers Association Position, Official, Consensus, and Support Statements 5 Employment settings for athletic trainers 8 Full-time, on-site athletic trainer coverage for secondaryschool athletic programs 11 The use of qualified athletic trainers in secondary schools 12 Secondary School Student Athletes’ Bill of Rights 12 Strength of Recommendation Taxonomy (SORT) 22 Levels of Evidence 22 Grading of Recommendations Assessment, Development and Evaluation (GRADE) 23 List of available patient-related outcome measures used in sports medicine 25 Duties of the team physician 28 Specializations for physicians 31 Board of Certification requirements for certification as an athletic trainer 35 State regulation of the athletic trainer 36 Items to include in a policies and procedures manual 44 Safety when using electrical equipment 48 Models of supervision for the head athletic trainer 49 Additional certifications for athletic trainers working in a clinic or hospital 53 Information contained in medical records 56 HIPAA authorization 57 Suggested components of a preparticipation physical examination 64 Recommendations for activity restriction and disqualification 65 Classification of sports 69 Key Features and Benefits of the Affordable Care Act 79 Common insurance terminology 80 Description of billing codes used by athletic trainers 85 Guidelines for documentation of patient records 86 Dynamic warm-up routine 93 Comparison of aerobic versus anaerobic activities 97 Rating of perceived exertion 98 Exercise training variables 104 Proper spotting techniques 108 Guidelines and precautions for stretching 119 Fitness testing 123 Periodization training 124 Vitamins 134 Minerals 135 2015–2020 Dietary Guidelines for Americans 138 Commonly used herbs 141 The pregame meal 144 Examples of fast-food choices and nutritional value 146 Tips for selecting fast foods 147 Determining body mass index 150

Key Recommendations for weight loss and weight maintenance 151 Identifying the individual with an eating disorder 153 Variations in sweat rates 160 NATA recommendations for preventing heat illness 161 Recommendations for fluid replacement 163 NCAA-mandated guidelines for acclimatization in preseason football practices 163 Universal WBGT Index Fluid Replacement Recommendations 165 Activity restrictions for outdoor physical conditioning in hot weather 165 Heat disorders 167 Measuring rectal temperature 168 Environmental conduct of sports, particularly football 170 Lightning safety 176 Air quality guide for ozone 177 Minimizing the effects of jet lag 178 Equipment regulatory agencies 186 Guidelines for selecting, purchasing, and fitting protective gear and sports equipment to help minimize liability 187 Guidelines for purchasing and reconditioning helmets 187 Proper football helmet fit 190 Properly fitting the ice hockey helmet 191 Guidelines for fitting a cycling helmet 191 Rules for fitting football shoulder pads 197 Shoe comparisons 200 Proper running shoe design and construction 201 Shoe lacing techniques 202 How to construct a hard-shell pad 210 Taping supplies 224 Classification and load characteristics of injuries 249 Recognizing signs and symptoms of staleness in athletes 293 Sudden exercise abstinence syndrome 293 Emotional first aid 294 Educating the injured patient about the rehabilitation process 295 The meditation technique 297 Healing images 298 Keys to recognition and referral of student-athletes with psychological concerns 300 Sample emergency action plan 307 Consent form for medical treatment of a minor 308 Evaluating the unconscious athlete 310 CPR summary 312 Official statement—automated external defibrillators 313

xvii

Procedures for using airway adjunct devices 316 American Heart Association recommended blood pressure levels 323 Guidelines for proper splinting 327 Standard orthopedic definitions for positions and deviations 347 Off-the-field evaluation sequence 349 History of musculoskeletal injuries 350 Manual muscle strength grading 352 Range of joint motion 354 Cranial nerves and their functions 355 Myotome patterns of weakness resulting from spinal nerve root lesion 356 Deep tendon reflex grading 357 Constructing and using a volumetric tank 358 Overhead squat compensation patterns 360 Single leg squat compensation patterns 360 Landing technique “errors” 361 Tuck jump test technique flaws 362 Functional movement screen 363 Clinical test reliability 363 Interpreting likelihood ratios 365 Clinical prediction rules currently used in diagnosis and clinical practice 366 Standard abbreviations and symbols used in medical documentation 368 Normal laboratory values of a complete blood count 376 Blood electrolyte levels (normal adult range) 376 Normal laboratory values of a urinalysis 376 Common infectious diseases 382 Suggestions for preventing the spread of infectious diseases 385 Body fluids 386 Transmission of hepatitis B and C viruses and human immunodeficiency virus 388 HIV risk reduction 389 Risk categories for HIV transmission in sports 390 Glove use and removal 392 Physiological responses to thermotherapy 399 Whirlpool temperatures for treatment of the extremities 400 Skin response to cold 403 Physiological variables of cryotherapy 403 Adverse reactions to cold 404 Summary of cryokinetics 406 Precautions when using shortwave diathermy 412 Sample shortwave diathermy dosage 412 Guidelines for an effective massage 422 Safe use of therapeutic modalities 426 Suggested aquatic workouts 446 Drug vehicles 465 Agencies and regulations that govern the provision of pharmaceutical care 467 General body responses produced by drugs 469

xviii

Applications at a Glance

List of drug classifications and definitions 471 Athletic trainers’ guide to frequently used medications 472 Medications recommended for the management of asthma 476 Frequently used NSAIDs 480 Drugs reported to predispose to heat illness 483 Protocols for the use of over-the-counter drugs for athletic trainers 484 Identifying the substance abuser 490 Examples of caffeine-containing products 491 Examples of deleterious effects of anabolic steroids 492 Contacting the poison control center 497 Banned drugs—common ground 498 NCAA banned drug classes 499 Intrinsic muscles of the foot 512 Suggested shoe components based on foot type 518 Management plan: Plantar fasciitis 528 Metatarsal pad support 532 Functional progression for the foot 541 Function of key ankle ligaments 548 Muscles of the ankle and lower leg 550 Mechanisms of ankle sprain and ligament injury 557 Management plan: Grade 2 inversion ankle sprain 562 Management plan: Medial tibial stress syndrome 570 Return to running following ankle injury functional progression 576 Muscles of the knee 586 Knee stability tests 595 Classification of instabilities 595 Lysholm knee scoring scale 601 Management plan: Surgical repair of anterior cruciate ligament 609 Management plan: Patellofemoral pain 619 Muscles of the thigh 633 Muscles of the hip 643 Management plan: Acute groin strain 654 Muscles of the shoulder complex 674 Management plan: Anterior glenohumeral dislocation 690 Management plan: Shoulder impingement 696 The peripheral nerves 698 Throwing progression 706 Muscles acting on the elbow joint 716 Management plan: Posterior elbow dislocation 726 Muscles of the forearm acting on the wrist, hand, and fingers 737 Intrinsic muscles of the hand 743 Releasing blood from beneath the fingernail 754 Conservative treatment and splinting of finger injuries 756 Muscles that move the vertebral column 773 Brachial plexus 774 Lumbar and sacral plexuses 776 Recommended postures to prevent low back pain 778 Summary of special tests for the spine 793

Management plan: Cervical sprain (whiplash) 798 Management plan: Lumbosacral strain 804 Sports with a high risk of head injury 825 Balance Error Scoring System (BESS) 830 SCAT3 Sport Concussion Assessment Tool 3 831 Commonly used neurocognitive tests for sport concussion 835 On-field or sideline evaluation of acute concussion 837 Home instructions for concussion 838 Graduated return-to-play protocol 839 Conditions indicating the possibility of increasing intracranial pressure 841 Care of scalp lacerations 842 Nose splinting 847 Percentage of sports eye injuries in the UnitedStates 850 Supplies for managing eye injuries 852 Removing a foreign body from the eye 854 Muscles of the thorax 862 Muscles of the abdominal wall 865 Summary of breathing patterns and sounds 874

Five steps of a breast self-exam 878 Self-examination of the testes 887 The skin’s structure and function 894 Primary skin lesions 896 Secondary skin lesions 897 Managing blisters 899 Foot hygiene for excessive perspiration and odor 900 Care of open wounds 904 Wound care 906 Management of impetigo 908 Basic care of athlete’s foot 913 Treatment of scabies 919 Management of the acute asthmatic attack 932 Management during a seizure 937 Blood pressure 938 Suggested factors in secondary amenorrhea 942 Identifying a woman at risk for female athlete triad 943 American College of Obstetricians and Gynecologists guidelines for exercise during pregnancy and postpartum 944

Applications at a Glance

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PART

Professional Development and Responsibilities

The Athletic Trainer as a Health Care Provider ■ Objectives When you finish this chapter you should be able to • Recognize the historical foundations of athletic training. • Identify the various professional organizations dedicated to athletic training and sports medicine. • Identify various employment settings for the athletic trainer. • Differentiate the roles and responsibilities of the athletic trainer, the team physician, and the coach.

• Define evidence-based practice as it relates to the clinical practice of athletic training. • Explain the function of support personnel in sports medicine. • Discuss certification and licensure for the athletic trainer.

■ Outline Historical Perspectives 3 Sports Medicine and Athletic Training 4 Employment Settings for the Athletic Trainer 7 Roles and Responsibilities of the Athletic Trainer 14 Professional Responsibilities of the Athletic Trainer 19 Referring the Patient to Other Medical and Nonmedical Support Services and Personnel 29

Recognition and Accreditation of the Athletic Trainer as an Allied Health Care Professional 33 Requirements for Certification as an Athletic Trainer 35 State Regulation of the Athletic Trainer 36 Future Directions for the Athletic Trainer 37 Summary 38

■ Key Terms patient athletic training clinic evidence-based practice

PICO ATC

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • Clinical application scenarios covering professional role responsibilities • Click-and-drag question format covering professional organizations, BOC domains, and support personnel • Multiple-choice questions covering history of athletic training, employment settings, and certification and licensure for the athletic trainer

thletic trainers are health care professionals who specialize in preventing, recognizing, managing, and rehabilitating injuries. In cooperation with physicians, other allied health personnel, administrators, coaches, and parents, the athletic trainer functions as an integral member of the health care team in clinics, secondary schools, colleges and universities, professional sports programs, and other athletic health care settings. As you will The certified athletic trainer is see throughout the a highly educated and skilled course of this text, professional specializing in athletic trainers health care for the physically provide a critical active. link between the medical community and individuals who participate in all types of physical activity (Figure 1–1).

HISTORICAL PERSPECTIVES Early History The drive to compete was important in many early societies. Sports developed over a period of time as a means of competing in a relatively peaceful and nonharmful way. Early civilizations show little evidence of highly organized sports. Evidence indicates that in Greek and Roman civilizations there were coaches, trainThe history of athletic training ers (people who draws on the disciplines of helped the athlete exercise, medicine, physical therapy, physical education, and reach top physisports. cal condition), and physicians (such as Hippocrates and Galen) who assisted the athlete in reaching optimum performance. Many of the roles that emerged during this early period are the same in modern sports. For many centuries after the fall of the Roman Empire, there was a complete lack of interest in sports activities. Not until the beginning of the Renaissance did these activities slowly gain popularity. Athletic training as we know it came into existence during the late nineteenth century with the firm establishment of intercollegiate and interscholastic athletes in the United States. Because the first athletic trainers of this era possessed no technical knowledge, their athletic training techniques usually consisted of a rub, the application of some type of counterirritant, and occasionally the prescription of various home remedies and poultices. It has taken many years for the athletic trainer to attain the status of a well-qualified allied health care professional.69

Evolution of the Contemporary Athletic Trainer The terms training and athletic training, trainer, and athletic trainer are often used interchangeably and are

FIGURE 1–1 The field of athletic training provides

a critical link between the medical community and the physically active individual. © William E. Prentice

frequently confused with one another. Historically, training implies the act of coaching or teaching. In comparison, athletic training has traA certified athletic trainer ditionally been provides health care to physically known as the field active individuals. that is concerned with the athlete’s health and safety. A trainer is someone who trains dogs or horses or functions in coaching or teaching areas. The certified athletic trainer is one who is a specialist in athletic training. Athletic training has evolved over the years to play a major role in the health care of a variety of patient populations in general and the athlete in particular. This evolution occurred rapidly after World War I with the appearance of the athletic trainer in intercollegiate athletics. During this period, the major influence in developing the athletic trainer as a specialist in preventing and managing athletic injuries came from the work of S. E. Bilik, a physician who wrote the first major text on athletic training and the care of athletic injuries, called The Trainer’s Bible, in 1917.8 In the early 1920s, the Cramer family in G ardner, Kansas, started a chemical company and began producing a liniment to treat ankle sprains. Over the years, the Cramers realized that there was a market for products to treat injured athletes. In an effort to enhance communication and facilitate an exchange of ideas among coaches, athletic trainers, and athletes, Cramer began publication of First Aider in 1932. The members of this family were instrumental in the early development of the athletic training profession and have always played a prominent role in the education of athletic training students.70 During the late 1930s, an effort was made, primarily by several college and university athletic trainers, to establish a national organization named the National Athletic Trainers’ Association (NATA). After struggling for existence from 1938 to 1944, the association essentially disappeared during the difficult years of World War II.

Chapter One ■ The Athletic Trainer as a Health Care Provider

Between 1947 and 1950, university athletic trainers once again began to organize themselves into separate regional conferences, which would later become district organizations within NATA. In 1950, some 101 athletic trainers from the various conferences met in Kansas City, Missouri, and officially formed the National Athletic Trainers’ Association. The primary purpose for its formation was to establish professional standards for the athletic trainer.70 Since NATA was formed in 1950, many individuals have made contributions to the development of the profession. After 1950, the growth of the athletic training profession has been remarkable. In 1974, when NATA membership numbers were first tracked, there were 4,500 members. Today those numbers have grown to more than 42,000 members. Certified athletic trainers can be found internationally with more than 500 working in 25 countries outside the United States. The majority of these are in Japan and Canada.22 As the athletic training profession has grown and evolved over the last 50 years, many positive milestones have occurred that have collectively shaped the future direction of the profession, including the establishment of a certification exam; recognition of athletic trainers as health care providers; increased diversity of practice settings; the passage of practice acts that regulate athletic trainers in most states; third-party reimbursement for athletic training services; and ongoing reevaluation, revision, and reform of athletic training educational programs.

The Changing Face of the Athletic Training Profession Over the years since the origins of the athletic training profession in the 1930s, the majority of athletic trainers have been employed at colleges and universities and in secondary schools, providing services almost exclusively to an athletic population. Historically, this work environment has been referred to as the “traditional setting” for employment for athletic trainers. Today the role of the athletic trainer has gradually evolved into one that is unquestionably more aligned with that of a health care provider. More than 40 percent of certified athletic trainers are employed in clinics and hospitals, or in industrial and occupational settings working under the direction of a physician as athletic trainers in physician practice. Although many athletic trainers continue to work in colleges, universities, and secondary schools, others can be found working as health care providers in hospitals; all kinds of professional sports, including rodeo and NASCAR; in industrial settings; in performing arts and the entertainment industry; in medical equipment sales and support; in the military; with law enforcement departments; and with government agencies, including NASA, the U.S. Senate, and the Pentagon. 4

Part One ■ Professional Development and Responsibilities

This expansion of potential employment settings has forced the profession not only to change the methods by which health care is delivered to a variety of patient populations but also to change athletic training education programs to teach and/or establish professional competencies and proficiencies that are universal to all settings. Depending on the employment settings in which they work, athletic trainers no longer provide health care only to athletes, nor do they provide health care only to individuals who are injured as a result of physical activity. Additionally, the desire to align the athletic trainer more closely with other allied health professionals and to establish athletic training as a clinical health care profession has necessitated changes in terminology that has been “traditionally” accepted as appropriate. Certainly, athletic trainers continue to work with athletes. It has been suggested that a more appropriate term to use when treating an athlete who sustains an injury is patient or client. Thus, throughout this text the term athlete is used to refer to a physically active individual who participates in recreational or organized sport activities who is not currently injured. Any individual who is ill or injured who is being treated by an athletic trainer is referred to as a patient. It has also been recommended that instead of r eferring to treating athletes in the athletic training room, it is more appropriate to refer to treating patients in the athletic training clinic or facility. Thus, the term athletic training clinic is used to refer to a health care facility for treating individuals who have an illness or injury.

SPORTS MEDICINE AND ATHLETIC TRAINING The Field of Sports Medicine The term sports medicine refers generically to a broad field of health care related to physical activity and sport. The field of sports medicine encompasses a number of more specialized aspects of dealing with the physically active or athletic populations that may be classified as relating either to performance enhancement or to injury care and management (Figure 1–2). Those areas of specialization that are primarily concerned Athletic training must be considered a specialization under with performance the broad field of sports medicine. enhancement include exercise physiology, biomechanics, sport psychology, sports nutrition, strength and conditioning coaches, and personal fitness training. Areas of specialization that focus more on injury care and management specific to the athlete are the practice of medicine, athletic training, sports physical therapy, sports massage therapy, sports dentistry, osteopathic medicine, orthotics/prosthetics, chiropractic, podiatry, and

Performance Enhancement

Exercise Physiology Biomechanics Sport Psychology Sports Nutrition Strength & Conditioning Coaching Personal Fitness Training

e cin

M e s di t r o

Growth of Professional Sports Medicine Organizations

Injury Care & Management

Practice of Medicine Athletic Training Sports Physical Therapy Sports Massage Therapy Sports Dentistry Osteopathic Medicine Orthotics/Prosthetics Sports Chiropractic Sports Podiatry Emergency Medical Technician Paramedics

FIGURE 1–2 Areas of specialization under the sports medicine “umbrella.”

emergency medical technology. The American College of Sports Medicine (ACSM) has defined sports medicine as multidisciplinary, including the physiological, biomechanical, psychological, and pathological phenomena associated with exercise and sports.3 The clinical application of the work of these disciplines is performed to improve and maintain an individual’s functional capacities for physical labor, exercise, and sports. Sports medicine also includes the prevention and treatment of diseases and injuries related to exercise and sports.

The twentieth century brought with it the development of a number of professional organizations dedicated to athletic training and sports medicine. Professional organizations have many goals: (1) to upgrade the field by devising and maintaining a set of professional standards, including a code of ethics; (2) to bring together professionally competent individuals to exchange ideas, stimulate research, and promote critical thinking; and (3) to give individuals an opportunity to work as a group with a singleness of purpose, thereby Many professional organizations making it posthat are dedicated to achieving sible for them to health and safety in sports developed in the twentieth achieve objectives century. that, separately, they could not accomplish. The organizations identified below are presented in chronological order according to their year of establishment. Addresses, phone numbers, and/or Web sites for these and other related sports medicine organizations can be found in Appendix A in the back of this text. Several of these professional organizations also disseminate information to the general public about safe participation in sport activities in the form of guidelines or position statements. See Focus Box 1–1: “Key National Athletic Trainers Association Position, Official, Consensus, and Support Statements” for a list of statements addressing the practice of athletic training.

FOCUS 1–1 Focus on Healthcare Administration and Professional Responsibilities Key National Athletic Trainers Association Position, Official, Consensus, and Support Statements Consensus Statements (www.nata.org /news-publications/pressroom /statements/consensus)

Official Statements (www.nata.org/news -publications/pressroom/statements /official)

Support Statements (www.nata.org/news -publications/pressroom/statements /support)

Inter-Association Consensus Statement on Best Practices for Sports Medicine Management for Secondary Schools and Colleges (January 2014) Appropriate Medical Care for Secondary School-Age Athletes (2003)

Proper Supervision of Secondary School Student Aides (2014) Full-Time On-Site Athletic Trainer Coverage for Secondary School Athletic Programs (2004) Providing Quality Health Care and Safeguards to Athletes of All Ages and Levels of Participation (December 2011) Use of Qualified Athletic Trainers in Secondary Schools (2004)

American Academy of Family Physicians’ Support of Athletic Trainers for High School Athletes (2007) NCAA Support of Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics (August 2003) American Medical Association’s Support of Athletic Trainers in Secondary Schools (1998)

Chapter One ■ The Athletic Trainer as a Health Care Provider

Appendix B provides a complete listing of all position, consensus, official, and support statements developed by or with support from the National Athletic Trainers Association. Also listed in this appendix are specific Web sites where these statements may be found. International Federation of Sports Medicine Among the first major organizations was the Fédération Internationale de Médecine du Sport (FIMS). In English it is called the International Federation of Sports Medicine. It was created in 1928 at the Olympic Winter Games in St. Moritz, Switzerland, by Olympic medical doctors with the principal purpose of promoting the study and development of sports medicine throughout the world. FIMS is made up of the national sports medicine associations of more than 100 countries. This organization includes many disciplines that are concerned with the physically active individual. To some degree, the ACSM has patterned itself after this organization. American Academy of Family PhysiciansThe American Academy of Family Physicians (AAFP) was founded in 1947 to promote and maintain high-quality standards for family doctors who are providing continuing comprehensive health care to the public. AAFP is a medical association of more than 100,000 members. Many team physicians are members of this organization. It publishes American Family Physician. National Athletic Trainers’ Association Before the formation of the National Athletic Trainers’ Association in 1950, athletic trainers occupied a somewhat insecure place in the athletic program. Since that time, as a result of the raising of professional standards and the establishment of a code of ethics, there has been considerable professional advancement. The stated mission of NATA is To enhance the quality of health care provided by certified athletic trainers and to advance the athletic training profession.

The association accepts as members only those athletic trainers who are properly qualified and who are prepared to subscribe to a code of ethics and to uphold the standards of the association. NATA currently has more than 42,000 members. It publishes a quarterly journal, The Journal of Athletic Training, and Athletic Training Education Journal online, and holds an annual convention at which members have an opportunity to keep abreast of new developments and to exchange ideas through clinical programs. The organization is constantly working to improve both the quality and the status of athletic training. American College of Sports Medicine As discussed previously, the ACSM is interested in the study of all aspects of sports. Established in 1954, ACSM has a membership of more than 45,000, composed of medical doctors, doctors of philosophy, physical educators, athletic trainers, coaches, exercise physiologists, biomechanists, and others 6

Part One ■ Professional Development and Responsibilities

interested in sports. The organization holds national and regional conferences and meetings devoted to exploring the many aspects of sports medicine, and it publishes a quarterly magazine, Medicine and Science in Sports and Exercise. This journal includes articles in French, Italian, German, and English, and provides complete translations in English of all articles. It reports recent developments in the field of sports medicine on a worldwide basis. American Orthopaedic Society for Sports Medicine The American Orthopaedic Society for Sports Medicine (AOSSM) was created in 1972 to encourage and support scientific research in orthopedic sports medicine; the organization works to develop methods for safer, more productive, and more enjoyable fitness programs and sports participation. Through programs developed by the AOSSM, members receive specialized training in sports medicine, surgical procedures, injury prevention, and rehabilitation. AOSSM’s 3,000 members are orthopedic surgeons and allied health professionals committed to excellence in sports medicine. Its official bimonthly publication is the American Journal of Sports Medicine. National Strength and Conditioning Association The National Strength and Conditioning Association (NSCA) was formed in 1978 to facilitate a professional exchange of ideas in strength development as it relates to the improvement of athletic performance and fitness and to enhance, enlighten, and advance the field of strength and conditioning. NSCA has a membership of more than 30,000 professionals in 52 countries, including strength and conditioning coaches, personal trainers, exercise physiologists, athletic trainers, researchers, educators, sport coaches, physical therapists, business owners, exercise instructors, fitness directors, and students training to enter the field. In addition, the NSCA Certification Commission offers two of the finest and the only nationally accredited certification programs: the Certified Strength and Conditioning Specialist (CSCS) and the NSCA Certified Personal Trainer (NSCA-CPT). NSCA publishes both the Journal of Strength and Conditioning Research and Strength and Conditioning. American Academy of Pediatrics, Council on Sports Medicine and Fitness The American Academy of Pediatrics, Sports Committee was organized in 1979. Its primary goal is to educate all physicians, especially pediatricians, about the special needs of children who participate in sports. Between 1979 and 1983, this committee developed guidelines that were incorporated into a report, Sports Medicine: Health Care for Young Athletes, edited by Nathan J. Smith, M.D. American Physical Therapy Association, Sports Physical Therapy Section In 1981, the Sports Physical Therapy Section of the American Physical Therapy Association (APTA) was officially established. The mission

of the Sports Physical Therapy Section is “to provide a forum to establish collegial relations between physical therapists, physical therapist assistants, and physical therapy students interested in sports physical therapy.” The Section and its 6,000 members promote the prevention, recognition, treatment, and rehabilitation of injuries in an athletic and physically active population through special interest groups (SIGs); provide educational opportunities through sponsorship of continuing education programs and publications; promote the role of the sports physical therapist to other health professionals; and support research to further establish the scientific basis for sports physical therapy. The Section’s official journal is the Journal of Orthopaedic and Sports Physical Therapy. NCAA Committee on Competitive Safeguards and Medical Aspects of Sports The National Collegiate Athletic Association (NCAA) Committee on Competitive Safeguards and Medical Aspects of Sports collects and develops pertinent information about desirable training methods, prevention and treatment of sports injuries, utilization of sound safety measures at the college level, drug education, and drug testing; disseminates information and adopts recommended policies and guidelines designed to further the objectives just listed; and supervises drug-education and drug-testing programs. Each year, this committee publishes the Sports Medicine Handbook that contains a wealth of continuously updated information related to sports medicine, which can be very useful to the athletic trainer. National Academy of Sports Medicine The National Academy of Sports Medicine (NASM) was 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. According to its mission statement, “NASM is dedicated to transforming lives and revolutionizing the health and fitness industry through its unwavering commitment to deliver innovative education, solutions and tools that produce remarkable results.” In addition to offering a fitness certification (Certified Personal Trainer) and performance certification (Performance Enhancement Specialist), NASM offers advanced credentials and more than 20 continuing education courses in a variety of disciplines. NASM serves more than 100,000 members and partners in 80 countries. Other Health-Related Organizations Many other health-related professions, such as dentistry, podiatristry, and chiropractic, have, over the years, become interested in the health and safety aspects of sports. Besides national organizations that are interested in athletic health and safety, there are state and local associations that are extensions of the larger bodies. National, state, and local sports organizations have all provided extensive support to the reduction of illness and injury risk to the athlete.

Other Sports Medicine Journals Other journals that provide an excellent service to the field of athletic training and sports medicine are The International Journal of Sports Medicine, which is published in English by ThiemeStratton, Inc., New York; The Journal of Sports Medicine and Physical Fitness, published by Edizioni Minerva Medica SPA, ADIS Press Ltd., Auckland10, New Zealand; the Journal of Sport Rehabilitation and Athletic Therapy and Training, both published by Human Kinetics Publishers, Inc., Champaign, Illinois; the Physician and Sportsmedicine, published by McGraw-Hill, Inc., New York; Physical Therapy and Clinical Management, both published by the American Physical Therapy Association, Fairfax, Virginia; Physical Medicine and Rehabilitation Clinics and Clinics in Sports Medicine, both published by W. B. Saunders, Philadelphia; Training and Conditioning, published by MAG, Inc., Ithaca, New York; Sports Health: A Multidisciplinary Approach, published by Sage in Thousand Oaks, California; and Athletic Training and Sports Health Care: The Journal for the Practicing Clinician, published by Slack Inc., in Thorofare, New Jersey. There is a significant number of other journals that relate in some way to sports medicine. They are listed in Appendix C located at the end of this text.

EMPLOYMENT SETTINGS FOR THE ATHLETIC TRAINER Opportunities for employment as an athletic trainer have changed dramatically in recent years. Athletic trainers no longer work only in athletic training clinics at the college, university, or secondary-school level. The employment opportunities for athletic trainers are more diverse than ever.46 A discussion of the various employment settings follows (Table 1–1).

Clinics and Hospitals Today, more than 40 percent of certified athletic trainers are employed in clinics and hospitals—more than in any other employment setting. The role of the athletic trainer varies from one clinic to the next. Athletic trainers may be employed in an outpatient ambulatory rehabilitation clinic working in general patient care; in hospital emergency rooms: as health, wellness, or performance enhancement specialists; or as clinic administrators. Their job may also involve ergonomic assessment, work hardening, CPR training, or occasionally overseeing drugtesting programs. They may also The largest percentage of be employed by a certified athletic trainers are hospital but work employed in clinics and hospitals. in a clinic. Other clinical athletic trainers are employed by a hospital, but work only in local secondary schools or small colleges for practice, game, or single event coverage. For the most part, private clinics have well-equipped facilities in which

Chapter One ■ The Athletic Trainer as a Health Care Provider

TABLE 1–1 Employment Settings for Athletic Trainers* Clinic • Hospital-based (employed by hospital; work in a clinic) • General patient care • Health/wellness/performance enhancement • Occupational/industrial (100%/split) • Administration • Outpatient/ambulatory/rehabilitation clinic • General patient care • Health/wellness/performance enhancement • Occupational/industrial (100%/split) • Administration • Physician-owned clinic (patient care or administration) • Orthopedic • Pediatric • Primary care • Physiatry • Family practice • Other • Secondary school/clinic (employed by clinic; work in school) • Secondary school (100%) • Secondary school (split) • Clinic, other Hospital (work in a hospital but not in a hospital-based clinic) • Administration • Orthopedics • Emergency department • Other Industrial/occupational (work on-site at an industrial or occupational facility) • Clinic • Ergonomics • Health/wellness/fitness • Other Corporate (work for company that sells to the profession or in patient care for that company) • Business/sales/marketing • Ergonomics • Health/wellness/fitness • Patient care College/university • Professional staff/athletics/clinic • Faculty/academic/research • Split appointment • Division 1 • Division 1AA • Division 2 • Division 3 • Administration Two-year institution • Professional staff/athletics/clinic • Faculty/academic/research • Split appointment • Administration *Modified from National Athletic Trainers’ Association. 8

Part One ■ Professional Development and Responsibilities

Secondary school (employed by school or district) • High school (teacher/clinical/split) • Public • Private • Middle school (teacher/clinical/split) • Public • Private Professional sports • Baseball, M • Basketball, M/W • Football, M • Hockey, M • Soccer, M/ W • Lacrosse, M • Softball, W • Golf, M/ W • Tennis, M/ W • Wrestling • Boxing • Rodeo • Auto racing (NASCAR, Indy Car) Amateur/recreational/youth sports • Amateur (work for NGB, USOC, or amateur athletics) • Recreational (work for municipal or recreational league or facility) • Youth sports (AAU) Performing arts • Dance • Theater • Entertainment industry (Disney, casinos, tour bands) Military/law enforcement/government • Military (Air Force, Army, Navy, Marines, Coast Guard, Merchant Marines, National Guard) • Active duty/civilian • Academy • Hospital/clinic • Administration • Other • Law enforcement • Local department or agency (police/fire/rescue) • State department or agency (police/investigation) • Federal department or agency (FBI, CIA, ATF) • Government • Local • State • Federal (Senate, House, judicial) • Agencies (NASA, FDA) Health/fitness/sports/performance enhancement clinics/clubs (work for franchise, chain, or independent club) Independent contractor (work for themselves and are not employees)

to work. In many sports medicine clinics, the athletic trainer may be responsible for formulating a plan to market or promote athletic training services offered by that clinic throughout the local community30 (Figure 1–3A). Athletic Trainers in Physician Practice Some athletic trainers work in clinics that are owned by physicians. Although virtually all athletic trainers work under the direction of a physician, those employed as an athletic trainer in physician practice actually work in the physician’s office, where patients of all ages and backgrounds are being treated.66 The educational preparation for athletic trainers allows them to function in a variety of domains, including injury prevention, evaluation, diagnosis, management and rehabilitation, health education, nutrition, training and conditioning, preparticipation physicals, and maintenance of essential documentation.104 Although the contact with only the physically active population may not be as great as in other employment settings, the athletic trainer in physician practice can expect regular hours, few weekend or evening responsibilities, opportunity for growth, and, in general, better pay.26,31 All these factors collectively make athletic trainer in physician practice positions attractive for the athletic trainer. Potentially, many new jobs can be created as physicians become more and more aware of the value that an athletic trainer, functioning as an athletic trainer in physician practice, can provide to their medical practice24 (Figure 1–3B).

Industrial/Occupational Settings It is becoming relatively common for industries to employ athletic trainers to oversee fitness and injury rehabilitation programs for their employees.1 The athletic trainer working in an industrial or occupational setting must have a sound understanding of the principles and concepts of workplace ergonomics, including inspecting, measuring, and observing dimensions of the work space, as well as specific tasks that are performed at the workstation.23 Once a problem has been identified, the athletic trainer must be able to implement proper adjustments to workplace ergonomics to reduce or minimize possible risks for injury. In addition to these responsibilities, athletic trainers may be assigned to conduct wellness programs and provide education and individual counseling. It is likely that many job opportunities will exist for the athletic trainer in industrial/occupational settings in the next few years (Figure 1–3C&D).

Corporate Settings Opportunities are expanding for athletic trainers to use their educational background as preparation for working in business, sales, or marketing of products that other athletic trainers may use. Athletic trainers might also be employed by a company to administer health, wellness, and fitness programs or to provide some patient care to their employees.

Colleges or Universities At the college or university level, clinical positions for athletic trainers vary considerably from institution to institution. In smaller institutions, the athletic trainer may be a half-time teacher in physical education and half-time athletic trainer. In some cases, if the athletic trainer is a physical therapist rather than a teacher, he or she may spend part of the time in the school health center and part of the time in athletic training. Increasingly at the college level, athletic training services are being offered to members of the general student body who participate in intramural and club sports. In most colleges and universities, the athletic trainer is full-time, does not teach, works in the department of athletics, and is paid by the institution. However, it has been suggested that athletic trainers at colleges and universities should be employed by the campus or student health services rather than by the athletic department.15 In February 1998, the NATA created the Task Force to Establish Appropriate Medical Coverage for Intercollegiate Athletics (AMCIA) to establish recommendations for the extent of appropriate medical coverage to provide the best possible health care for all intercollegiate studentathletes. Essentially, the AMCIA task force made recommendations for the number of athletic trainers who should be employed at a college or university based on a mathematical model created by a number of variables existing at each institution. These guidelines were revised and updated in 2003. (For directions to determine the recommended number of athletic trainers, consult “Recommendations and Guidelines for Appropriate Medical Coverage of Intercollegiate Athletics,”68 see Focus Box 1–1.) In August 2003, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports (CSMAS) recommended that NCAA institutions “examine the adequateness of their sports medicine coverage”54—in particular, whether the increased time demands placed on certified athletic trainers reduces their ability to p rovide high-quality care to all student-athletes. After reviewing the Recommendations and Guidelines, the CSMAS “encouraged NCAA institutions to reference the NATA AMCIA in their assessment of the adequateness of their sports medicine coverage . . . and share the responsibility to protect student athlete health and safety through appropriate medical coverage of its sports and supporting activities.” A number of athletic trainers working at colleges and universities are employed as faculty members.40 These individuals may or may not be assigned clinical responsibilities. Instead, in addition to teaching responsibilities, these faculty members may serve as program directors and/or as researchers.

Secondary Schools There are more than 42,000 public and private secondary schools in the United States. It would be ideal to have

Chapter One ■ The Athletic Trainer as a Health Care Provider

A: Clinics and Hospitals

B: Athletic Trainer in Physician Practice

D: Work Hardening/Occupational

G: Youth Sports

J: Law Enforcement

E: Professional Sports—NASCAR

H: Performing Arts

K: NASA

C: Industrial-Rehabilitation

F: Professional/Sports—Rodeo

I: Military

L: Health Clubs

FIGURE 1–3 Athletic trainers work in a variety of employment settings. (a) © Ingram Publishing/AGE Fotostock; (b) © Thinkstock/Getty Images; (c) © aabejon/Getty Images; (d) © YAY Media AS/Alamy; (e) Courtesy Logan Stewart; (f) Courtesy Dwayne Durham; (g) © William E. Prentice; (h) © Marc Romanelli/Blend Images LLC; (i) US Navy; ( j) Courtesy The National Athletic Trainers’ Association; (k) NASA-JSC; (l) © Fuse/Getty Images

Part One ■ Professional Development and Responsibilities

FOCUS 1–2 Focus on Healthcare Administration and Professional Responsibilities Full-time, on-site athletic trainer coverage for secondary-school athletic programs “The National Athletic Trainers’ Association, as a leader in health care for the physically active, believes that the prevention and treatment of injuries to student-athletes are a priority. The recognition and treatment of injuries to student-athletes must be immediate. The medical delivery system for injured student-athletes needs a coordinator

within the local school community who will facilitate the prevention, recognition, treatment and reconditioning of sports related injuries. Therefore, it is the position of the National Athletic Trainers’ Association that all secondary schools should provide the services of a full-time, on-site, certified athletic trainer (ATC) to student-athletes.”

certified athletic trainers serve every secondary school and middle school in the United States.49 Many of the physical problems that occur later from improperly managed sports injuries could be avoided initially if proper care from an athletic trainer had been provided.7 If a secondary school or middle school hires an athletic trainer, it is very often in a faculty–athletic trainer capacity.73 This individual is usually employed as a teacher who carries a reduced teaching load and performs athletic training duties. In this instance, compensation usually is on the basis of both teaching, a stipend as an athletic trainer, or both.41 Salaries for the secondary-school athletic trainer are continuing to improve.5 Some school districts have found it effective to employ a centrally-placed certified athletic trainer. In this case, the athletic trainer, who may be full- or part-time, is a nonteacher who serves a number of schools. The advantage is savings; the disadvantage is that one individual cannot provide the level of service usually required by a typical school. A less desirable means of obtaining secondary-school athletic training coverage is using a certified graduate student from a nearby college or university. However, this practice may prevent a school from employing a certified athletic trainer on a full-time basis. In 1995, the NATA adopted an official statement on hiring athletic trainers in secondary schools that appears in Focus Box 1–2: “Full-time, on-site athletic trainer coverage for secondary-school athletic programs.” Based on a proposal from the American Academy of Pediatrics, in 1998 the American Medical Association adopted a policy calling for certified athletic trainers to be employed in all secondary-school athletic programs (see Appendix B). Although this policy was simply a recommendation and not a requirement, it was a very positive statement supporting the efficacy of athletic trainers in the secondary schools (Focus Box 1–1). To date Hawaii is the only state that requires an athletic trainer to be employed at each school. Following the adoption of this policy, the NATA provided a second official statement on certified athletic

From NATA official statement Full time, on-site athletic trainer coverage for secondary-school athletic programs (2004) (http://www.nata.org/sites/default/files /SecondarySchool.pdf). Reprinted with permission from the National Athletic Trainers’ Association.

trainers in secondary schools, which appears in Focus Box 1–3: “The use of qualified athletic trainers in secondary schools.” In 2008, the NATA published a c onsensus statement “Appropriate medical care for the secondary-school-age athlete” in which recommendations were provided for handling specific medical situations that can arise in the secondary-school setting (see Focus Box 1–1).2 In 2013, a group called the Youth Sports Safety Alliance, composed of more than 100 professional organizations, released a list of proposed rules and recommendations called the Secondary School Student Athletes’ Bill of Rights. This “Bill” focuses on protecting students who participate in secondary-school sports. It calls for health providers such as athletic trainers and/or doctors to be available at every secondary school participating in interscholastic athletics. Focus Box 1–4 shows the recommendations included in the “Secondary school student athletes’ bill of rights.” Most recently in 2014, an inter-association consensus statement on the best practices for sports medicine management of secondary schools and colleges was released that defined the roles and responsibilities of the athletic trainer working in the secondary schools (http:// natajournals.org/doi/pdf/10.4085/1062-6050-49.1.06).

Professional Sports Although the availability of positions for athletic trainers working at the professional level is limited, opportunities to work in this setting continue to expand. Virtually every professional team, regardless of the sport, employs at least one and occasionally as many as four certified athletic trainers. Athletic trainers work with both male and female professional teams, including football, basketball, baseball, hockey, soccer, lacrosse, softball, golf, and tennis. They are also employed in professional rodeo, auto racing (NASCAR), and wrestling. The athletic trainer for professional sports teams usually performs specific team athletic training duties for 6 to 8 months out of the year; the other 4 to 6 months

Chapter One ■ The Athletic Trainer as a Health Care Provider

FOCUS 1–3 Focus on Healthcare Administration and Professional Responsibilities The use of qualified athletic trainers in secondary schools “The National Athletic Trainers’ Association (NATA) is confident the best way to protect the public is to allow only Board of Certification–certified athletic trainers and state licensed athletic trainers to practice as athletic trainers. NATA is not alone in these beliefs. The American Medical Association has stated that certified athletic trainers should be used as part of a high school’s medical team. The American Academy of Family Physicians agrees and states on its Web site, ‘The AAFP encourages high schools to have, whenever possible, a

BOC-certified or registered/licensed athletic trainer as an integral part of the high-school athletic program. “In states with athletic training regulation, allowing other individuals to continue practicing as athletic trainers without a valid state license or BOC certification places the public at risk. Athletic trainers have unique education and skills that allow them to properly assess and treat acute and traumatic injuries in high-school athletics. In coordination with the team physician, they routinely make decisions regarding the

return-to-play status of student-athletes. Other allied health professionals are not qualified to perform these tasks. Finally, most situations encountered by athletic trainers should not be left to a coach or layperson who does not have the necessary education and medical and emergency care training.” From NATA Official statement Use of qualified athletic trainers in secondary schools (2004) (http://www.nata.org /sites/default/files/ATsInHSs.pdf) Reprinted with permission from the National Athletic Trainers’ Association.

FOCUS 1–4 Focus on Healthcare Administration and Professional Responsibilities Secondary-school student athletes’ bill of rights I. Student Athletes have the right to be coached by individuals who are well trained in sport-specific safety and to be monitored by athletic health care team members. II. Student Athletes have the right to quality, regular preparticipation examinations and each athlete has the right to participate under a comprehensive concussion management plan. III. Student Athletes have the right to participate in sporting activities on safe, clean playing surfaces, in both indoor and outdoor facilities. IV. Student Athletes have the right to utilize equipment and uniforms that are safe, fitted appropriately and routinely maintained, and to

appropriate personnel trained in proper removal of equipment in case of injury. V. Student Athletes have the right to participate safely in all environmental conditions where play follows approved guidelines and medical policies and procedures, with a hydration plan in place. VI. Student Athletes have the right to a safe playing environment with venue-specific emergency action plans that are coordinated by the athletic health care team and regularly rehearsed with local emergency personnel. VII. Student Athletes have the right to privacy of health information and proper referral for medical, psychosocial and

are spent in off-season conditioning and individual rehabilitation. The athletic trainer working with a professional team is involved with only one sport and is paid according to contract, much as a player is. Playoff and championship money may be added to the yearly income (Figure 1–3E&F). 12

Part One ■ Professional Development and Responsibilities

nutritional counseling. VIII. Student Athletes have the right to participate in a culture that finds “playing through pain” unacceptable unless there has been a medical assessment. IX. Student Athletes have the right to immediate, on-site injury assessments with decisions made by qualified sports medicine professionals. X. Student Athletes have the right, along with their parents, to the latest information about the benefits and potential risks of participation in competitive sports, including access to statistics on fatalities and catastrophic injuries to youth athletes. Reprinted with permission from the National Athletic Trainers’ Association.

Amateur/Recreational/Youth Sport Athletic trainers are working at all levels of amateur sport. The United States Olympic Committee employs athletic trainers and interns at three training centers. Every national governing body (NGB) for each of the

Olympic sports employs either a single athletic trainer or a group of athletic trainers to work with the national teams and developmental programs for younger athletes. Some municipal or community-based recreational programs employ athletic trainers either full-time or as independent contractors to cover their programs. The Amateur Athletic Union (AAU) also employs athletic trainers to cover its tournaments (Figure 1–3G).

Performing Arts A relatively new and expanding employment opportunity exists in the performing arts and entertainment industry. Athletic trainers can be found working with dance companies and theater performance groups. They are employed by Disney television shows, movie sets, and the large casinos. Some touring bands even employ athletic trainers to work with their performers and road crew who sustain injuries while traveling (Figure 1–3H).

The Military/Law Enforcement/Government The United States military, particularly the Navy, the Marines, and the Army, have demonstrated increased emphasis on injury prevention and health care for the troops.64 Treatment centers are being developed that closely resemble and, to a great extent, function as athletic training clinics. The centers are staffed by sports medicine physicians, orthopedists, athletic trainers, physical therapists, and support staff. Injured personnel are seen as soon as possible by an athletic trainer, who evaluates an injury, makes decisions on appropriate referral, and begins an immediate rehabilitation program. Currently, over 100 athletic trainers are in the military as either active duty or reserve personnel.64 Occasionally, some contract positions are available. It is likely that the role of the athletic trainer in the military will increase substantially over the next several years (Figure 1–3I). Opportunities are increasing for athletic trainers to become involved with local, state, and federal law enforcement groups and agencies. Athletic trainers are working with police and firefighters as well as with agencies such as the FBI and the American Federation of Teachers (AFT) (Figure1–3J). Other athletic trainers are employed by government agencies such as the United States Senate, NASA, and the Pentagon (Figure 1–3K).45

population. Physically active individuals engage in athletic, recreational, or occupational activities that require physical skills and utilize strength, power, endurance, speed, flexibility, range of motion, and agility. Physical activity consists of athletic, recreational, or occupational activities that require physical skills and utilize strength, power, endurance, speed, flexibility, range of motion, and agility. The Adolescent Athlete Children have always been physically active. But in today’s society, playtime or physical activity for many adolescents is focused on organized competition. Certainly, many relevant sociological issues arise in answer to questions such as how old children should be when they begin to compete and when a child should begin training and conditioning. Skeletally immature adolescents present a particular challenge to the athletic trainer involved in some aspect of their health care. Adolescents cannot be approached either physically or emotionally in the same manner as adults. Thus, the athletic trainer must be aware of patterns of growth and development and all the special considerations that this process brings with it.

Treating Physically Active Populations

The Aging Athlete Aging involves a lifelong series of changes in physiological and performance capabilities. These capabilities increase as a function of the growth process throughout adolescence, peak sometime between the ages of 18 and 40 years, then steadily decline with increasing age. However, this decline may be due as much to the sociological constraints of aging as to biological effects. In most cases, after age 35, qualities such as muscular endurance, coordination, and strength tend to decrease. Recovery from vigorous exercise requires a longer amount of time. Regular physical activity, however, tends to delay and in some cases prevent the appearance of certain degenerative processes. It is possible for individuals to maintain a relatively high level of physiological functioning if they maintain an active lifestyle. Consistent participation in vigorous physical activity can result in improvement of many physiological parameters regardless of age. The effects of exercise on the aging process and the longterm health benefits of exercise have been convincingly documented. Generally, exercise is considered a safe activity for most individuals. ACSM has recommended that individuals under age 40 who are apparently healthy with no significant risks can generally begin an exercise program without further medical evaluation, as long as the exercise program progresses gradually and moderately, and no unusual signs or symptoms develop.3 Individuals who are over age 40 or who are at high risk should have a complete medical examination and undergo an exercise test before beginning an exercise program.

In the various employment settings, athletic trainers no longer treat only athletes, but instead a physically active

The Occupational Athlete The occupational, industrial, or worker “athlete” often engages in strenuous,

Health and Fitness Clubs It is likely that a significant number of job opportunities for athletic trainers exist in health and fitness clubs. Some clubs may offer patient care, but it is more likely that the athletic trainer is a performance-enhancement specialist or an instructor. These clubs may be a chain, a franchise, or an independent club (Figure 1–3L).

Chapter One ■ The Athletic Trainer as a Health Care Provider

Athletes with Disabilities Over the past several decades there has been increased emphasis on the role of physical activity and sport in enhancing health and quality of life of individuals with disabilities and chronic illnesses. Most recently, sport for athletes with disabilities has transitioned away from a medical rehabilitation model and moved toward a recreational, competitive, and even an elite-level sports model. Athletes with amputations, with spinal cord injuries who are confined to wheelchairs, with cerebral palsy, with visual or hearing impairments, with mental or other impairments have special needs when engaging in sport activities. Athletic trainers working with these individuals need advanced knowledge and understanding of these conditions and illnesses to be able to provide for the needs of athletes with special challenges. Opportunities to work with athletes who have disabilities are certainly increasing.

ROLES AND RESPONSIBILITIES OF THE ATHLETIC TRAINER Of all the professionals charged with injury prevention and health care provision for an injured patient, perhaps none is more intimately involved than the athletic trainer. The athletic trainer is the one individual who deals with the patient throughout the period of rehabilitation, from the time of the initial injury until the patient’s complete, unrestricted return to activity. Certainly, providing effective health care for an injured athlete requires input from a cadre of individuals who compose the sports medicine team, including the physicians, coaches, and many other support personnel.11 The athletic trainer is most directly responsible for all phases of health care, including preventing injuries from occurring, providing initial first aid and injury management, evaluating injuries, and designing and supervising a timely and effective program of rehabilitation that can facilitate the safe and expeditious return to activity. The athletic trainer must be knowledgeable and competent in a variety of specialties encompassed under the 14

Part One ■ Professional Development and Responsibilities

umbrella of “sports medicine” if he or she is to be effective in preventing and treating injuries. The specific roles and responsibilities of the athletic trainer differ and to a certain extent are defined by the situation in which he or she works.10

Board of Certification Domains of Athletic Training In 2015 the Board of Certification (BOC)* completed the latest Practice Analysis (7th Edition),** which defines the profession of athletic training.10 The latest Practice Analysis replaced the Role Delineation Study (6th edition) and went into effect in 2017. This Practice Five Domains of Athletic Training Analysis was de• Injury/illness prevention and signed to examine wellness promotion the primary tasks • Examination, assessment, and performed by the diagnosis entry-level athletic • Immediate and emergency care • Therapeutic intervention trainer and the • Healthcare administration and knowledge and professional responsibilities skills required to perform each task. The panel determined that the roles of the practicing athletic trainer could be divided into five major domains: (1) injury/ illness prevention and wellness promotion; (2) examination, assessment, and diagnosis; (3) immediate and emergency care; (4) therapeutic interAn athletic trainer has vention; and (5) healthcare taken a job at a sports administration and profesmedicine clinic that has sional responsibilities. Injury/Illness Prevention and Wellness Promotion A primary responsibility of the athletic trainer is to make the competitive environment as safe as possible to minimize the risk of injury. If injury can be prevented initially, there will be no need for first aid and subsequent rehabilitation. The athletic trainer should educate all of those individuals who are in some way either directly or indirectly responsible for the health care of the athlete. The athletic trainer can minimize the risk of injury by (1) conducting

four physical therapists and two physical therapy assistants. This clinic has never employed an athletic trainer before, and there is some uncertainty among the physical therapists as to exactly what role the athletic trainer will play in the function of the clinic.

How does the role of the athletic trainer working in the clinic differ from the responsibilities of the athletic trainer working in a university setting?

The Board of Certification (BOC) has been responsible for the certification of athletic trainers since 1969. Upon its inception, the BOC was The Certification Committee for NATA, the profession’s membership association. However, in 1989, the BOC became an independent nonprofit corporation. Formerly known as the NATABOC, the BOC officially changed its name in 2004. ** The 2015 Practice Analysis went into effect in 2017 and continues through 2022. *

1–1 Clinical Application Exercise

demanding, or repetitive physical activities while performing his or her job. Like other athletes, these activities can lead to accidents and injuries. Although an objective of any athletic trainer remains the immediate, accurate, and appropriate medical care of those injured in physical activity, the significant reduction of workers’ compensation costs and improved employee productivity becomes critically important in the corporate or industrial world. Training a worker to use appropriate ergonomic techniques while engaging in the physical demands of the job is essential for preventing or at least minimizing the incidence of injury. Should injury occur, intervention strategies that correct faulty body mechanics, strength deficits, or lack of flexibility can help the worker return to performing his or her normal job.

preparticipation exams; (2) ensuring appropriate training and conditioning of the athlete; (3) monitoring environmental conditions to ensure safe participation; (4) selecting, properly fitting, and maintaining protective equipment; (5) making certain that the athlete is eating properly; and (6) making sure the athlete is using medications appropriately, while discouraging substance abuse.

1–2 Clinical Application Exercise

Conducting Preparticipation Physical Examinations The athletic trainer, in cooperation with the team physician, should obtain a medical history and conduct physical examinations of the athletes before participation as a means of screening for existing or potential problems (see Chapter 2). The medical history should be reviewed closely, and clarification should be sought for any point of concern. The preparticipation examination should include the measurement of height, weight, blood pressure, and body composition. The physician examination should concentrate on cardiovascular, respiratory, abdominal, genital, dermatological, and ear, nose, and throat systems, and may include blood work and urinalysis. A brief orthopedic evaluation would include range of motion, muscle strength, and functional tests to assess joint stability. When the athletic trainer knows at the beginning of a season that an athlete has a physical problem that may predispose that athlete to an injury during the course of the season, he or she may immediately implement corrective measures that may significantly reduce the possibility of additional injury. Developing Training and Conditioning Programs Perhaps the most important aspect of injury prevention is making certain that the athlete is fit and thus able to handle the physiological and psychological demands of competition. The athletic trainer works with the coaches to develop and implement an effective training and conditioning program for the athlete (see Chapter4). It is essential that the athlete maintain a consistently high level of fitness during the preseason, the competitive season, and the All-American High School off-season. This consistent is considering hiring an level of fitness is critical athletic trainer instead of using an emergency medical not only for enhancing performance parameters technician. However, the but also for preventing administrators do not completely understand why injury and reinjury. An athletic trainer must be an athletic trainer may be more beneficial for their knowledgeable in the area athletes. A group of area of applied physiology of athletic trainers will be exercise, particularly with holding a meeting to discuss regard to strength trainthe potential change. ing, flexibility, improvement of cardiorespiratory What reasons should the athletic trainers use to fitness, maintenance of persuade the administrators body composition, weight to hire an athletic trainer? control, and nutrition. Many colleges and most

professional teams employ full-time strength coaches to oversee this aspect of the total program. The athletic trainer, however, must be acutely aware of any aspect of the program that may have a negative impact on an athlete or a group of athletes and must offer constructive suggestions for alternatives when appropriate. At the secondaryschool level, the athletic trainer may be totally responsible for designing, implementing, and overseeing the fitness and conditioning program for the athletes. Ensuring a Safe Playing Environment by Minimizing Safety Hazards To the best of his or her ability, the athletic trainer must ensure a safe environment for competition. This task may include duties not typically thought to belong to the athletic trainer, such as collecting trash, picking up rocks, or removing objects (e.g., hurdles, gymnastics equipment) from the perimeter of the practice area, all of which might pose potential danger to the athlete. Athletic trainers must also identify safety hazards involving issues such as workplace ergonomics, equipment considerations, maintenance, and sanitation. The athletic trainer should call these potential safety hazards to the attention of an administrator. The interaction between the athletic trainer and a concerned and cooperative administrator can greatly enhance the effectiveness of the sports medicine team. The athletic trainer should also be familiar with the potential dangers associated with practicing or competing under inclement weather conditions, such as high heat and humidity, extreme cold, or electrical storms. Practice should be restricted, altered, or canceled if weather conditions threaten the health and safety of the athlete. If the team physician is not present, the athletic trainer must have the authority to curtail practice if the environmental conditions become severe (see Chapter 6). Selecting, Fitting, and Maintaining Protective Equipment The athletic trainer works with coaches and equipment personnel to select protective equipment and is responsible for maintaining its condition and safety (see Chapter 7). Because liability lawsuits have become the rule rather than the exception, the athletic trainer must make certain that high-quality equipment is purchased and that it is constantly being worn, maintained, and reconditioned according to specific guidelines recommended by the manufacturers. Protective equipment and devices can consume a significant portion of the athletic budget. The person responsible for purchasing protective equipment is usually inundated with marketing literature on a variety of braces, supports, pads, and other types of protective equipment. Decisions on purchasing specific pieces or brands should be based on research data that clearly document effectiveness in reducing or preventing injury (Figure 1–4). Equipment is expensive, and schools are certainly subject to budgeting restrictions. However, purchasing decisions about protective equipment should always be made in the best interest of the athlete. Most colleges and

Chapter One ■ The Athletic Trainer as a Health Care Provider

FIGURE 1–4 The athletic trainer should be responsible for taping and for the fitting of protective devices. © William E. Prentice

professional teams hire full-time equipment managers to oversee this area of responsibility, but the athletic trainer must be knowledgeable about and aware of the equipment being worn by each athlete. The design, building, and fitting of specific protective orthopedic devices are also responsibilities of the athletic trainer. Once the physician has indicated the problem and how it may be corrected, the athletic trainer should be able to construct an orthopedic device to correct it. Explaining the Importance of Diet and Lifestyle Choices Good nutrition can have a substantial impact on health and well-being. Poor nutritional habits can certainly have a negative effect on ability to perform at the highest level possible. However, for all the attention that athletes, coaches, and athletic trainers direct at practicing sound nutritional habits, good nutritional decisions are still subject to a tremendous amount of misunderstanding, misinformation, and occasionally quackery. An athletic trainer is often asked for advice about matters related to diet, weight loss, and weight gain and is occasionally asked about disordered eating. The athletic trainer does not need to be an expert on nutrition but must possess some understanding of the basic principles of nutrition101 (see Chapter 5). The athletic trainer should also be able to discuss nonhealth lifestyle habits, such as alcohol, tobacco, and drug use. They must educate and encourage patients to make healthy lifestyle choices. Using Medications Appropriately The athlete, like anyone else, may benefit greatly from using medications prescribed for various medical conditions by qualified physicians. Under normal circumstances, an athlete would be expected to respond to medication just as anyone else would. However, because of the nature of physical activity, the athlete’s situation is unique; intense physical activity requires that special consideration be given to the effects of certain types of medication. For the athletic trainer who is overseeing the health care of the athlete, some knowledge of the potential effects of certain types of drugs on performance is essential. Occasionally, the athletic trainer must make 16

Part One ■ Professional Development and Responsibilities

decisions regarding the appropriate use of medications based on knowledge of the indications for use and of the possible side effects in athletes who are involved in training and conditioning as well as in injury rehabilitation programs. The athletic trainer must be cognizant of the potential effects and side effects of over-the-counter and prescription medications on the athlete during rehabilitation as well as during competition (see Chapter 17). In addition, the athletic trainer should also be aware of the problems of substance abuse, both in ergogenic aids that may be used in an effort to enhance performance and in the abuse of so-called recreational or street drugs. The athletic trainer may be involved in drug testing of the athlete and should thus be responsible for educating the athlete in drug use and substance abuse. Examination, Assessment, and Diagnosis Frequently, the athletic trainer is the first person to see a patient who has sustained an injury. The athletic trainer must be skilled in recognizing the nature and extent of an injury through competency in injury evaluation. Once the injury has been diagnosed, the athletic trainer must be able to provide the appropriate first aid and then refer the patient to appropriate medical personnel. The athletic trainer must be able to efficiently and accurately diagnose an injury and illnesses. Information obtained in an initial evaluation may be critical later on when swelling, pain, and guarding mask some of the functional signs of the injury. It is essential that the athletic trainer be alert and observe, as much as possible, everything that goes on in practice. Invaluable information regarding the nature of an injury can be obtained by seeing the mechanism of the injury. The subsequent off-the-field examination should include (1) a brief medical history of exactly what happened, according to the athlete; (2) observation; (3) palpation; and (4) special tests, which might include tests for range of motion, muscle strength, or joint stability or a brief neurological examination. Information obtained in this initial examination should be documented by the athletic trainer and given to the physician once the athlete is referred. The team physician is ultimately responsible for providing medical diagnosis of an injury. The initial clinical diagnosis often provides the basis for this medical diagnosis (see Chapter 13). Understanding the Pathology of Injury and Illness The athletic trainer must be able to recognize both general medical conditions and the various types of musculoskeletal and nervous system injuries that can occur in the physically active population. Based on this knowledge of different injuries, the athletic trainer must possess some understanding of both the sequence and time frames for the various phases of healing, realizing that certain physiological events must occur during each of the phases (see Chapter 10). Anything done during training and conditioning or during a rehabilitation program that interferes with this healing process will likely delay a return to full

activity. The healing process must have an opportunity to accomplish what it is supposed to. At best, the athletic trainer can only try to create an environment that is conducive to the healing process. Little can be done to speed up the process physiologically, but many things may be done to impede healing both during training and conditioning and during rehabilitation. Referring to Medical Care After the initial management of an injury, the athletic trainer should routinely refer the patient to a physician for further evaluation and to confirm the diagnosis. If an athlete requires treatment from medical personnel other than the team physician, such as a dentist or an ophthalmologist, the athletic trainer should arrange appointments as necessary. Referrals should be made after consultation with the team physician.

1–3 Clinical Application Exercise

Referring to Support Services If needed, the athletic trainer must be familiar with and should have access to a variety of personal, school, and community health service agencies, including community-based psychological and social support services available to the patient. With assistance and direction from these agencies, the athletic trainer, together with the athlete, should be able to formulate a plan for appropriate intervention following injury. Immediate and Emergency Care The athletic trainer is often responsible for the initial on-the-field injury assessment and diagnosis following acute injury. Once this initial diagnosis is done, the athletic trainer then must assume responsibility for administering appropriate first A high-school basketball aid and for making correct player suffers a grade2 decisions in the manageankle sprain during ment of acute injury (see midseason of the Chapter 12). Although competitive schedule. the team physician is freAfter a 3-week course of quently present at games or rehabilitation, most of the competitions, in most cases pain and swelling have been eliminated. The he or she cannot be at every athlete is anxious to get practice session, where inback into practice and juries are more likely to competitive games as soon occur. Thus, the athletic as possible, and subsequent trainer must possess sound injuries to other players skills not only in the initial have put pressure on the recognition and evaluacoach to force the athlete’s tion of potentially serious return. Unfortunately, the or life-threatening injuries athlete is still unable to and/or illnesses but also in perform the functional tasks (cutting and jumping) emergency care. essential in basketball.

? Who is responsible

for making the decision regarding when the athlete can fully return to practice and game situations?

The athletic trainer must be certified in cardiopulmonary resuscitation and the use of automated external defibrillators (AEDs) by the American Red Cross,

the American Heart Association, or the National Safety Council. Athletic trainers must also consider seeking certification in first aid by the American Red Cross or the National Safety Council. Many athletic trainers have gone beyond these essential basic certifications and have completed emergency medical technician (EMT) requirements. The athletic trainer should establish well-defined emergency action plans in cooperation with local rescue squads and the community hospitals that can provide emergency treatment.75 Emergency care is expedited, and the injured athlete’s frustration and concern are lessened if arrangements regarding transportation, logistics, billing procedures, and appropriate contacts are made before an injury occurs. Therapeutic Intervention An athletic trainer must work closely with and under the direction of the team physician with respect to designing rehabilitation and reconditioning protocols that make use of appropriate therapeutic exercise, rehabilitative equipment, manual therapy techniques, or therapeutic modalities. The athletic trainer should then assume the responsibility of overseeing the rehabilitative process, ultimately returning the patient to full activity (see Chapter 16). Designing Rehabilitation Programs Once an injury or illness has been evaluated and diagnosed, the rehabilitation process begins immediately. In most cases, the athletic trainer designs and supervises an injury rehabilitation program, modifying that program based on the healing process. It is critical for an athletic trainer to have a sound background in anatomy. Without this background, an athletic trainer cannot evaluate an injury. And if the athletic trainer cannot evaluate an injury, there is no point in the athletic trainer knowing anything about rehabilitation because he or she will not know at what phase the injury is in the healing process. The athletic trainer must also understand how to incorporate therapeutic modalities and appropriate therapeutic exercise techniques into the rehabilitation program if it is to be successful. Supervising Rehabilitation Programs The athletic trainer is responsible for designing, implementing, and supervising the rehabilitation program from the time of initial injury until return to full activity. It is essential that the athletic trainer has a solid foundation in the various techniques of therapeutic exercise and an understanding of how those techniques can be incorporated most effectively into the rehabilitation program. The athletic trainer must also be familiar with the skills and normal biomechanics necessary for optimal performance on particular sport activity. The athletic trainer must establish both short-term and long-terms goals for the rehabilitation process and then be able to modify the program to meet those goals. The athletic trainer should constantly reassess the status of an existing injury so that correct decisions can be made

Chapter One ■ The Athletic Trainer as a Health Care Provider

about altering and/or progressing the rehabilitation program. All those individuals who are in some way involved with the rehabilitative process, such as coaches, parents, administrators, and other health care professionals, should be consistently informed of the patient’s progress toward full return to activity, while maintaining the necessary confidentiality regarding the patient’s injury. Incorporating Therapeutic Modalities Athletic trainers use a wide variety of therapeutic modalities in the treatment and rehabilitation of injuries. Modality use may involve a relatively simple technique, such as using an ice pack as a first-aid treatment for an acute injury, or may involve more complex techniques, such as the stimulation of nerve and muscle tissue by electrical currents. Certainly, therapeutic modalities are useful tools in injury rehabilitation, and when used appropriately these modalities can greatly enhance the patient’s chances for a safe and rapid return to athletic competition. It is essential for the athletic trainer to possess knowledge about the scientific basis and the physiological effects of the various modalities on a specific injury (see Chapter15). Modalities, though important, are by no means the single most critical factor in injury treatment. Therapeutic exercise that forces the injured anatomical structure to perform its normal function is the key to successful rehabilitation. However, therapeutic modalities play an important role in reducing pain and are extremely useful as an adjunct to therapeutic exercise. Offering Psychosocial Intervention The psychological aspect of dealing with an injury is a critical yet often neglected aspect of the rehabilitation process. Injury and illness produce a wide range of emotional reactions. Therefore, the athletic trainer needs to develop an understanding of the psyche of each patient (see Chapter 11). Patients vary in terms of pain threshold, cooperation and compliance, competitiveness, denial of disability, depression, intrinsic and extrinsic motivation, anger, fear, guilt, and ability to adjust to injury. Principles of sport psychology may be used to improve total performance through visualization, selfhypnosis, and relaxation techniques. The athletic trainer plays a critical role in social support for the injured patient.6 Athletic trainers should recognize that patients may exhibit abnormal social, emotional, and mental behaviors. Athletic trainers should also be able to recognize the role of mental health in injury and recovery, and use intervention strategies to maximize the connection between mental health and restoration of participation. If the athletic trainer recognizes that a problem exists, he or she should refer the patient to the a ppropriate medical personnel for intervention. Healthcare Administration and Professional Responsibilities The athletic trainer is responsible for the organization and administration of the training clinic, including the maintenance of health and injury records for each patient, the requisition and inventory of necessary supplies and equipment, maintenance and safety of equipment, the supervision of assistants or athletic training students, and the 18

Part One ■ Professional Development and Responsibilities

establishment of policies and procedures for day-to-day operation of the athletic training program (see Chapter 2).5 Record Keeping Accurate and detailed record k eeping— including medical histories, preparticipation examinations, injury reports, treatment records, and rehabilitation programs—are critical for the athletic trainer, particularly in light of the number of lawsuits directed toward malpractice and negligence in health care. Maintaining accurate records may also be a requirement of many state licensing boards. Many athletic trainers are responsible for filing insurance claims for reimbursement. Although record keeping may be difficult and time consuming for the athletic trainer who treats and deals with a large number of patients each day, it is an area that simply cannot be neglected. Ordering Equipment and Supplies Although tremendous variations in operating budgets exist, depending on the level and the institution, decisions regarding how the available money may best be spent are always critical. The athletic trainer must keep on hand a wide range of supplies to enable him or her to handle whatever situation may arise. At institutions with severe budgetary restrictions, prioritization based on experience and past needs must become the mode of operation. A creative athletic trainer can make do with very little equipment, which should include at least a taping and treatment table, an ice machine, and a few free weights. As in other health care professions, the more tools available for use, the more effective the practitioner can be, as long as he or she understands how to use those tools most effectively. Supervising Personnel In an athletic training environment, the quality and efficiency of the certified assistant athletic trainers and graduate assistants and athletic training students in carrying out their specific responsibilities are absolutely essential.14 The person who supervises these individuals has a responsibility to design a reasonable work schedule that is consistent with their other commitments and responsibilities outside the clinic. It is the responsibility of the head athletic trainer to provide an environment in which assistants and athletic training students can continually learn and develop professionally.18 The supervision of athletic training students necessitates constant visual and auditory interaction and the ability to intervene physically on behalf of the patient or student. Establishing Policies for the Operation of an Athletic Training Program Although the athletic trainer must be able to easily adjust and adapt to a given situation, it is essential that specific policies, procedures, rules, and regulations be established to ensure the smooth and consistent day-to-day operation of the athletic training program. A plan should be established for emergency management of injury. Appropriate channels for referral after injury and emergency treatment should be used consistently. Policies and procedures must be established and implemented that reduce the likelihood of exposure to

infectious agents by following universal precautions, which can prevent the transmission of infectious diseases (see Chapter 2).

PROFESSIONAL RESPONSIBILITIES OF THE ATHLETIC TRAINER

1–4 Clinical Application Exercise

The Athletic Trainer and Continuing Education As the clinical competencies for a practicing athletic trainer continue to expand, the certified athletic trainer should assume personal responsibility for continuously expanding his or her own knowledge base and expertise within the field. This professional development may be accomplished by attending continuing education programs offered at state, district, and national meetings. A young athletic trainer Athletic trainers must also has taken his first job at Allroutinely review profesAmerican High School. The sional journals and conschool administrators are sult current textbooks to extremely concerned about stay abreast of the most the number of athletes who up-to-date techniques. get hurt playing various The athletic trainer should sports. They have charged also make an effort to be the athletic trainer with the task of developing an involved professionally athletic training program with national, regional, that can effectively help or state organizations that prevent the occurrence are committed to enhancof injury to athletes in all ing the continued growth sports at that school. and development of the profession. What actions can the

athletic trainer take to reduce the number of injuries and to minimize the risk of injury in the competitive athletes at that high school?

The Athletic Trainer as an Educator

The athletic trainer must take time to help educate athletic training students. The continued success of any profession lies in its ability to educate its students. Education should not simply be a responsibility; it should be a priority. To be an effective educator, the athletic trainer needs an understanding of the basic principles of learning and pedagogy (the methods and practice of teaching). The athletic trainer should seek and develop competence in presenting information to students through the use of a variety of instructional techniques.48 The athletic training educator should also make an effort to stay informed about the availability of relevant audiovisual aids, multimedia, newsletters, journals, workshops, and seminars that can enhance the breadth of the students’ educational experience.103 The athletic trainer must also be able to evaluate student knowledge and competencies through

the development and construction of appropriate tests.18 The athletic training educator should also assume some responsibility for helping the students secure a professional position following graduation. Guiding the athletic training student in constructing an appropriate resume will help in this effort (see Appendix D at the end of this text). Students of athletic training must be given a sound academic background in a curriculum that stresses the competencies that are outlined in this chapter and presented in detail throughout this text. As a health care provider, the athletic trainer must understand the importance of teaching students how to incorporate the best available research-based evidence with clinical experience and individual patient values to achieve optimal patient outcomes. Athletic trainers should provide students with the rationale for practicing patient-centered care with regard to the psychosocial barriers that patients and clinicians face with injury/disease, the importance of effective patient education, and strategies for open collaboration/communication between the patient and his or her health care network. They should help students develop the knowledge needed to continuously improve the quality of care they are providing to the patient by learning how to consistently identify a treatment objective, incorporate an appropriate clinical intervention, and determine the extent to which that intervention enhanced the quality of care resulting in an improved patient outcome. Athletic trainers should expose students to the knowledge base and skill sets specific to various exercise scientists and health care providers, including physical therapists, nutritionists, physicians, dentists, podiatrists, nurse practitioners, radiologists, chiropractors, and pharmacologists, so that they may gain an understanding of and an appreciation for the value that appropriate interprofessional referral can have in delivering optimal care to their patients. Athletic trainers should help students learn how to use online databases to access the most recent evidence pertaining to optimal patient care, to use electronic medical records and software programs to manage clinical data, and to use e-mail, texting, and social media to more efficiently communicate with patients and other clinicians. Finally, they should expose students to, and gain an appreciation for the behavioral characteristics and the leadership qualities that an individual needs to possess to portray a positive professional impression of themselves, the health care team, and the profession of athletic training to their patients and colleagues. They must be able to translate the theoretical base presented in the classroom into practical application in a clinical setting if they are to be effective in treating patients.14 The athletic training educator accomplishes this application by organizing appropriate laboratory and/or clinical experiences to evaluate the students’ clinical competencies.80 Certainly, the preceptors can have a significant impact on the development of the athletic training student.48

Chapter One ■ The Athletic Trainer as a Health Care Provider

The athletic trainer must also educate the general public, in addition to a large segment of the various allied medical health care professions, as to exactly what athletic trainers are and the scope of their roles and responsibilities. This education is perhaps best accomplished by organizing workshops and clinics in the community and with corporate and industrial groups, holding professional seminars, meeting with local and community organizations, publishing research in both scholarly and popular journals, and, most important, doing a professional job of providing quality health care to an injured patient.

The Athletic Trainer as a Counselor The athletic trainer should take responsibility for informing parents and coaches about the nature of a specific injury and how it may affect the ability of the patient to compete. The athletic trainer should be concerned primarily with counseling and advising the patient not only with regard to the prevention, rehabilitation, and treatment of specific injuries but also on any matter that might be of help to the patient.61,62 Perhaps one of the most rewarding aspects of working as an athletic trainer can be found in the relationships that the athletic trainer develops with individual patients. During the period of time that athletes are competing, the athletic trainer has the opportunity to get to know them very well on a personal basis because he or she spends a considerable amount of time with them. Athletes often develop a degree of respect for and trust in the athletic trainer’s judgment, which carry over from their athletic life into their personal life. It is not uncommon for an athletic trainer to be asked questions about a number of personal matters, at which point he or she crosses a bridge from athletic trainer to friend and confidant. This considerable responsibility is perhaps best handled by first listening to the problems, presenting several options, and then letting the athlete make his or her own decision. Certainly, the role of counselor and advisor cannot be taken lightly.81,84

CAATE-accredited Post-Professional Athletic Training Education Programs are required to conduct research either as part of their job description or as a requirement for attaining their degree. It is likely that, as the numbers of educators, academicians, and graduate students continue to increase, more and more scholarly papers will be submitted for publication in professional journals.95 Regardless of whether an individual possesses the inclination or the ability to conduct research, each certified athletic trainer must at the very least take responsibility for developing some comprehension of basic research design and statistical analysis and thus be able to interpret and evaluate new research. The athletic training profession cannot continue to move forward unless its members generate their own specific body of knowledge.72 Although the transition to evidence-based practice will be difficult for some, it is absolutely essential that the entire athletic training profession must become familiar and comfortable with that process as it is now the gold standard in our clinical practice.50

The Importance of Engaging in EvidenceBased Practice for the Athletic Trainer Athletic trainers, like other health care professionals, must routinely integrate evidence-based practice into patient care. Most simply, evidence-based practice is making decisions about the clinical care of individual patients based on the current best available evidence in the professional literature.90 Practicing evidence-based medicine means integrating external clinical evidence from systematic research with clinical expertise while focusing on patient values and preferences (Figure1–5). Individual clinical expertise is the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.77 External clinical evidence is clinically relevant research either from the basic sciences or medicine, or from patient-centered clinical research into the accuracy and precision of preventive, therapeutic, and rehabilitative techniques.56 For athletic trainers, the evidence-based approach raises questions about

The Athletic Trainer as a Researcher As the athletic training profession continues to gain credibility as an allied health care profession, it is essential that athletic trainers work to enhance their visibility and credibility by engaging in research and scholarly publication.96 Certainly, not everyone who works as an athletic trainer, in every employment setting, would be expected to engage in publishing research as part of his or her job responsibilities. Although it is true that many clinical athletic trainers publish case studies, assist in large research studies, and even conduct their own research, most often the research that is published in professional journals is conducted by individuals who are program directors, faculty members, or doctoral students employed in colleges and universities.89 These individuals, along with graduate students seeking masters degrees at most 20

Part One ■ Professional Development and Responsibilities

Patient values and experiences

Evidence-based practice

Best available evidence in literature

Clinical experience

FIGURE 1–5 The evidence-based practice model.

1–5 Clinical Application Exercise

clinical techniques such as specific evaluative tests, certain rehabilitation techniques, or the effectiveness of using therapeutic modalities.13 External clinical evidence often invalidates previously accepted clinical techniques and treatments and replaces them with new ones that are more appropriate and ef How should she go about answering this clinical ficient.100 Without makquestion? ing use of the current best available evidence, clinical practice is in danger of becoming rapidly out of date, and this will undoubtedly have a negative impact on patient outcomes.3 In evidence-based practice, there are five steps that athletic training clinicians should take when attempting to determine the efficacy of using a speFive Steps in Evidence-Based cific clinical techPractice nique: (1) develop (1) Develop a clinical question. a clinical question; (2) Search the literature. (2) search the litera (3) Appraise the evidence. ture to find the best (4) Apply the best-available evidence; (3) evaluevidence. ate the strength (5) Assess the outcomes. of that evidence; (4) apply the bestavailable evidence in the literature to clinical experience and specific patient needs; and (5) assess the outcome or effectiveness of the treatment.90 A secondary school athletic trainer is concerned about the number of anterior cruciate ligament injuries that are occurring in the female athletes in all sports. She wants to find out whether incorporating a jump-landing training program will have any effect on reducing the number ACL injuries.

Developing a Clinical Question When developing a clinical question, a PICO format which is based on three or four specific components should be used. PICO is an acronym for (1) Patient problems or condition; (2) Interventions that are possible treatment options; (3) a Comparison of the alternatives that might be used PICO = in the interven• Patient condition tion (a clinical • Interventions question does not • Comparison • Outcome always need a specific comparison, in which case the acronym would simply be PIO); and (4) the Outcome that you want the patient to achieve.90 Searching the Literature When conducting a literature search, several different bibliographic databases will likely be used most often by athletic trainers, including Articles Plus, Google Scholar, PubMed/MEDLINE, CINAL, SPORTDiscus, and E BSCO host. These databases are called “pre-appraised,” or EBP, databases.

Enter key words from the clinical question you are interested in answering into a search within the database. For example, if your clinical question is “Is ultrasound effective in treating ankle sprains?” enter the key term “ultrasound,” which would be what is referred to as a medical subject heading term (MeSH). If you enter “ultrasound AND/OR ankle sprains” you would be using a Boolean Operator that searches for articles that include both terms.82 Evaluating the Strength of the Evidence When evaluating the strength of the evidence found in the literature, it is important to understand that many different types of research studies exist that have different purposes and individual strengths and weaknesses.47 Among the different types of research, study designs are randomized controlled trials, including meta-analyses and systematic reviews; cohort studies that include outcomes research; case-control studies; case studies; and anecdotal evidence often based on expert opinion. Case studies provide the least scientific rigor while a meta-analysis is more rigorous and allows for less bias or systematic error.56 The type of study can certainly have an effect on the quality of the information that study provides relative to the original clinical question. Critical assessment of results When critically assessing the results of a study, the evidence-based medicine approach requires you to answer three primary questions: 1. Are the results valid, and did the study measure what it was supposed to measure? 2. If the study is valid, what is the clinical significance of the study? 3. If the results are valid and clinically important, are the results applicable to the patient? Critical appraisal papers (CAPs) or critical appraisal topics (CATs) are scholarly papers that analyze the level or quality of the evidence of a specific research study or topic, which is developed and written based on these three questions.55 Scholarly journals are beginning to include the publication of CAPs and CATs as standalone papers.

Types of Research Studies Randomized Controlled Trials Meta-analyses Systematic reviews Cohort studies Outcome studies Clinical practice guidelines Case-control studies Case studies Anecdotal evidence Expert Opinion

Most Rigorous

Least Rigorous

Chapter One ■ The Athletic Trainer as a Health Care Provider

Rating levels of evidence and levels of recommendation There are three commonly used scales that assess the level or quality of the evidence in a specific research study.54 The three scales are the Strength of Recommendation Taxonomy (SORT), the Level of Evidence from the Oxford Centre for Evidence-Based Medicine (CEBM), and the Grading of Recommendations Assessment Development and Evaluation (GRADE). These scales look at the level of evidence that is based on the validity of the study. All of these scales are used to indicate the degree of confidence in the evidence to be recommended for use in clinical practice. The SORT scale was developed by the American Academy of Family Physicians20 and has been adopted for use by the National Athletic Trainers Association. The SORT scale uses letters A, B, and C to rate the strength of the evidence (A is highest) (Table 1–2). The CEBM scale assigns a number from 1 to 5 (1 is highest) to rate its quality based on the type of research study (Table 1–3). Levels 1, 2, and Strength of recommendations 3 of evidence are (SoR) based on the NATA further subdivided Position, Official, and Consensus statements published since 2008 into subcategories are identified throughout the text a, b, and c, again and can be easily found next to based on the type the reference in bold text where of study. The appropriate. GRADE uses four grades, from A to D, to rate the quality of the evidence from High to Very Low58 (Table 1–4). Using Systematic Reviews Several additional databases publish systematic reviews and meta-analyses of the existing research. These systematic reviews provide clinicians with pre-filtered evidence, save time, and minimize the need for appraisal expertise. They provide the TABLE 1–2 Strength of Recommendation Taxonomy (SORT) Strength of Recommendation Definition A B C

Consistent, good-quality, patient-oriented evidence Inconsistent or limited-quality, patient-oriented evidence Consensus, disease-oriented evidence, usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening

Source: Ebell, MH, Siwek, J, Weiss, BD, Woolf, SH, Susman, J, Ewigman, B, et al.: Strength of recommendation taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature, American Family Physician 69(3):548–556, 2004. 22

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TABLE 1–3 Levels of Evidence* Level

Type of Study

Randomized controlled trials a. Meta-analysis/systematic reviews of randomized controlled trials b. Randomized controlled studies with small standard deviation c. All or none randomized controlled studies Cohort studies a. Systematic reviews of cohort studies b. Individual cohort studies with low-quality randomized controls c. Outcomes research Case-control studies a. Systematic reviews of case-control studies b. Individual case-control studies Case reports/studies Anecdotal evidence, expert opinions without critical appraisal

4. 5.

*From the Centre for Evidence-Based Medicine, Oxford.

“state-of-the-art” information relative to a given research question.82 The Cochrane Database of Systematic Reviews currently contains the largest database, and it is recommended that athletic trainers begin their search of systematic reviews here. Scientific American Medicine and the ACP Journal Club are databases that provide systematic overviews of the literature relative to a specific clinical question. These databases identify, review, synthesize, and appraise all of the high-level research evidence, to provide the clinician with recommendations as to which techniques should be incorporated into clinical practice. But simply locating these systematic reviews is only part of the process. The clinician must The Cochrane Database is the be able to further most comprehensive collection distinguish those of systematic reviews. systemic reviews that are high quality and those that are not. The type of research study design, the analysis of data, and the way the data are reported determine the overall quality of the study. There are a number of scales and systems that rate the quality of these systematic reviews and meta-analyses.97 Among the more commonly used scales to rate study quality are the Physiotherapy Evidence Database (PEDro), the Jadad Scale, and the New Castle—Ottawa Scale (NOS). These scales cannot be universally applied to all types of research designs. For example, the

TABLE 1–4 Grading of Recommendations Assessment, Development and Evaluation (GRADE) Quality of Evidence

Definition

High

Moderate

Low

Very low

Further research is very unlikely to change our confidence in the estimate of effect. • Several high-quality studies with consistent results • In special cases: one large, high-quality multi-center trial Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. • One high-quality study • Several studies with some limitations Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. • One or more studies with severe limitations Any estimate of effect is very uncertain. • Expert opinion • No direct research evidence • One or more studies with very severe limitations

Code

Source: New Evidence Plus, 2016. Courtesy of John Wiley & Sons.

PEDro scale is designed to be used with systematic reviews and randomized controlled trials, whereas the NOS is designed to review nonrandomized studies with metaanalyses. The scales have totally different scoring systems, and scores from one scale cannot be compared to scores from a different scale.97 Standardized reporting guidelines assist authors with organizing critical pieces of information to include in doing a systematic review, and include Quality of Reports of Meta-Analyses of Randomized Controlled Trials (QUORUM), Standards for the Reporting of Diagnostic Accuracy Studies (STARD), Quality Assessment of Studies of Diagnostic Accuracy included in Systematic Reviews (QUADAS), Consolidated Standards of Reporting Trials (CONSORT), and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Applying the Best Available Evidence in Making Clinical Decisions Once the research that appears in the literature has been evaluated to determine the level of evidence and a level of recommendation for incorporating a specific technique into clinical practice, it becomes the responsibility of the clinician to understand those recommendations if they are to be correctly applied.85 Additionally, the clinician must then define the circumstances unique to each patient, and ask the patient whether he or she has any other existing problems that might influence the effectiveness or the safety of the treatment. The patient’s preferences, values, and rights should also be taken into consideration. The best available research evidence should be integrated with the patient’s specific clinical circumstances and wishes to come up with a correct and meaningful decision about management.57 It is critical to bridge the barriers between research evidence and clinical decision making to ensure that

patients receive optimal treatment. It is recommended that the current best available evidence be expeditiously incorporated into clinical decision making to minimize the delay between the generation of evidence and its clinical application.32 This should serve to increase the number of patients who can potentially benefit from the current best clinical treatments available. Assessing the Outcomes of a Treatment After the clinician has implemented a treatment technique that is supported by the best available evidence in the research literature, there needs to be some assessment of the effectiveness of that intervention on the ability of a patient to function normally. Outcomes research is done in an attempt to understand the end results of specific health care practices and interventions. In athletic training, examples of interventions could involve the use of a particular special test in evaluating an injury, a specific treatment technique, or the effectiveness of using a therapeutic modality. Outcomes assessment measures change in a patient’s functional status. These assessments may be based on either disease or condition-oriented evidence or patient-oriented evidence. Traditionally, disease or condition-oriented evidence has focused on mechanisms of the condition or injury, pathophysiology (ligament injury), impairments (strength, ROM, swelling), prevalence, functional limitations, and prognosis, and are based primarily on cliniciancentered outcome measures (CCO). The most recent trend in outcomes research has become to focus more on patientoriented evidence that looks at the effects of the disease on the patient’s overall health status (physical and mental health) and quality of life (social, emotional and physical well-being). Patient-oriented evidence takes into consideration the patient’s perceptions and experiences from patientcentered/rated outcome measures (PROMs) on variables

Chapter One ■ The Athletic Trainer as a Health Care Provider

that are important to the patient. If • Patient-centered/rated outcome clinicians can sysmeasures (PROMs) tematically identify clearly defined patient-centered goals, they will be more likely to provide treatment and care that is patient-centered. As a result, the approach may be more effective in determining whether a treatment or intervention meets the established goals.98 Outcomes Assessment based on:

The Disablement Model Clinical outcomes are the end result of health care services. Clinical outcomes assessment is based on the conceptual framework of the disablement model that looks at functional loss due to a specific impairment and the associated impact on quality of life instead of focusing solely on a medical diagnosis. This model also serves as the measurement method for the collection of patient-oriented evidence, a concept central to evidence-based practice.98 A number of disablement models have been proposed, including the Nagi Model, the National Center for Medical Rehabilitation Research Disablement Model (NCMRR), and, the World Health Organization International Classification of Functioning Model (IFC). Although differences exist among their terminology, all models consistently stress the whole individual beginning with the origin of the existing pathology (what type of tissue is injured); the organ level, which describes specific impairments associated with that body system; the person level, which looks at specific functional limitations; and the social implications created by the patient’s disability and its effect on quality of life (Figure 1–6). Disablement models should help the athletic training clinician to a more comprehensive view of overall health-related quality of life (HRQOL), rather than a concentration on specific functional impairments.88

information directly from the patient using structured questionnaires that have been demonstrated to provide meaningful, quantitative assessments of how the patient feels and how they are able to function with their disorders as a result of a treatment or intervention.97 They serve to influence patient care, provide meaningful information regarding the effectiveness of interventions, contribute to the process of clinical reasoning, enhance communication, and motivate patients.97 Patient-derived scores that reflect changes in a clinical intervention that are meaningful for the patient are referred to as the minimal clinically important difference (MCID). The MCID is a published value of change in an instrument that indicates the clinical bottom line, which is the minimum amount of change required for your patient to feel a difference in the variable being measured.37 Several different types of PROMs are available to look at health status and quality of life:

• Generic instruments look at a broad range of aspects of health status and the consequences of illness or conditions that may be found in a wide range of primarily healthy populations (e.g., SF-36—Medical Outcomes Study 36-Item Short-Form Health Survey, Musculoskeletal Function Assessment). These should be used in initial examinations and then follow-ups and reevaluations. • Dimension-specific instruments focus on one specific aspect of health status concentrating primarily on psychological well-being (e.g., McGill Pain Questionnaire). • Disease-specific instruments are specific to a particular patient group that share a common disease (e.g., The Asthma Quality of Life Scale). • Site or region specific instruments assess health problems in a specific part of the body (e.g., The Oxford Hip Score). Patient–Reported Outcome Scales (PROs) • Summary-item Types of Patient-Reported Although the disablement model serves as the foundaOutcome Scales instruments tion for outcomes research, clinician-centered outcomes include single Generic (CCOs) are measures that provide insight into the physiolitems and may Dimension-specific ogy of illness or injury. Clinician-centered outcomes are Disease-specific be specific to Site or region specific generally more important to the clinician than the patient.60 either a region Summary-item Patient-centered/rated outcome measures (PROMs) gather or disease.98

Origin

Organ level

Anterior cruciate ligament sprain

Decreased range of motion instability swelling pain

FIGURE 1–6 Disablement model. 24

Part One ■ Professional Development and Responsibilities

Person level

Societal level

Inability to run or cut

Cannot compete as a midfielder on soccer team

Table 1–5 lists the existing outcome measures that are currently being used by athletic trainers and other sports medicine professionals. Global Rating of Change Scales Athletic trainers commonly ask their patients whether their injury has gotten better or worse with treatment, and then they use this information to determine the efficacy of a particular treatment or to guide future injury management decisions. Global rating of change (GRC) scales are commonly used in clinical research particularly with musculoskeletal injuries.39 With GRC scales the patient must assess a particular aspect of their current health status (e.g., pain), then also be able to recall that status at a previous point in time, and finally to calculate the difference between the two. The magnitude of this difference is then scored on a balanced 7–11 point numerical or visual scale with written descriptors on the ends and at the midpoint. The minimum detectable change of a measure gives an indication of the degree to which scores change. However, what the clinician is really interested in is the minimally clinically important change, which is the change that is likely to be clinically relevant to a patient. The simplicity, ease of administration, and ease of interpretation of GRC scales makes them an attractive alternative to the more complex and time-consuming PROs (e.g., SF-36) for use in clinical practice.43 Patient-centered clinical outcomes assessments are a critical component in evidence-based practice. Athletic training clinicians and researchers must make concerted efforts to focus on patient-based outcomes that ultimately guide and direct the practice of athletic training.83,88,97,100

Professional Behaviors of the Athletic Trainer Personal Qualities There is probably no field of endeavor that can provide more work excitement, variety of tasks, and personal satisfaction than athletic training.42 A person contemplating going into this field should love sports and should enjoy the world of competition, in which there is a level of intensity seldom matched in any other area. An athletic trainer’s personal qualities, not the facilities and equipment, determine his or her success.4 Personal qualities are the many characteristics that identify individuals in regard to their actions and reactions as members of society. PerPersonal qualities of the athletic sonality is a comtrainer: plex mix of the • Stamina and ability to adapt many characteris• Empathy tics that together • Sense of humor • Ability to communicate give an image of • Intellectual curiosity the individual to • Ethics those with whom he or she associates.76 The personal qualities of athletic trainers are important, because they in turn work with many complicated and diverse personalities. Although no attempt

TABLE 1–5

List of Available Patient-Related Outcome Measures Used in Sports Medicine*

Generic Instruments • Disablement in the Physically Active Scale (DPA) • Patient Specific Functional Scale (PSFS) Generic Lower Extremity Instruments • Lower Extremity Functional Scale (LEFS) Generic Upper Extremity Instruments • Disabilities of the Arm, Shoulder, and Hand (DASH) • Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) • Upper Extremity Functional Index (UEFI) • Global Rating of Change Scale (GROC) Pain Instruments • Numeric Pain Rating Scale (NPRS) • Short-form McGill Pain Questionnaire (SF-MPQ-2) Anatomy Specific Instruments Neck • Neck Disability Index (NDI) • Neck Bournemouth Questionnaire (NBQ) Shoulder • Shoulder Pain and Disability Index (SPADI) • Disabilities of the Arm, Shoulder, and Hand (DASH) • Quick Disabilities of the Arm, Shoulder, and Hand Questionnaire (QuickDASH) Elbow • Patient-Rated Tennis Elbow Evaluation (PRTEE) Hip • Western Ontario and McMaster Universities Arthritis Index (WOMAC) • Oxford Hip Scale (OHS) • International Hip Outcome Tool (iHOT) Knee • Cincinnati Knee Rating System • Knee Injury and Osteoarthritis Outcomes Score (KOOS) • Anterior Knee Pain Rating Scale (AKPS) Ankle • Foot and Ankle Disability Index (FADI), also used with FADI sport • FADI sport • Foot and Ankle Ability Measure (FAAM) Lumbar Spine • Oswestry Disability Index • Quebec Back Pain Disability Scale • Roland-Morris Disability Questionnaire *Courtesy of Jennifer O’Donoghue PhD, LAT, ATC, CSCS, Department of Sports Medicine, North Carolina State University; and Rich Patterson MS, ATC, Department of Athletic Training, University of Charleston.

Chapter One ■ The Athletic Trainer as a Health Care Provider

has been made to establish a rank order, the qualities discussed in the following paragraphs are essential for a good athletic trainer. Stamina and Ability to Adapt Athletic training is not the field for a person who likes an 9-to-5 job. Long, arduous hours of often strenuous work will sap the strength of anyone not in the best of physiAs a member of a helping profession, the athletic trainer is cal and emotional subject to burnout. health. Athletic training requires abundant energy, vitality, and physical and emotional stability.86 Every day brings new challenges and problems that must be solved. The athletic trainer must be able to adapt to new situations with ease.17 A problem that can happen in any helping profession and does on occasion occur among athletic trainers and athletic training students is burnout.102 This problem can be avoided if addressed early. The term burnout is commonly used to describe feelings of exhaustion and disinterest toward work.44 Clinically, burnout is most often associated with the helping professions; however, it is seen in athletes and other types of individuals engaged in physically or emotionally demanding endeavors.44 Most persons who have been associated with sports have known athletes, coaches, or athletic trainers who just drop out.16 Such workers have become dissatisfied with and disinterested in the profession to which they have dedicated a major part of their lives.94 Signs of burnout include excessive anger, blaming others, guilt, being tired and exhausted all day, sleep problems, high absenteeism, family problems, and self-preoccupation.44 Athletic trainers who have high levels of perceived stress tend to experience higher emotional exhaustion and depersonalization and lower levels of personal accomplishment.33 Persons experiencing burnout may cope by consuming drugs or alcohol. The very nature of athletic training is one of caring about and serving the patient. When the emotional demands of work overcome the professional’s resources to cope, burnout may occur.25 Too many athletes to care for, coaches’ expectations to return an injured athlete to action, difficulties in caring for chronic conditions, and personality conflicts involving athletes, coaches, physicians, or administrators can leave the athletic trainer physically and emotionally drained at the end of the day. Sources of emotional drain include little reward for one’s efforts, role conflicts, lack of autonomy, and a feeling of powerlessness to deal with the problems at hand. Commonly, the professional athletic trainer is in a constant state of high emotional arousal and anxiety during the working day. Individuals entering the field of athletic training must realize that it is extremely demanding. Even though the field is often difficult, they must learn that they cannot be “all things to all people.” They must learn to say no when their health is at stake, and they 26

Part One ■ Professional Development and Responsibilities

must make leisure time for themselves beyond their work.42 Perhaps most important, athletic trainers must make time to spend with their family, friends, and loved ones.53 Empathy Empathy is the capacity to enter into the feeling or spirit of another person. Athletic training is a field that requires both the ability to sense when an athlete is in distress and the desire to alleviate that stress. Sense of Humor Many patients rate having a sense of humor as the most important attribute that an athletic trainer can have. Humor and wit help release tension and provide a relaxed atmosphere. The athletic trainer who is too serious or too clinical will have problems adapting to the often lighthearted setting of the sports world.87 Ability to Communicate Athletic training requires a constant flow of both oral and written communication. As an educator, a psychologist, a counselor, a therapist, and an administrator, the athletic trainer must be a good communicator. The athletic trainer must communicate on a daily basis with athletes, coaches, physicians, administrators, school boards, and members of the patient’s family. Intellectual Curiosity and Critical Thinking Ability The athletic trainer must always be a student. The field of athletic training is so diverse and ever changing that it requires constant study. The athletic trainer must have an active intellectual curiosity. Through reading professional journals and books, communicating with the team physician, and attending professional meetings, the athletic trainer stays abreast of the field. The athletic trainer is constantly challenged to think critically and problem solve when making clinical decisions relative to patient care. This is essential in achieving optimal patient outcomes. Ethics The athletic trainer must act at all times with the highest standards of conduct and integrity.19,28,38,79,92,99 To ensure this behavior, the NATA has developed a code of ethics, which was approved in 1993 and was most recently revised in 2013.65 The complete code of ethics appears in Appendix E. The four basic ethics principles are as follows: 1. Members shall respect the rights, welfare, and dignity of all. 2. Members shall comply with the laws and regulations governing the practice of athletic training. 3. Members shall maintain and promote high standards in their provision of services. 4. Members shall not engage in conduct that could be construed as a conflict of interest or that reflects negatively on the profession. Members who act in a manner that is unethical or unbecoming to the profession can ultimately lose their certification. Professional Memberships It is essential that an athletic trainer become a member of and be active in

professional organizations. Such organizations are continuously upgrading and refining the profession. They provide an ongoing source of information about changes occurring in the profession and include the NATA, district associations within the NATA, various state athletic training organizations, and ACSM. Some athletic trainers are also physical therapists. Increasingly, physical therapists are becoming interested in working with physically active individuals. Physical therapists and athletic trainers often have a good working relationship. Other athletic trainers may also be occupational therapists (OTs), physician assistants (PAs), certified strength and conditioning specialists (CSCS), nurses, or performance enhancement specialists (PESs). As a health care professional, the athletic trainer must be a member of and be active in professional organizations.

The Athletic Trainer and the Athlete The major concern of the athletic trainer should always be the injured patient. It is essential to realize that decisions made by the physician, coach, and athletic trainer ultimately affect the athlete. Athletes are often caught in the middle between coaches telling them to do one thing and medical staff telling them to do something else. Thus, the injured athlete must always be informed and made aware of the why, how, and when that collectively dictate the course of an injury rehabilitation program. The athletic trainer should make it a priority to educate the athlete about injury prevention and management. Athletes should learn about techniques of training and conditioning that may reduce the likelihood of injury. They should be well informed about their injuries and taught how to listen to what their bodies are telling them to prevent reinjury. The Athletic Trainer and the Athlete’s Parents In the secondary-school setting, the athletic trainer must take the time to explain to and inform the parents about injury management and prevention.27 With a patient of secondary-school age, the parents’ decisions regarding health must be a primary consideration. In certain situations, particularly at the secondary school and middle-school levels, many parents will insist that their child be seen by their family physician rather than by the individual designated as the team physician. It is also likely that the choice of a physician that the athlete can see will be dictated by the parents’ insurance plan (that is, their HMO or PPO). This creates a situation in which the athletic trainer must work and communicate with many different “team physicians.” The opinion of the family physician must be respected even if the individual has little or no experience with injuries related to sports. The coach, athletic trainer, and team physician should make certain that the athlete and his or her

family are familiar with the Health Insurance Portability and Accountability Act (HIPAA), which regulates how individuals who have health information about an athlete can share that information with others and not be in violation of the privacy rule.39 HIPAA was created to protect a patient’s privacy and limit the number of people who can gain access to medical records. HIPAA regulations are discussed in more detail in Chapter 2.

The Athletic Trainer and the Team Physician In most situations, the athletic trainer works primarily under the direction of the team physician, who is ultimately responsible for directing the total health care of the athlete (Figure 1–7). In cooperation with the team physician, the athletic trainer must make decisions that ultimately have a direct effect on the patient. From the viewpoint of the athletic trainer, the team physician should assume a number of roles and responsibilities with regard to injury prevention and the health care of the athlete.51 (See Focus Box 1–5: “Duties of the team physician.”) The physician should be an advisor to the athletic trainer.35 However, the athletic trainer must be given the flexibility to function independently in the decisionmaking process and must often act without the advice or direction of the physician. Therefore, it is critical that the team physician and the athletic trainer share philosophical opinions regarding injury management and rehabilitation programs; this cohesion will help minimize any discrepancies or inconsistencies that may exist.59 Most athletic trainers would prefer to work with, rather than for, a team physician. Compiling Medical Histories The team physician should be responsible for compiling medical histories and conducting physical examinations for each athlete, both of which can provide critical information that may reduce the possibility of injury. Preparticipation screening done by both the athletic trainer and the physician are important in establishing baseline information to be used for comparison, should injury occur during the season.

FIGURE 1–7 The athletic trainer carries out the directions of the physician. © William E. Prentice

Chapter One ■ The Athletic Trainer as a Health Care Provider

FOCUS 1–5 Focus on Healthcare Administration and Professional Responsibilities Duties of the team physician • Seeing that a complete medical history of each athlete is compiled and is readily available and determining the athlete’s health status through a physical examination • Diagnosing and treating injuries and illnesses • Directing and advising the athletic trainer about health matters • If possible, attending all games, athletic contests, scrimmages, and practices • Deciding when, on medical grounds, athletes should be disqualified from participation and when they may be permitted to reenter competition • Serving as an advisor to the athletic trainer and the coach and, when necessary, as a counselor to the athlete • Working closely with the school administrator, school dentist, athletic trainer, coach, and health services personnel to promote and maintain consistently high standards of care for the athlete • Acting, when necessary, as an instructor to the athletic trainer, assistant athletic trainer, and student athletic trainers about special therapeutic methods, therapeutic problems, and related procedures

Diagnosing Injury The team physician should assume responsibility for making a medical diagnosis of an injury and should be keenly aware of the program of rehabilitation as designed by the athletic trainer after the diagnosis. Athletic trainers should be capable of doing an accurate initial evaluation after acute injury and determining a clinical diagnosis. Input from that evaluation may be essential to the physician, who may not see the patient for several hours or perhaps days after the injury. However, the physician has been trained specifically to diagnose injuries and to make recommendations to the athletic trainer for treatment based on that medical diagnosis. The athletic trainer, with a sound background in injury rehabilitation, designs and supervises an effective rehabilitation scheme. The closely related yet distinct roles of the physician and the athletic trainer require both cooperation and close communication if they are to be optimized. Recommendations for Disqualification and Return to Play The physician determines when a recommendation should be made that an athlete be disqualified from competition on medical grounds and must have the final say as to when an injured athlete may return to activity.34 28

Part One ■ Professional Development and Responsibilities

Any decision to Team physicians must have allow an athlete absolute authority in determining to resume activity the health status of an athlete should be based who wishes to participate in the on recommendasports program. tions from the athletic trainer.52 An athletic trainer often has an advantage in that he or she knows the injured athlete well, including how the athlete responds to injury, how the athlete moves, and how hard to push to return the athlete safely to activity. The physician’s judgment must be based not only on medical knowledge but also on knowledge of the psychophysiological demands of a particular sport.93 Attending Practices and Games A team physician should make an effort to attend as many practices, scrimmages, and competitions as possible. This attendance obviously is difficult at an institution that has twenty or more athletic teams. Thus, the physician must be readily available, should the athletic trainer (who generally is at most practices and games) require consultation or advice. If the team physician cannot attend all practice sessions and competitive events or games, it is sometimes possible to establish a plan of rotation involving a number of physicians. In this plan, any one physician needs to be present at only one or two activities a year. The rotation plan has proved practical in situations in which the school district is unable to afford a full-time physician or has so limited a budget that it must ask for volunteer medical coverage. In some instances, the attending physician is paid a per-game stipend. Commitment to Sports and the Athlete Most important, the team physician must have a strong love of sports and must be generally interested in and concerned about the young people who compete. Colleges and universities typically employ someone to act as a full-time team physician. Secondary schools most often rely on a local physician who volunteers his or her time. To serve as a team physician for the purpose of enhancing social standing in the community can be a frustrating and potentially dangerous situation for everyone involved in the athletic program. When a physician is asked to serve as a team physician, arrangements must be made with the employing educational institution about specific required responsibilities. Policies must be established regarding emergency care, legal liability, facilities, personnel relationships, and duties.21 It is essential that the team physician at all times promotes and maintains consistently high-quality care for the athlete in all phases of the sports medicine program. Academic Program Medical Director Accredited athletic training education programs must have a physician medical director who is responsible for the coordination and guidance of the medical aspects of the program. The medical director—who may or may not be the team physician—should provide input to the program’s educational content and provide classroom, laboratory, and/or clinical instruction.

The Athletic Trainer and the Coach It is critical for the coach to understand the specific roles and responsibilities of each individual who could be involved in treating an injured patient. This is even more critical if there is no athletic trainer to oversee the health care and the coach is forced to assume this responsibility. Individual states differ significantly in the laws that govern what nonmedical personnel can and cannot do when providing health care.

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.

The coach is directly responsible for preventing injuries by seeing that athletes have undergone a preventive injury conditioning program. The coach must ensure that sports equipment, especially protective equipment, is of the highest quality and is properly fitted. The coach must also make sure that protective equipment is properly maintained. A coach must be All head and assistant coaches keenly aware of should be certified in CPR, AED, and first aid. what produces injuries in his or her sport and what measures must be taken to avoid them (Figure 1–8). When necessary, a coach should be able to apply proper first aid. This knowledge is especially important in serious head and spinal injuries. All coaches (both

head and assistant) should be certified in cardiopulmonary resuscitation (CPR) and AED by the American Red Cross,

the American Heart Association, or the National Safety Council. Coaches should also be certified in first aid by the American Red Cross or the National Safety Council.78 For the coach, obtaining these certifications is important so that he or she is able to provide correct and appropriate health care for the injured athlete. But it is also true that not having these certifications can have some negative legal implications for the coach and his or her employer.

It is essential that a coach have a thorough understanding of the skill techniques and environmental factors that may adversely affect the athlete. Poor biomechanics in skill areas such as throwing and running can lead to overuse injuries of the arms and legs, whereas overexposure to heat and humidity may cause death. Just because a coach is experienced in coaching does not mean that he or she knows proper skill techniques. Coaches must engage in a continual process of education to further their knowledge in their sport. When a sports program or specific sport is without an athletic trainer, the coach very often takes over this role. Coaches work closely with athletic trainers; therefore, both must develop an insight into each other’s problems, so that they can function effectively. The athletic trainer must develop patience and must earn the respect of the coaches, so that his or her judgment in all medical matters is fully accepted. In turn, the athletic trainer must avoid questioning the abilities of the coaches in their fields and must restrict opinions to athletic training matters. To avoid frustration and hard feelings, the coach must coach, and the athletic trainer must conduct athletic training matters. In terms of the health and well-being of the athlete, the physician and the athletic trainer must have the last word. This position must be backed at all times by the athletic administrator. This is not to say, however, that the coach should not be involved with the decision-making process. For example, during the time the athlete is rehabilitating an injury, there may be drills or technical instruction sessions that the athlete can participate in that will not exacerbate the existing problem. Thus, the coach, the athletic trainer, and the team physician should be able to negotiate what the athlete can and cannot do safely in the course of a practice. Any personal relationship takes some time to grow and develop. The relationship between the coach and the athletic trainer is no different. The athletic trainer must demonstrate to the coach his or her capability to correctly manage an injury and guide the course of a rehabilitation program. It will take some time for the coach to develop trust and confidence in the athletic trainer. The coach must understand that what the athletic trainer wants for the athlete is exactly the same as what the coach wants— to get an athlete healthy and back to practice as quickly and safely as possible.

REFERRING THE PATIENT TO OTHER MEDICAL AND NONMEDICAL SUPPORT SERVICES AND PERSONNEL FIGURE 1–8 The coach, in conjunction with other

members of the sports medicine team, is responsible for preventing injuries in his or her sport. © William E. Prentice

In certain situations, an individual may require treatment from or consultation with a variety of both medical and nonmedical services or personnel other than the athletic trainer or team physician. After the athletic trainer consults with the team physician about a particular matter, Chapter One ■ The Athletic Trainer as a Health Care Provider

either the athletic trainer or the team physician can arrange for appointments as necessary. When referring an athlete for evaluation or consultation, the athletic trainer must be aware of the community-based services available and the insurance or managed care plan coverage available for that athlete. A number of support health services and personnel may be used. These services and personnel include school health services; nurses; physicians, including orthopedists, neurologists, internists, family medicine specialists, ophthalmologists, pediatricians, psychiatrists, dermatologists, gynecologists, and osteopaths; dentists; podiatrists; physician’s assistants; physical therapists; strength and conditioning specialists; biomechanists; exercise physiologists; nutritionists; sport psychologists; massage therapists; occupational therapists; social workers; emergency medical technicians; sports chiropractors; orthotists/ prosthetists; equipment personnel; and referees.

School Health Services Colleges and universities maintain school health services that range from a department operating with one or two nurses and a physician available on a part-time basis to an elaborate setup comprised of a Support personnel concerned full complement with the athlete’s health and of nursing sersafety: vices with a staff • School health services of full-time medi• Nurse cal specialists and • Physician complete labora• Dentist tory and hospital • Podiatrist • Physician’s assistant facilities. At the • Physical therapist secondary-school • Strength and conditioning level, health serspecialist vices are usually • Biomechanist organized so that • Exercise physiologist one or two nurses • Nutritionist conduct the pro• Sport psychologist gram under the • Massage therapist direction of the • Occupational therapist school physician, • Emergency medical technician who may serve a and paramedic • Sports chiropractors number of schools • Orthotist/prosthetist in a given area or • Equipment personnel district. This or• Referee ganization poses • Social worker a problem, because it is often difficult to have qualified medical help at hand when it is needed. Local policy determines the procedure for referral for medical care. If such policies are lacking, the athletic trainer should see to it that an effective method is established for handling all athletes requiring medical care or opinion. The ultimate source of health care is the physician. The effectiveness of athletic health care service can 30

Part One ■ Professional Development and Responsibilities

be evaluated only to the extent to which it meets the following criteria: 1. Availability at every scheduled practice or contest of a person qualified and delegated to render emergency care to an injured or ill participant 2. Planned access to a physician by phone or nearby presence for prompt medical evaluation of the health care problems that warrant this attention 3. Planned access to a medical facility, including plans for communication and transportation

Nurse (RN, LPN, NP) As a rule, the nurse is not usually responsible for the recognition and management of sports injuries. However, in certain institutions that lack an athletic trainer, the nurse may assume the majority of the responsibility in providing health care for the athlete. The nurse works under the direction of the physician. It is essential that the nurse works in liaison with the athletic trainer and the school health services. A nurse practitioner (NP) is a registered nurse with advanced education and clinical training. NPs diagnose and treat common acute and chronic problems, and prescribe and manage medications.

Physician (MD) A number of physicians with a variety of specializations can aid in treating the patient (see Focus Box1–6: “Specializations for physicians”).

Osteopath (DO) An osteopath is a trained physician who emphasizes the role of the musculoskeletal system in health and disease using a holistic approach to the patient. An osteopath incorporates a variety of manual and physical treatment interventions in the prevention and treatment of disease.

Dentist (DDS, DMD) The role of team dentist is somewhat analogous to that of team physician. He or she serves as a dental consultant for the team and should be available for first aid and emergency care. Good communication between the dentist and the athletic trainer should ensure a good dental program. There are three areas of responsibility for the team dentist: 1. Organizing and performing the preseason dental examination 2. Being available to provide emergency care when needed 3. Conducting the fitting of mouth protectors

Podiatrist (DPM) Podiatry, the specialized field dealing with the study and care of the foot, has become an integral part of sports health care. Many podiatrists are trained in surgical

FOCUS 1–6 Focus on Healthcare Administration and Professional Responsibilities Specializations for physicians Orthopedist The orthopedist is responsible for treating injuries and disorders of the musculoskeletal system. Many colleges and universities have a team orthopedist on their staff. Osteopath (DO) An osteopath emphasizes the role of the musculoskeletal system in health and disease, using a holistic approach to the patient. An osteopath incorporates a variety of manual and physical treatment interventions in the prevention and treatment of disease. Pediatrician A pediatrician cares for and treats injuries and illnesses that occur in young children and adolescents. Physiatrist Physical Medicine and Rehabilitation (PM&R) is a branch of medicine that provides integrated care in the prevention, diagnosis, and treatment of disorders related to the brain, muscles, and bones, spanning from traumatic brain injury to lower back pain. Psychiatrist Psychiatry is a medical practice that deals with the diagnosis, treatment, and prevention of mental illness.

Dermatologist A dermatologist should be consulted for problems and lesions occurring on the skin. Family medicine physician A physician who specializes in family medicine supervises or provides medical care to all members of a family. Many team physicians in colleges and universities, and particularly at the secondary-school level, are engaged in family practice. Gynecologist A gynecologist is consulted when health issues in the female reproductive system are of primary concern. Internist An internist is a physician who specializes in the practice of internal medicine. An internist treats diseases of the internal organs by using methods other than surgery. Neurologist A neurologist specializes in treating disorders of and injuries to the nervous system. There are common situations in athletics in which consultation with a neurologist is warranted, such as for head injury or peripheral nerve injury. Ophthalmologist Physicians who manage and treat injuries to the eye are ophthalmologists. An optometrist evaluates and fits patients with glasses or contact lenses.

procedures, foot biomechanics, and the fitting and construction of orthotic devices for the shoe. Like the team dentist, a podiatrist should be available on a consulting basis.

Physician Assistant (PA)

be certified as a sports certified specialist (SCS). The physical therapist is prepared to treat a variety of patient populations with different types of injuries, whereas the athletic trainer is focused primarily on treating and working with the physically active population.

Physician assistants (PAs) are trained to assume many of the responsibilities for patient care traditionally done by a physician. A physician assistant is licensed to triage, conduct patient evaluations, diagnose and treat patients, arrange for various hospital-based diagnostic tests, and prescibe appropriate medications without conferring with or being seen by a physician. PAs have a physician supervisor but there are several levels of supervision to include the physician being available by phone. A number of athletic trainers have also become PAs in recent years.

Strength and Conditioning Specialist (CSCS)

Physical Therapist (PT)

Biomechanist

Some athletic trainers use physical therapists to supervise the rehabilitation programs for injured athletes, whereas the athletic trainer concentrates primarily on getting a player ready to practice or compete. In many sports medicine clinics, athletic trainers and physical therapists work in teams, jointly contributing to the supervision of a rehabilitation program. A number of athletic trainers are also physical therapists. A physical therapist can

An individual who possesses some expertise in the analysis of human motion can also be a great aid to the athletic trainer. The biomechanist uses sophisticated video and computer-enhanced digital analysis equipment to study movement. By advising the athlete, coach, and athletic trainer on matters such as faulty gait patterns or improper throwing mechanics, the biomechanist can reduce the likelihood of injury to the athlete.

Many colleges and universities and some secondary schools employ full-time strength coaches to advise athletes on training and conditioning programs. Athletic trainers should routinely consult with these individuals and advise them about injuries to a particular athlete and exercises that should be avoided or modified relative to a specific injury. A strength coach can be certified by the National Strength and Conditioning Association as a CSCS.

Chapter One ■ The Athletic Trainer as a Health Care Provider

Exercise Physiologist The exercise physiologist can significantly influence the athletic training program by giving input to the athletic trainer regarding training and conditioning techniques, body composition analysis, and nutritional considerations. Exercise physiologists monitor and assess cardiovascular and metabolic effects and mechanisms of exercise, replenishment of fluids during exercise, and exercise for cardiac and musculoskeletal rehabilitation.

Nutritionist (RD) Increasingly, individuals in the field of nutrition are becoming interested in athletics. Many college athletic training programs have sports dietitians who are engaged as consultants, either part-time or full-time. These dietitians are registered dietitians (RDs) that are also certified as specialists in sports dietetics (CSSD) programs that are geared to the needs of a particular sport. He or she also assists individual athletes who need special nutritional counseling.

Sport Psychologist The sport psychologist can advise the athletic trainer on matters related to the psychological aspects of the rehabilitation process. The way the athlete feels about the injury and how it affects his or her social, emotional, intellectual, and physical dimensions can have a substantial effect on the course of a treatment program and how quickly the athlete may return to competition. The sport psychologist uses different intervention strategies to help the athlete cope with injury. Sport psychologists can seek certification through the Association for the Advancement of Sport Psychology.

Massage Therapist (NCBTMB) The mission of the American Massage Therapy Association (AMTA) is “to serve its members while advancing the art, science, and practice of massage therapy.” Many massage therapists choose to become nationally certified in massage therapy, whereas others are required by their states to pass a national certification exam administered by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). National certification indicates that these massage therapists possess core skills, abilities, knowledge, and attributes to practice safely and competently, as determined by the NCBTMB. The massage therapy profession is regulated in most states in the form of either a license, registration, or certification making it illegal for anyone to work as a massage therapist unless he or she has a license.

Occupational Therapist (OT) Occupational therapists work with patients who have conditions that are mentally, physically, developmentally, or emotionally disabling to improve their ability to perform tasks in their daily living and working environments. Some occupational therapists treat individuals whose ability to function in a work environment has 32

Part One ■ Professional Development and Responsibilities

been impaired. These practitioners arrange employment, evaluate the work environment, plan work activities, and assess the client’s progress.

Emergency Medical Technician (EMT) and Paramedic There are four levels of emergency medical service (EMS) providers: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. Emergency Medical Responders are the first to arrive at the scene of an incident and are trained to provide basic emergency medical care. The EMT is trained to care for patients at the scene of an accident and while transporting patients by ambulance to the hospital under medical direction. An Advanced EMT (AEMT) has more advanced training that allows the administration of intravenous fluids, the use of manual defibrillators, and the application of advanced airway techniques. Paramedics provide the most extensive prehospital care by administering drugs orally and intravenously, interpreting electrocardiograms (ECGs), performing endotracheal intubations, and using monitors and other complex equipment.

Sports Chiropractor (DC) Chiropractors emphasize diagnosis and treatment of mechanical disorders of the musculoskeletal system, believing that these disorders affect general health by way of the nervous system. Chiropractors make use of spinal and extremity manipulations in their treatments.

Orthotist/Prosthetist (ROT) These individuals custom fit, design, and construct braces, orthotics, and support devices based on physician prescriptions.

Equipment Personnel Sports equipment personnel are becoming specialists in the purchase and proper fitting of protective equipment. They work closely with the coach and the athletic trainer.

Referee Referees must be highly knowledgeable regarding rules and regulations, especially those that relate to the health and welfare of the athlete. They work cooperatively with the coach and the athletic trainer. They must be capable of checking the playing facility for dangerous situations and equipment that may predispose the athlete to injury. They must routinely check athletes to ensure that they are wearing adequate protective pads.

Social Worker Occasionally, athletes or their families need a referral for social support services within the community. Social workers can offer counseling and support for a variety of personal or family difficulties, such as substance abuse or family planning.

In June 1990, the American Medical Association (AMA) officially recognized athletic training as an allied health care profession. The primary purpose of this recognition was to have the profession of athletic training recognized in the same context as other allied health care professions and to be held to similar professional and educational expectations, as well as to allow for the accreditation of educational programs.29 Overseen by NATA’s Professional Education Committee (PEC), since 1969 athletic training education programs became the responsibility of the AMA. The AMA’s Committee on Allied Health Education and Accreditation (CAHEA) was charged with developing the requirements (Essentials and Guidelines) for the structure and function of academic programs to prepare entry-level athletic trainers. The Joint Review Committee on Athletic Training (JRC-AT) was originally charged with evaluating athletic training education programs seeking accreditation and making recommendations to CAHEA as to whether those educational programs met the necessary criteria to become an accredited program in athletic training education. The JRC-AT was made up of representatives from the NATA, the American Academy of Pediatrics, the American Orthopedic Society for Sports Medicine, and the American Academy of Family Physicians. As of 1993, all entry-level athletic training education programs became subject to the CAHEA accreditation process. In June 1994, CAHEA was dissolved and was replaced immediately by the Commission on Accreditation of Allied Health Education Programs (CAAHEP). The CAAHEP is recognized as an accreditation agency for allied health education programs by the Council for Higher Education Accreditation (CHEA). CHEA is a private, nonprofit national organization that Evolution of athletic training coordinates aceducation accreditation bodies: creditation activ• PEC, 1969 ity in the United • Recognition of ATC as an allied States. Formed health professional, 1990 in 1996, its mis• CAHEA, 1993 sion is to promote • CAAHEP, 1994 academic qual• JRC-AT, 2003 • CAATE, 2006 ity through formal recognition of higher education accreditation bodies and to work to advance self-regulation through accreditation. Recognition by CHEA affirms that standards and processes of accrediting organizations are consistent with the quality, improvement, and accountability expectations that CHEA has established. Entry-level bachelors and masters

athletic training education A second-semester programs that were at one college sophomore has time approved by NATA, decided that she is and subsequently accredinterested in becoming a ited by CAHEA, were certified athletic trainer. accredited by CAAHEP She happens to be in an through 2005. institution that offers an advanced masters degree In 2003, the JRC-AT in athletic training yet leadership decided that the does not offer an entryprofession of athletic trainlevel CAATE-approved ing had matured and outcurriculum. grown the structure and constraints of C AAHEP How can this student most effectively achieve and that the profession her goal of becoming a would be better served if certified athletic trainer? the JRC-AT became an independent accrediting agency like those in the other allied health professions. This change meant that, instead of the JRC-AT making accreditation recommendations to CAAHEP, the JRC-AT would accredit athletic training education programs. In 2006, the JRC-AT had officially become the Committee for Accreditation of Athletic Training Education (CAATE). As of 2014, CAATE was officially recognized by the Council for Higher Education Accreditation (CHEA). Through recognition by CHEA, CAATE is in the same context/level as CAAHEP and other national accreditors. The effects of CAATE accreditation are not limited to just educational aspects. In the future, this recognition may affect regulatory legislation, the practice of athletic training in nontraditional settings, and insurance considerations. This recognition will continue to be a positive step in the development of the athletic training profession.

Other Health Care Organization Accrediting Agencies Although CAATE is the accrediting organization for athletic training, other organizations accredit various health care agencies and organizations. Joint Commission on Accreditation of Healthcare Organizations The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) is the nation’s largest standards-setting and accrediting body in health care. JCAHO accredits more than 18,000 health care organizations and programs in the United States. Its mission is to improve the quality of care provided to the public through the provision of health care accreditation and related services that support performance improvement in health care organizations. Commission on Accreditation of Rehabilitation Facilities The Commission on Accreditation of Rehabilitation Facilities (CARF) is an accrediting organization

Chapter One ■ The Athletic Trainer as a Health Care Provider

1–6 Clinical Application Exercise

RECOGNITION AND ACCREDITATION OF THE ATHLETIC TRAINER AS AN ALLIED HEALTH CARE PROFESSIONAL

that promotes quality rehabilitation services by establishing standards of quality for organizations to use as guidelines in developing and offering their programs or services to consumers. CARF uses the standards to determine how well an organization is serving its consumers and how it can improve. CARF standards are developed with input from consumers, rehabilitation professionals, state and national organizations, and funders. Every year the standards are reviewed and new ones are developed to keep pace with changing conditions and current consumer needs.

CAATE Accredited Entry-Level Athletic Training Education Programs Since 2006, the CAATE has been responsible for accrediting entry-level athletic training education programs at both the graduate and undergraduate levels. Subsequently, the CAATE assumed responsibility for accrediting post-professional masters degree and residency programs as well, both of which are designed to provide certified athletic trainers an advanced clinical, research, and scholarly experience beyond the entry-level professional degree. In 2015, the CAATE with the support of the NATA Board of Directors, the Board of Certification, and the NATA Research and Education Foundation made the decision to establish the entry-level degree for professional practice at the masters level. Using a medicalbased model, athletic training students are educated to serve in the role of allied health care professionals, with an emphasis on clinical reasoning skills. Professional Education Committee (PEC) Competencies and Clinical Proficiencies In 1996, the leadership of the NATA established the Executive Committee for Education to dictate the course of educational preparation for the athletic training student. In the Role Delineation Study, the Board of Certification (BOC) defined the minimum competencies required to practice as an athletic trainer and thus reflects the contemporary standards of practice. The Professional Education Committee (a subcommittee of the Executive Committee for Education) determines the competencies that should be taught in CAATE-accredited education programs. Entry-level athletic training education programs use a evidence-based approach both in the classroom and in clinical settings. Educational content is based on knowledge and skills and clinical integrated proficiencies. In the document “Athletic Training Education Competencies” (5th edition), the Professional Education Council has assigned the competencies to eight areas.63 These competencies are required for both curriculum development and the education of students enrolled in entry-level athletic training education programs. They define the educational content that students enrolled in these programs must master. The eight areas currently established by the Professional Education Committee are (1) evidence-based 34

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practice, (2) prevention and health promotion, (3)clinical examination and diagnosis, (4) acute care of injury and illness, (5) therapeutic interventions, (6) psychosocial strategies and referral, (7) health care administration, and (8) professional development and responsibility. Foundational Behaviors of Professional Practice These affective competencies can be found in every aspect of the educational program, including lecture, laboratory, and clinical instruction. They represent the “people” components of professional practice.63 Some are easily defined; others must be modeled by instructors. Foundational behaviors include the following: 1. Recognizing that the primary focus of practice should be the patient 2. Understanding that competent health care requires a team approach 3. Being aware of the legal components of patient care 4. Practicing in an ethical manner71 5. Advancing the knowledge base in athletic training 6. Appreciating the cultural diversity of individual patients 7. Being an advocate and model for the athletic training profession

Post-Professional Athletic Training Education Programs Post-Professional Athletic Training Education Programs are currently accredited by CAATE. The CAATE- accredited Post-Professional Athletic Training Education Programs are designed to enhance the academic and clinical preparation of individuals who are already certified athletic trainers and those who have completed the requirements for certification.

Specialty Certifications The NATA is in the process of developing specialty certifications to further enhance the professional development of certified athletic trainers by expanding their scope of practice. Entry-level athletic training education programs provide a general educational foundation, whereas specialty certifications build on this foundation. Specialty certifications in athletic training will be voluntary areas of postgraduate study, and certification in areas more advanced than entry level. According to the NATA Postprofessional Athletic Training Education Committee, the purpose is to “provide the athletic trainer with an advanced clinical practice credential that demonstrates the attainment of knowledge and skills that will enhance the quality of patient care, optimize clinical outcomes, and improve patients’ health-related quality of life, in specialized areas of athletic training practice.” Specialization in any field of health care requires significant clinical experience in a specific content area and a continuous training effort, which ultimately results in a credential that signifies clinical expertise.

FOCUS 1–7 Focus on Healthcare Administration and Professional Responsibilities Board of Certification requirements for certification as an athletic trainer Purpose of certification

The process

The Board of Certification (BOC) was incorporated in 1989 to provide a certification program for entry-level athletic trainers and recertification standards for certified athletic trainers. The purpose of this entry-level certification program is to establish standards for entry into the profession of athletic training. Additionally, the BOC has established the continuing education requirements that a certified athletic trainer must satisfy to maintain current status as a BOCcertified athletic trainer.

Annually, the Board of Certification reviews the requirements for certification eligibility and standards for continuing education. Additionally, the board reviews and revises the certification examination in accordance with the test specifications of the BOC role delineation study, which is reviewed and revised every 5 years. Requirements for candidacy for the BOC certification examination Candidates who are enrolled and/ or registered in their final semester/

REQUIREMENTS FOR CERTIFICATION AS AN ATHLETIC TRAINER An athletic trainer who is certified by the BOC is a highly qualified health care professional educated and experienced in dealing with the injuries that occur with physical activity. Candidates for certification are required to have an extensive background of both formal academic preparation and supervised practical experience in a clinical setting, according to CAATE guidelines.29 The guidelines listed in Focus Box 1–7: “Board of Certification requirements for certification as an athletic trainer” have been established by the BOC.10 Since 2004, the only way that a candidate can become certified is by completing an entry-level athletic training education program that has been accredited by CAATE.

The Certification Examination Once the requirements have been fulfilled, applicants are eligible to sit for the certification examination. The certification examination was developed by the BOC in conjunction with an independent examination development and administration company and is currently administered at various locations throughout the United States.67 In 2007, the certification examination became a computer-based exam (CBE). The CBE tests for knowledge and skill in five major domains: (1) injury/illness prevention and wellness protection; (2) clinical evaluation and diagnosis; (3) immediate and emergency care; (4) treatment and rehabilitation; and (5) organizational and professional health and well-being. Successful

quarter prior to graduation are eligible to sit for the BOC exam. Qualified candidates for the BOC exam must have received confirmation on their exam application by the Program Director recognized by the CAATE that they have earned or will earn their Bachelor’s or Master’s degree. Candidates who graduated with a Bachelor’s or Master’s degree from a CAATE (previously JRC-AT) accredited program in 2003 or later meet the education requirements for the BOC exam.

performance on the certification examination leads to BOC certification as an athletic trainer with the credential of ATC. (For the latest information on certification requirements, visit the BOC Web site at www.bocatc .org) BOC certification is a prerequisite for licensure in most states.

Continuing Education Requirements To ensure the ongoing professional growth and involvement by the certified athletic trainer, BOC has established requirements for continuing education.9,72 The purposes of the requirements are to encourage certified athletic trainers to continue to obtain current professional development information, to explore new knowledge in specific content areas, to master new athletic training–related skills and techniques, to expand approaches to effective athletic training, to further develop professional judgment, and to conduct professional practice in an ethical and appropriate manner. To maintain certification, all certified athletic trainers must document a minimum of 50 continuing education units (CEUs), 10 of which must be approved evidencebased practice programs or courses, attained during each 2-year recertification term. CEUs may be awarded for attending symposiums, seminars, workshops, or conferences; completing w ebinars or home study courses; serving as a speaker, panelist, or certifica tion exam writer; authoring a research article in a professional journal; authoring or editing a textbook; and completing postgraduate course work. All certified athletic trainers must also demonstrate proof of current CPR/AED certification.

Chapter One ■ The Athletic Trainer as a Health Care Provider

FOCUS 1–8 Focus on Healthcare Administration and Professional Responsibilities State regulation of the athletic trainer* Alabama (L) Alaska (L) Arizona (L) Arkansas (L) Colorado (E) Connecticut (L) Delaware (L) Florida (L) Georgia (L) Hawaii (E) Idaho (L) Illinois (L) Indiana (L) Iowa (L) Kansas (L) Kentucky (C) Louisiana (C) Maine (L) Maryland (L)

Massachusetts (L) Michigan (L) Minnesota (R) Mississippi (L) Missouri (L) Montana (L) Nebraska (L) Nevada (L) New Hampshire (L) New Jersey (L) New Mexico (L) New York (C) North Carolina (L) North Dakota (L) Ohio (L) Oklahoma (L) Oregon (R) Pennsylvania (C) Rhode Island (L)

1–7 Clinical Application Exercise

STATE REGULATION OF THE ATHLETIC TRAINER During the early 1970s, the leadership of the NATA realized the necessity of obtaining some type of official recognition by Forms of state regulation: other medical allied health orga• Licensure nizations of the • Certification • Registration athletic trainer as • Exemption a health care professional. Laws and statutes specifically governing the practice of athletic training were nonexistent in most states. Based on this perceived need, the athletic trainers in many states organized their efforts to secure recognition by seeking some type of regulation by state liA certified athletic trainer moves to a different censing agencies. To state to take a new job. She date, this ongoing effort discovers that in that state has resulted in 49 of the the ATC must be licensed to 50 states enacting some practice athletic training. type of regulatory statutes governing the practice of Because she was registered as an athletic athletic training.69 trainer in the other state, Rules and regulations must she go through the governing the practice process of licensure in her of athletic training vary new state? tremendously from state to state. Regulation may

Part One ■ Professional Development and Responsibilities

South Carolina (C) South Dakota (L) Tennessee (L) Texas (L) Utah (L) Vermont (L) Virginia (L) Washington (L) West Virginia (R) Wisconsin (L) Wyoming (E) States with no regulation: California *As of 2016. E = exempt from existing licensure standards; C = certification; R = registration; L = licensure. For additional information about individual state regulating boards, visit www.nata.org.

be in the form of licensure, certification, registration, or exemption (see Focus Box 1–8: “State regulation of the athletic trainer”). For the most part, legislation regulating the practice of athletic training has been positive and to some extent protects the athletic trainer from litigation. In 2016 the U.S. House of Representatives passed H.R. Bill 921 whichclarifies medical liability rules for licensedathletic trainers and other medical professionalsallowing them to legallytreat their athleteswhile traveling in other states. This bill ensuresthat they will be deemed to havesatisfied any licensure requirements of the secondary state thusprotecting themfrom litigation.

Licensure Licensure limits the practice of athletic training to those who have met minimal requirements established by a state licensing board. Through this licensing board, the state limits the number of individuals who can perform functions related to athletic training as dictated by the practice act. Requirements for licensure vary from state to state, but most require a specific educational and training background, evidence of good moral character, letters of recommendation from current practitioners, and minimal acceptable performance on a licensing examination. Licensure is the most restrictive of all the forms of regulation. Individuals who are providing health care services to an athlete cannot call themselves athletic trainers in a particular state unless they have met its requirements for licensure.12

Certification State certification as an athletic trainer differs from certification as an athletic trainer by the BOC. An individual who has passed the BOC exam does not automatically obtain a state certification. Although certification does not restrict the use of the title of athletic trainer to those certified by the state, it can restrict the performance of athletic training functions to only those individuals who are state certified. State certification indicates that a person possesses the basic knowledge and skills required in the profession and has passed a certification examination. Many states that offer certification use the BOC exam as a criterion for granting state certifi.12

Registration Registration means that, before an individual can practice athletic training, he or she must register in that state. The individual has paid a fee for being placed on an existing list of practitioners. The state may or may not have a mechanism for assessing competency. However, registration does prevent individuals who are not registered with the state from calling themselves athletic trainers.12

Exemption Exemption means that a state recognizes that athletic trainers perform functions similar to those of other licensed professions (e.g., physical therapy) yet allows them to practice athletic training despite the fact that they do not comply with the practice acts of other regulated professions. Exemption is most often used in those states in which there are not enough practitioners to warrant the formation of a state regulatory board.12

FUTURE DIRECTIONS FOR THE ATHLETIC TRAINER Certified athletic trainers possess a strong, highly structured academic background in addition to a substantial amount of closely supervised clinical experience in their chosen area of expertise. The athletic trainer continues to gain credibility and recognition as a health care professional. Certainly, recognition as an allied health profession by the American Medical Association in 1990 was a major milestone for the profession. In the future, this recognition may affect regulatory legislation, the practice of athletic training in nontraditional settings, and third-party reimbursement. Without question, this recognition will continue to be a positive factor in the development of the athletic training profession. Future directions for athletic training will be determined by the efforts of the NATA and its membership and will likely include the following:

• Athletic trainers, like other health care professionals, routinely integrate evidence-based practice into patient care. • Ongoing reevaluation, revision, and reform of athletic training education programs will continue to be a priority. • Recognition of CAATE by the Council for Higher Education Accreditation will further enhance the credibility of athletic training as an allied health profession. • Athletic trainers must continue to actively seek thirdparty reimbursement for athletic training services provided. • Eventually, every state will regulate the practice of athletic training, and there will be a move to standardize the state practice acts to make them more consistent from state to state. • Athletic trainers will seek and achieve specialty certifications to better assist in expanding their scope of practice. • It is very likely that the greatest number of job opportunities during the next decade will be in public and private secondary and middle schools. • Although the largest percentage of athletic trainers currently work in clinical settings, the number of clinics owned and staffed by athletic trainers will increase. • Recognition of the athletic trainer in physician practice, who can be incorporated into the daily operations of a physician’s office will increase. • The potential for expansion of athletic trainers in the military is great. • The potential exists for increasing job opportunities for certified athletic trainers in industrial and corporate settings. • There will be opportunities for athletic trainers to work with children and teenagers as sport performance specialists. • Opportunities for athletic trainers working in fitness and wellness settings will increase. • As the general population continues to age, opportunities for athletic trainers to work with the elderly physically active population will increase. • Athletic trainers must continue to enhance their visibility through research efforts and scholarly publication. Certified athletic trainers must strive to develop some comprehension of basic research design and statistical analysis to be able to interpret new research. • Athletic trainers should continue to make themselves available for local and community meetings to discuss the health care of the athlete. • The certified athletic trainer will become recognized internationally as a health care provider and will be found in Canada, South America, Europe, Asia, and Australia. • Most important, athletic trainers must continue to focus on injury prevention and to provide appropriate, high-quality health care to physically active individuals regardless of the setting in which injury occurs.

Chapter One ■ The Athletic Trainer as a Health Care Provider

SUMMARY • Athletic trainers are health care professionals who specialize in preventing, recognizing, managing, and rehabilitating injuries. • A number of organizations dedicated to athletic training and sports medicine have developed over the years. They devise and maintain professional standards of practice, exchange ideas, stimulate research, and collectively work toward a common goal. Among these organizations are the National Athletic Trainers’ Association and the American College of Sports Medicine. • Athletic trainers are employed in a variety of settings, including clinics, hospitals, industries, corporations, colleges and universities, secondary schools, professional sports, amateur and youth sports, the performing arts, the military, law enforcement, the government, and health or fitness clubs. • The primary roles of an athletic trainer include injury/ illness prevention and wellness promotion, examination, assessment, and diagnosis, immediate and emergency care, therapeutic intervention, and healthcare administration and professional responsibilities.

• Practicing evidence-based health care means integrating external clinical evidence from systematic research with clinical expertise while focusing on patient values and preferences. • Athletic trainers should exhibit professional behavior characteristics that will allow them to communicate and work in cooperation with patients, clients, athletes, administrators, physicians, parents, and coaches. • They may refer to or consult with variety of both medical and nonmedical services and/or personnel to obtain help and advice in overseeing the health care needs of the physically active population. • Educational programs for athletic trainers are accredited by the Committee for Accreditation of Athletic Training Education (CAATE). Once an individual completes an accredited program, she or he is eligible to become certified as an athletic trainer (ATC). In most states, a state licensing board regulates certified athletic trainers’ practices.

WEB SITES National Athletic Trainers’ Association: www.nata.org

This site describes the athletic training profession, how to become involved in athletic training, and the role of an athletic trainer.

American Sports Medicine Institute: www.asmi.org

The American Sports Medicine Institute’s mission is to improve through research and education the understanding, prevention, and treatment of sports-related injuries. In addition to stating this mission, the site provides access to current research and journal articles.

American Academy of Orthopaedic Surgeons: www.aaos.org

provides access to the American Journal of Sports Medicine and a wide variety of links to related sites.

Athletic Trainer.com: www.athletictrainer.com

This Web site is specifically designed to give information to athletic trainers, including students, and those interested in athletic training. It provides access to interesting journal articles and links to several informative Web sites.

National Collegiate Athletic Association: www.ncaa.org

This site gives general information about the NCAA and the publications that the NCAA circulates. This site may be useful for those working in the collegiate setting.

This site provides some information for the general public as well as information to its members. The public information is in the form of patient education brochures; the site also includes a description of the organization and a definition of orthopedics.

Commission on Accreditation of Athletic Training Education: www.caate.net

American Orthopaedic Society for Sports Medicine: www.sportsmed.org

This site provides up-to-date information on requirements for certification as well as a listing of certification test dates and sites.

This site is dedicated to educating health care professionals and the general public about sports medicine. The site

This site contains information on accreditation for athletic training education programs.

Board of Certification: www.bocatc.org

SOLUTIONS TO CLINICAL APPLICATION EXERCISES 1–1 To some extent, the role of the clinical athletic trainer is dictated by that state’s regulation of the practice of athletic training. Certainly, the clinical and academic preparation of athletic trainers should enable them to effectively evaluate an injured patient and guide that patient through a rehabilitative program. The athletic trainer should treat only those individuals who have sustained injury related to physical activity and not patients with neurological or orthopedic conditions. The athletic trainer may work part-time in the clinic and then cover one or several secondary 38

Part One ■ Professional Development and Responsibilities

schools around the area. The athletic trainer and physical therapist should work as a team to maximize the effectiveness of patient care. 1–2 Although emergency medical technicians are qualified to handle emergency situations, an athletic trainer is able to provide comprehensive health care to the All-American High School athletes. An athletic trainer is responsible for the prevention of athletic injuries; the recognition, evaluation, and assessment of injuries; and the treatment and rehabilitation of athletic injuries.

1–3 Ultimately, the team physician is responsible for making that decision. However, that decision must be made based on collective input from the athletic trainer, the coach, and the athlete. Remember that everyone on the sports medicine team has the same ultimate goal—to return the athlete to full competitive levels as quickly and safely as possible. 1–4 To help prevent injury, the athletic trainer should (1) a rrange for physical examinations and preparticipation screenings to identify conditions that predispose an athlete to injury; (2) ensure appropriate training and conditioning of the athletes; (3) monitor environmental conditions to ensure safe participation; (4) select and maintain properly fitting protective equipment; and (5) educate parents, coaches, and athletes about the risks inherent in sport participation. 1–5 The athletic trainer should make use of an evidence-based practice approach to find an answer to her clinical question “Can incorporating a jump-landing training program reduce the number of ACL injuries in female athletes?” The next step is to search the

literature to find the best evidence and then evaluate the strength of that evidence. She needs to apply the evidence that she finds in the literature and use her clinical experience to address the specific goal of reducing the incidence of ACL tears. Finally she needs to assess the outcome or effectiveness of having integrated this jump-landing training program in reducing ACL injuries in her female athletes. 1–6 As of 2004, everyone must graduate from a CAATE-accredited program to take the BOC exam and become a certified a thletic trainer. Therefore, she must transfer to an institution that offers an entry-level CAATE-approved program, in which she must complete course work and directly supervised clinical experience. 1–7 The laws regarding regulation of the certified athletic trainer vary from state to state. It is likely that she will have to apply for a license through the athletic training licensing board in her new state to get a license to practice in that state. It is not likely that there is reciprocity between the two states.

REVIEW QUESTIONS AND CLASS ACTIVITIES 1. How do modern athletic training and sports medicine compare with early Greek and Roman approaches to the care of the athlete? 2. What professional organizations are important to the field of athletic training? 3. Why is athletic training considered a team endeavor? Contrast the coach’s, athletic trainer’s, and team physician’s roles in athletic training. 4. Define evidence-based practice as it relates to athletic training clinical practice.

5. What qualifications should the athletic trainer have in terms of education, certification, and personality? 6. What are the various employment opportunities available to the athletic trainer? 7. Explain the criteria for becoming certified as an athletic trainer. 8. Discuss the methods by which different states regulate the practice of athletic training.

REFERENCES 1. Albensi R: The impact of health problems affecting worker productivity in a manufacturing setting. Athletic Therapy Today 8(3):13, 2003. 2. Almquist J: Summary statement: Appropriate medical care for the secondary school–aged athlete, J Athl Train 43(4):417, 2008. 3. American College of Sports Medicine: ACSM’s resource manual: For guidelines for exercise testing and prescription, Baltimore, 2009, Lippincott, Williams & Wilkins. 4. Arnold B: Importance of selected athletic trainer employment characteristics in collegiate, sports medicine clinic, and high school settings, J Athl Train 33(3):254, 1998. 5. Arnold B: 1994 athletic trainer employment and salary characteristics, J Athl Train 31(3): 215, 1996. 6. Barefield S: Social supports in the athletic training room: Athletes’ expectations of staff and student athletic trainers, J Athl Train 32(4): 333, 1997. 7. Berry J: High school athletic therapy, Part 2, Athletic Therapy Today 3(1):47, 1998. 8. Bilik S: The trainer’s bible, New York, 1956, Reed (originally published 1917). 9. Board of Certification (BOC), Continuing Education Office: Continuing education file 2012– 2015, Dallas, 2007, BOC. 10. Board of Certification, Inc.: Practice Analysis, 7th Edition, Omaha, Nebraska, 2015, Board of Certification. 11. Brukner P: Sports medicine: The team approach. In Brukner P: Clinical sports medicine, ed 3, Sydney, 2010, McGraw-Hill. 12. Campbell D: Regulation of athletic training. In Konin J: Clinical athletic training, Thorofare, NJ, 1997, Slack.

13. Casa D: Question everything: The value of integrating research into an athletic training education (editorial), J Athl Train 40(3):138, 2005. 14. Coker C: Consistency of learning styles of undergraduate athletic training students in the traditional classroom versus the clinical setting, J Athl Train 35(4):441, 2000. 15. Courson R, et al.: Inter-association consensus statement on best practices for sports medicine management for secondary schools and colleges, J Athl Train 49(1):128–137, 2014. 16. Craig, D: Educating students on athletic training political involvement, Athletic Therapy and Training 14(2):3, 2009. 17. Cuppett M: A survey of physical activity levels of certified athletic trainers, J Athl Train 37(3):281, 2002. 18. Curtis N: Student athletic trainer perceptions of clinical supervisor behaviors: A critical incident study, J Athl Train 33(3):249, 1998. 19. Dunn, W: Ethics in sports medicine, The American Journal of Sports Medicine 35(5):840–844, 2007. 20. Ebell M: Strength of Recommendation Taxonomy (SORT): A patient-centered approach to grading evidence in the medical literature, Am Fam Physician 69(3):548–556, 2004. 21. Editorial: The ethics of selecting a team physician. “Show me the money” shouldn’t be part of the process, Sports Med Digest 23(4):37, 2001. 22. Ferrara M: Globalization of the athletic training profession, J Athl Train 41(2):135, 2006. 23. Fícca M: Injury prevention in the occupational setting, Athletic Therapy Today 8(3):6, 2003. 24. Finkam S: The athletic trainer or athletic therapist as physician extender, Athletic Therapy Today 7(3):50, 2002.

25. Giacobbi P: Low burnout and high engagement levels in athletic trainers: Results of a nationwide random sample, J Athl Train 44(4): 370–77, 2009. 26. Green J: Athletic trainers in an orthopedic practice, Athletic Therapy Today 9(5):62, 2004. 27. Gould T: Secondary-school administrators’ knowledge and perceptions of athletic training, Athletic Therapy Today 8(1):57, 2003. 28. Graber G: Ethics 101, Athletic Therapy Today 8(2):6, 2003. 29. Grace P: Milestones in athletic trainer certification, J Athl Train 34(3):285, 1999. 30. Gray R: The role of the clinical athletic trainer. In Konin J: Clinical athletic training, Thorofare, NJ, 1997, Slack. 31. Hajart A: The financial impact of an athletic trainer working as a physician extender in orthopedic practice, The Journal of Medical Management Practice, 29(4):250–54, 2013. 32. Haynes B: Barriers and bridges to evidence based clinical practices, British Medical Journal 317(7135):273–76, 1998. 33. Hendrix A: An examination of stress and burnout in certified athletic trainers at division 1-A universities, J Athl Train 35(2):139, 2000. 34. Herring S, et al.: Sideline preparedness for the team physician: A consensus statement, Med Sci Sports Exerc 33(5):846, 2001. 35. Herring, S: Team physician consensus statement: 2013 Update, Medicine and Science in Sports and Exercise, 45(8):1618–22, 2013. 36. Hertel J: Research training for clinicians: The crucial link between evidence-based practice and third-party reimbursement (editorial), J Athl Train 40(2):69, 2005.

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37. Jaeschke R: Ascertaining the minimal clinically important difference. Controlled Clinical Trials 10(4):407–15,1989. 38. Jonas J: Ethics in injury management, Athletic Therapy Today 11(1):28, 2006. 39. Jones D: HIPAA: Friend or foe to athletic trainers? Athletic Therapy Today 8(2):17, 2003. 40. Judd M: Athletic training education program directors’ perceptions on job selection, satisfaction, and attrition, J Athl Train 39(2):185, 2004. 41. Kahanov L, Andrews L: A survey of athletic training employers’ hiring criteria, J Athl Train 36(4):408, 2001. 42. Kaiser D: Finding satisfaction as an athletic trainer, Athletic Therapy Today 10(6):18, 2005. 43. Kamper S: Global rating of change scales: A review of strengths and weaknesses and considerations for design, Journal of Manual and Manipulative Therapy 17(3):163–70, 2009. 44. Kania M: Personal and environmental characteristics predicting burnout among certified athletic trainers at National Collegiate Athletic Association institutions, J Athl Train 44(1): 58–66, 2009. 45. Kirkland M: A case study of athletic training at the Kennedy Space Center, Athletic Therapy Today 8(3):9, 2003. 46. Kirkland M: Increasing diversity of practice settings for athletic trainers, Athletic Therapy Today 10(5):1, 2005. 47. Knight K: Study/experimental/research design: Much more than statistics, J Athl Train 45(1): 98–100, 2010. 48. Laurent T: Clinical instructors and student athletic trainers’ perceptions of helpful clinical instructor characteristics, J Athl Train 36(1):58, 2001. 49. Lyznicki J: Certified athletic trainers in secondary school: Report of the Council on Scientific Affairs, American Medical Association, J Athl Train 34(3):272, 1999. 50. Manspeaker S: Overcoming barriers to implementation of evidence-based practice concepts in athletic training education: Perceptions of select educators, J Athl Train 46(5):514–22, 2011. 51. Matheson G: Advocating injury prevention: The team physician’s role, Physician Sportsmed 33(8):1, 2005. 52. Matheson G: Return-to-play decisions: Are they the team physician’s responsibility? Clinical Journal of Sport Medicine 21(1):25, 2011. 53. Mazerolle S: Assessing strategies to manage work and life balance of athletic trainers working in the National Collegiate Athletic Association Division I setting, J Athl Train 46(2):194–205, 2011. 54. Mitten M: Support for certified athletic trainers in intercollegiate athletics, Memorandum from National Collegiate Athletic Association, August 14, 2003. 55. McKeon P: Assessment of the quality of clinically relevant research, Athletic Therapy and Training 14(3):4–9, 2009. 56. McKeon P: Hierarchy of research design in evidence-based sports medicine, Athletic Therapy Today 11(4):42, 2006. 57. McKeon P: Finding context: A new model for interpreting clinical evidence, Athletic Therapy and Training 16(5):10–13, 2011. 58. Medina J: Rating the levels of evidence in sports medicine research, Athletic Therapy Today, 11(1):38–41, 2006. 59. Mellion M: The team physician. In Mellion M: Sports medicine secrets, Philadelphia, 2002, Hanley-Balfus.

60. Michener L: Patient-and clinician-rated outcome measures for clinical decision making in rehabilitation, Journal of Sport Rehabilitation, 20(1):37, 2011. 61. Misasi S: Academic preparation of athletic trainers as counselors, J Athl Train 31(1):39, 1996. 62. Moulton M: The role of counseling collegiate athletes, J Athl Train 32(2):148, 1997. 63. National Athletic Trainers’ Association: Athletic training competencies , ed 5, Dallas, 2010, National Athletic Trainers’ Association. 64. National Athletic Trainers’ Association: A closer look at the military setting, NATA News 12:30, 2003. 65. National Athletic Trainers’ Association: NATA code of ethics, NATA, Dallas, 2013. 66. National Athletic Trainers’ Association: What is the physician extender? NATA News 1:12, 2004. 67. National Athletic Trainers’ Association Board of Certification: Study guide for the NATA BOC entry-level athletic trainer certification examination, Philadelphia, 1995, Davis. 68. National Athletic Trainers’ Association Education Council: NCAA Recommendations and Guidelines for Appropriate Medical Coverage for Intercollegiate Athletics, 2003, National Athletic Trainers’ Association. 69. National Athletic Trainers’ Association Government Affairs & Advocacy: http://www.nata.org /government-affairs-advocacy. 70. O’Shea M: A history of the National Athletic Trainers’ Association, Greenville, NC, 1980, National Athletic Trainers’ Association. 71. Peer K: Ethics education: The cornerstone of foundational behaviors of professional practice, Athletic Therapy Today 12(1):2, 2007. 72. Pittney W: Continuing education in athletic training: An alternative approach based on adult learning theory. J Athl Train 33(1):72, 1998. 73. Pittney W: A qualitative examination of professional role commitment among athletic trainers working in the secondary school setting, J Athl Train 45(2):198–204, 2010. 74. Pitney W: Qualitative inquiry in athletic training: Principles, possibilities, and promises. J Athl Train 36(2):185–89, 2001. 75. Potter B: Developing professional relationships with emergency medical services providers, Athletic Therapy Today 11(3):18, 2006. 76. Raab S: Characterizations of a quality certified athletic trainer, J Athl Train 46(5):672–79, 2011. 77. Raina P: Athletic therapy and injury prevention: Evidence-based practice, Athletic Therapy Today 9(6):10, 2004. 78. Ransone J: Assessment of first-aid knowledge and decision making of high school athletic coaches, J Athl Train 34(3):267, 1999. 79. Ray R: Ethical practice in athletic training: A thing of the past? Athletic Therapy Today 8(2):1, 2003. 80. Rich V: Clinical instructors’ and athletic training students’ perceptions of teachable moments in an athletic training clinical education setting, J Athl Train 44(3):294–303, 2009. 81. Rock J: A preliminary investigation into the use of counseling skills in support of rehabilitation from sport injury, J Sport Rehabil 11(4):284, 2002. 82. Rosenberg W: Evidence-based medicine: An approach to clinical problem-solving, BMJ 310:1122, 1995. 83. Sauers E: A team approach: Demonstrating sport rehabilitation’s effectiveness and enhancing patient care through clinical outcomes

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assessment. Journal of Sport Rehabilitation 20(1):3, 2011. 84. Scriber K: The challenge of balancing our professional and personal lives, Athletic Therapy Today 10(6):14, 2005. 85. Sexton, P: Clinical decision making: Assumptions made in the absence of evidence, Athletic Therapy and Training 16(2):1–3, 2011. 86. Shelley G: Practical counseling skills for athletic therapists, Athletic Therapy Today 8(2):57, 2003. 87. Shibinski K: The role of humor in enhancing the classroom climate, Athletic Therapy and Training 15(5): 27–29, 2010. 88. Snyder A: Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, Part I: Disablement models, J Athl Train 43(4):428–36, 2008. 89. Starkey C: Scholarly productivity of athletic training faculty members, J Athl Train 36(2):156, 2001. 90. Steves R: Evidence-based medicine: What is it and how does it apply to athletic training? J Athl Train 39(1):83, 2002. 91. Stiller-Ostrowski J: Recently certified athletic trainers’ undergraduate educational preparation in psychosocial intervention and referral, J Athl Train 44(1):67–75, 2009. 92. Swisher J: Professionalism & ethics—ethical issues in athletic training: A foundational descriptive investigation, Athletic Therapy and Training 14(2), 2009. 93. Team physician consensus statement, Med- Sci Sports Exerc 32(4):877, 2002. 94. Terranova A: National Collegiate Athletic Association division and primary job title of athletic trainers and their job satisfaction or intention to leave athletic training, J Athl Train 46(3):312– 18, 2011. 95. Turocy P: Overview of athletic training education research publications, J Athl Train 37(4S):s162, 2002. 96. Turocy P: Survey research in athletic training: The scientific method of development and implementation, J Athl Train 37(4S):s174, 2002. 97. Valier A: Beyond the basics of clinical outcomes assessment: Selection appropriate patient-rated outcome instruments for patient care, Athletic Training Education Journal 10(1), 91–100, 2015. 98. Valovich McLeod, T: Using disablement models and clinical outcomes assessment to enable evidence-based athletic training practice, Part II: Clinical outcomes assessment, Journal of Athletic Training 43(4):437–45, 2008. 99. Velasquez BJ: Sexual harassment in the athletic training room: Implications for athletic trainers, Athletic Therapy Today 8(2):20, 2003. 100. Vesci B: Current evidence guiding clinical practice in athletic training, Athletic Training & Sports Health Care: The Journal for the Practicing Clinician 2(2):57, 2010. 101. Vinci DM: Nutrition communication and counseling skills, Athletic Therapy Today 6(4):34, 2001. 102. Walter J: An assessment of burnout in undergraduate athletic training education program directors, J Athl Train 44(2):190–96, 2009. 103. Wiksten D: Effective use of multimedia technology in athletic training education, J Athl Train 37(4S):213, 2002. 104. Xerogeanes J: The athletic trainer as orthopedic physician extender, Athletic Therapy Today 12(1):1, 2007.

ANNOTATED BIBLIOGRAPHY Amato H, Cole S, Hawking C: Clinical skills documentation guide for athletic training, Thorofare, NJ, 2006, Slack. Reflects the standards and specific outcomes of the NATA Clinical Proficiencies by presenting clinical skills set following a checklist design format. Bilik SE: The trainer’s bible, ed 9, New York, 1956, Reed. A classic book, first published in 1917, by a major pioneer in athletic training and sports medicine. Board of Certification: Role delineation study, ed 5, Philadelphia, 2010, F.A. Davis. Contains a complete discussion of the 2004 role delineation study that redefined the responsibilities of the athletic trainer. Cartwright L, Pittney W: Athletic training for student assistants, Champaign, IL, 2001, Human Kinetics. A practical guide for student athletic training assistants, including their roles and responsibilities within the sports medicine team.

Hannum S: Professional behaviors in athletic training, Thorofare, NJ, 2000, Slack. Focuses on essentials of effective career development. Addresses many of the skills students will require to build their image as health care professionals, such as communication, critical thinking, networking, interpersonal skills, and recognition of cultural differences.

Laurent T: Athletic training clinical education guide 2009, Delmar Learning. Provides a structured format for goal setting, reflection, skills verification, and journaling.

Long B, Hale C: Athletic Training Exam review. Baltimore, 2009, Lippincott, Williams & Wilkins. Provides a framework for athletic students to begin their certification examination preparation. Mueller F, Ryan A: Prevention of athletic injuries: the role of the sports medicine team, Philadelphia, 1991, F.A. Davis. Provides an in-depth discussion of the various members of the sports medicine team. National Athletic Trainers’ Association: Far beyond a shoe box: fifty years of the National Athletic Trainers’ Association, Dallas, 1999, National Athletic Trainers’ Association. An interesting text about the history of NATA that should be read by any student interested in athletic training as a career. VanLunen, B, Hankemeier, D, Welch, C: Evidence guided practice: a framework for clinical decision making in athletic training, Thorofare, NJ, 2015, Slack. This text will help students and practicing clinicians to incorporate evidence-based concepts into clinical practice. Van Ost L, Manfre K: Athletic training exam review: a student guide to success, Thorofare, NJ, 2009, Slack. Emphasizes the roles and responsibilities of student athletic trainers necessary to make them successful as health care professionals.

Chapter One ■ The Athletic Trainer as a Health Care Provider

Health Care Organization and Administration in Athletic Training ■ Objectives When you finish this chapter you should be able to • Establish a strategic plan for conducting an athletic training program in secondary-school, collegiate, professional, clinic, corporate, and industrial settings. • Plan a functional, well-designed athletic training clinic for a secondary-school, collegiate, or professional setting. • Discuss issues relative to operating an athletic training program in secondary-school, collegiate, professional settings, clinic, hospital, corporate, and industrial settings.

• Identify policies and procedures that should be enforced in the athletic training clinic. • Explain the importance of the preparticipation physical examination. • Construct the necessary records that must be maintained by the athletic trainer. • Describe current systems for gathering injury surveillance data.

■ Outline Establishing a System for Athletic Training Health Care 43 Issues Specific to Athletic Training Program Operation in the Secondary-School, College, or University Setting 43 Issues Specific to Athletic Training Program Operation in the Clinic, Hospital, Corporate, or Industrial Setting 52

Record Keeping 56 Computers, Tablets, and Smartphones as Tools for the Athletic Trainer 67 Collecting Injury Data 68 Summary 71

■ Key Terms accident

injury

epidemiology

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • Clinical application scenarios covering athletic training clinic design, risk management, policies, and procedures • Click-and-drag questions covering budgeting, athletic training clinic design, and preparticipation physical examination • Multiple-choice questions covering preparticipation physical examination, maintaining records, and developing a strategic plan for an athletic training clinic • Selection questions covering preparticipation physical examination and classification of sport

perating an effective athletic health care program requires careful organization and administration regardless of whether the setting is a secondary school, college, university, or professional team or a clinical, hospital, or industrial facility. Besides being a clinical practitioner, the athletic trainer must be an administrator who performs both managerial and supervisory duties.12 This chapter looks at the administrative tasks required of the athletic trainer for successful operation of the program, including facility design, policies and procedures, budget considerations, personnel management, administration of physical examinations, record keeping, and injury data collection.

ESTABLISHING A SYSTEM FOR ATHLETIC TRAINING HEALTH CARE Developing a Strategic Plan Perhaps the first step in establishing a health care program in athletic training is to determine why such a program is needed and what the goals of this program should be.19 The basic questions in the strategic planning process must be answered by clinic, hospital, or school administrators; medical directors; athletic directors; or school boards who, in most cases, will ultimately be responsible for funding and supporting the health care program in athletic training.21,44 The depth of the commitment from these decision makers toward providing quality health care will, to a large extent, determine the size of the staff, the size of the facility, and the scope of operation of the health care program. Clearly written Mission and Vision statements will help focus the direction of the program and should be an outcome of the strategic planning process.32 Strategic planning should involve many individuals, including administrators, other allied health care providers, student-athletes, coaches, physicians, staff athletic trainers, patients, parents, and community-based health leaders. Including many individuals in the planning process will help secure allies who are committed to seeing the program succeed.44 Strategic planning should be an ongoing process that takes a critical look at the strengths and weaknesses of the program and then takes immediate SWOT analysis action to correct • Strengths deficiencies. The • Weaknesses SWOT analysis— • Opportunities which looks at • Threats Strengths, Weaknesses, Opportunities, and Threats underlying planning42—is a useful and effective technique in strategic planning for existing athletic health care programs. Administrators should take a close

look at a cost-effectiveness analysis of operating an athletic health care program to determine the value of the return on their investment.

Developing a Policies and Procedures Manual Once the strategic planning process is complete and some consensus has been reached by those involved in the process, the next step is Every athletic training program to create a demust develop policies and procedures that carefully tailed policies and delineate the daily routine of the procedures manprogram. ual based on the mission and vision statements. This manual will be used by everyone who is involved with providing some aspect of health care, including the athletic training staff, physicians, other allied health personnel, and administrators.4 Policies are clear and accurate written statements that identify the basic rules and principles (the what and why) used to control and expedite decision making. Policies are essential for operating the athletic training clinic. Procedures describe the process by which something is done (the how). Focus Box 2–1: “Items to include in a policies and procedures manual” includes recommendations for topics to be included.

ISSUES SPECIFIC TO ATHLETIC TRAINING PROGRAM OPERATION IN THE SECONDARYSCHOOL, COLLEGE, OR UNIVERSITY SETTING It is imperative that every athletic program develop policies and procedures that carefully delineate the daily routine of the program.20

The Scope of the Athletic Training Program An important consideration in any athletic training program is to determine who is to be served by the athletic training staff.55 The individual athlete/patient, the institution, and the community are considered. The Athlete The athletic trainer must decide the extent to which the athlete/patient will be served. For example, will prevention and care activities be extended to athletes for the entire year, including summer and other vacations, or only during the competitive season? Also, the athletic trainer must decide what care will be rendered. Will it extend to all systemic illnesses or just to musculoskeletal problems?

Chapter Two ■ Health Care Organization and Administration in Athletic Training

FOCUS 2–1 Focus on Healthcare Administration and Professional Responsibilities Items to include in a policies and procedures manual Program Operation • Goals and objectives • Mission statement • Vision statement • Organizational structure • Scope of operation • Hours of operation • Patient scheduling • Patient billing • Patient referral • Facility cleaning, sanitation, and hygiene • Equipment use, maintenance, and repair • Documentation and maintenance of medical records • Release of medical records • Budget and purchasing • Supplies • Equipment • Emergency procedures • Fire • Code (cardiac arrest)

The Institution A policy must be established as to who will be served by the athletic training program. Often, legal concerns and the school liability insurance dictate who, beyond the athlete, is to be served. A policy should make it clear whether students other than athletes/patients, athletes from other schools, faculty, and staff are to receive care. If so, how are they to be referred and medically directed? Also, it must be decided whether the athletic training program will act as a clinical setting for athletic training students.

• Emergency action plan • Disaster plan (tornado) • Active shooter plan • Safety and security considerations • Access to facility • OSHA guidelines • Inclement weather • Incident reports Human Resources Issues • Job descriptions • Hiring practices • Quarterly and yearly employee evaluations • Licensure and certification • Dress code • Vacation policy • Benefits • Sexual harassment • Termination policy • Staff attendance

for practice or a contest; and late afternoons and early evenings are spent in injury management. Secondary schools with limited available supervision may be able to provide athletic training clinic coverage only in the afternoons.

The Community A decision must be made as to which, if any, outside group(s) or people in the community will be served by the athletic training staff. Again, legality and the institution’s insurance program must be taken into consideration when making this decision. If a policy is not delineated in this matter, outside people may abuse the services of the athletic training clinic and staff.

Health Care Services for Sports Ideally, all sports should have a certified and licensed athletic trainer in attendance at all practices and contests, both at home and away. Many colleges and universities have sufficient personnel to provide coverage to a variety of sports simultaneously. At the secondary-school level, however, only one or occasionally two athletic trainers may be available to cover every sport that the secondary school offers. Thus, it is impossible for the athletic trainer to be in several places at one time. The athletic trainer in this difficult situation must make some decisions about where the greatest need for coverage is, based on the potential risk of a particular sport and the number of athletes involved.40

Providing Health Care Services

Hygiene and Sanitation

Health Care Services for Facility Personnel A concern of any athletic department is whether proper health care services are provided for the athletic training clinic and specific sports. If a school has a full-time athletic training staff, an athletic training clinic could, for example, operate from 6 a.m. to 11 p.m. Mornings are commonly reserved for treatments and exercise rehabilitation; early afternoons are for treatment, exercise rehabilitation and preparation

The practice of good hygiene and sanitation is of the utmost importance in an athletic training program. The prevention of infectious diseases is a direct responsibility of the athletic trainer, whose duty it is Good hygiene and sanitation are to see that all athessential for an athletic training letes/patients are program. surrounded by the

Part One ■ Professional Development and Responsibilities

most hygienic environment possible and that each individual is practicing sound health habits. Chapter 14 discusses the management of bloodborne pathogens. The athletic trainer must be aware of and adhere to guidelines for the operation of an athletic care facility as dictated by the Occupational Safety and Health Administration (OSHA). The Athletic Training Clinic The athletic training clinic should be used only for the prevention and care of sports injuries.27 Too often, the athletic training clinic becomes a meeting or club room for the coaches and athletes. Unless definite rules are established and practiced, cleanliness and sanitation become an impossible chore. Unsanitary practices or conditions must not be tolerated. The following are some important athletic training clinic policies: 1. No cleated shoes are allowed. Dirt and debris tend to cling to cleated shoes; therefore, athletes should remove cleated shoes before entering the athletic training clinic. 2. Game equipment is kept outside. Because game equipment, such as balls and bats, add to the sanitation problem, they should be kept out of the athletic training clinic. Coaches and athletes must be continually reminded that the athletic training clinic is not a storage room for sports equipment. 3. Shoes must be kept off treatment tables. Because of the tendency of shoes to contaminate treatment tables, they must be removed before any care is given to the patient. 4. Athletes should shower with antimicrobial soap, after every practice before receiving treatment.59 SoR:B The athlete should make it a habit to shower before being treated if the treatment is not an emergency. This procedure helps keep tables and therapeutic modalities sanitary. 5. Roughhousing and profanity should not be allowed. Athletes must be continually reminded that the athletic training clinic is for injury care and prevention. Horseplay and foul language lower the basic purpose of the athletic training clinic. 6. No food or smokeless tobacco should be allowed. 7. Cell phones must not be used for photos or other social media posts due to issues with HIPAA and patient privacy. General cleanliness of the athletic training clinic, the locker rooms, and the athletic venues must be constantly maintained. Through the athletic trainer’s example, the athlete may develop an appreciation for cleanliness and in turn develop wholesome personal health habits. Cleaning responsibilities in most schools are divided among the athletic training staff, equipment managers, and the custodial staff. The custodial staff, equipment managers, and the athletic training staff should work closely together to make certain that all duties relative to cleanliness are covered. Ultimately,

the athletic trainer is responsible for making sure that a lack of cleanliness of the facilities and equipment is not a threat to the health and well-being of the athletes. Care of permanent building structures and trash disposal are usually the responsibilities of custodians, whereas the upkeep of specialized equipment falls within the responsibilities of both the athletic trainers and the equipment managers. Used, dirty clothing, including practice gear, undergarments, outerwear, and uniforms, must be laundered on a daily basis.59 SoR:B Equipment, including knee sleeves and braces, ankle braces, etc., should be disinfected in the manufacturer’s recommended manner on a daily basis.58 The division of routine cleaning responsibilities may be generally organized as follows: 1. Custodial staff a. Sweeps floors daily b. Cleans and disinfects sinks and built-in tubs daily c. Mops and disinfects hydrotherapy area twice a week d. Refills paper towel and drinking cup dispensers as needed e. Empties wastebaskets and disposes of trash daily 2. Athletic training staff a. Cleans and disinfects treatment tables daily b. Cleans and disinfects hydrotherapy modalities daily c. Cleans and polishes other therapeutic modalities weekly d. Disinfects equipment, including knee sleeves and braces, and the like, according to the manufacturer’s recommendations, on a daily basis.59 SoR:C 3. Equipment managers a. Clean and disinfect frequently touched surfaces such as wrestling mats, locker room benches, and floors.59 SoR:A b. Have all practice and game gear, including soiled clothing, practice gear, undergarments, outerwear, and uniforms, laundered daily.59 SoR:B The Gymnasium Maintaining a clean environment is a continual battle in the secondary-school, college, and university settings.48 Practices such as passing a common towel to wipe off perspiration, using common water bottles, disposable razors, and hair clippers, and failing to change dirty clothing for clean are prevalent violations of sanitation in sports.59 SoR:A The following is a suggested cleanliness checklist that may be used by the athletic trainer: 1. Facilities cleanliness a. Are the gymnasium floors swept daily? b. Are drinking fountains, showers, sinks, urinals, and toilets cleaned and disinfected daily? c. Are lockers aired and sanitized frequently? d. Are mats cleaned routinely (wrestling mats and wall mats cleaned daily)?

Chapter Two ■ Health Care Organization and Administration in Athletic Training

2. Equipment and clothing issuance a. Are equipment and clothing fitted to the athlete and properly maintained to avoid skin irritations? b. Is swapping of equipment and clothes prevented? c. Is clothing laundered and changed frequently? d. Is wet clothing allowed to dry thoroughly before the athlete wears it again? e. Is individual attention given to proper shoe fit and upkeep? f. Is protective clothing provided during inclement weather or when the athlete is waiting on the sidelines? g. Are clean, dry towels provided each day for each athlete? The Athlete To promote good health among the athletes, the athletic trainer should encourage sound health habits. The following checklist may be a useful guide for coaches, athletic trainers, and athletes: 1. Promptly report injuries, illnesses, open wounds, and skin disorders to the athletic trainer. 2. Practice good daily living habits of resting, sleeping, and proper nutrition. 3. Shower after practice. 4. Dry thoroughly and cool off before departing from the gymnasium. 5. Avoid drinking from a common water dispenser. 6. Avoid using a common towel. 7. Avoid exchanging workout clothes with teammates. 8. Practice good foot hygiene. 9. Avoid contact with teammates who have a contagious disease or infection. 10. Understand the role exercise can play in maintaining a healthy lifestyle and preventing chronic disease.

Emergency Telephones Every individual responsible for overseeing an athletic health care program as well as athletic personnel who are conducting practices or competitions should all have access to wireless phones for the purpose of contacting or communicating with emergency services or medical health care providers should a need arise. Also note that in certain calling areas outside of the wireless area code, 911 calls are routed back to the originating service area code, which does no good in an emergency situation. Cell phone reception and connectivity should be routinely assessed. Walkie-talkies are also useful when practices or games occur at several different facilities simultaneously. These devices can greatly enhance communication capabilities. It may be necessary to at least have access to a land line just in case wireless service is disrupted.

Budgetary Concerns A seemingly ongoing problem that athletic trainers face is to obtain a budget of sufficient size to permit them to 46

Part One ■ Professional Development and Responsibilities

perform an adequate job of providing athletic health care.39 Most secondary schools provide only limited budgetary provisions for athletic trainA major problem facing many athletic trainers is a budget of ing, except for the insufficient size. purchase of tape, ankle wraps, and an athletic training kit that contains a minimum amount of supplies.7 Many fail to provide a room and any of the special facilities that are needed to establish an effective athletic training program. Some school boards and administrators fail to recognize that the functions performed in the athletic training clinic are an essential component of the athletic program.7 Colleges and universities face similar problems, but not to the extent of secondary schools. By and large, athletic training at the college level is recognized as an important aspect of the athletic program. Budgetary needs vary considerably within programs; some require only a few thousand dollars, whereas others spend hundreds of thousands of dollars. The amount spent on building and equipping an athletic training clinic, of course, is entirely a matter of local option. In purchasing equipment, immediate needs and the availability of personnel to operate specialized equipment should be kept in mind. Budgeting should be a continuous process involving prioritizing, planning, documenting, and evaluating the goals of the athletic training program and formulating a plan for how available resources can be utilized and expended during the next budget period.42 Budget records should be kept on file, so that they are available for use in projecting the following year’s budgetary needs. The records present a picture of the distribution of current funds and substantiate future budgetary requests. Supplies The supplies that the athletic trainer uses to carry out daily tasks may be classified as either expendable or nonexpendable. Some athletic trainers spend much of their budget on exSupplies may be expendable or pendable supplies, nonexpendable. which cannot be reused. Supplies that are expendable are used for injury prevention, first aid, and management. Examples of expendable supplies are adhesive tape, adhesive bandages, and hydrogen peroxide. Nonexpendable supplies are those that can be reused. Examples are compression wraps, scissors, and neoprene sleeves. An annual inventory must be conducted at the end of the year or before supplies are ordered. Accurate records must be kept to justify future requests. Equipment The term equipment refers to items that may be used in the athletic training clinic for a number of years. Equipment may be further divided into nonconsumable

capital and capital equipment. Nonconsumable capital equipment is not usually removed from the athletic training clinic. Examples of nonEquipment may be consumable capinonconsumable capital or capital. tal equipment are ice machines, treatment tables, isokinetic machines, and electrical therapeutic modalities. Capital equipment includes crutches, coolers, and athletic training kits.

2–1 Clinical Application Exercise

Purchasing Systems The purchase of supplies and equipment must be done through either direct buy or competitive bid. For expensive purchases, an institutional purchasing agent Purchasing may be done through is sent out to comdirect buy or competitive bid. peting vendors, who quote a price on specified supplies or equipment. Orders are generally placed with the lowest bidder. Smaller purchases and emergency purchases may be made directly from a single vendor.7 An alternative to purchasing expensive equipment is to lease it. Many manufacturers and distributors are willing to lease equipment on a monthly or yearly basis. Over the long run, purchasing equipment is less costly. In the short term, however, if a large capital expenditure is not possible, a leasing agreement should be considered.42 Additional Budget Considerations In addition to supplies and equipment, the athletic trainer must also consider other costs included in the operation of an athletic training program; these include telephone and The principal at Allpostage, program. These American High School include utilities, contracts has received a mandate with physicians or clinics from the school board to for services, professional develop a risk management plan for the athletic liability insurance, memprogram. The principal asks berships in professional the athletic trainer to chair organizations, profesa committee to develop sional journals or textthis plan. books, travel and expenses for attending professional What considerations are important for inclusion in meetings, and clothing this risk management plan? to be worn in the athletic training clinic.42,44

Developing a Risk Management Plan The athletic trainer, working in conjunction with the appropriate administrative personnel, must be responsible for developing a risk management plan that covers security issues, fire safety, electrical and equipment safety, and emergency action plans.3,4,14,17,51,52 Security Issues The athletic trainer must decide who will have access to the athletic training clinic. In addition

to the staff athletic trainers, the team physician must have keys to access the athletic training clinic. Graduate assistant athletic training students may also be given keys as necessary at the collegiate level; at the secondary-school level, however, athletic training students should be in the athletic training clinic only when directly supervised. At the collegiate level, coaches do not need to have access to the athletic training clinic; however, at the secondaryschool level, coaches might need to have a key to get into the clinic at times when the athletic trainer is not available. Access to areas of the building other than the athletic training clinic should be strictly limited. Fire Safety The athletic trainer should establish and clearly post a plan for evacuating the athletic training clinic, should a fire occur. Smoke detectors and fire alarm systems must be tested periodically and inspected to make certain that they are functioning normally. Electrical Equipment Safety Electrical safety in the athletic training setting should be of primary concern to the athletic trainer. Accidents can be avoided by taking some basic precautions and acquiring some understanding of the power distribution system and electrical grounds. Focus Box 2–2: “Safety when using electrical equipment” lists considerations for electrical safety. Emergency Action Plan In cooperation with existing community-based emergency health care delivery systems, the athletic trainer should develop a systematic plan for accessing the emergency medical system and subsequent transportation of injured athletes to an emergency care facility.5 Meetings should be scheduled periodically with EMTs or paramedics who work in the community to make certain that they understand the role of the athletic trainer as a provider of emergency health care.23 It is important to communicate the special considerations for dealing with athletic equipment issues before an emergency arises. Chapter 12 discusses the emergency action plan in detail. Crisis Management Plan Crisis management must be a central component of an institution’s risk management program. It is unfortunate that a climate currently exists in the United States in which educational institutions can be affected either directly or indirectly at any moment by some type of crisis situation. A crisis could be caused by weather, public health, or act of terror emergencies. Crisis management involves knowing how to respond to a crisis situation quickly and efficiently to protect and ensure the health, safety, and well-being of all those who might inadvertently become victims of the crisis. Everyone at that institution must know exactly what needs to be done immediately to mitigate the threat of injury to specific individuals and the general population. Administrators, health care providers, and community-based emergency management and public safety personnel

Chapter Two ■ Health Care Organization and Administration in Athletic Training

FOCUS 2–2 Focus on Injury/Illness Prevention and Wellness Promotion Safety when using electrical equipment • The entire electrical system of the building or athletic training clinic should be designed or evaluated by a qualified electrician. • Problems with the electrical system may exist in older buildings or in situations in which rooms have been modified to accommodate therapeutic devices (e.g., putting a whirlpool in a locker room in which the concrete floor is always wet or damp). • It should not be assumed that all three-pronged wall outlets are grounded. The ground must be checked. Ground fault interrupters (GFIs) should be installed, particularly in those areas in which water and electricity are used together (e.g., whirlpools, hydrocollator, electric stimulation). • The athletic trainer should become very familiar with the equipment being used and with any problems that exist or may develop.

must collectively be involved in the planning and documentation of specifically how all parties should act and react in a crisis situation.

2–2 Clinical Application Exercise

Accessing Community-Based Health Services In addition to the community-based emergency medical services personnel, the athletic trainer should become familiar with existing local and regional community health services and agencies that may be accessed, should a need arise to refer an State University has an athlete for psychologiopening for an assistant cal or sociological serathletic trainer in its Department of Athletics. vices. Referrals should The athletic director has be made with input and asked the head athletic assistance from the team trainer to be in charge physician. The family of of the recruitment and an athlete requiring referhiring process for the new ral for psychological or position. sociological counseling What factors must be must be informed of the considered in hiring a new existing problems, paremployee? ticularly when the athlete is a minor.

Human Resources and Personnel Issues Putting together the appropriate personnel to accomplish program goals and objectives is critical to success. Any program is only as good as the group of individuals who make up the team. Recruiting, hiring, and retaining the 48

Part One ■ Professional Development and Responsibilities

• Any defective equipment should be labeled and removed immediately from the clinic. • The plug should not be jerked out of the wall by pulling on the cable. • Extension cords or multiple adapters should never be used. • Equipment should be reevaluated on a yearly basis and should conform to National Electrical Code guidelines. A clinic that is not in compliance with this code has no legal protection in a lawsuit. • Common sense should always be exercised when using electrotherapeutic devices. A situation that appears to be potentially dangerous may, in fact, result in injury or death.

most qualified personnel is essential if the athletic training program is to be effective.22 • Specific policies dealing with recruitment, hiring and firing, performance evaluations, and promotions are mandated by federal law (Equal Employment Opportunity Commission). The policies for recruitment and hiring clearly mandate that all qualified applicants should receive equal consideration regardless of their race, gender, sexual preference, religion, or nationality. Athletic trainers who are in a position to hire new staff must strictly adhere to these mandates.24 • Once an individual has been hired, it is important for everyone to understand what his or her roles and responsibilities are. Individual job descriptions and job specifications that describe qualifications, accountability, a code of conduct, and the scope of that position should be written. A well-defined organizational chart should be created to show the chain of command.44 • The head athletic trainer must serve as a supervisor for the staff assistants, graduate students, and undergraduate athletic training students.30 The supervisor should strive to improve the job performance and enhance the professional development of those being supervised. Focus Box 2–3: “Models of supervision for the head athletic trainer” defines supervisory models.44 • Performance evaluations should be done at regularly scheduled intervals to analyze the quality of the work being performed. Evaluations should focus first on the positive aspects of job performance and then on any weaknesses.30

Focus 2–3 Focus on Healthcare Administration and Professional Responsibilities Models of supervision for the head athletic trainer*

Each of these policies relative to personnel issues should be included in the policies and procedures manual.

Designing an Athletic Training Clinic Maximizing the use of facilities and effectively using equipment and supplies are essential to the function of any athletic program.43 The athletic training clinic must be designed to meet the many requirements of the athletic training program (Figure 2–1).11,37,46 The size and layout of the athletic The athletic training clinic training clinic is a multipurpose area used will depend on for first aid, therapy and the scope of the rehabilitation, injury prevention, medical procedures (such athletic training as preparticipation physical program, includexaminations), and athletic ing the size and training administration. number of teams and athletes and what sports are offered.40 The hospital/clinical setting has a much broader patient population than a secondary-school or university athletic training clinic, and thus the requirements for equipment and supplies are somewhat different.37 To accommodate the various functions of an athletic training program, the athletic training clinic must serve as a health care center for patients.11 Size The size of the athletic training clinic can range anywhere from a large storage closet in some secondary schools to 15,000 + square-foot (1,394 sq.m) sports medicine complexes in some universities. Certainly, the size of the clinic can have a major impact on how the athletic training program is managed. But the most important consideration is to organize the athletic training program in a manner that most efficiently takes advantage of the space available. When designing a new athletic training

Inspection production supervision—An authoritative management style in which the head athletic trainer demands that lines of authority be strictly maintained to accomplish the stated goals of the athletic training program *These models should not be confused with the models of clinical supervision established by the Education Council for Students.

clinic, the athletic trainer should work closely with design architects to communicate the specific needs of the institution and the number of athletes who will be served.45

The members of the school board at AllAmerican High School voted to allocate $25,000 to renovate a 25’ × 40’ storage space and to purchase new equipment for an athletic training clinic. The athletic trainer has been asked to provide the school principal with a wish list of what should be included in this facility. The physical renovation will cost approximately $17,000.

Location The athletic train ing clinic should have an outside entrance from the athletic field or court. It should also have direct access to courts and fields to provide practice and game setup as well. This arrange How can this space be ment makes it unnecessary best used, and what type to take injured athletes in of equipment should be through the building and purchased to maximize possibly through several the effectiveness of the new facility? doors; it also permits access when the rest of the building is not in use. All entrances must be ADA handicapped accessible. A double door at each entrance is preferable to allow easy passage of a wheelchair or a stretcher. A ramp at the outside entrance is safer and far more functional than are stairs. The athletic training clinic should be near the locker rooms if possible, so that showers are readily available to athletes/patients going in for treatment following practice. Toilet facilities should be located adjacent to the athletic training clinic and should be readily accessible through a door in the athletic training clinic. Because the athletic training clinic is where emergency treatment is given, its light, heat, and water sources should be independent from those for the rest of the building.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

2–3 Clinical Application Exercise

Clinical supervision—Involves direct observation of the assistant athletic trainers in the performance of their written job responsibilities, followed by an analysis of strengths and weaknesses and a collaborative effort to correct weaknesses Developmental supervision—A mentoring approach in which the head athletic trainer works in a collaborative manner with the assistants, helping them develop professionally while meeting the needs of the day-to-day athletic training program

Stool

Storage Shelf

Treatment Table

Door to Locker Rms. & Lavatories

Sink

Stool

Ice Machine

Hydrocollator (Traction) Table

Laundry

EMS

Refrig.

Hydrotherapy

Supplies

Towels

Treatment Table

Ultrasound

Book Shelf

Storage Closet

Office

Wall is 1/2 Brick, 1/2 Glass

Evaluation Table

Supplies

Taping Table #4

Evaluation Table

File Cabinets

EMS

Taping Table #5

Evaluation Table Office Walls are 1/2 Brick, 1/2 Glass

Treatment Table

Paraffin Bath

Intermittent Compression

Treatment Table

Desk

Isokinetic

Mirror on Wall

Stair Elliptical Climber Machine

Book Shelf

Stationary Bicycles

Taping Table #6

Walls are 1/2 Brick, 1/2 Glass

Electrotherapy Area

Ultrasound

Supplies

Sink

Cold Packs

Treatment Table

Door to Storeroom

Tile Floor

Treatment Area

Mobile Traction Unit Treatment Table

Storage Cabinets Above & Below Taping Counter

Desk

Storage

Physician’s Examining Room

Storage Shelf

Treatment Table

Storage Shelf

Sink Refrig. Treatment Table

Computer

Sink

Matted Floor Sink

Desk

Double Wall Pulleys

First-Aid Counter Rehabilitation Area

Dumbbells and Band Weight Rack

Weight Rack

Incline Board

Weight Scale

Outside Entrance Double Doors

Computer Table Records Area

Low Files

Ankle Board

Swiss Ball Rack

Counter

Exercise Table

Taping Table #3

Supplies

Taping Table #2

Supplies

Taping Table #1

Rehabilitation Area

Exercise Tubing

Supplies

Waiting Area

Table

Chairs

2 Wrap Rollers on Wall

Supplies

FIGURE 2–1 The ideal athletic training clinic should be well designed to maximize its use. A, Larger athletic training clinic at a college or university. © William E. Prentice

Illumination The athletic training clinic should be well lighted throughout. Lighting should be planned with the advice of a technical lighting engineer. Obviously, certain areas need to be better lit than others. For example, the wound care, taping, evacuation, and treatment areas need better lighting than is necessary in the rehabilitation area. Ceilings and walls act as reflective surfaces to help provide an equitable distribution and balance of light. Natural lighting through windows or skylights can be helpful. Special Service Areas Apart from the storage and office space, a portion of the athletic training clinic should be divided into special sections, preferably by half walls or partial glass walls. Space, however, may not permit a separate area for each service section, and an overlapping of functions may be required. Treatment Area The treatment area should include a number of treatment tables, preferably of adjustable height, that can be used during the application of therapeutic modalities. Adjustable stools on rollers should also be readily 50

Part One ■ Professional Development and Responsibilities

Continued available. The hydrocollator unit and ice bags should be easily accessible to this area. Electrotherapy Area The electrotherapy area is used for treatment by ultrasound, diathermy, or electrical stimulating units. Equipment should include treatment tables, wooden chairs, dispensing tables for holding supplies, shelves, and a storage cabinet for supplies and equipment. The area should contain a sufficient number of grounded outlets, preferably in the walls and several feet above the floor. It is advisable to place rubber mats or runners on each side of the treatment tables as a precautionary measure. This area must be under supervision at all times, and cabinets used for storage of equipment and supplies should be kept locked when not in use. Hydrotherapy Area In the hydrotherapy area, the floor should slope toward a centrally located drain to prevent standing water. Equipment may include whirlpool baths (one permitting complete immersion of the body), several lavatories, and storage shelves. Because some of this equipment is electrically operated, many precautions

Exit to storage area WP

Ice machine

Hydrotherapy area Treatment table

Ultrasound

Exercise bike

(Area tiled with splash wall)

Treatment table Treatment area

Hot packs

1/2 Wall

Treatment table

Weight rack

Rehabilitation area

Can be closed off with curtain for private treatment area

EMS Treatment table

Surgical tubing

Ref.

Wall pulleys

Exit to men’s and women’s lockers 1/2 Wall 1/2 Glass

Towels/ laundry

Office

Taping area Bench with supplies underneath Entrance

FIGURE 2–1 continued, B. Small athletic training clinic at a secondary-school. © William E. Prentice

must be taken. All electrical outlets should be placed 4 to 5 feet (1.2 to 1.5 m) above the floor and should have spring-locked covers and water spray deflectors. All cords and wires must be kept clear of the floor to eliminate any possibility of electrical shock. To prevent water from entering the other areas, glass should be used to separate the hydrotherapy area from the rest of the clinic due to noise, heat, humidity while still allowing visibility. When an athletic training clinic is planned, ample outlets must be provided; under no circumstances should two or more devices be operated from the same outlet. All outlets must be properly grounded using ground fault interrupters (GFIs).36 Rehabilitation and Reconditioning Area Ideally, an athletic training clinic should accommodate injury reconditioning under the strict supervision of the athletic trainer. Selected pieces of resistance equipment should be made available. Depending on the existing space, dumbbells and free weights; exercise machines for knee, ankle, shoulder, hip, and so forth; isokinetic equipment; devices for balance and proprioception; and space for using resistance bands may all be available for use. Taping, Bandaging, and Orthotics Area Each athletic training clinic should provide a place in which taping,

bandaging, and applying orthotic devices can be executed. This area should have taping tables, a sink, and a storage cabinet. Physician’s Examination Room In most clinics, colleges and universities, the team physician/medical director has a room in which examinations and treatments may be given. This room contains an examining table, a sink, locking storage cabinets for medications and supplies, and a small desk with a desktop computer. At all times, this clinic must be kept locked to outsiders. Storage Facilities Many athletic training clinics lack ample storage space. Often, storage facilities are located a considerable distance away, which is extremely inconvenient. In addition to the storage It is essential to have adequate cabinets and storage space available for supplies and equipment. shelves provided in each of the three special service areas, a small storage closet should be placed in the athletic trainer’s office. All these cabinets should be used for the storage of general supplies as well as for the small, specialized equipment used in the respective areas. A large storage area is a necessity for the storage of bulky equipment, medical supplies, adhesive tape,

Chapter Two ■ Health Care Organization and Administration in Athletic Training

2–4 Clinical Application Exercise

bandages, and protective devices (Figure 2–2). A refrigerator for the storage of frozen water in paper cups for ice massage and other necessities is also an important piece of equipment. In small sports programs, a large refrigerator is probably sufficient for How should the athletic all ice needs. If at all trainer deal with this possible, an ice-making request? machine should be installed in an auxiliary area to provide an ample and continuous supply of ice for treatment purposes. There should also be storage spaces provided for patients in which to place their belongings (e.g., book bags, clothes) while they are being treated. A clinical athletic trainer is approached by the community recreation department with a request to use the clinic to treat its communitybased recreational football and basketball league participants who are injured.

Athletic Trainer’s Office A space at least 10 feet by 10 feet (3 by 3 m) is ample for the athletic trainer’s office. The office should be located so that all areas of the athletic training clinic can be well supervised without the athletic trainer having to leave the office. Glass partitions on two sides permit the athletic trainer to observe all activities even while seated at the desk. A desk, desktop computers, a tackboard for clippings and other information, telephones, and a record file are the basic equipment. The office should have an independent lock-and-key system so that it is accessible only to authorized personnel. Additional Areas If space is available, several other areas could be included as part of an athletic training clinic. Pharmacy Area A separate room that can be secured for storing and administering medications is helpful. All medications, including over-the-counter drugs, should be kept under lock and key. If prescription medications are kept in the athletic training clinic, only the team physician

or pharmacist from a campus health center should have access to the storage cabinet. Records for administering medications to patients should be kept in this area. It is essential to adhere to state regulations regarding the storage and administration of medications (see Chapter 17). Rehabilitation Pool If the clinic has the space and the institution can afford one, a pool can be an extremely useful rehabilitation tool. The pool should be accessible to individuals with various types of injuries. It should have a graduated depth to at least 7feet (2.1m), the deck should have a nonslip surface, and the filter system should be in a separate room.42 Restrooms There should be at least one restroom available in the athletic training clinic. Requirements for the number of restrooms are usually dictated by the building code occupancy limits assigned to that facility.

ISSUES SPECIFIC TO ATHLETIC TRAINING PROGRAM OPERATION IN THE CLINIC, HOSPITAL, CORPORATE, OR INDUSTRIAL SETTING As is the case for those working in secondary schools and colleges or universities, athletic trainers working in clinical, hospital, corporate, and industrial settings must be competent in preventing and recognizing injuries and supervising injury rehabilitation programs. However, staff athletic trainers working in these settings treat and rehabilitate a wider range of patients in terms of age and physical condition. The athletic trainer may provide care to pediatric, adolescent, young adult, adult, and geriatric patients. The patients have physical ailments that may or may not be related to physical activity. In addition, athletic trainers who work in clinical, corporate, or industrial facilities may find themselves in the role of an entrepreneur who owns a clinic facility or practice; an administrator who oversees the day-to-day operations; a marketing director; or a community outreach coordinator. They must also be knowledgeable regarding administrative and management skills, marketing, fiscal responsibilities, reimbursement, documentation, and outcomes assessment.30

Scope of Practice

FIGURE 2–2 An effective athletic training program must

have appropriate storage facilities that are highly organized. Courtesy Hausmann Industries 52

Part One ■ Professional Development and Responsibilities

Athletic trainers who work in a clinic, hospital, or ambulatory care center will likely see a patient population that is diverse not only in age but also in the variety of injuries, illnesses, and conditions. Athletic trainers in hospitals may be involved in inpatient, outpatient, or ambulatory care. For the most part, the owner of an outpatient clinic or its chief administrator will dictate the patient population that the clinic will treat (i.e., orthopedic, sports, occupational, cardiac, etc.). Athletic trainers working

FOCUS 2–4 Focus on Healthcare Administration and Professional Responsibilities Additional certifications for athletic trainers working in a clinic or hospital Certification

Association/Organization

Orthopedic technologist (OT) Orthotics and prosthetics (ABC)

National Association of Orthopedic Technologists American Board for Certification in Orthotics and Prosthetics Association of Surgical Technologists Board of Certification for Professional Ergonomists National Strength and Conditioning Association National Academy of Sports Medicine National Academy of Sports Medicine Association of Clinical Research Professionals

Certified surgical technologist (CST) Certified professional ergonomist (CPE) Certified strength and conditioning specialist (CSCS) Performance enhancement specialist (PES) Corrective exercise specialist (CES) Certified clinical research associate (CRA)

in either a privately owned clinic or a corporate/industrial setting may be involved in individual patient care, working in on-site employee fitness centers, working in ergonomic and occupational work hardening safety programs, supervising employee drug-testing programs, overseeing wellness programs, or overseeing and engaging in outreach programs and athletic event coverage, which essentially helps market the clinic to the community. Regardless of the setting, limitations and restrictions on what an athletic trainer can do and who can be treated are in large part determined by the regulatory statutes governing professional practice in individual states. It is the responsibility of both the administrator and the athletic trainer to know the limits of practice. Location of the Clinic Because most privately owned clinics are in business to make a profit, it is essential to build a patient base. Certainly, the location of the facility is a key to attracting patients and making it a successful business.37 Several other factors may determine whether the chosen location is good: • What are the zoning laws in the area? • Is there any type of traffic problem that would create an accessibility issue for potential patients? • Are there doctors in the area who will refer patients to this clinic? • Will these doctors use an athletic trainer to treat their patients? • Are there businesses in the area for which this clinic could provide industrial rehabilitation or on-site workplace assessment? • Are there schools in the area that could use sports medicine coverage by an athletic trainer? • Are there any other clinics or hospitals that provide similar services that may directly or indirectly compete with the new business?

Hours of Operation To most effectively meet the scheduling needs of potential patients, the clinic must be open at times that do not conflict with normal school or work hours. This means that the clinic must be open early in the morning and remain open at least into the early evening, so patients can get to the facility either before or immediately after school or work. Also, it is important to maintain hours of operation at least one day over the weekend.37

Clinic Personnel and Human Resources Issues The athletic trainer must work with a number of different health care providers in the clinical or corporate setting, including physicians, physician’s assistants, physical therapists, physical therapy assistants, occupational therapists, occupational therapy assistants, nutritionists, and nurses. Additionally, if the clinic is in a hospital, respiratory therapists, speech therapists, recreational therapists, and pharmacists may also be involved in patient care. Each of these individuals should have a formal, specific job description developed by human resources personnel. The most effective treatment models seem to involve a team approach and require communication and cooperation on the part of all involved in providing some aspect of health care. Athletic trainers who work in a clinical or hospital setting may seek additional certifications that can expand the scope of their roles and responsibilities. Focus Box 2–4: “Additional certifications for athletic trainers working in a clinic or hospital” lists those certifications.

Potential Athletic Training Duties Ergonomic Assessment Ergonomics is the science of designing products, machines, and systems to maximize the comfort, efficiency, and safety of the people who use them.56 Ergonomics is based on the principles of

Chapter Two ■ Health Care Organization and Administration in Athletic Training

anthropometry (the science of human measurement) and biomechanics (the study of muscular activity) applied to industrial engineering to adapt or alter the design of products and workplaces to an individual’s physical strengths, limitations, size, and shape. One of the primary goals of ergonomics is the prevention of accidents and injuries in the workplace by attempting to minimize risk factors, such as repetition, vibration, force, and awkward/static postures as they relate to musculoskeletal disorders.56 Ergonomists work to eliminate these problems by designing workplaces, such as assembly lines, computer workstations and to prevent injuries. They position machinery and tools to be accessible without twisting, reaching, or bending. They design adjustable desks, chairs, and workbenches to comfortably accommodate workers of many different sizes, preventing the need to continuously lean or overextend the arms. An athletic trainer may work with an occupational therapist or an ergonomist to provide an ergonomic assessment, an evaluation of a workstation and the physical environment and its interaction with the employee.50 This assessment involves not only adjusting and making recommendations regarding the employee’s workstation but also providing instruction on injury prevention techniques, including suitable stretches, strengthening exercises, and suggested rest breaks. An ergonomic assessment report outlines the results of the assessment and is forwarded to the injured employee, workplace manager or administrator, medical practitioner, and other involved parties.56 A follow-up review may be conducted to ensure that the recommendations have been implemented (Figure 2–3). Work Hardening/Conditioning Programs Athletic trainers may supervise or participate in work hardening or conditioning programs that involve intensive outpatient

therapy for individuals injured on the job. The goal is to regain functionality and return to work in a full-duty capacity. The starting point for these patients is a musculoskeletal evaluation of their strength, posture, flexibility, gait, sensation, and reflexes.50 This is followed by a functional capacity evaluation to determine skill deficits as measured against physical job requirements. The following skills may be evaluated in a functional capacity evaluation:50 • • • • • • • • • •

Tolerance for prolonged sitting and standing Hand grip strength and coordination Repetitive lifting capacity at various levels Repetitive push, pull, and carrying capacities Lifting biomechanics and proper postures/mechanics in the workplace Repetitive squat Prolonged trunk flexion or rotation in sitting and standing Prolonged crawling, kneeling, and crouch positions Maximum walking, stairs, and stepladder capacity Balance

The athletic trainer then discusses the results and recommendations of these evaluations with the patient. This collective information is used to develop a rehabilitation plan to allow the patient to return to work at the appropriate level of performance. Work conditioning refers to intensive rehabilitation offered 3 hours a day for 3 days a week, whereas work hardening refers to intensive therapy offered 8 hours a day for 5 days a week. Treatments may involve simulated work, education about avoiding reinjury, and job site analysis to assist the employer in making appropriate equipment modifications for an employee returning to work after an injury (Figure 2–4). Wellness Center Athletic trainers may supervise a wellness center and assume responsibility for organizing wellness screenings, workshops, and employee health

FIGURE 2–3 Ergonomic assessment.

FIGURE 2–4 Work hardening.

Part One ■ Professional Development and Responsibilities

fairs. Worksite health screenings may be offered for asthma, hypertension, diabetes, cholesterol, osteoporosis, prostate cancer, skin cancer, glaucoma, weight loss, smoking cessation, and stroke. Early detection can save both the employees and a company the emotional and financial costs of medical conditions that have advanced because they went undetected. Results may be given directly to employees or sent to their homes with a detailed explanation. Wellness workshops raise employees’ awareness about their health, help them understand their susceptibility to disease, and motivate them to seek medical consultation or make important changes that will reduce their risks and enhance the quality of their lives. Workshop topics might include nutrition, men’s health, women’s health, skin care, fitness and exercise, family and personal development, and workplace health and safety. Health fairs are an effective and enjoyable means of educating employees about various health issues. In addition to offering multiple screening services at various booths, employees can obtain health education materials at information tables while learning from and interacting with health professionals. Community Outreach and Marketing When employed by some clinics or a hospital, athletic trainers may see patients or have other in-house responsibilities during part of the day. But in the afternoons or evenings they may be assigned to provide athletic training coverage for an athletic program at a local secondary school or college. They may also cover single athletic events in the community. These outreach programs not only provide a valuable service to athletes in the community but also serve as an effective marketing tool to promote and advertise the clinic. This marketing strategy helps provide visibility for the clinic to physicians, other health care providers, parents, and other schools at all levels, as well as other potential patients from throughout the community. Corporate Fitness Programs Athletic trainers working in corporate settings are commonly charged with the responsibility of overseeing in-house employee fitness programs.32 Physical fitness offers a variety of proven health benefits, including a decreased risk of heart disease and heart attack. Physically fit employees can also handle physical work tasks better and deal with stressful situations more easily, and they tend to be less susceptible to illness and injuries. Corporations offer fitness programs to their employees to reduce health costs, increase productivity, reduce absenteeism, decrease turnover, improve morale, lower health care expenditures, and reduce sick leave (Figure 2–5). After an initial consultation, the athletic trainer administers fitness evaluations for all participating employees to determine their baseline fitness levels for

FIGURE 2–5 A corporate fitness program. © Erik Isakson/Blend Images LLC

cardiorespiratory endurance, body composition, flexibility, muscle strength, and endurance. Based on information from the initial consultation and fitness evaluation, an individual exercise prescription may be developed for each participating employee. Typical exercise sessions may include warm-up activities, aerobic conditioning, strength training, flexibility exercises, and cool-down. Training sessions should teach safe, effective exercise techniques and educate employees on training intensity, frequency, and progression to maximize results and reduce injuries. By following these guidelines, employees can meet their fitness goals, while the corporation benefits from a healthier workforce.34 Drug-Testing Programs An athletic trainer working in a corporate or a clinic setting may be asked to oversee a drug-testing program for employees. A drug-testing program can deter employees from coming to work unfit for duty. It also discourages drug abusers from applying to a company in the first place. A corporation may require a full-service testing program to comply with federal requirements or a simple preemployment screening program. Legal defensibility is the most important aspect of any drug-testing program. The corporation should use federally certified laboratories and confirm and verify all positive results through a medical review department.

Fiscal Management When an athletic trainer is employed by a for-profit business, such as a clinic or a hospital, he or she must have some understanding of basic business practices and fiscal management.44 Certainly, if the athletic trainer is an administrator or an owner of a clinic, it is even more critical to understand how to run a profitable business.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

FOCUS 2–5 Focus on Healthcare Administration and Professional Responsibilities Information contained in medical records Medical History Family history Social history Habits Immunization history Growth chart and developmental history Substance abuse inquiry Surgical history Obstetric history

For the most part in the health care industry, businesses rely on billing a patient’s insurance company and being reimbursed for services provided to that patient. Third-party reimbursement and issues with managed care are discussed in detail in Chapter 3. Maintaining a positive accounts payable to accounts receivable (AP/AR) ratio, in which more money is being collected than must be paid out in expenses, is the goal of every successful business. Other responsibilities include financial planning, which assesses the goals and objectives of the company; establishing contractual obligations with payors and providers; developing an efficient billing and collection system; formulating a budget, which requires the coordination of resources and expenditures; and deciding on expenditures for necessary equipment and supplies.

RECORD KEEPING For athletic trainers, as for all health care providers, keeping accurate, updated medical records is essential. Some athletic Keeping adequate records is trainers object to critical for any athletic trainer. keeping records and filling out forms, stating that they have neither the time nor the inclination to be bookkeepers. Nevertheless, because lawsuits are the rule rather than the exception, accurate and up-to-date records are an absolute necessity. Medical records are also critical for accurate and timely assessment and evaluation of practices and for documentation of practices and activities to ensure that responsibilities and expectations are being met. Focus Box2–5 lists the type of information usually found in standard medical records. Medical records, injury reports, treatment logs, personal information cards, injury evaluations and progress notes, supply and equipment inventories, and annual 56

Part One ■ Professional Development and Responsibilities

Medical Encounters Chief complaint History of the present illness Complete physical examination Assessment and plan Orders and Prescriptions Progress Notes Results of Previous Diagnostic Tests

reports are essential records that should be maintained by the athletic trainer.

Electronic Versus Paper Medical Records An electronic health record (EHR) or electronic medical record (EMR) is a digital version of the paper records used in the past, which contains all of a patient’s medical history; medications and allergies; immunizations; lab test results; images; vital signs; demographics, such as age, height, weight, and other relevant data; and insurance and billing information. EMRs can be easily shared among different health care providers. An EHR provides a long-term collection of an individual’s health care information, whereas an EMR is a patient record that is created and used for specific visits in a clinic, hospital, or physician’s office in an institution that can be accessed by health care providers within the institution. Electronic medical records can certainly simplify the process for any health care provider who may need to review a complete medical record for an individual patient between facilities. It seems fairly clear that using electronic medical records improves overall efficiency, reduces errors, and reduces costs. The downside to using electronic medical records is that the improved portability and accessibility creates security issues that threaten patient privacy.

Patient File Management Systems Effective management of patient records and supporting documents is a critical factor in the efficiency of operation an athletic training program. Optimally, athletic trainers should use some type of comprehensive patient-file management system for appropriate chart documentation, risk management, outcomes, and billing.

FOCUS 2–6 Focus on Healthcare Administration and Professional Responsibilities HIPAA authorization Following is a list of core elements that must be present for a disclosure authorization to be valid: • A description of the information to be used or disclosed • Identification of the persons or class of persons authorized to make use of or disclosure of the protected health information • Identification of the persons or class of persons to whom the covered entity is authorized to provide or disclose information

Maintaining Confidentiality in Record Keeping Release of Medical Records The athletic trainer may not release a patient’s medical records to anyone without written consent. If the patient/athlete wishes to have medical records released to professional sports organizations, insurance companies, the news media, or any other group or individual, the athlete must sign a waiver that specifies which information is to be released. The only exception to this is the appropriate disclosure of information among those professionals who are involved in providing health care to the injured individual. Health Insurance Portability and Accountability Act (HIPAA) The Health Insurance Portability and Accountability Act (HIPAA) regulates how athletic trainers, physicians, administrators, and other allied health personnel with private health information (PHI) about patients can share that information with others.26 The regulation guarantees that patients have access to their medical records, gives them more control over how their protected health information is used and disclosed, and provides a clear avenue of recourse if their medical privacy is compromised.31 Authorization by a patient to release medical information is not necessary on a per-injury basis.25 A written blanket authorization signed by the patient at the beginning of the year will suffice for all injuries and treatments during the course of participation for that year. These one-time, blanket authorizations must indicate what information may be released, to whom, and for what length of time.25 Focus Box 2–6: “HIPAA authorization” is a list of core elements that must be present for the authorization to be valid. Family Educational Rights and Privacy Act (FERPA) The Family Educational Rights and Privacy Act (FERPA) protects the privacy of student educational records. It has been suggested that in some instances medical records should be kept along with a student’s educational records; thus, the

• A description of each purpose of the use or disclosure • An expiration date or event • The individual’s signature and date • If signed by a personal representative, a description of his or her authority to act for the individual

right to privacy of medical records would be protected under FERPA instead of HIPAA.26 FERPA gives parents certain rights with respect to their children’s educational records. These rights transfer to the student when he or she reaches the age of 18 or attends a school beyond the secondary-school level. Students to whom the rights have been transferred are “eligible students.” Parents and eligible students have the right to inspect and review the student’s educational records maintained by the school. Parents and eligible students have the right to request that a school correct records that they believe to be inaccurate or misleading. Schools must have written permission from the parent or eligible student to release any information from a student’s educational records.

Preparticipation Examinations (PPE) The first piece of information that the athletic trainer should collect on each athlete is obtained from an initial preparticipation examination bePreparticipation health examination: fore the start of practice.29 The pri• Medical history mary purpose of • Physical examination the preparticipation • Cardiovascular screening exam is to identify • Maturity assessment an athlete who may • Orthopedic screening • Wellness screening be at risk before he or she participates in a specific sport.1 It also allows comparisons from one year to the next with regard to growth and development, weight gain/loss, and the like. The preparticipation examination should consist of a medical history, and a physical examination, which includes a cardiovascular screening, orthopedic screening, general medical screening, neurologic screening (only if warranted), and, a wellness screening.41 In addition, if the athlete indicates a history of concussion on the medical history form, a thorough neurologic assessment should be done to rule out other neurologic conditions such

Chapter Two ■ Health Care Organization and Administration in Athletic Training

2–5 Clinical Application Exercise

A sports medicine clinic has agreed to organize and conduct preparticipation exams for All-American High School, which offers 18 sports—6 in the fall, 6 in the winter, and 6 in the spring. There are a total of approximately 500 athletes, and approximately 200 of them are involved in the fall sports. The athletic trainer who works in the clinic is charged with arranging and administering preparticipation examinations so that each athlete can be cleared for competition.

? How can the athletic

trainer most efficiently set up the preparticipation exams to clear 200 athletes for competition in the fall sports?

as seizure disorder, cervical spine stenosis, or spinal cord injury.13 SoR:C Information obtained during this examination establishes a baseline to which comparisons may be made after injury. It may also reveal conditions that could warrant disqualification from certain sports.29 The examination also satisfies insurance and liability issues. The NATA has published a position statement “Preparticipation Physical Examinations and Disqualifying Conditions” (www.nata.org /sites/default/files/Conley .pdf) that provides guidelines for conducting preparticipation exams.

Medical History A comprehensive medical and family history form is perhaps the most important part of the preparticipation exam and should be completed before the physical examination and orthopedic screening. Its purpose is to identify any past or existing medical problems.1 And to identify any underlying condition that might predispose an athlete to injury.13 SoR:B For younger athletes it may be necessary to have input from parents to ensure the accuracy of the history. This form should be updated for each individual every year. Medical histories should be closely reviewed by both the physician and the athletic trainer with the athlete, so that personnel can be prepared, should a medical emergency arise.13 SoR:C Necessary participation release forms and insurance information should be collected along with the medical history (Figure 2–6).33 Physical Examination The physical examination should include an assessment of height, weight, body composition, blood pressure, and pulse rate. The general medical screening portion of the physical exam should include vision, musculoskeletal, skin, dental, ear, nose, throat, heart and lung function, abdomen, lymphatics, genitalia (males only), and maturation index. The use of routine laboratory tests such as urinalysis, complete blood count (CBC), lipid profile, ferritin level, and others may be included as part of the physical exam but is not necessary unless specific concerns arise from the medical history.13 SoR:B (Figure 2–7).33

Part One ■ Professional Development and Responsibilities

In 2010, the NCAA instituted mandatory testing for sickle cell trait for all athletes in Division I. Students are given a blood test to screen for the sickle cell trait prior to the first season that they are eligible to compete. Under the current rules, athletes can avoid testing by proving they have previously been tested or by signing a waiver releasing the NCAA and their university from liability. The NATA has published a consensus statement, “Sickle Cell Trait and the Athlete” (www.nata.org/sites/default /files/SickleCellTraitAndTheAthlete.pdf) that provides guidelines and precautions for modifying workouts in athletes with sickle cell trait. Cardiovascular Screening In 1996, the American Heart Association (AHA) published recommendations concerning the cardiovascular component of the preparticipation exam in competitive athletes.49 The Potentially lethal cardiovascular critical task of the conditions: preparticipation • Hypertrophic cardiomyopathy cardiac examina• Aortic stenosis tion is identifying • Marfan’s syndrome life-threatening conditions from specific questions regarding risk factors and symptoms of cardiovascular disease asked when obtaining the medical history.13 SoR:C Although the cardiac examination need not involve complex tests, it must permit the recognition of abnormal heart sounds, heart murmurs, and other signs of pathology through auscultation.13 SoR:C It has been suggested that an electrocardiogram (ECG) should be mandatory in the preparticipation screening of athletes.10 However, while there is a general consensus that an ECG would certainly increase the diagnostic accuracy of the screening exam, it is not currently considered to be costeffective in screening athletes. The vast majority of exams are negative, but the physician should be alert to such potentially lethal conditions as hypertrophic cardiomyopathy, aortic stenosis, and Marfan’s syndrome. A history of symptoms during exertion, certain features of physical appearance, and clinical findings require referral to a cardiologist.49 Cardiac testing using ECG or exercise stress testing is not a routine aspect of the PPE unless warranted by findings from the personal and family history.13 SoR:B Some physicians have advocated for the addition of an echocardiogram to the screening process even though an ECG is easier to administer and has a lower cost. Orthopedic Screening Orthopedic screening may be done as part of the physical examination or separately by the athletic trainer. A quick orthopedic screening exam is accurate in detecting existing musculoskeletal injuries usually takes about 90 seconds13 SoR:A (Figure2–8).1 A more detailed, site-specific orthopedic examination may

FIGURE 2–6 Sample medical history form.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

FIGURE 2–7 Sample physical examination form.

Part One ■ Professional Development and Responsibilities

Orthopedic Screening Examination Activity and Instruction Stand facing examiner Look at ceiling, floor, over both shoulders; touch ears to shoulders Shrug shoulders (examiner resists) Abduct shoulders 90º (examiner resists at 90º) Full external rotation of arms Flex and extend elbows Arms at sides, elbows 90º flexed; pronate and supinate wrists Spread fingers; make fist Tighten (contract) quadriceps; relax quadriceps “Duck walk” four steps (away from examiner with buttocks on heels) Stand with back to examiner Knees straight, touch toes Raise up on toes; raise heels

To Determine Acromioclavicular joints; general habitus Cervical spine motion Trapezius strength Deltoid strength Shoulder motion Elbow motion Elbow and wrist motion Hand or finger motion and deformities Symmetry and knee effusion; ankle effusion Hip, knee, and ankle motion Shoulder symmetry; scoliosis Scoliosis, hip motion, hamstring tightness Calf symmetry, leg strength

FIGURE 2–8 Orthopedic screening. Equipment that may be needed includes reflex hammer, tape measure, pin, and examining table.

be conducted to assess strength, range of motion, and stability at various joints (Figure 2–9). General Medical Screening In addition to a physical screening of the eyes, mouth, ear, nose, throat, thorax, abdomen, lymph nodes, urinary system, and skin, several additional assessments may be necessary. A maturity assessment should be part of the physical examination as a means of protecting the young, physically developing athlete.35 The most commonly used methods are circumpubertal (sexual maturity), skeletal, and dental assessments. Of the three, Tanner’s five stages of maturity assessment, indicating the maturity of secondary sexual characteristics, is the most expedient for use in the station method of examination.53 The Tanner approach evaluates pubic hair and genitalia development in boys and pubic hair and breast development in girls (Figure 2–10). Other indicators are facial and axillary hair. Stage 1 indicates that puberty is not evident, and stage 5 indicates full development. The crucial stage in terms of collision and high-intensity noncontact sports is stage 3, in which the fastest bone growth occurs. In this stage, the growth plates are two to five times weaker than the joint capsule and tendon attachments.34 Young athletes in grades 7 through 12 must be matched by maturity, not age.53 An assessment of all medications and dietary supplements currently being used by the athlete should be closely reviewed by the physician and athletic trainer. The athletic trainer should be able to provide the athlete with up-to-date information regard the use of dietary supplements (see Chapter 5).13 SoR:B Athletes who report feelings of depression, sadness, hopelessness, or stress on the medical history form

should be referred to mental health practitioners for more in-depth assessment when appropriate.13 SoR:C For those athletes who report a history of anemia, abnormal menstrual cycles, diabetes, asthma, elevated cholesterol or lipid levels, or other such symptoms will require additional laboratory tests and referral to a physician who specializes in that condition.13 SoR:C Wellness Screening Some preparticipation exams include a screening for wellness. The purpose is to determine whether the athlete is engaging in healthy lifestyle behaviors and should include questions about diet, rest, exercise, and weight control, as well as questions about lifestyle habits that pose a threat to wellness such as alcohol, drug, and tobacco use, and stress. A number of wellness screening tools are available. Figure 2–11 provides an example of a wellness screening questionnaire.

Health Maintenance and Personal Hygiene Screening

A screening tool for assessing the general principles of health maintenance and personal hygiene, should include questions about skin care, dental hygiene and dental care, sanitation, immunizations, avoiding infectious and contagious diseases, and sleep habits. Administering the Preparticipation Exam Currently a standardized and universally accepted process for administering a preparticipation exam (PPE) does not exist. It is recommended that a complete PPE be administered to all new athletes initially. Once an initial PPE has been administered, for subsequent seasons, at minimum, an update and review of the medical history should be conducted.13 SoR:C Ideally, the PPE should be administered 4 to 6 weeks before the preseason to allow time for proper

Chapter Two ■ Health Care Organization and Administration in Athletic Training

ORTHOPEDIC SCREENING FORM Name_________________________ID#_________________ Posture Normal Asymmetrical /Abnormal Comments ___________________________________________________________________________________ Head Tilt Shoulders Level Spinal Curves-Cervical Thoracic, Lumbar Scapular winging Pelvis, hips, knees, ankles level Leg length ............................................................................................................................................................................................................ Joint/Movement ROM Strength Shoulder: Normal Asymmetrical Comments Normal Asymmetrical Comments Abduction Adduction Extension Flexion Internal rotation External rotation Elbow: Flexion Extension Wrist: Flexion Extension Flexion Hip: Flexion Extension Internal Rotation External Rotation Adduction Abduction Knee: Flexion Extension Ankle: Dorsiflexion Plantar flexion Inversion Eversion Trunk: Flexion Extension Rotation Lateral flexion ___________________________________________________________________________________________ Joint Instability Comments Shoulder Elbow Hip Knee Ankle ___________________________________________________________________________________________ Evaluator’s Signature

Date

FIGURE 2–9 Sample of a detailed orthopedic screening form.

Part One ■ Professional Development and Responsibilities

Males Stage 1. No evidence of pubic hair. Stage 2. Slightly pigmented hair laterally at the base of the penis. Usually straight. Stage 3. Hair becomes darker and coarser, begins to curl, and spreads over the pubic region. Stage 4. Hair is adult in type but does not extend onto thighs. Stage 5. Hair extends onto the thighs and frequently up the linea alba. Females Stage 1. No evidence of pubic hair. Stage 2. Long, slightly pigmented, downy hair along the edges of the labia. Stage 3. Darker, coarser, slightly curled hair spread sparsely over the mons pubis. Stage 4. Adult type of hair but it does not extend onto thighs. Stage 5. Adult distribution, including spread along the medial aspects of the thighs.

FIGURE 2–10 Tanner’s five stages of maturity.53 1. Circle the appropriate response for each question. 2. Add the total number of points for each section. Almost Almost Always Sometimes Never

BEHAVIOR TOBACCO USE If you never smoke or use tobacco products, enter a score of 10 for this section and go to the next section on Alcohol and Drugs. 1. I avoid smoking cigarettes and chewing tobacco. 2. I smoke only low-tar and low-nicotine cigarettes, or I smoke a pipe or cigars. ALCOHOL AND DRUGS 1. I avoid drinking alcoholic beverages or I drink no more than one or two a day. 2. I avoid using alcohol or other drugs (especially illegal drugs) as a way of handling stressful situations or problems in my life. 3. I am careful not to drink alcohol when taking certain medicines (e.g., medicine for sleeping, pain, colds, and allergies) or when pregnant. 4. I read and follow the label directions when using prescribed and over-the-counter drugs.

2 2

1 1

0 0

Tobacco Use Score: 4

Alcohol and Drug Score: EATING HABITS 1. I eat a variety of foods each day, such as fruits 4 1 and vegetables, whole-grain breads and cereals, lean meats, dairy products, dry peas and beans, and nuts and seeds. 2. I limit my intake of fat, saturated fat, and 2 1 cholesterol (including fat in meats, eggs, butter and other dairy products, shortenings, and organ meats, such as liver). 3. I limit the amount of salt I eat by cooking with 2 1 only small amounts, not adding salt at the table, and avoiding salty snacks. 4. I avoid eating too much sugar (especially 2 1 frequent snacks of sticky candy or soft drinks). Eating Habits Score: EXERCISE/FITNESS HABITS 1. I maintain a desired weight, avoiding 3 1 overweight and underweight. 2. I do vigorous exercises for 15–30 minutes at 3 1 least three times a week (examples include running, swimming, and brisk walking). 3. I do exercises that enhance my muscle tone for 2 1 15–30 minutes at least three times a week (examples include yoga and calisthenics). 4. I use part of my leisure time participating in 2 1 individual, family, or team activities that increase my level of fitness (such as gardening, bowling, golf, and baseball).

Almost Almost Always Sometimes Never

STRESS CONTROL 1. I have a job or do other work that I enjoy. 2 1 2. I find it easy to relax and to express my feelings 2 1 freely. 3. I anticipate and prepare for events or situations 2 1 likely to be stressful for me. 4. I have close friends, relatives, or others with 2 1 whom I can discuss personal matters and call on for help when needed. 5. I participate in group activities (such as church 2 1 and community organizations) or hobbies that I enjoy. Stress Control Score: SAFETY 1. I wear a seat belt when riding in a car. 2 1 2. I avoid driving while under the influence of 2 1 alcohol and other drugs. 3. I obey traffic rules and the speed limit when 2 1 driving. 4. I am careful when using potentially harmful 2 1 products or substances (such as household cleaners, poisons, and electrical devices). 5. I avoid smoking in bed. 2 1 6. I am not sexually active or I have sex with only 2 1 one mutually faithful, uninfected partner, or I always engage in safe sex (using condoms), and I do not share needles to inject drugs. Safety Score:

0 0 0 0 0

0 0 0 0 0 0

WHAT YOUR SCORES MEAN Scores of 9 and 10: Excellent. Your answers show that you are aware of the importance of this area to your health. Scores of 6 to 8: Good. Your health practices in this area are good, but there is room for improvement. Scores of 3 to 5: Fair. Your health risks are showing. Scores of 0 to 2: Poor. Your answers show that you may be taking serious and unnecessary risks with your health. Perhaps you are not aware of the risks and what to do about them. You can easily get the information and help you need to improve, if you wish.

If you have questions or concerns, you should consult your athletic trainers for advice.

Exercise/Fitness Score:

FIGURE 2–11 Wellness screening questionnaire. Source: Modified from Health Style: A Self-Test, U.S. Department of Health and Human Services, Public Health Service, National Clearing House, Washington, DC.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

follow-up on any findings that cause concern. In some instances, the PPE may be administered on the same day or the day before preseason begins. However, this makes it difficult to make certain that all of the athletes are cleared to participate on the first day of practice.13 SoR:C The preparticipation exam may be effectively administered either on an individual basis by a personal physician, or it may be done using a station examination system with a team of examiners.13,54 SoR:C Examination by a personal physician has the advantage of yielding an in-depth history and an ideal physician–patient relationship. A disadvantage of this type of examination is that it may not be directed to the detection of the factors that predispose the athlete to a sports injury. The most thorough and sport-specific type of preparticipation examination is the station examination (Table 2–1). This method can provide the athlete with a detailed examination in a short period of time. A team may include physicians, osteopaths, nurses, athletic trainers, physical therapists, or physician’s assistants, exercise physiologists, nutritionist, and athletic training students. Privacy must be respected at all times when the findings of the PPE are communicated. HIPAA regulations require written authorization from the athlete, or the legal guardian if the athlete is a minor, before any private health information may be released.13 SoR:C TABLE 2–1

Clearance to Participate The purpose of the preparticipation exam is to identify the athlete who may be at risk for injury before he or she participates in a specific sport. It is the responsibility of the physician and the athletic trainer to make decisions regarding the appropriate interventions to remediate and ultimately alleviate those medical issues that are of concern before clearing an athlete to fully engage in or return to sport activity. Decisions to clear an athlete for participation must be based on the best available evidence and should always be in the best interest of the athletes’ health and well-being.

Sport Disqualification As discussed previously, sports participation involves risks. Certain injuries and conditions warrant concern on the part of both the athlete and sports medicine personnel about continued participation in sport activities. Table 2–2 lists those conditions.2 A team physician and institution have the legal right to restrict an individual from participating in athletics as long as the decision is individualized, reasonably made, and based on competent medical evidence.13 Most conditions that potentially warrant disqualification should be identified by a preparticipation examination and noted in the medical history.1 The NATA has published a position

Suggested Components of a Preparticipation Physical Examination

Station

Points Noted

1. Individual history (reviewed); height, weight, body composition, body mass index (BMI) 2. Snellen test, vision 3. Oral (mouth), ears, nose, throat 4. Chest, heart, lungs

“Yes” answers are probed in depth; height and weight relationships

5. Abdomen 6. Genitalia (male only) 7. Skin 8. Musculoskeletal 9. Urinalysis 10. Blood work Review

Upper limits of visual acuity—20/40 Dental prosthesis or caries; abnormalities of the ears, nose, throat Heart abnormalities, blood pressure, pulse, murmurs, clarity of lungs Masses, tenderness, organomegaly Abnormalities of genitalia, hernia Suspicious rashes or lesions Postural asymmetry, decreased range of motion or strength, abnormal joint laxity Lab test for sugar and protein Lab test to determine hematocrit and sickle cell trait (mandated by NCAA History and physical examination reports are evaluated and the following decisions are made: (a) No sports participation (b) Limited participation (no participation in specific activities or sports) (c) Clearance withheld until certain conditions are met (e.g., additional tests taken, rehabilitation completed) (d) Full, unlimited participation allowed

Source: Adapted from Myers, GC and Garrick, JG: The preseason examination of school and college athletes. In Strauss, RH (ed.): Sports medicine, Philadelphia: WB Saunders, 1984. 64

Part One ■ Professional Development and Responsibilities

TABLE 2–2

Recommendations for Activity Restriction and Disqualification

Atlantoaxial instability Acute illnesses

Noncontact Contact

Moderately Contact/ Limited Contact/ Strenuous Strenuous Nonstrenuous Collision Collision Yes* Yes Yes No No * * * * *

*Needs individual assessment (e.g., contagiousness to others, risk of worsening illness)

Cardiovascular Carditis Hypertension Mild Moderate Severe Congenital heart disease

No No No No No Yes Yes Yes Yes Yes * * * * * * * * * * † † † † †

*Needs individual assessment † Patients with mild forms can be allowed a full range of physical activities; patients with moderate or severe forms or who are postoperative should be evaluated by a cardiologist before athletic participation.

Eyes Absence or loss of function of eye * Detached retina †

* †

*Availability of American Society for Testing and Materials (ASTM)–approved eye guards may allow competitor to participate in most sports, but this must be judged on an individual basis. † Consult ophthalmologist.

Inguinal hernia Yes Yes Yes Yes Yes Kidney: absence of one Yes Yes Yes No Yes Liver: enlarged Yes Yes Yes No No Musculoskeletal disorders * * * * * *Needs individual assessment

Neurological status History of serious head or spine Yes Yes Yes * * trauma, repeated concussions, or craniotomy Convulsive disorder Well controlled Yes Yes Yes Yes Yes Poorly controlled Yes† Yes Yes†† No No *Needs individual assessment † No swimming or weight lifting †† No archery or riflery

Ovary: absence of one Respiratory status Pulmonary insufficiency Asthma

Yes Yes Yes Yes Yes * * Yes * * Yes Yes Yes Yes Yes

*May be allowed to compete if oxygenation remains satisfactory during a graded stress test

Sickle-cell trait Yes Yes Skin: Boils, herpes, impetigo, scabies Yes Yes

Yes Yes Yes Yes * *

Spleen: enlarged No Yes Testicle: absent or undescended Yes Yes

Yes No No Yes Yes* Yes*

*No gymnastics with mats, martial arts, wrestling, or contact sports until not contagious

*Certain sports may require protective cup. Source: Data from Committee on Sports Medicine: Pediatrics 81:738, 1988.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

statement “Preparticipation Physical Examinations and Disqualifying Conditions” (www.nata.org/sites /default/files/Conley.pdf) that provides guidelines for recommending disqualification of injured athletes.

athlete’s personal information file. This file is created by the athlete at the time of the health examination and serves as a means of contacting the athlete’s family, personal physician, and insurance company in case of emergency.

Personal Information Card

Injury Reports and Injury Disposition

Always on file on the desktop or tablet in the athletic trainer’s office or on the more portable smartphone is the

An injury report serves as a record for future reference (Figure 2–12). If the emergency procedures followed are

ATHLETE/PATIENT INJURY RECORD FORM Sport

Name

Date:

Age:

Player I.D. Initial injury

Recheck

Reinjury

Time:

Location:

Injury record number:

Intercollegiate—nonintercollegiate

Preseason—Practice—Game

Incurred while participating in sport: yes

Description: How did it happen? Initial impression:

SITE OF INJURY

BODY PART

STRUCTURE

1 Right

Head

25 MP joint

2 Left

2 Face

26 PIP joint

2 Muscle

3 Proximal

3 Eye

27 Abdomen

3 Fascia

4 Distal

4 Nose

28 Hip

4 Bone

5 Anterior

5 Ear

29 Thigh

5 Nerve

6 Posterior

6 Mouth

30 Knee

6 Fat pad

7 Medial

7 Neck

31 Patella

7 Tendon

8 Lateral

8 Thorax

32 Lower leg

8 Ligament

9 Other

9 Ribs

33 Ankle

9 Cartilage

10 Sternum

34 Achilles tendon

10 Capsule

11 Upper back

35 Foot

11 Compartment

12 Lower back

36 Toes

12 Dental

1 Health Service

13 Shoulder

37 Other

2 Athletic Trn Clinic

14 Rotator cuff

3 Site-Competition

15 AC joint

16 Glenohumeral

SITE OF EVALUATION

17 Sternoclavicular

Medication

NONTRAUMATIC

NATURE OF INJURY Contusion

18 Upper arm

1 Dermatological

1 Physical exam

19 Elbow

2 Allergy

2 Strain

2 X-ray

20 Forearm

3 Influenza

3 Sprain

3 Splint

21 Wrist

4 Urinary

4 Fracture

4 Wrap

22 Hand

5 Genitourinary

5 Rupture

5 Cast

23 Thumb

6 Systemic Infection

6 Tendonitis

6 Aspiration

24 Finger

7 Local Infection

7 Bursitis

8 Other

8 Myositis

PROCEDURES

7 Other

DISPOSITION

REFERRAL

Treatment Plan

Skin

DISPOSITION OF INJURY

Prescription Administered

9 Laceration

1 Antibiotics

5 Muscle relaxant

10 Concussion

2 Antiinflammatory

6 Enzyme

11 Avulsion

3 Decongestant

12 Abrasion

4 Analgesic

1 Health Service

1 Orthopedic

1 No part.

2 Athletic Trainer

2 Neurological

2 Part part.

3 Hospital

3 Int. Med.

3 Full part.

4 Physician

4 Mental Health

5 Other

5 ENT

3 Analgesics

6 Dentist

INJECTIONS

7 Other Previous injury

Physician/Athletic Trainer Signature

FIGURE 2–12 Athletic injury record form. 66

1 Corticosteroids

Degree

Part One ■ Professional Development and Responsibilities

2 Antibiotics

questioned at a later date, an athletic trainer’s memory of the details may be somewhat hazy, but a report completed at the time of injury provides specific information. In a litigation situation, an athletic trainer may be asked questions about an injury that occurred three years in the past. All injury reports should be filed in the athletic trainer’s office and in the patient’s medical records.

Patient Treatment Log Each athletic training clinic should maintain individual daily treatment logs for each patient who receives any service. Emphasis is placed on recording the treatments for the patient who is receiving daily therapy for an injury. Like accident records and injury dispositions, these records often have the status of legal documents and are used to establish certain facts in a civil litigation, an insurance action, or a criminal action after injury. Injury Evaluation and Progress Notes Injuries should be evaluated by the athletic trainer, who must record information obtained in some consistent format. The SOAP format (Subjective, Objective, Assessment, Plan for treatment) is a concise method of recording the initial evaluation and progress notes for the injured athlete and is discussed in detail in Chapter 13. The subjective portion of the SOAP note refers to what the patient tells the athletic trainer about the injury relative to the history or what he or she felt. The objective portion documents information that the athletic trainer gathers during the evaluation, such as range of motion, strength levels, patterns of pain, and so forth. The assessment records the athletic trainer’s professional opinion about the injury based on the information obtained during the subjective and objective portions. The plan for treatment indicates how the injury will be managed and includes short- and long-term goals for rehabilitation.

2–6 Clinical Application Exercise

Supply and Equipment Inventory The athletic trainer is responsible for managing a budget, most of which is spent on equipment and supplies. Every year an inventory must be conducted and recorded The athletic trainer has requested that the school on such items as new purchase a new computer equipment needed, equipto be housed in the ment that needs to be reathletic training room. The placed or repaired, and administrator indicates that the expendable supplies funds are tight; however, the that need replenishing. athletic trainer is asked to develop a written proposal to justify the purchase.

? What information can the

athletic trainer include in the request that could justify purchasing a new computer for the athletic training room?

Annual or Seasonal Reports Both clinic administrators and athletic administrators require an annual or seasonal report on the functions of

the athletic training program. This report serves as a means for making program changes and improvements. It commonly includes the number of patients served, a survey of the number and types of injuries, an analysis of the program, and recommendations for future improvements.

COMPUTERS, TABLETS, AND SMARTPHONES AS TOOLS FOR THE ATHLETIC TRAINER As is the case in all of our society, computers, tablets, and smartphones have become indispensable tools for the athletic trainer and have completely revolutionized the way information is managed. A great deal of information can be efficiently located and stored for immediate and future use because of constant improvement in storage and retrieval capacities. Software packages are available to help store and retrieve any type of relevant records or information.18 The first step in integrating computers, tablets, and smartphones into an athletic training program is to decide exactly how and Computers facilitate the recordfor what purposes keeping process. they will be used. It is essential to seek advice from expert professionals or consultants prior to purchasing a system to ensure that the hardware and corresponding operating system are capable of supporting the software that will make them useful information management and communication tools. Thousands of software programs are available that will allow the user to store, manipulate, and retrieve information; create written documents through word processing; analyze data statistically; and communicate with many individuals in a variety of forms. Record keeping is a time-consuming but essential chore for all athletic trainers regardless of whether they work at a college or university, at a secondary school, in the clinical setting, or in industry. Several software packages are available specifically for managing injury records in the athletic training setting. A problem that athletic trainers must address is ensuring security and protecting the confidentiality of medical records stored on a computer, tablet, or smartphone. Databases that contain such information must be accessible only to the athletic trainer or team physician/medical director and must be protected by a password. Besides record keeping, software can also be used for budgeting and inventory; managing a personal schedule or calendar; and creating a database or a spreadsheet from which injury data can be organized, retrieved, or related to specific injury situations or other injury records for statistical analysis. Other software can analyze and provide information about nutrition, body composition, and injury risk profiles based on other anthropometric

Chapter Two ■ Health Care Organization and Administration in Athletic Training

2–7 Clinical Application Exercise

measures and can be used to record isokinetic evaluation and exercise.36 The use of educational software to assist in teaching and the academic preparation of athletic training students has become an integral component in the majority of athletic training educational programs. New instructional and educational software with interactive capabilities of eBooks has made the multimedia presentation of instructional material, and thus learning, more interesting A basketball coach at Alland effective for the athAmerican High School is letic training student. concerned about what seems to be an abnormally The Internet and the high frequency of ankle World Wide Web have sprains on her varsity team. impacted and changed all Her philosophy is to require of our lives. We live in all her players to wear higha world where any kind top shoes, yet the budget of information is imwill not permit the athletic mediately accessible to trainer to tape all players’ anyone who knows how ankles for practices and to use the system. The games. Together the coach sports medicine comand athletic trainer decide munity in general and to purchase a number of lace-up ankle braces in the athletic trainer spean attempt to reduce the cifically can access thounumber of ankle sprains. sands of Web sites and apps that have direct ap How can the athletic plication to clinical practrainer determine whether tice, to the education of the braces are helping decrease the frequency athletic training students, of ankle sprains in these and to the general base basketball players? of knowledge that is relevant to the field.

COLLECTING INJURY DATA Because of the vast number of physically active individuals involved with organized and recreational sports, some knowledge relative to the number and types of injuries sustained during participation in these activities is essential.47 Although methods are much improved over the past, many weaknesses exist in systematic data collection and analysis of sports injuries.28

The Incidence of Injuries An accident is an unplanned event capable of resulting in loss of time, property damage, injury, disablement, or even death.57 An injury may be defined as damage to the body that restricts activity or causes disability to such an extent that the patient is not able to practice or compete the next day.57 Injury data may be analyzed by looking at several factors. The incidence of injury analyzes the risk of sustaining an injury during some specified time period (i.e., practice, games). Injury prevalence analyzes the total

Part One ■ Professional Development and Responsibilities

number of injuries The epidemiological approach in a specific poputoward injury data collection lation. Incidence provides the most information. rate is the number of new injuries that occur in a Risk of injury is determined particular populaby the type of sport—contact tion during a specor collision, limited contact, or ified time period. noncontact. Injury exposure rates look at the incidence of injuries per the number of individual athlete exposures during a specific time period. Risk factors that might potentially contribute to the incidence of injury can be analyzed using outcome studies to determine the strength of their relevance and whether modifying these risk factors is effective in reducing injury rates.6,58 There is little doubt that a case study approach, which looks at one incidence of an injury, can yield some critical information about the cause and subsequent efficacy of treatment for that injury. However, an approach that analyzes a large number of similar injuries can provide the greatest amount of information. In general, the incidence of sports injuries can be studied epidemiologically from many points of view—in terms of age at occurrence, gender, body regions that sustain injuries, or the occurrence in different sports.58 Sports are usually classified according to the risk, or chances, of injuries occurring under similar circumstances and are broadly divided into contact or collision, limited contact, or noncontact2 (Table 2–3). Athletes in all sports, recreational and organized, who participate in sports in the span of one year face a 50 percent chance of sustaining some injury. Of the 50 million estimated sports injuries per year, 50 percent require only minor care and no restriction of activity.28 Approximately 90 percent of injuries are muscle contusions, ligament sprains, and muscle strains; however, 10 percent of these injuries lead to microtrauma complications and eventually to a severe, chronic condition in later life. Of the sports injuries that must be medically treated, sprains or strains, fractures, dislocations, and contusions are the most common.28 In terms of the body regions most often injured, the knee has the highest incidence, with the ankle second and the upper limb third. For both males and females the most commonly injured body part is the knee, followed by the ankle; however, males have a much higher incidence of shoulder and upper-arm injuries than do females.

Catastrophic Injuries Although millions of individuals participate in organized and recreational sports, there is a relatively low incidence of fatalities or catastrophic injuries. Ninetyeight percent of individuals with injuries requiring

TABLE 2–3

Classification of Sports*

Noncontact

Limited Contact

Contact or Collision

Weight lifting Windsurfing or surfing Wrestling Track Volleyball Water polo Tennis Ultimate Frisbee Team handball Table tennis Squash Soccer Swimming Softball Ski jumping Shot put Snowboarding Rugby Scuba diving Skiing (cross-country, downhill, water) Rodeo Sailing Skating (ice, in-line, roller) Martial arts Running Skateboarding Lacrosse Rope jumping Racquetball Ice hockey Riflery Pole vault Football (tackle) Race walking Horseback riding Field hockey Power lifting High jump Diving Orienteering Handball Boxing Javelin Gymnastics Baseball Golf Football (flag) Field events Floor hockey Discus Field events Dancing (ballet, modern, Jazz) Fencing Curling Cheerleading Crew or rowing Canoeing or kayaking (white water) Canoeing or kayaking (flat water) Bicycling Bowling Baseball Bodybuilding Badminton Archery Source: Data from the American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical conditions affecting sports participation, Pediatrics 107(5):1205, 2001.

hospital emergency room medical attention are treated and released.9 Deaths have been attributed to chest or trunk impact with projectiles, other players, or nonyielding objects (e.g., goalposts). Deaths have occurred when players were struck in the head by sports implements (bats, golf clubs, hockey sticks) or by missiles (baseballs, soccer balls, golf balls, hockey pucks). Death has also resulted when an individual received a direct blow to the head from another player or the ground. On record are a number of sports deaths in which a playing structure, such as a goalpost or backstop, fell on a participant. The highest incidence of indirect sports death stems from heatstroke. Less common indirect causes include cardiovascular and respiratory problems or congenital conditions not previously known. Catastrophic injuries leading to cervical injury and quadriplegia are seen mainly in American football. Although the incidence is low for the number of players involved, it could be lowered even further if more precautions were taken.38 In most popular organized and recreational sports activities, the legs and arms have the highest risk factor

for injury, with the head and face next. Muscle strains, joint sprains, contusions, and abrasions are the most frequent injuries sustained by the active sports participant. The major goal of this text is to provide the reader with the fundamental principles necessary for preventing and managing illnesses and injuries common to the athlete.

Current National Injury Data-Gathering Systems The state of the art of sports injury surveillance is unsatisfactory.57 Currently, most local, state, and federal systems are concerned with the accident or injury only after it has happened, and they focus on injuries requiring medical assistance or those that cause time loss or restricted activity. The ideal system takes an epidemiological approach.57 Epidemiology is the scientific study of factors affecting the health and illness of individuals and populations.58 Epidemiology takes an evidence-based approach for identifying risk factors for injury and determining optimal

Chapter Two ■ Health Care Organization and Administration in Athletic Training

National Safety Council The National Safety Council* is a nongovernmental, nonprofit public service organization. It draws sports injury data from a variety of sources, including educational institutions. Annual Survey of Football Injury Research In 1931, the American Football Coaches Association (AFCA) conducted its first Annual Survey of Football Fatalities. Since 1965, this research has been conducted at the University of North Carolina. In 1980, the survey’s title was changed to the Annual Survey of Football Injury Research. Every year, with the exception of 1942, data have been collected about public school, college, professional, and sandlot football. Information is gathered through personal contact interviews and questionnaires. The sponsoring organizations of this survey are the AFCA, the NCAA, and the National Federation of State High School Associations (NFHS). This survey classifies football fatalities as direct or indirect. Direct fatalities are those resulting directly from participation in football. Indirect fatalities are produced by systemic failure caused by the exertion of playing football or by a complication that arose from a nonfatal football injury. National Center for Catastrophic Sports Injury Research In 1977, the NCAA initiated the National Survey of Catastrophic Football Injuries. As a result of the injury data collected from this organization, several *National Safety Council, Itasca, IL.

Part One ■ Professional Development and Responsibilities

significant rule changes have been incorporated into collegiate football. Because of the success of this football project, the research was expanded to all sports for both men and women, and a National Center for Catastrophic Sports Injury Research was established at the University of North Carolina. With support from the NCAA, the NFHS, the AFCA, and the Section on Sports Medicine of the American Association of Neurological Sciences, this center compiles data on catastrophic injuries at all levels of sport.9 NCAA Injury Surveillance System The NCAA Injury Surveillance System (ISS) was established in 1982 primarily for the purpose of studying the incidence of football injuries, so that rule change recommendations could be made to reduce the injury rate.16 Since that time, this system has been A collegiate athletic greatly expanded and now trainer is approached by collects data on most major sports. For the most part, the school administration to determine the potential athletic trainers are primarrisk of injury to their ily involved in the collecfootball team. tion and transmission of What approach is best injury data.

suited to gather this

The ISS had previously information? relied on the willingness of athletic trainers to submit paper forms reporting injuries in various NCAAsponsored sports. In Fall 2004, the ISS fully converted to a Web-based data-collection system that can compile far more data than ever before, providing member institutions with a low-cost means of tracking medical information and analyzing injury trends. National Electronic Injury Surveillance System In 1972, the federal government established the Consumer Product Safety Act (CPSA), which created and granted broad authority to the Consumer Product Safety Commission to enforce the safety standards for more than 10,000 products that may be risky to the consumer.57 To perform this mission, the National Electronic Injury Surveillance System (NEISS)† was established. Data on injuries related to consumer products are monitored 24 hours a day from a selected sample of 5,000 hospital emergency rooms nationwide. Sports injuries represent 25 percent of all injuries reported by NEISS. It should be noted that a product may be related to an injury, but not be the direct cause of that injury.57 National Electronic Injury Surveillance System, U.S. Consumer Product Safety Commission, Directorate for Epidemiology, National Injury Information Clearinghouse, Washington, DC. †

2–8 Clinical Application Exercise

treatment methods in clinical practice. It serves as the foundation for interventions made in the interest of public health and preventive medicine. When considering the risks inherent in a particular sport, both extrinsic and intrinsic factors must be studied. 42 Thus, information is gleaned from both epidemiological data and the individual measurements of the athlete. The term extrinsic factor refers to the type of activity that is performed, the amount of exposure to injury, factors in the environment, and the equipment. The term intrinsic factor refers directly to the athlete and includes age, gender, neuromuscular aspects, structural aspects, performance aspects, and mental and psychological aspects. Over the years, a number of athletic injury surveillance systems have been implemented; most have collected data for a few years and then ceased to exist. The currently active systems that are most often mentioned are the National Safety Council, the Annual Survey of Football Injury Research, the National Center for Catastrophic Sports Injury Research, the NCAA Injury Surveillance System, the National Electronic Injury Surveillance System (NEISS), and the National High School Sports-Related Injury Surveillance Study.

Once a product is considered hazardous, the commission can seize the product or create standards to decrease the risk. Also, manufacturers and distributors of sports recreational equipment must report to the commission any product that is potentially hazardous or defective. The commission can also research the reasons that a sports or recreational product is hazardous.

collects data weekly on athlete exposure, injury type, and the injury event, using certified, licensed athletic trainers to provide data.57 The data collected meets the needs of the high-school sports community that includes student-athletes, parents, pediatric sports medicine clinicians, high-school athletic directors, local/state high-school athletic associations/ administrators, and the NFHS (National Federation of State High School Associations).15

National High School Sports-Related Injury Surveillance Study

Using Injury Data

The National High School Sports-Related Injury Surveillance Study, administered through the Center for Injury Research and Policy, was first implemented in 2005 and has collected data annually since then. It was first established as the high-school version of the NCAA Injury Surveillance System. Known as High School RIO™, it is an Internet-based data collection tool that looks at time-loss injuries in a national sample of U.S. high-school athletes. This system

Valid, reliable sports injury data can materially help decrease injuries. If properly interpreted, the data can be used to modify rules, assist parents, coaches, and players in understanding risks, and help manufacturers evaluate their products against the overall market. The public, especially parents, should understand the risks inherent in a particular sport, and insurance companies that insure athletes must know risks in order to set reasonable costs.

SUMMARY • The administration of a program of health care demands a significant portion of the athletic trainer’s time and effort. The efficiency and success of the athletic training program depend in large part on the administrative abilities of the athletic trainer in addition to the clinical skills required to treat the injured patient. • The athletic training health care program may best serve the athlete; the hospital, clinic, or corporation; and the community by establishing specific policies, procedures, and regulations governing the use of available services. • An athletic training program in secondary schools, colleges, and universities should decide whom the program will serve and how coverage will be provided, establish rules for hygiene and sanitation of the facility, develop a budget, develop a risk management plan, and address human resources and personnel issues. • The athletic training program can be enhanced by designing or renovating a facility to maximize the potential use of the space available. Space designed for injury treatment, rehabilitation, modality use, office space, physician examination, record keeping, and storage of supplies should be designated within each facility. • An athletic training program in the hospital, clinical, corporate, or industrial setting must decide

• •

what type of patients will be treated in that facility; how that facility can best serve that patient population; how to resolve clinic personnel and human resources issues; exactly what an athletic trainer might be responsible for in the day-to-day operation of that facility; and the fiscal management issues in a for-profit clinic. Preparticipation exams must be given to athletes and should include a medical history, a general physical examination, and orthopedic screenings. The athletic trainer must maintain accurate and up-todate medical records in addition to the other administrative tasks that are necessary for the operation of the athletic training program in all settings in which an athletic trainer may work. Computers, tablets, and smartphones are extremely useful tools that enable athletic trainers to retrieve and store a variety of records. A number of data-collection systems tabulate the incidence of sports injuries. The systems mentioned most often are the National Safety Council, the Annual Survey of Football Injury Research, the National Electronic Injury Surveillance System, the NCAA Injury Surveillance System, the National Center for Catastrophic Sports Injury Research, and the National High School Sports-Related Injury Surveillance Study.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

WEB SITES National Athletic Trainers Association Position, Official, Consensus, and Support Statements

Sickle Cell Trait and the Athlete: www.nata.org/sites /default/files/SickleCellTraitAndTheAthlete.pdf Appropriate Medical Care for Secondary SchoolAge Athletes: www.nata.org/sites/default/files /appropriatemedicalcare4secondaryschoolageathletes.pdf Emergency Planning in Athletics: www.nata.org/sites /default/files/EmergencyPlanningInAthletics.pdf

Preparticipation Physical Examinations and Disqualifying Conditions: www.nata.org/sites/default/files/Conley.pdf Skin Diseases: www.nata.org/sites/default/files /position-statement-skin-disease.pdf

SOLUTIONS TO CLINICAL APPLICATION EXERCISES 2–1 The athletic trainer should work in conjunction with the appropriate administrative personnel to develop a risk management plan that includes security issues, fire safety, electrical and equipment safety, and emergency injury management. 2–2 Federal law mandates specific policies for recruitment, hiring, and firing. All qualified applicants should receive equal consideration regardless of their race, gender, religion, or nationality. The head athletic trainer must strictly adhere to these mandates. 2–3 The athletic training clinic should have specific areas designated for taping and preparation, treatment and rehabilitation, and hydrotherapy. It should have an office for the athletic trainer and adequate storage facilities positioned within the space to allow for an efficient traffic flow. Equipment purchases might include four or five treatment tables and two or three taping tables (these could be made in-house, if possible), a large-capacity ice machine, a combination ultrasound/electrical stimulating unit, a whirlpool, and various free weights and exercise tubing. 2–4 The athletic trainer should take this request to the clinic administrator to have it approved. They must decide on a fee for treating these patients and hours for treatment. A decision should also be made about personnel for game and event coverage. A budget should also be developed for supplies and equipment. 2–5 The preparticipation examination should consist of a medical history, a physical examination, and a brief orthopedic screening. The preparticipation physical may be effectively administered using a station examination system with a team of examiners. A station

examination can provide the athlete with a detailed examination in a short period of time. A team of people is needed to examine this many individuals. The team should include several physicians, medically trained nonphysicians (nurses, athletic trainers, physical therapists, or physician’s assistants), and managers, athletic training students, or assistant coaches. 2–6 The athletic trainer should explain that the computer can be used for maintaining medical records, word processing, planning a budget, managing a personal schedule or calendar, and creating a database containing injury data that can be organized, retrieved, or related to specific injury situations or to other injury records for analysis. Additional software can provide the athletic trainer with analysis and information about nutrition, body composition, and injury risk profiles. 2–7 The athletic trainer should do a simple study in which one-half of the players are randomly placed in the ankle braces while the other half continue to play in their high-top shoes. By comparing the number of ankle injuries in the group wearing the braces with those in the group without the braces, the athletic trainer can make a decision as to the effectiveness of the braces in preventing ankle injuries. Collecting and analyzing injury data is helpful in determining the efficacy of many of the techniques used by the athletic trainer. 2–8 The NCAA Injury Surveillance System would best suit this purpose. This system of information can also be used to prevent injuries by presenting information to coaches, referees, and administrators to enforce necessary changes to the football program.

REVIEW QUESTIONS AND CLASS ACTIVITIES 1. What are the major administrative functions that an athletic trainer must perform? 2. Design two athletic training clinics—one for a secondary school and one for a large university. 3. Observe the activities in the athletic training clinic. Pick both a slow time and a busy time to observe. 4. Why do hygiene and sanitation play an important role in athletic training? How should the athletic training clinic be maintained? 5. Fully equip a new medium-size secondary-school, college, or clinical athletic training clinic. Pick equipment from current catalogs. 6. Establish a reasonable budget for a small secondary school, a large high school, and a large college or university.

7. Identify the groups or individuals to be served in a collegiate athletic training clinic. 8. What job duties and responsibilities might an athletic trainer be assigned when working in a clinic, hospital, corporate, or industrial setting? 9. Help organize a preparticipation health examination for ninety football players. 10. Record keeping is a major function in athletic training. What records are necessary to keep? How can a computer help? 11. Debate what conditions constitute good grounds for medical disqualification from a sport. 12. Discuss the epidemiological approach to recording sports injury data.

REFERENCES 1. American Academy of Pediatrics: Preparticipation physical evaluation, ed 4, Elk Grove Village, IL, 2010, American Academy of Pediatrics. 2. American Academy of Pediatrics Committee on Sports Medicine and Fitness: Medical conditions affecting sports participation, Pediatrics 107(5):1205, 2001.

3. Ammon R: Sport facility management: Organizing events and mitigating risks, Morgantown, WV, 2010. Fitness Information Technology. 4. Anderson B: Policies and philosophies related to risk management in the athletic setting, Athletic Therapy Today, 11(1):10, 2006. 5. Anderson J, et al.: National Athletic Trainers’ Association Position Statement: Emergency

Part One ■ Professional Development and Responsibilities

planning in athletics, J Athl Train 37(1):99, 2002. 6. Armsey T: Medical aspects of sports: Epidemiology of injuries, preparticipation physical examination, and drugs in sports, Clin Sports Med 23(2):255–79, 2004. 7. Bagnall D: Budget planning key in secondary schools, NATA News, January 15, 2001.

8. Barker A: Developing a crisis management plan. Athletics Administration 40(2):41, 2005. 9. Boden, B: Catastrophic injuries in pole-vaulters, Am J Sports Med 29(1):50, 2001. 10. Borjesson M: Is there evidence for mandating electrocardiogram as part of the pre-participation examination?, Clinical Journal of Sports Medicine 21(1):13–17,2011. 11. Brown J: Athletic training facilities. In Sawyer T, editor: Facilities planning for health, fitness, physical activity, recreation & sports , Champaign, IL, 2013, Sagamore Publishing. 12. Claiborne T: Certified athletic trainers provide effective care in the high school setting, Athletic Therapy Today 12(2):34, 2007. 13. Conley K, et al. National Athletic Trainers’ Association position statement: Preparticipation physical examinations and disqualifying conditions, Journal of Athletic Training, 49(1):102– 20, 2014. 14. Curtis N: Risk management, Athletic Therapy Today 11(1):34, 2006. 15. Darrow, C: Epidemiology of severe injuries among United States high school athletes 2005– 2007, American Journal of Sports Medicine 37(9):1798–1805, 2009. 16. Dick R: NCAA injury surveillance system: A tool for health and safety risk management, Athletic Therapy Today 11(1):42, 2006. 17. Eickhoff-Shemek J: Risk management for health/fitness professionals: Legal issues and strategies. Baltimore, MD: 2008, Lippincott, Williams & Wilkins. 18. Eng J: Computerizing clinical documentation, Phys Ther 14(6):36, 2006. 19. Fried G: Managing sport facilities. Champaign, IL, 2015, Human Kinetics. 20. Goforth M: Understanding organization structures of the college, university, high school, clinical, and professional settings. Clinics in Sports Medicine 26(2):201, 2007. 21. Gratto J: Management principles for health professionals, Burlington, MA, 2011, Jones and Bartlett Learning. 22. Harrelson G: Administrative topics in athletic training: Concepts to practice, Thorofare, NJ, 2009, Slack. 23. Herbert D: Emergency preparedness recommendations for high school and college athletic programs. Sports, Parks & Recreation Law Reporter 21(1):71, 2007. 24. Jonas J: Ethics in injury management, Athletic Therapy Today 11(1):28, 2006. 25. Jones D: HIPAA: Friend or foe to athletic trainers? Athletic Therapy Today 8(2):17, 2003. 26. Keil J: HIPAA and FERPA: Competing or collaborating? Journal of Allied Health 39(4):161– 65, 2010.

27. Knight K: Athletic training clinic operations. In Knight K, editor: Developing clinical proficiency in athletic training, ed 3, Champaign, IL, Human Kinetics, pp. 14–19, 2009. 28. Knowles S: Issues in estimating risks and rates in sports injury research, J Athl Train 41(2):207, 2006. 29. Koester M: Preparticipation screening of high school athletes: Are recommendations enough? Physician Sportsmed 31(8):330, 2003. 30. Konin J: The athletic trainer as a personnel manager. In Konin J, editor: The clinical athletic trainer, Gaithersburg, MD, 1997, Slack. 31. Krager C: HIPAA for health care professionals, Independence, KY, 2008, Cengage Learning. 32. Kurtz M: Leadership in athletic training: Implications for practice and education in allied health care, Journal of Allied Health , 39(4):265–79, 2010. 33. Landry G: Preparticipation physical examination. In Landry G, editor: Essentials of primary care sports medicine, Champaign, IL, 2003, Human Kinetics. 34. Marshall A: Challenges and opportunities for promoting physical activity in the workplace, Journal of Science and Medicine in Sport 7(1 Supplement):60, 2004. 35. Mirwald R: An assessment of maturity from anthropometric measurements. Med Sci Sports Exerc 34(4):689, 2002. 36. Moss R: Facilities and foibles, Athletic Therapy Today 7(1):22, 2002. 37. Moyer-Knowles J: Planning a new athletic facility. In Konin J, editor: The clinical athletic trainer, Gaithersburg, MD, 1997, Slack. 38. Mueller F: Fatal and catastrophic injuries in athletics: Epidemiological data and challenging circumstances. In Casa D, editor: Preventing sudden death in sport and physical activity, Sudbury, MA, 2012, Jones and Bartlett. 39. Oliver, C: Athletic training room essentials. Interscholastic, Athletic Administration 28(4):21, 2002. 40. Peterson E: Insult to injury: Feeling understaffed, underequipped and undervalued, athletic trainers say minimum of space and equipment will yield extensive benefits, Athletic Business 23(1):57, 1999. 41. Physician and sportsmedicine: Preparticipation physical evaluation monograph, ed 3, New York, 2004, McGraw-Hill. 42. Rankin J: Athletic training management: Concepts and applications, St. Louis, 2006, McGraw-Hill. 43. Ray R: Where athletic trainers work: Facility design and planning. In Ray R, Konin J,

editors: Management strategies in athletic training, ed 4, Champaign, IL, 2011, Human Kinetics. 44. Ray R, Konin J, editors: Management strategies in athletic training, ed 4, Champaign, IL, 2011, Human Kinetics. 45. Sabo J: Athletic training room design and layout. In Proceedings, National Athletic Trainers’ Association 50th Annual Meeting and Clinical Symposium, June 16–19, 1999, Kansas City, MO, 1999, Human Kinetics. 46. Sabo J: Design and construction of an athletic training facility, NATA News, May 10, 2001. 47. Schiff M: Soccer injuries in female youth players: Comparison of injury surveillance by certified athletic trainers and Internet, J Athl Train, 45(3):238–42, 2010. 48. Schwartz E: Sport facility operations management. St. Louis, 2010, Elsevier. 49. Shappy J: Preparticipation exam to identify risk for sudden cardiac death, Athletic Training and Therapy , 14(6):13–16, 2009. 50. Shephard R: Supervision of occupational fitness assessments, Canadian Journal of Applied Physiology 28(2):225, 2003. 51. Streator S: Risk management in athletic training, Athletic Therapy Today 6(2):55, 2001. 52. Swann E: Managing risk in an athletic training education program, Athletic Therapy Today 11(1):17, 2006. 53. Tanner M: Growth of adolescence, ed 2, Oxford, England, 1962, Blackwell Scientific. 54. Von Fange T: The preparticipation physical exam. In Hoffman R, editor: Common musculoskeletal problems, New York, 2010, Springer. 55. Wham G: Key factors for providing appropriate medical care in secondary school athletics: Athletic training services and budget, J Athl Train 45(1):75–86, 2010. 56. Wilson A: Effective management of musculoskeletal injury: A clinical ergonomics approach to prevention, treatment, and rehabilitation, Philadelphia, 2002, Churchill Livingstone. 57. Yard E: A comparison of high school sports injury surveillance data reporting by certified athletic trainers and coaches, J Athl Train, 44(6):645–52, 2009. 58. Zemper E: Epidemiology of athletic injuries. In McKeag D: ACSM’s primary care sports medicine, Philadelphia, 2007, Lippincott, Williams & Wilkins. 59. Zinder S, et al.: National Athletic Trainers’ Association Position Statement: Skin diseases, Journal of Athletic Training 45(4):411–28, 2010.

ANNOTATED BIBLIOGRAPHY Board of Certification. BOC facility principles, 2013, www.bocatc.org /imstories/resources/boc_facility_safety_1404af.pdf This document provides the means for secondary and postsecondary educational institutions and organizations to self-assess their policies, procedures, and facilities to ensure the safe, effective, and legal provision of athletic health care services. Harrelson G, Gardner G, Winterstein A: Administrative topics in athletic training: Concepts to practice, Thoroughfare, NJ, 2009, Slack Incorporated.

Addresses important administrative issues and procedures as well as fundamental concepts, strategies, and techniques related to the management of all aspects of an athletic training health care delivery system. Karwowski W, Marras W: Occupational ergonomics: engineering and administrative controls, Boca Raton, FL, 2003, CRC Press. Focuses on prevention of work-related musculoskeletal disorders with an emphasis on engineering and administrative controls.

Chapter Two ■ Health Care Organization and Administration in Athletic Training

Konin J: The clinical athletic trainer, Gaithersburg, MD, 1997, Slack. A unique, practical book that specifically addresses the administration of a health care program for athletic trainers working in a clinical setting. Konin J, Frederick M: Documentation for athletic training, Thorofare, NJ, 2011, Slack. Presents the basic principles of medical documentation, various styles of writing, legal considerations, documentation for reimbursement, and many types of written documentation, including evaluations, injury reports, medical releases, and the like. Mueller F, Cantu R: Football fatalities and catastrophic injuries 1931–2008, Durham, NC, 2011, Carolina Academic Press. This text summarizes the epidemiologic data that has been collected on catastrophic injuries in football and other sports that has been collected over the past 70+ years. Occupational Safety and Health Administration: Ergonomics for the prevention of Musculoskeletal disorders, Washington, D.C., 2011, U.S. Department of Labor. Provides recommendations for industrial facilities to reduce the number and severity of work-related musculoskeletal disorders.

Part One ■ Professional Development and Responsibilities

Rankin J, Ingersoll C: Athletic training management: concepts and applications, St. Louis, 2006, McGraw-Hill. Designed for upper-division undergraduate or graduate students interested in all aspects of organization and administration of an athletic training program. Ray R, Konin J: Management strategies in athletic training, Champaign, IL, 2011. Human Kinetics. The first text that covered the principles of organization and administration as they apply to many different employment settings in athletic training; contains many examples and case studies based on principles of administration presented in the text. Wilson A, Boyling J: Effective management of musculoskeletal injury: a clinical ergonomics approach to prevention, treatment, and rehabilitation, Philadelphia, 2002, Churchill Livingstone. A practical guide designed to help clinicians understand the workplace and lifestyle factors that contribute to musculoskeletal injuries. Examines ergonomic causes as well as personal and psychosocial factors, in addition to discussing cumulative and chronic types of injury.

Legal Concerns and Insurance Issues ■ Objectives When you finish this chapter you should be able to • Analyze the legal considerations for the athletic trainer acting as a health care provider. • Define the legal concepts of torts, negligence, and assumption of risk. • Identify measures that the athletic trainer can take to minimize the chances of litigation.

■ Outline Legal Concerns for the Athletic Trainer 76 Insurance Considerations 79 Third-Party Reimbursement 82 Summary 86

• Explain product liability. • Categorize the essential insurance requirements for the protection of the patient. • Classify the types of insurance necessary to protect the athletic trainer who is acting as a health care provider.

■ Key Terms liability negligence torts nonfeasance malfeasance misfeasance duty of care

sovereign immunity Good Samaritan law assumption of risk health insurance managed care Affordable Care Act (ACA)

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • • • •

Clinical application scenarios covering chances of litigation, legal considerations, and insurance Click-and-drag questions covering legal considerations and insurance nomenclature Multiple-choice questions covering legal concepts and considerations, litigation, and insurance Selection questions covering chances of litigation

LEGAL CONCERNS FOR THE ATHLETIC TRAINER Ours is a litigious society in which legal actions and subsequent lawsuits have become the rule rather than the exception.35,43 Nowhere is this more true than in our health care system. Ironically, athletic trainers, like all health care providers, are constantly held accountable both for things they do and things they don’t do when treating patients. The potential always exists that techniques and procedures athletic trainers use in providing health care will result in some legal action regarding issues of liability and negligence, regardless of the setting in which they practice.33 Liability means being legally responsible for the harm one causes another person.35 A great deal of care must be taken in following athletic training procedures to reduce the risk of being sued by an athlete and being found liable for negligence.3,12,35,41

The Standard of Reasonable Care Negligence is the failure to use reasonable care—care that persons would normally exercise to avoid injury to themselves or to others under similar circumstances.14 The standard of reasonable care assumes that an individual is neither exceptionally skillful nor extraordinarily cautious but is a person of reasonable and ordinary prudence. Put another way, it is expected that an individual will be thoughtful and careful relative to the situation at hand and will exercise due care in its handling. In most cases in which someone has been sued for negligence, the actions of a hypothetical, reasonably prudent person are compared with the actions of the defendant to ascertain whether the course of action the defendant followed was in conformity with the judgment exercised by such a reasonably prudent person.16 Essentially, an athletic trainer is held to a reasonable prudent professional standard, rather than a reasonably prudent person standard. The standard of reasonable care requires that an athletic trainer act according to the standard of care of an individual with similar educational background or training.16 An athletic trainer who is well educated in his or her field and who is certified and/or licensed must act in accordance with those qualifications.

Torts Torts are legal wrongs committed against the person or property of another.34 All individuals are expected to conduct themselves without injuring others. When they do so, either intentionally or by negligence, they can be required by a court to pay money to the injured party (“damages”), so that ultimately the defendants need to “fix” their intentional or careless mistake by paying for the harm they cause. Punitive damages can “make them suffer,” but those are only awarded for intentional torts. 76

Part One ■ Professional Development and Responsibilities

A tort also serves as a deterrent by sending a message that people should expect to pay if they intentionally harm others. Such wrongs may emanate from nonfeasance (also referred to as an act of omission), wherein the individual fails to perform a legal duty; from malfeasance (also referred to as an act of commission), wherein an individual commits an act that is not legally his or hers to perform; or from misfeasance, wherein an individual improperly does something that he or she has the legal right to do.21 In any instance, if injury results, the person can be held liable. In the case of nonfeasance, an athletic trainer may fail to refer a seriously injured patient for the proper medical attention. In the case of malfeasance, the athletic trainer may perform a therapeutic treatment that violates the practice of another licensed health care professional and as a result serious medical complications develop. In a case of misfeasance, the athletic trainer may incorrectly administer a treatment technique procedure he or she has been trained to perform. Negligence If an athletic trainer is sued, the complaint typically is for the tort of negligence. To establish negligence, an individual making the complaint must establish four things: (1) a duty of care existed between the person injured and the person responsible for that injury; (2) the defendant breached this duty by conduct that fell short of the standard of care; (3) the defendant caused the injury to occur; and (4) personal, property, or punitive damages resulted.24 If the athletic trainer breaches a duty to exercise reasonable care, but there is no reasonable connection between the failure to use reasonable care and the injury suffered, the suit for negligence will not succeed. An example of negligence is when an athletic trainer, through improper or careless handling of a therapeutic agent, seriously burns a patient. Another illustration, occurring all too often in sports, is one in which a coach or some other individual moves a possibly seriously injured athlete from the field of play to permit competition or practice to continue and does so either in an improper manner or before consulting those qualified to know the proper course of action. Should a serious or disabling injury result, the individual who made the decision may be found liable.24 Athletic trainers employed by an institution have a duty to provide athletic training care to individuals at that institution. An athletic trainer who is employed by the public schools or by a state-funded college or university may be protected by the legal doctrine of sovereign immunity, which essentially states that neither the government nor any individual who is employed by the government can be held liable for negligence. However, it should be made clear that the level of protection afforded by sovereign immunity may vary significantly from state to state.

Statutes of Limitation A statute of limitation sets a specific length of time that individuals may sue for damages from negligence.39 The length of time to bring suit varies from state to state, but in general plaintiffs have How should the firstbetween one and five years aid care provided by a to file suit for negligence. certified athletic trainer The statute of limitations working in a health club differ from the care begins to run on a plaintiff’s time to file a lawsuit for that may be provided by a lay person? negligence either from the time of the negligent act or omission that gives rise to the suit or from the time of the discovery of an injury caused by the negligent act or omission. Some states permit an injured minor to file suit up to three years after the minor reaches the age of 18.7 Therefore, an injured minor’s cause of action for negligence against an athletic trainer remains valid for many years after the negligent act or omission occurred or after the discovery of an injury caused by the negligent act or omission.7

Assumption of Risk An athlete assumes the risk of participating in an activity when he or she knows of and understands the dangers of that activity and voluntarily chooses to be exposed to those dangers. An assumption of risk can be expressed in the form of a waiver signed by an athlete or his or her parents or guardian or can be implied from the conduct of an athlete under the circumstances of his or her participation in an activity.7 Assumption of risk may be asserted as a defense to a negligence suit. The athletic trainer bears the burden of proving that an individual assumed the risk. One way of proving this but not the only way is by producing the document signed by that individual or his or her parents or guardian or by proving that the risk of the activity was known, understood, and voluntarily accepted.7 Assumption of risk, however, is subject to many and varied interpretations by courts, especially when a minor is involved. Minors can assume risk, but the court will figure out whether it was reasonable based on the participant’s age, intelligence, instructions provided, and other criteria. Although individuals participating in a sports program are considered to assume a normal risk, this assumption in no way excuses those in charge from exercising reasonable care and prudence in the conduct of such activities, or from foreseeing and taking precautionary measures against accident-provoking circumstances.7,17 In general, courts have been fairly consistent in upholding assumption of risk releases of liability for adults unless there is evidence of fraud, Chapter Three ■ Legal Concerns and Insurance Issues

3–2 Clinical Application Exercise

3–1 Clinical Application Exercise

Clinical athletic trainers have a greater choice than institutional athletic trainers of whom they may choose to treat as a patient. Once the athletic trainer assumes the duty of caring for a patient, the athletic trainer has an obligation to make sure that appropriate care is given. It should be made clear that the athletic trainer, or any other person, is not obligated to provide first-aid care for an injured person outside his or her scope of employment. However, if the athletic trainer chooses to become involved as a caregiver for an injured person, he or she is expected to provide reasonable care consistent with his or her level of training. The Good Samaritan law has been enacted in most states to provide limited protection against legal liability to any indi If the patient brings a vidual who voluntarily lawsuit against the athletic chooses to provide first trainer, what must the aid, should something patient prove if he is to win a judgment? go wrong. As long as the first-aid provider does not overstep the limits of his or her professional training and exercises what would be considered reasonable care in the situation, the provider will not be held liable. Good Samaritan laws vary tremendously from state to state, so it is important for athletic trainers to know the laws of their state. A person possessing more training in a given field or area is expected to possess a correspondingly higher level of competence than is a student.15 An individual will therefore be judged in terms of his or her performance in any situation in which legal liability may be assessed. It must be recognized that liability per se in all its various aspects is not assessed at the same level nationally, but varies in interpretation from state to state and from area to area. Athletic trainers therefore should know and acquire the level of competence expected in their particular area. In essence, negligence is conduct that results in the creation of an unreasonable risk of harm to others.10 A baseball batter was struck with a pitched ball directly in the orbit of the right eye and fell immediately to the ground. The athletic trainer ran to the player to examine the eye. There was some immediate swelling and discoloration around the orbit, but the eye appeared to be normal. The player insisted that he was fine and told the athletic trainer he could continue to bat. After the game the athletic trainer told the patient to go back to his room, put ice on his eye, and check in tomorrow. That night the baseball player began to hemorrhage into the anterior chamber of the eye and suffered irreparable damage to his eye. An ophthalmologist stated that if the patient’s eye had been examined immediately after the injury, the bleeding could have been controlled and there would not have been any damage to his vision.

misrepresentation, or duress.8 The most important thing about assumption of risk and liability relative to the athletic trainer is not about whether the participant assumes the risk of participating, but whether the athletic trainer has fully informed him or her of the risks of treatment, return to play, and other risks.

Reducing the Risk of Litigation

3–3 Clinical Application Exercise

The athletic trainer can significantly decrease the risk of litigation by paying attention to a number of important guidelines: An athletic trainer is cleaning out a filing cabinet in a rehabilitation clinic and decides to throw some older medical files away. Concern is expressed, however, about how long these files should be maintained for legal purposes.

? What is the statute of limitations for an adult patient to file suit?

1. W ork to establish good personal relationships with athletes, parents, patients, clients, and coworkers. 2. Establish specific policies and guidelines for the operation of an athletic training facility or clinic, and maintain qualified and adequate supervision of the facility, its environs, facilities, and equipment at all times.

3. D evelop, review annually, and carefully follow an emergency action plan. 4. Become familiar with the health status and medical history of the individuals under his or her care (see Chapter 2) so as to be aware of problems that could present a need for additional care or caution. 5. Keep factually accurate and timely records that document all injuries and rehabilitation steps, and set up a record retention policy that allows records to be kept and used in defense of litigation that may be brought by a patient. A record retention system needs to keep records long enough to defend against suits brought by patients after they reach the age of 18. 6. Document efforts to create a safe rehabilitation or training environment. 7. Have a detailed job description in writing. 8. Obtain, from parents or guardians when minors are involved, written consent for providing health care (see Chapter 2). 9. Maintain the confidentiality of medical records (see Chapter 2). 10. Exercise extreme caution in the administration, if allowed by law, of nonprescription medications; athletic trainers may not dispense prescription drugs. 11. Use only those therapeutic methods that he or she is qualified to use and that the law states may be used. 12. Do not use or permit the presence of faulty or hazardous equipment. 78

Part One ■ Professional Development and Responsibilities

13. Work cooperatively with the coach and the team physician in the selection and use of sports protective equipment, and insist that the best equipment be obtained, properly fitted, and properly maintained. 14. Do not permit injured players to participate unless cleared by the team physician. 15. Develop an understanding with the coaches that an injured patient will not be allowed to reenter competition until, in the opinion of the team physician or the athletic trainer, he or she is psychologically and physically able. Athletic trainers should not allow themselves to be pressured to clear a patient until he or she is fully cleared by the physician. 16. Follow the express orders of the physician at all times. 17. Purchase professional liability insurance that provides adequate financial coverage, and be aware of the limitations of the policy. 18. Know the limitations of his or her expertise as well as the applicable state regulations and restrictions that limit the athletic trainer’s scope of practice. 19. Use common sense in making decisions about a patient’s health and safety. In the case of an injury, the athletic trainer must use reasonable care to prevent additional injury until further medical care is obtained.29 (See Chapter 12 for additional comments.)

Product Liability Product liability is the liability of any or all parties along the chain of commerce of any product for damage caused by that product.19 This includes the manufacturer of component parts, an assembling manufacturer, the wholesaler, and the retail store owner. Products containing inherent defects that cause harm to a consumer of the product or to someone to whom the product was loaned or given are the subjects of product liability suits. Product liability claims can be based on negligence, strict liability, or breach of warranty of fitness depending on the circumstances upon which the claim is based. Many states have enacted comprehensive product liability statutes, and these statutory provisions can be very diverse. There is no federal product liability law. Manufacturers of athletic and rehabilitation equipment have a duty to produce equipment that will not cause injury as long as it is used as intended.23 If the product is not used correctly by the consumer, the manufacturer cannot be held liable. Manufacturers are strictly liable for defects in the design and production of equipment that produces injury. An athletic trainer must not alter the equipment in any way. To do so invalidates the manufacturer’s warranty and places liability solely on the athletic trainer. An express warranty is the manufacturer’s written statement that a product is safe. For example, warning labels on football helmets inform the player of possible dangers inherent in using the product. Individuals must read and sign a form indicating that they have read and understand the warning. The National Operating

FOCUS 3–1 Key Features and Benefits of the Affordable Care Act* Coverage • Health plans can no longer limit or deny benefits to children under 19 due to a preexisting condition. • If you are under 26, you may be eligible to be covered under your parent’s employer-sponsored health plan. • Insurers can no longer cancel your coverage just because you made an honest mistake. • You now have the right to ask that your plan reconsider its denial of payment.

Costs • Lifetime limits on most benefits are banned for all new health insurance plans.

Committee on Standards for Athletic Equipment (NOCSAE) establishes minimum standards for football helmets that must be met to ensure their safety.

INSURANCE CONSIDERATIONS Because of the high cost of medical care, every athlete should be covered by appropriate insurance policies that maximize the benefits should injury occur.20 Health insurance is a contract between an insurance company and a policyholder in which the insurance company agrees to reimburse a portion of the total medical bill after some deductible has been paid by the policyholder.39 During the past 40 years, the insurance industry has undergone a significant evolutionary process. Health care reform initiated in the 1990s was focused on the concept of managed care, in which costs of a health care provider’s medical care were closely dictated, monitored, and scrutinized by insurance carriers. Higher costs for medical care and a substantial increase in litigation relative to health care providers significantly increased the costs of health insurance.20 In 2010, the Affordable Care Act (ACA) was signed into law, and it represents a substantial regulatory overhaul of the system of health care in the United States. The Affordable Care Act includes comprehensive health insurance reforms designed to eliminate some of the worst practices of insurance companies and to essentially put consumers back in charge of their health care.6 The ACA builds upon the existing managed care health insurance system by (1) making health insurance coverage more accessible and affordable, (2) improving the quality of health care, (3) establishing legal protections for consumers, and

• Insurance companies must now publicly justify any unreasonable rate hikes. • Your premium dollars must be spent primarily on health care—not administrative costs.

Care • New plans must cover certain preventive services. • You can choose the primary care doctor you want from your plan’s network. • You can seek emergency care at a hospital outside of your health plan’s network and not be turned away and not have your claim denied. *From www.hhs.gov/healthcare/facts/timeline/timeline-text.html.

(4) providing mechanisms for consumers to choose the insurance that is the best fit for them individually. As of 2014, most Americans not covered by either an employersponsored health plan, or other public insurance programs, are required to have an approved private-insurance policy or pay a penalty.44 Focus Box 3–1 identifies the key features and benefits of the Affordable Care Act.

Types of Insurance The major types of insurance about which individuals concerned with athletic training and sports medicine should have some understanding are general health insurance, accident insurance, professional liability insurance, and catastrophic insurance, as well as insurance for errors and omissions. There is a need to protect adequately all who are concerned with health and safety. Focus Box 3–2: “Common insurance terminology” lists some of the more common insurance terms. General Health Insurance Every person must have a general health insurance policy that covers illness, hospitalization, and emergency Every person must have a care. Some institugeneral health insurance tions offer primary policy that covers illness, insurance coverage hospitalization, and emergency care. in which all medical expenses are paid for by the institution. The institutions pay an extremely high premium for this type of coverage. Most institutions offer some type of secondary insurance coverage, which pays the remaining medical bills once the personal insurance company has made its payment. It will cover many Chapter Three ■ Legal Concerns and Insurance Issues

FOCUS 3–2 Focus on Healthcare Administration and Professional Responsibilities Common insurance terminology11 Allowable charge: the maximum amount, according to the individual policy, that insurance will pay for each procedure or service performed. Beneficiary: a person eligible to receive the benefits of a specific policy or program. Benefits: services that an insurer, a government agency, or a health care plan offers to pay for an insured individual. Case management services: the process in which the attending physician or agent coordinates the care given to a patient by other health care providers and/or community organizations. Claim: a form sent to an insurance company, requesting payment for covered medical expenses; information includes the insured’s name and address, procedure codes, diagnostic codes, charges, and date of service. Clean claim: a filed claim with all the necessary information that may be immediately processed. Coinsurance: also referred to as copayment; the insurer and the insured split the cost of health care at a specified percentage, usually either 80/20 or 70/30. Contract: a legally binding agreement between an insurance company and a physician describing the duties of both parties. Copayment: a provision in an insurance policy requiring the policyholder to pay a specified percentage of each medical claim. Customary fees: the average fee charged for a specified service or procedure in a defined geographical area. Deductible: the amount owed by the insured on a yearly basis before the insurance company will begin to pay for services rendered. Dependent: a person legally eligible for benefits based on his or her relationship with the policyholder.

additional charges such as deductibles, copays, or coverage limits the primary insurer does not pay for. For example, if an athlete is injured, many colleges or universities will submit the medical bill to the family’s primary insurer for payment. The college or university will use a secondary insurance policy to cover any out-of-pocket expenses that the family would have paid. It is important to look closely into the athlete’s family’s primary insurer coverage to see exactly what is covered and what is not before an injury occurs. This is a time-consuming process, but it may eliminate many surprises that often arise with insurers. Many people are covered under some type of family health insurance policy. However, the institution or corporation must make certain that personal health insurance is arranged for or purchased by individuals not covered under family policies.36 A form letter directed to the 80

Part One ■ Professional Development and Responsibilities

Exclusions: specified medical services, disorders, treatments, diseases, and durable medical equipment that are listed as uncovered or not reimbursable in an insurance policy. Explanation of benefits (EOB): an insurance report accompanying all claim payments that explains how the insurance company processed a claim. Fee schedule: a comprehensive listing of the maximum payment amount that an insurance company will allow for specified medical procedures performed on a beneficiary of the plan. Gatekeeper: the primary care physician assigned by the insurer who oversees the medical care rendered to a patient and initiates all specialty and ancillary services. Participating provider: a health care provider who has entered into a contract with an insurance company to provide medical services to the beneficiaries of a plan; the provider agrees to accept the insurance company’s approved fee and will only bill the patient for the deductible, the copayment, and uncovered services. Policyholder: the person who takes out the medical insurance policy. Premium: a periodic payment made to an insurance company by an individual policyholder. Third-party administrator: an independent organization that collects premiums, pays claims, and provides administrative services within a health care plan. UCR allowable charge: usual, customary, and reasonable charge that represents the maximum amount an insurance company will pay for a given service based on geographical averages.

parents of all minors should be completed and returned to the institution to make certain that appropriate coverage is provided (Figure 3–1). Some so-called comprehensive plans do not cover every health need. For example, they may cover physicians’ care but not hospital charges. Many of these plans require large prepayments before the insurance takes effect. Supplemental policies, such as accident insurance and catastrophic insurance, are designed to take over where general health insurance stops. Accident Insurance Besides general health insurance, low-cost accident insurance is available. It often covers accidents on school grounds while the student is in attendance or accidents that occur in the workplace. The purposes of this insurance are to protect against financial loss from medical and hospital bills, encourage an injured

STUDENT-ATHLETE INSURANCE INFORMATION Student’s Full Name:____________________________________________________ PID ___________________ Date of Birth: ______/_____/______

Sport: ___________________________________

Sex: M_____ F____

UNC Hospital Medical Record Number (if first year, see attached instructions) ______________________________ IS YOUR SON/DAUGHTER COVERED BY HEALTH INSURANCE? YES________ *NO_______ Please complete insurance information below. Submit a copy of insurance card, front & back. Make sure copy is legible. *If you check no, please note all eligible students are required to have health insurance. Policyholder’s Information (Required to obtain authorization) Insurance Company Name: ____________________________ _____________ Policy Number _____________________ Group # ____________________ Policyholder Name: _______________________________ Relationship to Student Athlete: _____________________

State issued _____________ Type-HMO, PPO ________

Date of Birth: _____/______/______ Email of Policyholder ___________________________

Home Address, City, State, Zip: ____________________________________________________________________ Home Phone Number:_______________________

Cell Number ______________________________

Policyholder’s Employer: _____________________________________________________ Phone: _______________ Address, City, State, Zip: __________________________________________________________________ Do you have prescription drug coverage? Yes____ No____ If so, please complete plan information below and send a copy of the front and back of the Rx card. Rx Insurance Plan Name: ___________________________________ ID # ____________________________________________________ Rx Group # ______________________________________________ PCN # __________________________________________________ BIN # ___________________________________________________ Pharmacy Health Desk # ___________________________________ Do you have a separate Rx card? Yes____ No____ I give my permission to file a claim for medical services with the above health care insurer. Parent’s Signature:_________________________ Date:_____________________________

FIGURE 3-1 Sample Student-Athlete Insurance Form

3–4 Clinical Application Exercise

Source: Data from Campus Health Service, University of North Carolina.

An athletic trainer who recently became certified is planning on working summer camps for an area high school before he starts his full-time employment in the fall.

? What should the athletic trainer do to protect himself from liability?

patient to receive prompt medical care, encourage prompt reporting of injuries, and relieve an institution or a corporation of financial responsibility.42 General insurance may be limited; thus, accident insurance for a specific activity may be needed to provide additional protection.4 This type of coverage is limited and does not require knowledge of fault, and the

amount it pays is limited. For serious injuries requiring surgery and lengthy rehabilitation, accident insurance is usually not adequate. This inadequacy can put families with limited budgets into a financial bind. Of particular concern is insurance that does not adequately cover catastrophic injuries. Catastrophic Insurance Although catastrophic injuries are relatively uncommon, when they do occur, the consequences to the individual, family, and institution, as well as to society, can be staggering.36 In the past when available funds have been completely diminished, the family was forced to seek funding elsewhere, usually through a lawsuit. For example, in athletics, organizations such as the National Collegiate Athletic Association (NCAA) Chapter Three ■ Legal Concerns and Insurance Issues

3–5 Clinical Application Exercise

and National Association of Intercollegiate Athletics (NAIA) provide plans for the athlete who requires a lifetime of extensive medical and rehabilitative care because of a permanent disability.4 A program at the secondary-school level is offered to districts by the National Federation of State High School Associations (NFHS). These plans provide coverage for medical, rehabilitation, and transportation costs not covered by other insurance benefits.36 Costs for catastrophic insurance are based on the number of sports and the number of hazardous sports offered by the institution.

and omissions, and acts of negligence.39 Even when working in a program that has good liability coverage, each person within that program who works directly with students must have his or her own personal liability insurance.

Professional Liability Insurance Most employers have general liability insurance to protect against damages that may arise from injuries occurring Because of the amount of on their property. litigation for alleged negligence, Liability insurance all professionals should be fully covers claims of protected by professional liability negligence on the insurance. part of individuals.9 Its major concern is whether supervision was reasonable and if unreasonable risk of harm was perceived by the individual who was injured.28 Because of the amount of litigation based on alleged negligence, premiums have become almost prohibitive. Typically, a victim’s lawsuit has taken a shotgun approach, suing the employer athletic trainer, physician, administrator, and company or school district. If a piece of equipment is involved, the product manufacturer is also sued. All athletic trainers should carry professional liability insurance and must clearly understand the limits of its coverage. Liability insurance typically covers negligence in a civil case. If a criminal complaint is filed, however, liability insurance will not cover the athletic trainer. To offset the shotgun approach of lawsuits and to cover what is not covered by a general liability policy, errors and omissions liability insurance has evolved. It is designed to cover school employees, officers, and the district against suits claiming malpractice, wrongful actions, errors

Health maintenance organizations (HMOs) provide preventive measures and limit where the individual can receive care. Except in emergencies, permission must be obtained before the individual can go to another provider. HMOs generally pay 100 percent of the medical costs as long as care is rendered at an HMO Third-party payers: facility. Many sup• HMO plemental policies • PPO do not cover the • POS medical costs that • EPO would normally be • PHO paid by the general • TPA • Medicare policy. Therefore, • Medicaid an athlete treated • Workers compensation outside the HMO • Indemnity plans may be ineligible • Capitation for any insurance benefits. Many HMOs determine fees using a capitation system, which limits the amount that will be reimbursed for a specific service. It is essential that the athletic trainer understand the limits of and restrictions on coverage at his or her institution or company.

During a state gymnastics meet, a gymnast fell off the uneven parallel bars and landed on her forearm. The athletic trainer suspected a fracture and decided an X-ray was needed. The gymnast’s parents had general health insurance through a PPO, but because the gymnast was in severe pain, she was sent to the nearest emergency room to be treated. Unfortunately, the emergency facility was not on the list of preferred providers, and the insurance company denied the claim. The athletic trainer assured the parents that the meet organizers would take care of whatever medical costs were not covered by their insurance policy.

? Because the PPO denied

the claim, what type of insurance policy should the meet organizers carry to cover the medical costs?

Part One ■ Professional Development and Responsibilities

THIRD-PARTY REIMBURSEMENT Third-party reimbursement is the primary mechanism of payment for medical services in the United States.20 The policyholder’s insurance company reimburses health care professionals for services performed. Third-party reimbursement Medical insurance involves reimbursement by the policyholder’s insurance companies may company for services performed provide group and by health care professionals. individual coverage for employees and dependents.20 Managed care involves a prearranged system for delivering health care that is designed to control costs while continuing to provide quality care. To cut payout costs, many insurance companies pay for preventive care (to reduce the need for hospitalization) and limit where the individual can go for care. A number of health care systems have been developed to contain costs.22

Health Maintenance Organizations

Preferred Provider Organizations Preferred provider organizations (PPOs) provide discount health care but also limit where a person can go for treatment of an illness. The athletic trainer must be apprised in advance as to where the ill patient should be sent. Patients sent to a facility that is not on the approved list may be

Point of Service Plan The point of service (POS) plan is a combination of the HMO and PPO plans. It is based on an HMO structure, yet it allows members to go outside the HMO to obtain services. This flexibility is allowed only with certain conditions and under special circumstances.

Exclusive Provider Organizations Exclusive provider organizations (EPOs) are also a combination of the HMO and PPO plans. They are restrictive in the number and types of providers they have and consequently are more like an HMO. Most will not pay anything if you use out-of-network providers.

Physician Hospital Organization

with the states responsible for handling the administration of the program. Individual states administer Medicaid; thus, benefits vary by state.

Workers Compensation Workers compensation laws and benefits for injured workers are mandated by the states. Employers pay the premiums, and the claims are settled by workers compensation insurance carriers whose goal is to return injured workers to the workforce as soon as possible.

Indemnity Plans An indemnity plan is the most traditional form of billing for health care. It is a fee-for-service plan that allows the insured party to seek medical care without restrictions on utilization or cost. The provider charges the patient or a third-party payer for services provided. Charges are based on a set fee schedule.

Capitation

Physician hospital organizations (PHOs) involve a major hospital or hospital chain and its physicians. A PHO organization contracts directly with employers to provide services and/or contracts with a managed care organization.

Capitation is a form of reimbursement used by managed care providers in which members make a standard payment each month regardless of how much service is rendered to the member by the provider.

Third-Party Administrators

Third-Party Reimbursement for Athletic Trainers

Third-party administrators (TPAs) are frequently used to administer services and to pay claims for self-insured group plans and thus function as pseudo insurance companies. They perform member services, such as enrollment and billing, and assist with controlling utilization without the financial risk.

Medicaid is a health insurance program for people with low incomes and limited resources. Medicaid is funded by both the federal government and individual states,

Athletic trainers have always been able to bill third-party payers for services rendered. For many years, most insurers were reluctant to reimburse the athletic trainer for the health care services provided. Throughout the 1990s and early 2000s, there was a significant increase in reimbursement from third-party payers for athletic trainers working in a variety of settings, including rehabilitation clinics, hospitals, physicians’ offices, and college and university settings.26 Most third-party payers view “licensed health care professionals” as the only reimbursable entities, and fortunately in most states An athletic trainer working this includes certified in a clinic is seeking thirdathletic trainers. party reimbursement for In 1995, NATA estabathletic training services lished the Reimbursement performed. The athletic Advisory Group to monitrainer is experiencing difficulty obtaining tor managed care changes reimbursement from and to help the athletic certain payers because trainer secure a place as a of uncertainty about health care provider. Spethe effectiveness of the cifically, this group was treatment program. charged with developing What can the athletic a model for approaching trainer do to address the third-party payers for the concerns of the thirdreimbursement of athparty payers? letic training services, of educating athletic trainers

Chapter Three ■ Legal Concerns and Insurance Issues

Medicare Medicare is the federal health insurance program for the aged and disabled. Most people at retirement age qualify for Medicare benefits. There are four parts, or sections, to Medicare. Part A, the hospital portion, is normally premiumfree at retirement to the beneficiary. Part B, the physician portion, has a monthly premium charge to the beneficiary. Part C is a program that allows a person to choose among several types of health care plans, including medical savings accounts, managed care plans, and private feefor-service plans. Part D, a federal program to subsidize the costs of prescription drugs for Medicare beneficiaries, went into effect in 2006. Beneficiaries can either join a Prescription Drug Plan (PDP) for drug coverage only, or they can join a Medicare Advantage (MA) plan that covers both medical services and prescription drugs.

Medicaid

3–6 Clinical Application Exercise

required to pay for care, whereas, if they are sent to a preferred facility, all costs are paid.1 PPOs may provide added services, such as physical therapy, more easily and at no cost or at a much lower cost than would another insurance policy. PPOs pay on a fee-for-service basis.

on issues related to reimbursement, and, perhaps most important, of designing and implementing a data-based clinical outcomes study.5 In 1996, NATA initiated the Athletic Training Outcomes Assessment project designed to present supporting data that measure the results of interventions involving athletic training procedures. This three-year study was designed to provide data that focused on functional outcomes, including assessing the patients’ perceptions of their functional capabilities and their overall satisfaction with their treatment program; assessing the physical, emotional, and social well-being of patients; assessing health care cost effectiveness relative to time lost from activity due to injury; and assessing the number of treatments.1 The results of this study were critical in securing reimbursement for athletic training services, because the majority of third-party payers currently require outcomes research when evaluating a contract.25 Centers for Medicare & Medicaid Services (CMS) Ruling In 2005, the Centers for Medicare & Medicaid Services (CMS) issued a decision that has had and will continue to have a crippling effect on the ability of athletic trainers to receive reimbursement for health care services.40 The ruling stated that they would “no longer pay for therapy ‘incident to’ a physician’s services unless the provider is a physical therapist, occupational therapist or speech/language pathologist.” The U.S. Congress subsequently passed this ruling making it a federal law. Under this law, physicians are not able to bill Medicare for treatment provided by athletic trainers. Though not bound by this law, there is little doubt that the majority of third-party payers tend to follow the lead of Medicare and Medicaid when deciding who will be reimbursed for health care services provided. With passage of this law, it became clear that the federal government does not recognize athletic trainers as providers of rehabilitative services for Medicare patients, no matter what age.40 Certainly, this law directly and immediately affected reimbursement for athletic trainers working in clinics and hospitals or as an athletic trainer in physician practice. It has also caused many clinical athletic trainers who also work in secondary schools to lose their jobs. It is likely that the CMS law will also negatively impact future state and national legislative efforts on behalf of athletic trainers. Since that law was enacted, the NATA has continued to explore every means of legal recourse to have this law reversed or at least modified. In 2009, the Athletic Trainers’ Equal Access to Medicare Act (bill HR 1137) was introduced in the United States House of Representatives. This act sought to ensure that Medicare beneficiaries would have better access to health care provided by state licensed, certified athletic trainers. Unfortunately, this bill did not make it out of the congressional committee level, and thus it never became a law. Certainly, securing third-party reimbursement for athletic training services must continue to be a priority, especially for the clinical athletic trainer.37 84

Part One ■ Professional Development and Responsibilities

Insurance Billing The athletic trainer must routinely make certain that insurance claims are filed immediately and correctly.38 Athletic trainers working in educational settings can facilitate this process by collecting insurance information on every individual at the beginning of the year. The athletic trainer must ensure that every individual is adequately covered by a reliable insurance company. Although extremely time consuming, the athletic trainer can save a lot of headaches by vetting individual athlete’s insurance policies to make sure exactly what is covered by that particular policy and what is not. Letters should be drafted to the parents of all athletes, explaining the limits of the school insurance policy and what the parents must do to process a claim if injury does occur. Schools with secondary policies should stress that the parents must submit all bills to their insurance company before they submit the remainder to the school. In educational institutions, most claims will be filed with a single insurance company, which will pay for medical services provided by individual health care providers. Filing an Insurance Claim In most cases, when filing an insurance claim for a patient seen in a clinic or hospital, individuals other than health care providers are employed to make certain that a patient has provided current insurance information.13 The athletic trainer will likely not be the individual who is responsible for following up on insurance claims filed with third-party payers. In other employment settings, filing claims becomes the responsibility of the athletic trainer. This task can be highly time-consuming, taking the athletic trainer away from his or her major role of working directly with the patient. Because of the intricacies and time involved with continuously updating policy information, filing claims, and following up on communications with patients, parents, doctors, and vendors, a staff person other than the athletic trainer should be assigned this responsibility. When filing an insurance claim to submit for reimbursement, athletic trainers will find that most carriers accept a standard form labeled HCFA-1500/HCFA-1450 (Blue Cross Blue Shield uses Form UB-92). These forms must be completed in detail with as much information as possible. Experience dictates that the more accurately and thoroughly these forms are completed, the quicker and higher the rate of reimbursement. In some situations it may be necessary for the athletic trainer to request approval from insurance companies before treating patients.37 For example, preauthorization from the insurance provider is usually required when ordering any type of imaging other than radiographs. Athletic trainers working in the clinical setting should understand that the clinic must be able to collect reimbursement from third-party payers for services provided. Pre-authorization from the insurance provider is usually necessary when ordering any type of imaging other than radiographs. Two types of billing codes must be used when submitting a claim on standard HCFA-1500 or UB-92 forms to

The Current ProceA sports medicine clinic dure Terminology Code is considering hiring an (CPT) was first developed athletic trainer. However, by the American Medical the clinic administrator Association in 1966. Each is concerned that the year, an annual publication athletic trainer cannot designates changes corbill third-party payers for responding to significant services provided. updates in medical technol What does the ogy and practice. The CPT administrator need to code is used to identify be told about thirdspecific medical procedures party reimbursement for used in treating a patient.32 athletic training services? Table 3–1 lists the current CPT codes most often used by the athletic trainer. Athletic trainers should never release medical records to third-party payers unless written authorization has

TABLE 3–1 Description of Billing Codes Used by Athletic Trainers The following is a guide to procedure billing codes that may be used by athletic trainers when billing for athletic training services: 97005/97006 97750 97116 97110 97112 97530 97113 97124 97530 97140 97504 97150 97150 11040 97139 97139 95831 95851 95852 97545 97035 97035 97032 97033 97032 97034 97014 97022 97010 97010 97012 97016

Athletic trainer evaluation and reevaluation (per visit) Physical performance test (each 15 minutes) treatment charges Gait training (each 15 minutes) Therapeutic exercise (each 15 minutes) Neuromuscular reeducation (each 15 minutes) Therapeutic activities (each 15 minutes) Aquatic therapeutic exercise (each 15 minutes) Massage (each 15 minutes) Body mechanics training (each 15 minutes) Manual therapy (each 15 minutes) Orthotics fitting and training (each 15 minutes) Therapeutic procedures—group (each visit) Supervised exercise (each visit) Debridement (each visit) Wound care (each 15 minutes) Taping (each visit) Manual muscle testing—extremity/trunk Range of motion (ROM) measurements ROM measurements of hand, with or without comparison with normal side Work hardening/conditioning (initial 2 hours) Ultrasound (each 15 minutes) Phonophoresis (each 15 minutes) (must bill for ultrasound if billing for this service) Electrical stimulation (each 15 minutes) Iontophoresis (each 15 minutes) Constant electrical stimulation (each 15 minutes) Contrast baths (each 15 minutes) Electric stimulation (application to one or more areas) Whirlpool (application to one or more areas) Hot packs (application to one or more areas) Cold packs/ice massage (application to one or more areas) Traction, mechanical (not time-based) Compression pump (application to one or more areas)

Chapter Three ■ Legal Concerns and Insurance Issues

3–8 Clinical Application Exercise

3–7 Clinical Application Exercise

third-party payers: a diagnostic code and a proinsurance claim for cedural code.18 A diagrehabilitation services nostic code is required following injury, what for all procedural billing, can an athletic trainer and they can be found in do to improve the a book called the Interreimbursement rate as national Statistical Claswell as to speed up the sification of Diseases and process? Related Health Problems (ICD-10-Clinical Modifications). This is a sixdigit code that specifies the condition or injury that the athletic trainer or any other health care provider is treating.32 For example, code S93.419 indicates that the patient has a sprain of the calcaneofibular ligament in the ankle.

? When filing an

FOCUS 3–3 Focus on Healthcare Administration and Professional Responsibilities Guidelines for documentation of patient records When the athletic trainer is submitting a bill to a thirdparty payer for reimbursement for services provided, the following information should be included: • The patient’s updated medical history form • The patient’s most recent physical examination findings • Initial evaluation of the patient by the athletic trainer (SOAP note format) • Copies of notes to or from the referring physician • Diagnostic test results • An impression or diagnosis • A prescription or other state-mandated documentation from a physician

been obtained from the patient, according to HIPAA and FERPA guidelines.27 (See Chapter 2.) It is also essential when billing for and receiving reimbursement that the athletic trainer keep meticulous, accurate, and detailed documentation of all procedures, charges submitted, and payments received for services.2,38 Focus Box 3–3: “Guidelines for documentation of patient records” identifies criteria that should be routinely followed when billing for charges. National Provider Identifier (NPI) All Athletic Trainers must obtain an NPI. The National Provider Identifier (NPI) is a government-issued identification number for

• Established functional, measurable, and time-based treatment goals • Documentation that the treatment plan and goals were discussed and understood by the patient or guardian • The type, frequency, and number of treatments necessary to treat the problem • Copies of daily treatment records • Weekly progress notes • Established prognosis for recovery

individual health care providers and provider organizations (i.e., clinics, hospitals, group practices). Covered health care providers and all health plans and health care clearinghouses must use the NPIs in administrative and financial transactions, according to the Health Insurance Portability and Accountability Act (HIPAA). The NPI is a 10-digit numeric identifier. As of 2007, any health care provider who uses standard electronic transactions, such as electronic claims, eligibility verifications, claims status inquiries, and claim attachments, is required by federal law to include NPIs on electronic transactions. To apply for an NPI, go to https://NPPES.cms.hhs.gov.

SUMMARY • A great deal of care must be taken in following athletic training procedures that conform to the legal guidelines governing liability for negligence. • Liability is the state of being legally responsible for the harm one causes another person. It assumes that an athletic trainer would act according to the standard of care of any individual with similar educational background and training. • An athletic trainer who fails to use reasonable care—care that persons would normally exercise to avoid injury to themselves or to others under similar circumstances— may be found liable for negligence. • Although athletes participating in a sports program are considered to assume a normal risk, this assumption in no way exempts those in charge from exercising reasonable care. 86

Part One ■ Professional Development and Responsibilities

• Athletic trainers can significantly decrease the risk of litigation by making certain that they have done everything possible to provide a reasonable degree of care to the injured patient. • The major types of insurance about which athletic trainers should have some understanding are general health insurance, accident insurance, professional liability insurance, catastrophic insurance, and insurance for errors and omissions. • Third-party reimbursement is the primary mechanism of payment for medical services in the United States. A number of different health care systems have been developed to contain costs. • It is essential that the athletic trainer ensure that insurance claims are filed immediately and correctly using appropriate forms and billing codes.

WEB SITES America’s Health Insurance Plans: www.ahip.org

The nation’s most prominent trade association representing the private health care system. It is the nation’s premier provider of self-study courses on health insurance and managed care.

Duhaime & Co. Legal Dictionary: www.duhaime.org /dictionary

Part of a series of legal information, this site specifically addresses law in sport but is rather technical. The relevant area to sports medicine is addressed in the area titled “Torts.”

Sports Lawyers Journal: www.law.tulane.edu/tlsjournals /slj/index.aspx Specialized academic and professional publication on legal aspects of sports.

This is a site that has put together an extensive list of legal terms with clear definitions and explanations.

Legal Information Institute at Cornell: www.law.cornell .edu/wex/Sports_law

SOLUTIONS TO CLINICAL APPLICATION EXERCISES 3–1 An athletic trainer who assumes the duty of caring for an athlete has an obligation to make sure that appropriate care is given. If the athletic trainer fails to provide an acceptable standard of care, there is a breach of duty on the part of the athletic trainer, and the athlete must then prove that this breach caused the injury or made the injury worse. 3–2 A person possessing more training in a given field or area is expected to possess a correspondingly higher level of competence than a layperson is. A certified athletic trainer will therefore be judged in terms of his or her performance in any situation in which legal liability may be assessed. 3–3 In personal injury cases, the individual would typically have between one and five years to file suit for negligence. The statute of limitations begins to run on a plaintiff’s time to file a lawsuit for negligence either from the time of the negligent act or omission that gives rise to the suit or from the time of the discovery of an injury caused by the negligent act or omission. 3–4 The athletic trainer should purchase private professional liability insurance. In addition, the athletic trainer should keep proper records of injuries and keep those records in his or her possession. 3–5 Besides general health insurance, low-cost accident insurance often covers accidents on school grounds while the athlete is competing. The purposes of this insurance are to protect against financial loss from medical and hospital bills, encourage an injured athlete

to receive prompt medical care, encourage prompt reporting of injuries, and relieve a school of financial responsibility. 3–6 The athletic trainer could initiate an outcomes research project designed to present supporting data that measure the results of interventions involving athletic training procedures. This research project would assess the athletes’ perceptions of their functional capabilities and overall satisfaction with their treatment program, the cost-effectiveness of the health care relative to time lost from activity due to injury, and the number of treatments. The majority of third-party payers currently require outcomes research when evaluating a contract. 3–7 The athletic trainer should file an insurance claim for reimbursement, using the standard form labeled HCFA-1500. The form should be completed in detail with as much information as possible. The athletic trainer who completes these forms accurately and thoroughly probably experiences a quicker and higher rate of reimbursement. 3–8 It should be pointed out that athletic trainers can bill third-party payers for services rendered to a patient. Whether the insurance company will reimburse the athletic trainer for services is up to the individual third-party payer. With the approval of the uniform billing code for athletic training services, it is more likely that the athletic trainer will be successfully reimbursed for treating patients.

REVIEW QUESTIONS AND CLASS ACTIVITIES 1. What are the athletic trainer’s major legal concerns for negligence and for assumption of risk? 2. What measures can an athletic trainer take to minimize the chances of litigation, should an athlete be injured? 3. Invite an attorney who is familiar with sports litigation to class to discuss how athletic trainers can protect themselves from lawsuits. 4. Discuss what the athletic trainer must do to provide reasonable and prudent care in dealing with an injured patient.

5. Why is it necessary for an individual to have both general health insurance and accident insurance? 6. Briefly discuss the various methods of third-party reimbursement. 7. Why should an athletic trainer carry individual liability insurance? 8. What are the critical considerations for filing insurance claims?

REFERENCES 1. Albolm M, Campbell D, Konin J: Reimbursement for athletic trainers, Thorofare, NJ, 2001, Slack. 2. Altman S: Legal aspects of crisis-management communication: What to communicate, Athletic Therapy Today 10(3):6, 2005. 3. Appenzeller H: Safe at first: A guide to help sports administrators reduce their liability, Chapel Hill, NC, 1999, Carolina Academic Press.

4. Belk J: Health insurance today: A practical approach, St. Louis, 2012, Elsevier. 5. Campbell D: Workshop on third-party reimbursement, NATA News 3:34, 1996. 6. Coffin R: Affordable Care Act. Journal of Medical Practice Management 28(5):317–19, 2013. 7. Cotten D: 2005. Are you safe? Courts in an increasing number of states are enforcing liability waivers signed by parents on behalf of minors, Athletic Business 29(3):66–68; 70–72, 2005.

8. Cotten D: Waivers and releases can protect against liability, Fitness Management 20(4):24, 2004. 9. Cotten D: What is covered by your liability insurance policy? A risk management essential, Exercise Standard and Malpractice Reporter 15(4):54, 2001. 10. Cozillio M: Sports law: Cases and materials, Durham, NC, 2007, Carolina Academic Press.

Chapter Three ■ Legal Concerns and Insurance Issues

11. De Carlo M: Reimbursement for healthcare services. In Konin J: Clinical athletic training, Thorofare, NJ, 1997, Slack. Used with permission. 12. Eickhoff-Shemek J, Evans J: An investigation of law and legal liability content in masters academic programs in sports medicine and exercise science, Journal of Legal Aspects of Sport 10(3):172, 2000. 13. Flight M: Law, liability, and ethics for medical office professionals, Independence, KY, 2010, Cengage Learning. 14. Frenkel D: Medico-legal aspects in sport (abstract), Exercise & Society Journal of Sport Science (28):90, 2001. 15. Gallup E: Law and the team physician, Champaign, IL, 1995, Human Kinetics. 16. Gardiner S: Sports law, New York, 2012, Routledge. 17. Gardiner S, Gray J: Training regimes and medical treatment of elite sports athletes: Issues of legal liability. (Abstract) Journal of Science & Medicine in Sport 7 (4 Supplement): 111, 2004. 18. Garrison S: Fundamentals of coding, payment and documentation: Understanding their role and impact in healthcare, Chicago, 2011, American Medical Association. 19. Gorman L: Product liability in sports medicine. Athletic Therapy Today 4(4):36, 1999. 20. Green M, Rowell J: Understanding health insurance: A guide to billing and reimbursement, Albany, 2010, Delmar.

21. Harris D: Contemporary issues in healthcare law and ethics, Chicago, 2007, Health Administration Press. 22. Health Insurance Association of America: Fundamentals of health insurance, Washington, DC, 1997, HIAA. 23. Henderson J: Products liability: Problems and the consumer. Canton, OH, 1995, Professional Reports Corporation. 24. Herbert D, Herbert W: Legal aspects of preventive, rehabilitative and recreational exercise programs, ed 4, Canton, OH, 2002, PRC. 25. Hertel J: Research training for clinicians: The crucial link between evidence-based practice and third-party reimbursement (editorial), J Athl Train 40(2):69, 2005. 26. Hunt V: Reimbursement efforts continue steady progress, NATA News, October 10–12, 2002. 27. Jones D: HIPAA: Friend or foe to athletic trainers? Athletic Therapy Today 8(2):17, 2003. 28. Jones R: Professional and general liability insurance: When and why you need it. Sports Medicine Bulletin 9(24):6, 2013. 29. Kane S, White R: Medical malpractice and the sports medicine clinician, Clinical Orthopedics and Related Research, 467(2):412–19, 2009. 30. McClean S: Legal and ethical aspects of healthcare, New York, 2009, Cambridge University Press. 31. Mitten M: Legal considerations in treating the injured athlete, J Orthop Sports Phys Ther 21(1):38, 1995.

32. Moisio M: Guide to health insurance billing, Clifton Park, NY, 2006, Thompson Delmar Learning. 33. Pozgar G: Legal aspects of health care administration, 2011, Jones & Bartlett. 34. Osborne B: Principles of liability for athletic trainers: Managing sport-related concussion, Journal of Athletic Training 36(3):316 –21, 2001. 35. Quandt E: Legal liability in covering athletic events, Sports Health: A Multidiciplinary Approach, 1(1):84–90, 2009. 36. Rankin J: Athletic training management: Concepts and applications, New York, 2006, McGraw-Hill. 37. Ray R: Uniform billing code takes effect for ATCs, NATA News, Winter: 20, 2000. 38. Ray R: Management strategies in athletic training, Champaign, IL, 2011, Human Kinetics. 39. Rosenbaum S: Law and the American health care system, St. Paul, MN, 2012, West Academic- Foundation Press. 40. Rule change jeopardizes referrals to ATCs: Physician Sportsmed 33(7):10, 2005. 41. Sharp, L: Sports law: A managerial approach, Scottsdale, AZ, 2014, Holcomb Hathaway Publishers. 42. Vaughn E: Fundamentals of risk and insurance, New York, 2002, Wiley. 43. Wong G: Essentials of sports law, ed 4, Westport, CT, 2010, Greenwood Press 44. Yagoda L: Affordable Care Act for dummies, Hoboken, NJ, 2014, John Wiley & Sons.

ANNOTATED BIBLIOGRAPHY Albolm M, Campbell D, Konin J: Reimbursement for athletic trainers, Thorofare, NJ, 2001, Slack. Presents a “how to” approach for filing claims, appealing denials, and approaching payers. Covers all current trends in health care reimbursement as well as future directions for reimbursement. Appenzeller, H: Youth sports and the law: A guide to legal issues, Chapel Hill, NC, 2000, Carolina Academic Press. Studies various court cases to understand the legal principles involved in sport participation. The objective of the book is to provide better and safer sporting experiences for today’s children. Appenzeller, H: Risk management in sport: Issues and strategies, Chapel Hill, NC, 2005, Carolina Academic Press. Discusses risk management in sport law and industry. Topics include tort liability; medical, event, and facility issues; warnings, waivers, and informed consent; and youth sport and the law. Champion, W: Fundamentals of sports law, St. Paul, MN, 2005, Thomson/West.

Part One ■ Professional Development and Responsibilities

This introductory text lays out the basic ideas and legal documents important to attorneys, compliance officers, agents, athletic directors, and sports administrators. Grayson, E: Ethics, injury and the law in sports medicine, New York, NY, 2000, Butterworth-Heinemann. Provides an up-to-date review of the status of sports medicine and the law. Addresses the key legal and ethical issues in sports and exercise medicine. For practitioners and students preparing for sport and exercise medicine exams. Green, M, Rowell, J: Understanding health insurance: A guide to billing and reimbursement, Albany, NY, 2010, Delmar. Provides a comprehensive resource for dealing with issues related to insurance. Moisio, M: Guide to health insurance billing, Clifton Park, NY, 2006, Thompson Delmar Learning. All aspects of the billing process, from key terms to state and federal regulations, to guidelines for completing and submitting claims to health insurance programs.

PART

Risk Management

Fitness and Conditioning Techniques ■ Objectives When you finish this chapter you should be able to • Examine the roles of the athletic trainer and the strength and conditioning coach in getting an athlete fit. • Identify the principles of conditioning. • Defend the importance of the warm-up and cooldown periods. • Evaluate the importance of strength and flexibility and cardiorespiratory endurance for both athletic performance and injury prevention.

■ Outline The Relationship between Athletic Trainers and Strength and Conditioning Coaches 91 Principles of Conditioning 91 Warm-Up and Cool-Down 92 Cardiorespiratory Endurance 93 The Importance of Muscular Strength, Endurance, and Power 100 Improving and Maintaining Flexibility 113 Fitness Assessment 122 Periodization in Conditioning 122 Summary 124

• Analyze specific techniques and principles for improving cardiorespiratory endurance, muscular strength, and flexibility. • Discuss fitness testing and identify specific tests to assess various fitness parameters. • Apply the concept of periodization and identify the various training periods in each phase.

■ Key Terms SAID principle cardiorespiratory endurance training effect high-intensity interval training muscular strength power muscular endurance hypertrophy atrophy core isometric exercise concentric (positive) contraction eccentric (negative) contraction

isotonic exercise accommodating resistance isokinetic exercise circuit training plyometric exercise agonist antagonist autogenic inhibition ballistic stretching dynamic stretching static stretching proprioceptive neuromuscular facilitation (PNF)

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • Clinical application scenarios covering cardiorespiratory endurance, fitness training, conditioning and periodization • Click-and-drag questions covering muscular endurance, cardiorespiratory fitness, and conditioning activities • Multiple-choice questions covering warm-up, cool-down, muscular strength, roles of the athletic trainer in training athlete, and fitness testing • Selection questions covering flexibility

xercise is an essential factor in fitness conditioning, injury prevention, and injury rehabilitation. An athletic trainer working with an athletic population in secondary schools, in colleges and universities, or at the professional level is well aware that to compete successfully at a high Lack of physical fitness is one level, the athlete of the primary causes of sports injury. must be fit. An athlete who is not fit is more likely to sustain an injury. The athletic trainer should recognize that improper conditioning is one of the primary contributing factors to sports injuries. It is essential that the athlete engage in conditioning exercises that can minimize the possibility of injury while maximizing performance.55 The basic principles of conditioning exercises also apply to techniques of therapeutic, rehabilitative, or reconditioning exercises that are specifically concerned with restoring normal body function following injury. Athletic trainers providing patient care in a clinic or hospital are more likely to apply these principles to reconditioning or rehabilitation of an injured patient. The term therapeutic exercise is perhaps most widely used to indicate exercises that are used in a rehabilitation program. Regardless of whether the primary focus is making certain an athlete is fit or reconditioning an injured patient, the athletic trainer must understand the basic principles for improving cardiorespiratory endurance, muscle strength and endurance, and flexibility.

feel free to offer suggestions and make recommendations that are in the best interest of the athletes’ health and well-being. If it becomes apparent that a particular exercise or a specific training session seems to be causing an inordinate number of injuries, the athletic trainer should inform the strength and conditioning coach of the problem, so that some alternative exercise can be substituted. If an athlete is injured and is undergoing a rehabilitation program, it should be the athletic trainer’s responsibility to communicate to the strength and conditioning coach how the conditioning program should be limited and/or modified. The athletic trainer must respect the role of the strength and conditioning coach in getting the athlete fit. However, the responsibility for rehabilitating an injured patient should belong to the athletic trainer. In the majority of secondary-school settings, if a strength and conditioning coach is not available, the responsibility for ensuring that the athlete gets fit lies with the athletic trainer and the team coaches. In this situation, the athletic trainer very often assumes the role of a strength and conditioning coach in addition to his or her athletic training responsibilities. The athletic trainer frequently finds it necessary not only to design training and conditioning programs but also to oversee the weight room and to educate young, inexperienced athletes about getting themselves fit to compete. The athletic trainer must demand the cooperation of the team coaches in supervising the training and conditioning program.

THE RELATIONSHIP BETWEEN ATHLETIC TRAINERS AND STRENGTH AND CONDITIONING COACHES

PRINCIPLES OF CONDITIONING The following principles should be applied in all conditioning programs to minimize the likelihood of injury:

The responsibility for making certain that an athlete is fit for competition depends on the personnel who are available to oversee this aspect of the athletic program. At the professional level and at most colleges and universities, a full-time strength and conditioning coach is employed to conduct both team and individual training sessions. Many, but not all, strength coaches are certified by the National Strength and Conditioning Association. If a strength coach is involved, it is essential that both the athletic trainers and the team coaches communicate freely and work in close cooperation with the strength coach to ensure that the athletes achieve an optimal level of fitness. The specific role of the athletic trainer is to critically review the training and conditioning program designed by the strength and conditioning coach and to be extremely familiar with what is expected of the athletes on a daily basis. The athletic trainer should

1. Safety. Make the conditioning environment safe. Take time to educate individuals regarding pro per techniques, how they should feel during the workout, and when they should push harder or back off.41 2. Warm-up/cool-down. Take time to do an appropriate warm-up before engaging in any activity. Do not neglect the cool-down period after a training bout. 3. Motivation. Athletes are generally highly motivated to work hard because they want to be successful in their sport. Varying the training program and incorporating techniques of periodization can keep the program enjoyable rather than routine and boring. (See the discussion of periodization at the end of this chapter.) 4. Overload. To improve in any physiological component, the individual must work harder than he or she is accustomed to working. Logan and Wallis identified

Chapter Four ■ Fitness and Conditioning Techniques

the SAID principle, which directly relates to the principle of overload.62 SAID is an acronym for specific adaptation to imposed demands. The SAID principle states that, when the body is subjected to stresses and overloads of varying intensities, it will gradually adapt over time to overcome whatever demands are placed on it. For example, in weight training, as you progressively add more weight, the muscle tends to adapt to this increase in resistance by increasing in size and efficiency. Although overload is a critical factor in conditioning, the stress must not be great enough to produce damage or injury before the body has had a chance to adjust specifically to the increased demands. 5. Consistency. An individual must engage in a conditioning program on a regularly scheduled basis if it is to be effective. 6. Progression. Increase the intensity of the conditioning program gradually and within the individual’s ability to adapt to increasing workloads. 7. Intensity. Stress the intensity of the work rather than the quantity. Coaches and athletic trainers too often confuse working hard with working for long periods of time. They make the mistake of prolonging the workout rather than increasing tempo or workload. The tired athlete is prone to injury. 8. Specificity. Identify specific goals for the conditioning program. The program must be designed to address specific components of fitness (i.e., strength, flexibility, cardiorespiratory endurance) relative to the activity in which the individual is participating. 9. Individuality. The needs of different individuals vary considerably. The successful coach is one who recognizes these individual differences and adjusts or alters the conditioning program accordingly to best accommodate the individual. 10. Minimal stress. Expect that athletes will train as close to their physiological limits as they can. Push the athletes as far as possible, but consider other stressful aspects of their lives and allow them time to be away from the conditioning demands of their sport.

WARM-UP AND COOL-DOWN Warm-Up It is generally accepted that a period of warm-up exercises should take place before a training session begins, although a systematic review of the evidence-based literature reveals that there is insufficient evidence to endorse or discontinue a warm-up prior to exercise to prevent injuries, although the weight of the evidence favors a decreased risk of injury.39 Nevertheless, most athletic trainers would agree empirically that a warm-up period is a precaution against unnecessary musculoskeletal injuries and possible muscle soreness.28 Some evidence suggests that 92

Part Two ■ Risk Management

a good dynamic warm-up may also improve certain aspects of performance.3,40,97 The function of the warm-up is to prepare the body physiologically for some upcoming physical work.27 The purpose is to gradually stimulate the cardiorespiratory system to a moderate degree to increase the blood flow to working skeletal muscles and increase muscle temperature.103 Moderate activity speeds up the metabolic processes that produce an increase in core body temperature. An increase in the temperature of skeletal muscle alters the mechanical properties of the muscle. The elasticity of the muscle (the length to which the muscle can be stretched) is increased, and the viscosity (the rate at which the muscle can change shape) is decreased, which means that the muscle changes in shape more rapidly. A good warm-up routine should begin with 2 or 3 minutes of slow walking, light jogging, or cycling to increase metabolism and warm up the muscles. Breaking into a light sweat is a good indication that muscle temperature has increased. Although research has indicated that increasing core temperature is effective in reducing injuries, there is moderate to strong evidence that stretching during the warm-up does not reduce injury.90 Empirically, many professionals feel that stretching should be a part of the warm-up, and they continue to recommend that flexibility exercises be included. Six to twelve minutes of dynamic stretching is recommended to improve flexibility.83 Passive stretching, although not harmful, may not improve performance.82 Dynamic Warm-Up For many years, the accepted technique was to perform a light jog followed by some static stretching. A more contemporary approach to the warm-up is to use an active, or “dynamic,” warmup to prepare for physical activity. A Warming up involves general dynamic warm-up body warming and warming specific body areas for the involves continuous demands of the sport. movement using hopping, skipping, and bounding activities with several different footwork drills and patterns. It enhances coordination and motor ability as it revs up the nervous system. It prepares the muscles and joints in a more activity-specific manner than static stretching. The dynamic warm-up forces individuals to focus and concentrate. It should include exercises that address all the major muscle groups. The entire dynamic warm-up can be done in as little as 5 minutes or as long as 20 minutes, depending on the goals, age, and fitness level of the group. FocusBox4–1: “Dynamic warm-up routine” lists a series of activities that can be included in a dynamic warm-up. Activity should begin immediately following the warm-up routine. The individual should not wait longer than 15 minutes to begin the main sports activity after the warm-up, although the effects may last up to about 45 minutes.77

FOCUS 4–1 Focus on Therapeutic Intervention Dynamic warm-up routine Two sets of cones are spaced 10 to 20 yards apart. The individual performs the following dynamic exercises between the cones, then jogs back to the start. 1. Jog forward 2. Jog backward 3. Walking calf stretch 4. Walking hamstring stretch 5. Hand-assisted knee stretch to chest 6. Hand-assisted knee stretch to opposite shoulder 7. Hand-assisted walking adductor stretch 8. Lateral shuffle moving to the right followed by the left 9. Walking lateral lunge to the right followed by the left 10. Skipping with low knees

11. Walking lunge, arms extended overhead 12. Walking lunge with rotation to each side 13. Walking quadriceps stretch 14. Jogging butt kicks 15. Open the gate exercise 16. Close the gate exercise 17. Carioca to the right followed by the left 18. Power high knees skipping 19. Prancing 20. High knees running 21. Back pedaling butt kicks 22. Forward sprint

4–1 Clinical Application Exercise

Cool-Down Following a workout or training session, a cool-down period may be beneficial. The cool-down period enables the body to cool and return to a resting state. Such a A marathon runner comes period should last about into the sports medicine 5 to 10 minutes. An exclinic, complaining of ample of a cool-down feeling tightness in her activity would be to have lower extremity during the individual jog and workouts. She states that progressively decrease she has a difficult time the pace to a walk to during her warm-up and allow the metabolism to cannot seem to “get loose” until her workout is almost return to resting levels. complete. She feels that This would be followed she is always on the verge by stretching activities. of pulling a muscle. Although the warmup period is common, What should the athletic the importance of a cooltrainer recommend as a specific warm-up routine down period afterward that this patient should is often ignored. Again, consistently do before experience and observabeginning her workout? tion indicate that persons who stretch during the

cool-down period tend to have fewer problems with muscle soreness after strenuous activity.79

CARDIORESPIRATORY ENDURANCE Cardiorespiratory endurance is the ability to perform whole-

body, large-muscle activities for extended periods of time. The cardiorespiratory system provides a means by which oxygen is supplied to the various tissues of the body.44 For anyone who engages in exercise, cardiorespiratory endurance is critical both for performance and for preventing undue fatigue that may predispose the person to injury.

Transport and Utilization of Oxygen Basically, transport of oxygen throughout the body involves the coordinated function of four components: heart, lungs, blood vessels, and blood. The improvement of cardiorespiratory endurance through training occurs because of the increased capability of each of these four elements collectively to provide necessary oxygen to the working tissues. The greatest rate at which oxygen can be taken in and used during exercise is referred to as maximum aerobic capacity (V· O2max).34 The performance of Chapter Four ■ Fitness and Conditioning Techniques

Time

Submaximal heart rate

2–3 minutes Time

Percentage of maximum aerobic capacity

FIGURE 4–1 The greater the percentage of maximum

aerobic capacity required during an activity, the less time the activity may be performed.

any activity requires a certain rate of oxygen consumption that is about the same for all persons, depending on the level of fitness. Generally, the greater the rate or intensity of the performance of an activity, the greater the oxygen consumption. Each person has his or her own maximal rate of oxygen consumption. That person’s ability to perform an activity or to fatigue is closely related to the amount of oxygen required by that activity and is limited by the person’s maximal rate of oxygen consumption. The greater the percentage of maximum oxygen consumption required during an activity, the less time the activity may be sustained (Figure 4–1).69 The maximal rate at which oxygen can be used is a genetically determined characteristic; a person inherits a certain range of maximum aerobic capacity, and the more active that person is, the higher the existing maximum aerobic capacity will be in that range.31 A conditioning program allows an individual to increase maximum aerobic capacity to its highest limit within that person’s range. Maximum aerobic capacity is most often presented in terms of the volume of oxygen used relative to body weight per unit of time (ml/kg/min). A normal maximum aerobic capacity for most college-age athletes would fall in the range of 45 to 60 ml/kg/min.92 A world-class male or female marathon runner may have a maximum aerobic capacity in the 70 to 80 ml/kg/min range. Three factors determine the maximal rate at which oxygen can be used: external respiration involving the ventilatory process or pulmonary function; gas transport, which is accomplished by the cardiovascular system (i.e., the heart, blood vessels, and blood); and internal respiration, which involves the use of oxygen by the cells to produce energy. Of these three factors, the most limiting is generally the ability to transport oxygen through the system; thus, the cardiovascular system limits the overall rate of oxygen consumption. 94

Part Two ■ Risk Management

FIGURE 4–2 Two to three minutes are required for heart rate to plateau at a given workload.

A high maximum aerobic capacity within an individual’s inherited range indicates that all three systems are working well.

Effects on the Heart The heart is the main pumping mechanism, circulating oxygenated blood throughout the body to the working tissues. As the body begins to exercise, the muscles use oxygen at a much higher rate, and the heart must pump more oxygenated blood to meet this increased demand. The heart is capable of adapting to this increased demand through several mechanisms. Heart rate shows a gradual adaptation to an increased workload by becoming more efficient and increasing proportionally to the intensity of the exercise. Heart rate will plateau at a given level after about 2 to 3 minutes (Figure 4–2). At rest, the heart beats about 70 times per minute. The maximal heart rate is different in everybody, but it can be estimated by multiplying the person’s age in years by .70 and subtracting it from 208. Monitoring heart rate is an indirect method of estimating oxygen consumption. In general, heart rate and oxygen consumption have a linear relationship, although at very low intensities and at high intensities this linear relationship breaks down (Figure 4–3).36 During higherintensity activities, maximal heart rate may be achieved before maximal oxygen consumption, which will continue to rise.59 The greater the intensity of the exercise, the higher the heart rate. Because of these existing relationships, it should become apparent that the rate of oxygen consumption can be estimated by taking heart rate.17 A second mechanism by which the heart is able to adapt to increased demands during exercise is to increase the stroke volume—the volume of blood being pumped out with each beat.17 The heart pumps out approximately 70 ml of blood per beat. Stroke volume can continue to increase only to the point at which there is simply not enough time between beats for the heart to

Cardiac output

Percentage of maximum aerobic capacity

Maximum

100 90 80 70 60 50 40 30 20 10 10 20 30 40 50 60 70 80 90 100 Heart rate

FIGURE 4–3 Maximal heart rate is achieved at about the same time as maximum aerobic capacity.

Aerobic capacity

Maximum

FIGURE 4–5 Cardiac output limits maximum aerobic capacity.

is a muscle, it will hypertrophy to some extent, but this hypertrophy is in no way a negative effect of training. Stroke volume

Increased stroke volume

Decreased heart rate

of maximal heart rate.

fill up. This point occurs at about 40 percent of maximal heart rate, and above this level increases in the volume of blood being pumped out per unit of time must be caused entirely by increases in heart rate (Figure 4–4).66 Stroke volume and heart rate together determine the volume of blood being pumped through the heart in a given unit of time. This is referred to as the cardiac output, which indicates how much blood the heart is capable of pumping in exactly 1 minute.66 Approximately 5 L of blood are pumped through the heart during each minute at rest. Thus, cardiac output is the primary determinant of the maximal rate of oxygen consumption possible (Figure 4–5). During exercise, cardiac output increases to approximately four times that experienced during rest in the normal individual and may increase as much as six times in the elite endurance athlete. A training effect occurs with regard to cardiac output of the heart—the stroke volume increases while exercise heart rate is reduced at a given standard exercise load. The heart becomes more efficient because it is capable of pumping more blood with each stroke. Because the heart

Cardiorespiratory endurance plays a critical role in an individual’s ability to resist fatigue. Fatigue is closely related to the percentage of maximum aerobic capacity that a particular workload demands.17 Without sufficient oxygen, glycogen stores are quickly depleted. For example, Figure 4–6 presents two individuals, A and B. A has a maximum aerobic capacity of 50ml/kg/min, whereas B has a maximum aerobic capacity of only 40 ml/kg/min. If A and B are both exercising at the same intensity, A will be working at a much lower percentage of maximum aerobic capacity than B. Consequently, A should be able to sustain his or her activity over a much longer period of time. Performance may be impaired if the ability to use oxygen efficiently is A

50 Percentage of maximum aerobic capacity (ml/kg/min)

40%

FIGURE 4–4 Stroke volume plateaus at 40 percent

Effects on Work Ability

Heart rate

Cardiac output

40 30

Workload

20 10 0

Percentage of maximum aerobic capacity

FIGURE 4–6 Person A should be able to work longer

than Person B as a result of lower utilization of maximum aerobic capacity. Chapter Four ■ Fitness and Conditioning Techniques

impaired. Thus, improvement of cardiorespiratory endurance should be an essential component of any conditioning program.

The Energy Systems

4–2 Clinical Application Exercise

Various sports activities involve specific demands for energy. For example, sprinting and jumping are high-energy activities, requiring a relatively large production of energy for a short time. Long-distance running and swimming, on the other hand, are mostly low-energy activities per unit of time, requiring energy production for a prolonged time. Other physical activities demand a blend of both high- and low-energy output. These various energy demands can be met by the different processes in which energy can be supplied to the skeletal muscles. ATP: The Immediate Energy Source Energy is produced from the breakdown of nutrient foodstuffs.66 This energy is used to produce adenosine triphosphate A professional football (ATP), which is the ultiplayer sustained a grade 2 mate usable form of enhamstring strain during the ergy for muscular activity. sixth week of the season. Just before the playoffs, he ATP is produced in the reinjured the muscle while muscle tissue from blood doing some slow-speed glucose or glycogen. cutting drills. Unfortunately, Glucose is derived from he was forced to remain on the breakdown of dietary the injured reserve list for carbohydrates. Glucose the duration of the season not needed immediately despite his best efforts to is stored as glycogen in return. He has lost a great the resting muscle and deal of cardiorespiratory liver. Stored glycogen in fitness because he has the liver can later be conbeen unable to run, and he exhibits weakness in verted back to glucose and lower-extremity muscular transferred to the blood to strength because lifting has meet the body’s energy been difficult. needs. Fats and proteins can also be metabolized to Given that he will be generate ATP. required to attend two minicamps during the spring Once much of the and early summer and that muscle and liver glycopreseason practice officially gen is depleted, the body begins in July, what should relies more heavily on his conditioning plan be fats stored in adipose tisduring the postseason and sue to meet its energy the off-season? needs. The longer the duration and the lower the intensity of an activity, the greater the amount of fat that is used, especially during the later stages of endurance events. During rest and submaximal exertion, both fat and carbohydrates are used as an energy substrate in approximately a 60 percent to 40 percent ratio.66 Regardless of the nutrient source that produces ATP, it is always available in the cell as an immediate energy source. When all available sources of ATP are depleted, more must be regenerated for muscular contraction to continue.

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Aerobic versus Anaerobic Metabolism Three energy- generating systems function in muscle tissue to produce ATP: the ATP, glycolytic, and oxidative systems. During sudden outbursts of activity in intensive, short-term exercise, ATP can be rapidly metabolized to meet energy needs. However, after a few seconds of intensive exercise, the small stores of ATP are used up. The body then turns to stored glycogen as an energy source. Glycogen is broken down to supply glucose, which is then metabolized within the muscle cells to generate ATP for muscle contractions without the need for oxygen. This breakdown also produces a by-product called lactic acid that immediately dissociates to lactate, which seeps out of the muscle cells into the blood to be used elsewhere. This energy system is referred to as anaerobic metabolism.85 As exercise continues, the body has to rely on a more complex form of carbohydrate and fat metabolism to generate ATP. This energy system requires oxygen and is therefore referred to as aerobic metabolism. The aerobic system burns the lactate using oxygen, thus removing it and creating far more ATP than the anaerobic system. Normally, it takes about 20 minutes to clear the lactate from the system. Training to improve endurance helps an individual get rid of the lactic acid before it can build to the point where it contributes to muscle fatigue.5 In most activities, both aerobic and anaerobic systems function simultaneously.66 The degree to which the two are involved is determined by the intensity and duration of the activity. If the intensity of the activity is such that sufficient oxygen can be supplied to meet the demands of working tissues, the activity is considered to be aerobic. Conversely, if the activity is of high enough intensity or the duration is such that there is insufficient oxygen available to meet energy demands, the activity becomes anaerobic. Consequently, an oxygen debt is incurred, which must be paid back during the recovery period. For example, short bursts of muscle contraction, as in running or swimming sprints, use predominantly the anaerobic system. However, endurance events depend a great deal on the aerobic system. Most activities use a combination of anaerobic and aerobic metabolism and all activities will initially utilize the anaerobic energy system (Table 4–1).

Training Techniques for Improving Cardiorespiratory Endurance Cardiorespiratory endurance may be improved through several different training techniques.68 Largely, the amount of improvement possible will be determined by an individual’s initial levels of cardiorespiratory endurance. Continuous Training Continuous training involves four considerations: • • • •

Frequency of the activity Intensity of the activity Type of activity Time of the activity

TABLE 4–1

Comparison of Aerobic versus Anaerobic Activities

Relative Mode Intensity

Performance

Frequency

Duration

Miscellaneous

4–3 Clinical Application Exercise

Aerobic Continuous, Less intense 50% to 85% of At least three but 20 to 60 min Less risk to activities long-duration, maximum not more than sedentary sustained range six times per or older activities week individuals Anaerobic Explosive, short- More intense 85% to 100% of Three to four 10 sec to 2 min Used in sport activities duration, maximum times per week and team burst-type range activities activities

Frequency To see at least minimal improvement in cardiorespiratory endurance, it is necessary for the average person to engage in no fewer than three sessions A female soccer player has per week.5 If possible, an a grade 1 ankle sprain that is likely to keep her out of individual should aim for practice for about a week. four or five sessions per She has worked extremely week. A competitive athhard on her fitness levels lete should be prepared and is concerned that not to train as often as six being able to run for an times per week. Everyone entire week will hurt her should take at least one cardiorespiratory fitness. day per week off to allow What types of activity for both psychological should the athletic trainer and physiological rest.

must first determine your maximum heart rate (MHR). Exact determination of MHR involves exercising an individual at a maximal level and monitoring the heart rate (HR) using an electrocardiogram. This is a difficult process outside of a laboratory. Maximum heart rate is related to age, and, as you get older, your MHR decreases. An approximate estimate of MHR for individuals of both genders would be:

Intensity of Activity The intensity of the exercise is also a critical factor, although recommendations regarding training intensities vary. This is particularly true in the early stages of training, when the body is forced to make a lot of adjustments to increased workload demands.

HRR = HRmax − HRrest

recommend during her rehabilitation period that can help her maintain her existing level of cardiorespiratory endurance?

Determining Exercise Intensity by Monitoring Heart Rate The objective of aerobic exercise is to elevate heart

rate to a specified target rate and maintain it at that level during the entire workout. Because heart rate is directly related to the intensity of the exercise and to the rate of oxygen utilization, it becomes a relatively simple process to identify a specific workload (pace) that will make the heart rate plateau at the desired level.35 By monitoring heart rate, athletes know whether the pace is too fast or too slow to get the heart rate into a target range.85 Heart rate can be increased or decreased by speeding up or slowing down the pace. As mentioned, heart rate increases proportionately with the intensity of the workload and will plateau after 2 to 3 minutes of activity. Thus, the athlete should be actively engaged in the workout for 2 to 3 minutes before measuring his or her pulse. Several formulas allow you to identify a training target heart rate.44,54 To calculate a specific target heart rate, you

HRmax = 208 − 0.7 × Age

For a 20-year-old individual, maximum heart rate would be about 194 beats per minute (208 − 0.7 × 20). Heart rate reserve is used to determine upper and lower limits of the target heart rate range. Heart rate reserve (HRR) is the difference between resting heart rate (HRrest)* and maximum heart rate (HRmax).* The greater the difference, the larger your heart rate reserve and the greater your range of potential training heart rate intensities. The Karvonen equation is used to calculate target heart rate at a given percentage of training intensity.53 To use the Karvonen equation, you need to know your HRR. Target HR = HRrest + % of target intensity × HRR

When using estimated HRmax or/and HRrest, the values are always predictions. So, in a 20-year-old with a calculated HRmax of 194 and an HRrest of 70 beats per minute, the heart rate reserve is (124 (194 − 70 = 124)). For moderate-intensity activity, the heart should work in a range between the lower limit and an upper limit. The lower limit is calculated by taking 70 percent of the heart rate reserve and adding the resting heart rate, which would be 157 beats per minute ((124 × 0.7) + 70 = 157). The upper limit is calculated by taking 79 percent of the heart rate reserve and adding the resting heart rate ((124 × 0.79) + 70 = 168). The American College of Sports Medicine (ACSM) recommends that young healthy individuals train at either *

True resting heart rate should be monitored with the subject lying down. Chapter Four ■ Fitness and Conditioning Techniques

moderate intensity (70 to 79 percent of maximum heart rate) or vigorous intensity (greater than 80 percent of maximum heart rate) levels to improve cardiorespiratory endurance and reduce the risk for chronic disease.5 Individuals who are less fit, have led a previously sedentary lifestyle, are overweight, have a history of risk factors for heart disease, are elderly, have arthritis, and who have special instructions from a physician should engage initially in low-intensity workouts. For those individuals, the important thing is for them to become active; if they are persistent they should gradually be able to increase the intensity of the activity.5 Determining Exercise Intensity through Rating of Perceived Exertion Rating of perceived exertion (RPE)

can be used in addition to heart rate monitoring to indicate exercise intensity.35 During exercise, individuals are asked to rate subjectively on a numerical scale from 6 to 20 exactly how they feel relative to their level of exertion (Table 4–2). More intense exercise that requires a higher level of oxygen consumption and energy expenditure is directly related to higher subjective ratings of perceived exertion. Over time, individuals can be taught to exercise at a specific RPE that relates directly to more objective measures of exercise intensity. Type of Activity The type of activity used in continuous training must be aerobic.17 Aerobic activities are those that elevate the heart rate and maintain it at that level for an extended time. Aerobic activities generally involve repetitive, whole-body, large-muscle movements performed over an extended time. Examples of aerobic activities are running, jogging, walking, cycling, swimming, rope skipping, stair-climbing, and cross-country skiing. The advantage of these aerobic activities as opposed to more intermittent activities, such as racquetball, squash, basketball, or tennis, is that aerobic activities are easy to regulate by either speeding up or slowing down the pace. Because

TABLE 4–2 Scale 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Rating of Perceived Exertion Verbal Rating Very, very light Very light Fairly light Somewhat hard Hard Very hard Very, very hard

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the given intensity of the workload elicits a given heart rate, these aerobic activities allow athletes to maintain heart rate at a specified or target level. Intermittent activities involve variable speeds and intensities that cause the heart rate to fluctuate considerably. Although these intermittent activities improve cardiorespiratory endurance, their intensity is much more difficult to monitor. Time (Duration) of Activity For minimal improvement to occur, the ACSM recommends 20 to 60 minutes of workout/activity with the heart rate elevated to training levels.5 Generally, the greater the duration of the workout, the greater the improvement in cardiorespiratory endurance. The competitive athlete should train for at least 45 minutes per session. High-Intensity Interval Training Unlike continuous training, high-intensity interval training involves activities that are more intermittent. Interval training consists of alternating periods of relatively intense work and active recovery.19 It allows for performance of much more work at a more intense workload over a longer period than does working continuously.19 In continuous training, the athlete strives to work at an intensity of about 60 to 85 percent of maximum heart rate. Obviously, sustaining activity at the higher intensity over a 20-minute period is extremely difficult. The advantage of high-intensity interval training is that it allows work at the 80 percent or higher level for a short period followed by an active period of recovery during which the athlete may be working at only 30 to 45 percent of maximum heart rate. Thus, the intensity of the workout and its duration can be greater than with continuous training. High-intensity interval training has also been shown to improve cardiorespiratory fitness (VO2max) in as little as 2 weeks.94

Most sports are intermittent, involving short bursts of intense activity followed by a sort of active recovery period (e.g., football, basketball, soccer, or tennis).42 Training with the high-intensity interval training technique allows the athlete to be more sport specific during the workout. With high-intensity interval training, the overload principle is applied by making the training period much more intense. There are several important considerations in high-intensity interval training. The training period is the amount of time that continuous activity is actually being performed, and the recovery period is the time between training periods. A set is a group of combined training and recovery periods, and a repetition is the number of training/recovery periods per set. Training time or distance refers to the rate or distance of the training period. The training/recovery ratio indicates a time ratio for training versus recovery. An example of high-intensity interval training is a soccer player running sprints. An interval workout would involve running ten 120-yard sprints in under 20 seconds each, with a 1-minute walking recovery period between each sprint. During this training session, the soccer player’s heart rate will probably increase to 85 to 90 percent of maximum level during the sprint and will probably fall to the 35 to 45 percent level during the recovery period.

Fartlek Training Fartlek, a training technique that is a type of cross-country running originated in Sweden. Fartlek literally means “speed play.” It is similar to interval training in that the athlete must run for a specified period; however, specific pace and speed are not identified. The course for a fartlek workout should be a varied terrain with some level running, some uphill and downhill running, and some running through obstacles such as trees or rocks. The object is to put surges into a running workout, varying the length of the surges according to individual purposes. One big advantage of fartlek training is that because the pace and terrain are always changing, the training session is less regimented and allows for an effective alternative in the training routine. Most people who jog or walk around the community are really engaging in a fartlek-type workout.

Again, if fartlek training is going to improve cardiorespiratory endurance, it must elevate the heart rate to at least minimal training levels (60 to 85 percent). Fartlek may best be used as an off-season conditioning activity or as a change-of-pace activity to counteract the boredom of a training program that uses the same activity day after day.

Equipment for Improving Cardiorespiratory Endurance The extent and variety of fitness and exercise equipment available to the consumer are at times mind boggling (Figure 4–7). Prices of equipment can range from $2 for a jump rope to $60,000 for certain computer-driven isokinetic devices. It is certainly not necessary to purchase

FIGURE 4–7 Fitness equipment. (A) Stationary bike. (B) Recumbent bike. (C) Treadmill. (D) Stair climber. (E) Elliptical exerciser. (F) Rowing machine. (G) Upper-extremity ergometer.

(a–c) Courtesy Cybex International; (d) Courtesy Stairmaster; (e) Courtesy Body-Solid, Inc; (f) Stamina Products, Inc.; (g) Courtesy First Degree Fitness

Chapter Four ■ Fitness and Conditioning Techniques

4–4 Clinical Application Exercise

THE IMPORTANCE OF MUSCULAR STRENGTH, ENDURANCE, AND POWER The development of muscular strength is an essential component of a conditioning program for every athlete. Strength is the ability of a muscle to generate force against some resistance. Most movements in sports are explosive and must include elements of both strength and speed if they are to be effective. If a large amount of force is generated quickly, the movement can be referred to as a power movement. Without the A college swimmer has been ability to generate power, engaged in an off-season an athlete is limited in weight-training program his or her performance to increase her muscular capabilities.77 strength and endurance. Muscular strength is Although she has seen some improvement in her closely associated with strength, she is concerned muscular endurance. that she also seems to be Muscular endurance is losing flexibility in her the ability to perform shoulders, which she feels is repetitive muscular con- critical to her performance tractions against some as a swimmer. She has also resistance for an exnoticed that her muscles tended period of time. are hypertrophying to some As muscular strength degree and is worried that increases, there tends to this may be causing her to be a corresponding inlose flexibility. She has just about decided to abandon crease in endurance.59,99 her weight-training program For example, an indialtogether. vidual can lift a weight 25 times. If muscular What can the athletic strength is increased trainer recommend to by 10 percent through her that will allow her to continue to improve weight training, it is her muscular strength likely that the maximum and endurance while number of repetitions maintaining or perhaps even will be increased because improving her flexibility? it is easier for the individual to lift the weight.

Physiological and Biomechanical Factors That Determine Levels of Muscular Strength Muscular strength is proportional to the cross-sectional diameter of the muscle fibers. The greater the crosssectional diameter or the bigger a particular muscle, the stronger it is, and thus the more force it is capable of generating. The size of a muscle tends to increase in 100

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cross-sectional diameter with weight training. This increase in muscle size is referred to as hypertrophy.51 Conversely, a decrease in the size of a muscle is referred to as atrophy. Size of the Muscle Strength is a function of the number and diameter of muscle fibers composing a given muscle. The number of fibers is an inherited characteristic; thus, an individual with a large number of muscle fibers to begin with has the potential to hypertrophy to a much greater degree than does someone with relatively fewer fibers.51 Explanations for Muscle Hypertrophy A number of theories have been proposed to explain why a muscle hypertrophies in response to strength training.66 Some evidence exists that the number of muscle fibers increases because fibers split in response to training.37 However, this research has been conducted in animals and should not be generalized to humans. It is generally accepted that the number of fibers is genetically determined and does not seem to increase with training. Another hypothesis is that because the muscle is working harder in weight training, more blood is required to supply that muscle with oxygen and other nutrients. Thus, the number of capillaries is increased. This hypothesis is only partially correct; few new capillaries are formed during strength training, but a number of dormant capillaries may become filled with blood to meet the increased demand for blood supply. A third theory to explain this increase in muscle size seems the most credible. Muscle fibers are composed primarily of small protein filaments, called myofilaments, which are the contractile elements in muscle. These myofilaments increase in both size and number as a result of strength training, causing the individual muscle fibers themselves to increase in cross-sectional diameter.37 This increase is particularly true in men, although women also see some increase in muscle size.1 More research is needed to further clarify and determine the specific causes of muscle hypertrophy. Improved Neuromuscular Efficiency Typically with weight training, an individual sees some remarkable gains in strength initially, even though muscle bulk does not necessarily increase. This gain in strength must be attributed to something other than muscle hypertrophy. For a muscle to contract, an impulse must be transmitted from the nervous system to the muscle.

A college freshman on the varsity basketball team lacks motivation to improve her strength and fitness over the summer and during the off-season. The coaches are frustrated with her attitude and go to the athletic trainer for advice.

? How can the athletic

trainer convince the athlete of the importance of strength and conditioning?

4–5 Clinical Application Exercise

expensive exercise equipment to see good results. Many of the same physiological benefits can be achieved from using a $2 jump rope as from running on a $10,000 treadmill.

Biceps

24 cm

Effort arm

Biceps

22 cm Effort arm

FIGURE 4–8 The position of attachment of the muscle tendon on the arm can affect the ability of that muscle to generate force. Person B should be able to generate greater force than person A because the tendon attachment is closer to the resistance.

Other Physiological Adaptations to Resistance Exercise In addition to muscle hypertrophy, there are a number of other physiological adaptations to resistance training.85 The strength of noncontractile structures, including tendons and ligaments, is increased. The mineral content of bone is increased, making the bone stronger and more resistant to fracture. Maximal oxygen uptake is improved when resistance training is of sufficient intensity to elicit heart rates at or above training levels. Several enzymes important in aerobic and anaerobic metabolism also increase.17,66 Biomechanical Factors Strength in a given muscle is determined not only by the physical properties of the muscle itself but also by biomechanical factors that dictate how much force can be generated through a system of levers to an external object.47 If we think of the elbow joint as one of these lever systems, we would have the biceps muscle producing flexion of this joint (Figure 4–8). The position of attachment of the biceps muscle on the lever arm—in this case, the forearm—will largely determine how much force this muscle is capable of generating.43 If there are two persons, A and B, and person B has a biceps attachment that is farther from the center of the joint than is person A’s, then person B should be able to lift heavier weights because the muscle force acts through a longer lever (moment) arm and thus can produce greater torque around the joint. The length of a muscle determines the tension that can be generated.47 By varying the length of a muscle,

different tensions may be produced. This length-tension relationship is illustrated in Figure4–9. At position B in the curve, the interaction of the crossbridges between the actin and myosin myofilaments within the sarcomere is at a maximum. Setting a muscle at this length will produce the greatest amount of tension. At position A the muscle is shortened, and at position C the muscle is lengthened. In either case, the interaction between the actin and myosin myofilaments through the crossbridges is greatly reduced, and the muscle is not capable of generating significant tension. Overtraining Overtraining can have a negative effect on the development of muscular strength. Overtraining can result in psychological breakdown (staleness) or physiological breakdown, which may involve musculoskeletal injury, fatigue, or sickness. Engaging in proper and efficient resistance training, eating a proper diet, and getting appropriate rest can minimize the potential negative effects of overtraining.

Tension

Each muscle fiber is innervated by a specific motor unit. By overloading a particular muscle, as in weight training, the muscle is forced to work efficiently. Efficiency is achieved by getting more motor units to fire, causing a stronger contraction of the muscle.101 Consequently, it is not uncommon to see extremely rapid gains in strength when a weight-training program is first begun due to an improvement in neuromuscular function.51

Muscle length

FIGURE 4–9 Because of the length-tension relation in muscle, the greatest tension is developed at point B, with less tension developed at points A and C. Chapter Four ■ Fitness and Conditioning Techniques

101

Fast-Twitch versus Slow-Twitch Fibers and Muscular Endurance Skeletal muscle fibers in a particular motor unit are either slow-twitch or fast-twitch fibers, each of which has distinctive metabolic and contractile capabilities. Slowtwitch (ST) fibers, also referred to as type I or slow oxidative (SO) fibers, are dense with Four basic types of muscle fibers: capillaries and are • Slow-twitch, or type I rich in mitochon• Fast-twitch type IIa dria and myoglo• Fast-twitch type IIb bin, giving the • Fast-twitch type IIx muscle tissue its characteristic red color. They can carry more oxygen and thus are more resistant to fatigue than are fast-twitch fibers.17 Slow-twitch fibers are associated primarily with long-duration, aerobictype activities.66 Fast-twitch (FT) fibers are referred to as type II or fast oxidative glycolytic (FOG) fibers. They are capable of producing quick, forceful contractions but have a tendency to fatigue more rapidly than do slow-twitch fibers. Fast-twitch fibers are useful in short-term, highintensity activities, which mainly involve the anaerobic system. Fast-twitch fibers are capable of producing powerful contractions, whereas slow-twitch fibers produce a long-endurance type of force. Fast-twitch fibers can be subdivided into three groups, although all three types are capable of rapid contraction. Type IIa fibers, like slow-twitch muscle fibers, are moderately resistant to fatigue. Type IIx, also known as fast glycolytic (FG) and occasionally type IId, are less dense in mitochondria and myoglobin than type IIa. This is the fastest muscle type in humans and it can contract more quickly and with a greater amount of force than type IIa. But these fibers can sustain only short, anaerobic bursts of acitivity before muscle contraction becomes painful. Type IIb fibers are less dense in mitochondria and myoglobin and fatigue rapidly. They are white in color and are considered the “true” fast-twitch fibers.66 Any given muscle contains all types of fibers, and the ratio in an individual muscle varies with each person.17 Those muscles whose primary function is to maintain posture against gravity require more endurance and have a higher percentage of slow-twitch fibers. Muscles that produce powerful, rapid, explosive strength movements tend to have a much greater percentage of fast-twitch 102

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fibers. Because this ratio is genetically determined, it may play a large role in determining ability for a given sport activity. Sprinters and weight lifters, for example, have a large percentage of fast-twitch fibers in relation to slow-twitch fibers.17 Conversely, marathon runners generally have a higher percentage of slow-twitch fibers. The metabolic capabilities of both fast-twitch and slow-twitch fibers may be improved through specific strength and endurance training. It appears that there can be an almost complete change from slow-twitch to fast-twitch and from fast-twitch to slow-twitch fiber types in response to training.66 Fibers that are in the process of transitioning from one fiber type to another share some properties of both type I and type II fibers and are referred to as “hybrid” fibers.

A high-school shotputter has been working intensely on weight training to improve his muscular power. In particular, he has been concentrating on lifting extremely heavy free weights, using a low number of repetitions (three sets of six to eight repetitions). Although his strength has improved significantly over the last several months, he is not seeing the same degree of improvement in his throws, even though his coach says that his technique is very good.

The athlete is frustrated with his performance and wants to know if there is anything else he can do in his training program that might enhance his performance.

Skeletal Muscle Contractions Skeletal muscle is capable of three types of contraction: isometric contraction, concentric contraction, and eccentric contraction.25 An Skeletal muscle is capable isometric contrac of three types of contraction: tion occurs when the muscle con• Isometric tracts to increase • Concentric tension but there • Eccentric is no change in the length of the muscle. Considerable force can be generated against some immovable resistance even though no movement occurs. In concentric contraction, the muscle shortens in length as a contraction is developed to overcome or move some resistance. In eccentric contraction, the resistance is greater than the muscular force being produced, and the muscle lengthens while continuing to contract. Concentric and eccentric contractions are both considered to be dynamic movements.25 It is critical to understand that functional movements involve acceleration, deceleration, and stabilization in all three planes of motion simultaneously. Functional movements are controlled by neuromuscular mechanoreceptors located within the muscle.25

4–6 Clinical Application Exercise

Reversibility If strength training is discontinued or interrupted, the muscle will atrophy, decreasing in both strength and mass. Adaptations in skeletal muscle that occur in response to resistance training may begin to reverse in as little as 48 hours. It does appear that consistent exercise of a muscle is essential to prevent loss of the hypertrophy that occurs due to strength training.

Techniques of Resistance Training There are a number of techniques of resistance training for strength improvement, including functional strengthtraining exercises, core stability training, isometric exercise, progressive resistance exercise, isokinetic exercise, circuit training, calisthenic strengthening exercises, and plyometric exercise. Regardless of which of these techniques is used, one basic principle of training is extremely important. For a muscle to improve in strength, it must be forced to work at a higher level than it is accustomed to working. In other words, the muscle must be overloaded. Without overload, the muscle will be able to maintain strength as long as training is continued against a resistance the muscle is accustomed to. To most effectively build muscular strength, weight training requires a consistent, increasing effort against progressively increasing resistance.32 If this principle of overload is applied, all eight conditioning techniques can produce improvement in muscular strength over a period of time. Functional Strength Training For many years, the strength-training techniques in conditioning or rehabilitation programs have focused on isolated, single-plane exercises used to elicit muscle hypertrophy in a specific muscle. These exercises have a very low neuromuscular demand because they are performed primarily with the rest of the body artificially stabilized on stable pieces of equipment.25 The central nervous system controls the ability to integrate the proprioceptive function of a number of individual muscles that must act collectively to produce a specific movement pattern that occurs in three planes of motion. If the body is designed to move in three planes of motion, then isolated training does little to improve functional ability. When strength training using isolated, single-plane, artificially stabilized exercises, the entire body is not being prepared to deal with the imposed demands of normal daily activities (walking up or down stairs, getting groceries out of the trunk, etc.).25 Functional strength training provides a unique approach that may revolutionize the way the sports medicine community thinks about strength training. To understand the approach to functional strength training, the athletic trainer must understand the concept of the kinetic chain and must realize that the entire kinetic chain is an integrated functional unit. The kinetic chain is composed of not only muscle, tendons, fasciae, and ligaments but also the articular system and the neural system. All of these systems function simultaneously as an integrated unit to allow for structural and functional efficiency. If any system within the kinetic chain is not working efficiently, the other systems are forced to adapt and compensate; this can lead to tissue overload, decreased performance, and predictable patterns of injury. The functional integration of the systems allows for optimal neuromuscular efficiency during functional activities.16,25

During functional movements, some muscles con tract concentrically (shorten) to produce movement, others contract eccentrically (lengthen) to allow movement to occur, and still other muscles contract isometrically to create a stable base on which the functional movement occurs. These functional movements occur in three planes. Functional strength training uses integrated exercises designed to improve functional movement patterns in terms of not only increased strength and improved neuromuscular control but also high levels of stabilization strength and dynamic flexibility.16 Unlike traditional strength-training techniques, which use barbells, dumbbells, or exercise machines and single-plane exercises day after day, a primary principle of functional strength training is to make use of training variations to force constant neural adaptations instead of concentrating solely on morphological changes. Exercise variables that can be changed include the plane of motion, body position, base of support, upper- or lower-extremity symmetry, the type of balance modality, and the type of external resistance.25 Table 4–3 lists these exercise training variables. Figure 4–10 provides examples of functional strengthening exercises. Core Stability Training A core stabilization training program is designed to help an individual gain strength, neuromuscular control, power, and muscle endurance of the muscles in the lumbar spine, in the abdomen, and around the hips and pelvis.87 These muscles are collectively referred to as the core.26 The concept of core stability training is essential. A weak core is a fundamental problem of inefficient movements that lead to injury.61 If the muscles in the extremities are strong and the core is weak, the force required for efficient movements cannot be produced. Core stability training should be an important component of all comprehensive strengthening programs.18,30,74 Dynamic core stabilization programs and exercises are discussed in detail in Chapters 16 and 25. Figure 4–11 shows several examples of exercises that may be used to improve core stability. Isometric Exercise An isometric exercise involves a muscle contraction in which the length of the muscle remains constant while tension develops toward a maximal force against an immovable resistance.9 The muscle should generate a maximal force for 10 seconds at a time, and this contraction should be repeated 5 to 10 times per day. Isometric exercises are capable of increasing muscular strength; unfortunately, strength gains are relatively specific to the joint angle at which training is performed. At other angles, the strength curve drops off dramatically because of a lack of motor activity at that angle. Another major disadvantage of isometric exercises is that they tend to produce a spike in systolic blood pressure, which can result in potentially life-threatening Chapter Four ■ Fitness and Conditioning Techniques

103

TABLE 4–3

Exercise Training Variables

Plane of Motion

Body Position

Base of Support

■

Sagittal Frontal ■ Transverse ■ Combination

■

Supine Prone ■ Side-lying ■ Sitting ■ Kneeling ■ Half kneeling ■ Standing

■

Exercise bench ■ Stability ball ■ Balance modality ■ Other

UpperExtremity Symmetry

LowerExtremity Symmetry

■

2 arms Alternate arms ■ 1 arm ■ 1 arm w/ rotation

■

2 legs Staggered stance ■ 1 leg ■ 2-leg unstable ■ Staggered stance unstable ■ 1-leg unstable

Balance Modality Floor Sport beam ■ ½ foam roll ■ Airex pad ■ Dyna disc ■ BOSU ■ Proprio shoes ■ Sand

External Resistance Barbell Dumbbell ■ Cable machines ■ Tubing ■ Medicine balls ■ Power balls ■ Bodyblade ■ Other ■

■

Source: Modified from National Academy of Sports Medicine, Phoenix, AZ.

FIGURE 4–10 Functional strengthening exercises use simultaneous movements (concentric, eccentric, and isometric

contractions) in three planes on both stable and unstable surfaces. (A) Stability ball diagonal rotations with weighted ball. (B) Tandem stance on Dyna disc with trunk rotation. ( C) Standing diagonal rotations with cable or tubing reistance. (D) Weight-resisted multiplanar lunges. (E) Front lunge balance to one-arm press. (F) Weighted-ball double arm r otation toss from squat. © William E. Prentice

104

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FIGURE 4–11 Core stability exercises. (A) Bridging. (B) Prone cobra. ( C) Side-lying isolated abdominal. (D) Human arrow. (E) Stability ball push-up. (F) Hip-ups on stability ball.

cardiovascular accidents.77 This sharp increase in blood pressure results from an individual holding his or her breath and increasing intrathoracic pressure. Consequently, the blood pressure the heart experiences is increased significantly. This phenomenon has been referred to as the Valsalva effect. To avoid or minimize this increase in pressure, it is recommended that breathing be continued during the maximal contraction. Isometric exercises are useful in the rehabilitation of certain injuries; this use is discussed in the rehabilitation sections in Chapters 18 through 26. Progressive Resistance Exercise A third technique of resistance training is perhaps the most commonly used and the most popular technique for improving muscular strength. Progressive resistance exercise (PRE) strengthens muscles through a contraction that overcomes some fixed resistance produced by equipment, such as dumbbells, barbells, resistance tubing or bands, or various weight machines (Figure 4–12). Progressive resistance exercise uses

isotonic contractions that generate force while the muscle is changing in length.32 Isotonic Contractions Isotonic contractions may be either concentric or eccentric. An individual who is performing a biceps curl offers a good example of an isotonic contraction. To lift the weight from the starting position, the biceps muscle must contract and shorten in length. This shortening contraction is referred to as a concentric, or positive, contraction. If the biceps muscle does not remain contracted when the weight is being lowered, gravity will cause the weight to simply fall back to the starting position. Thus, to control the weight as it is being lowered, the biceps muscle must continue to contract while gradually lengthening. A contraction in which the muscle is lengthening while still applying force is called an eccentric, or negative,

contraction.52

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FIGURE 4–12 (A) Barbells and dumbbells are free weights that assist in developing isotonic strength. (B) Many machine exercise systems provide a variety of exercise possibilities. © William E. Prentice

than with a concentric contraction. This greater force occurs because eccentric contractions require a much lower level of motor unit activity to achieve a certain force than do concentric contractions. Because fewer motor units are firing to produce a specific force, additional motor units may be recruited to generate increased force. In addition, oxygen utilization is much lower during eccentric exercise than during comparable concentric exercise. Thus, eccentric contractions are more resistant to fatigue than are concentric contractions. The mechanical efficiency of eccentric exercise may be several times higher than that of concentric exercise.52 Concentric contractions accelerate movement, whereas eccentric contractions decelerate motion. For example, the hamstrings must contract eccentrically to decelerate the angular velocity of the lower leg during running. Likewise, the external rotators in the rotator cuff muscles surrounding the shoulder contract eccentrically to decelerate the internally rotating humerus during throwing. Because of the excessive forces involved with these eccentric contractions, injury to the muscles is quite common. Thus, eccentric exercise must be routinely incorporated into the strength-training program to prevent injury to those muscles that act to decelerate movement. Free Weights versus Machine Weights Various types of exercise equipment can be used with progressive resistance exercise, including free weights (barbells and dumbbells) or exercise machines. Dumbbells and barbells require the use of iron plates of varying weights that can be changed easily by adding or subtracting equal amounts of weight to both sides of the bar. The exercise machines have a stack of weights that are lifted through a series of levers or pulleys. The stack of weights slides up and down on a pair of bars that restrict the movement to only one plane. Weight can be increased or decreased simply by changing the position of a weight key (Figure 4–13). Both free weights and exercise machines have advantages and disadvantages. The exercise machines are 106

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FIGURE 4–13 On most exercise machines the resistance can be easily changed by inserting a weight key into the weight stack at the desired weight level. © William E. Prentice

relatively safe to use compared with free weights. It is also a simple process to increase or decrease the weight on exercise machines by moving a single weight key, although changes can generally be made only in increments of 10 or 15 pounds. The iron plates used with free weights must be added or removed from each side of the barbell or dumbbell. Figure 4–14 shows examples of different isotonic strengthening exercises.

FIGURE 4–14 Examples of isotonic

strengthening exercises using barbells, shown with appropriate spotting techniques where required. (A) Squat. (B) Bench press. ( C) Military press. (D) Romanian dead lift. (E) Snatch. (F) Power clean. (G) Clean and jerk. (H) Dead lift. (I) Decline press. (J) Incline press. (K) Standing bicep curl. © William E. Prentice

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FOCUS 4–2 Focus on Therapeutic Intervention Proper spotting techniques • Make sure the lifter understands how to get out of the way of missed attempts, particularly with overhead techniques. • Check to see that the lifter is in a safe, stable position. • Communicate with the lifter to know how many reps are to be done, whether a liftoff is needed, and how much help the lifter wants in completing a rep. • Stand behind the lifter.

• When spotting dumbbell exercises, spot as close to the dumbbells as possible above the elbow joint. • If heavy weights exceed the limits of your ability to control the weight, use a second spotter. • Make sure the lifter uses the proper grip. • Make sure the lifter inhales and exhales during the lift. • Make sure the lifter moves through a complete range of motion at the appropriate speed. • Always be in a position to protect both the lifter and yourself from injury.

Spotting for free weight exercises When training with free weights, it is essential that the lifter have a partner who can assist in performing a particular exercise. This assistance is particularly critical when the weights to be lifted are extremely heavy. A spotter has three functions: to protect the lifter from injury, to make recommendations on proper lifting technique, and to help motivate the lifter. Focus Box 4–2: “Proper spotting techniques” provides some guidelines for correct spotting techniques.

a weight through a range of motion changes according to the angle of pull of the contracting muscle. The amount of force is greatest when the angle of pull is approximately 90 degrees. In addition, once the inertia of the weight has been overcome and momentum has been established, the force required to move the resistance varies according to the force that the muscle can produce through the range of motion. Thus, it has been argued that a disadvantage of any type of isotonic exercise is that the force required to move the resistance is constantly changing throughout the range of movement. Certain exercise machines are designed to minimize this change in resistance by using a cam system (Figure 4–15). The cam has been individually designed for each piece of equipment so that the resistance is variable throughout the movement. The cam system attempts to alter resistance so that the muscle can handle a greater load—at the points at which the joint angle or muscle length is at a mechanical disadvantage, the cam reduces the resistance to muscle movement. Whether this design does what it claims is

Isotonic Training Regardless of which type of equipment is used, the same principles of isotonic exercise may be applied. In progressive resistance exercise, it is essential to incorporate both concentric and eccentric contractions. Research has clearly demonstrated that the muscle should be overloaded and fatigued both concentrically and eccentrically for the greatest strength improvement to occur.59,66 When an individual is weight training specifically to develop muscular strength, the concentric, or positive, portion of the exercise should require 1 to 2 seconds, and the eccentric, or negative, portion of the lift should require 2 to 4 seconds. The ratio of negative to positive should be approximately one to two. Physiologically, the muscle will fatigue much more rapidly concentrically than eccentrically. Individuals who have weight trained with both free weights and machines realize the difference in the amount of weight that can be lifted. Unlike the machines, free weights have no restricted motion and can thus move in many different directions, depending on the forces applied. With free weights, an element of muscular control on the part of the lifter to prevent the weight from moving in any direction other than vertical will usually decrease the amount of weight that can be lifted.48 One problem often mentioned in relation to isotonic training is that the amount of force necessary to move 108

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FIGURE 4–15 The cam system on the Nautilus equipment is designed to equalize the resistance throughout the full range of motion. © William E. Prentice

debatable. This change in resistance at different points in the range is called accommodating resistance, or variable resistance. PRE Techniques Perhaps the single most confusing aspect of progressive resistance exercise is the terminology used to describe specific programs. The following list of terms and their operational definitions may help clarify the confusion: • Repetitions—the number of times a specific movement is repeated. • Repetitions maximum (RM)—the maximum number of repetitions at a given weight. • One repetition maximum (1 RM)—the maximum amount of weight that can be lifted one time. • Set—a particular number of repetitions. • Intensity—the amount of weight or resistance lifted. • Recovery period—the rest interval between sets. • Frequency—the number of times an exercise is done in 1 week. A considerable amount of research has been done in the area of resistance training to determine optimal techniques in terms of the intensity or the amount of weight to be used, the number of repetitions, the number of sets, the recovery period, and the frequency of training. It is important to realize that there are many different effective techniques and training regimens. Regardless of specific techniques used, it is certain that to improve strength the muscle must be overloaded in a progressive manner.15 This overload is the basis of progressive resistance exercise. The amount of weight used and the number of repetitions must be enough to make the muscle work at a higher intensity than it is used to working at. This overload is the single most critical factor in any strength-training program. The strength-training program must also be designed to meet the specific needs of the individual. There is no such thing as an optimal strength-training program. Achieving total agreement on a program of resistance training—with specific recommendations about repetitions, sets, intensity, recovery time, and frequency— among researchers or other experts in resistance training is impossible. However, the following general recommendations will provide an effective resistance-training program. In adults, for any given exercise, the amount of weight selected should be sufficient to allow six to eight repetitions maximum (RM) in each of three sets with a recovery period of 60 to 90 seconds between sets.12 Initial selection of a starting weight may require some trial and error to achieve this six to eight RM range. If at least three sets of six repetitions cannot be completed, the weight is too heavy and should be reduced. If it is possible to do more than three sets of eight repetitions, the weight is too light and should be increased.12 Progression to heavier weights is

determined by the ability to perform at least eight RM in each of three sets. An increase of about 10 percent of the current weight being lifted should still allow at least six RM in each of three sets.12 Occasionally, athletes may be tested at 1 RM to determine the greatest amount of weight that can be lifted one time.32 Extreme caution should be exercised when trying to determine 1 RM. Attention should be directed toward making sure the athlete has had ample opportunity to warm up and that the lifting technique is correct before attempting a maximum lift. Determining 1 RM should be done very gradually to minimize the chances of injuring the muscle. A particular muscle or muscle group should be exercised consistently every other day.12 Thus, the frequency of weight training should be at least three times per week but no more than four times per week. It is common for serious weight trainers to lift every day; however, they exercise different muscle groups on successive days. For example, Monday, Wednesday, and Friday may be used for upper-body muscles, whereas Tuesday, Thursday, and Saturday are used for lower-body muscles. Training for Muscular Strength versus Endurance Muscular endurance is the ability to perform repeated muscle contractions against resistance for an extended period of time. Most weight-training experts believe that muscular strength and muscular endurance are closely related.77 As one improves, the other tends to improve also. When weight training for strength, use heavier weights with a lower number of repetitions. Conversely, endurance training uses relatively lighter weights with a greater number of repetitions. Endurance training should consist of three sets of 10 to 15 repetitions, using the same criteria for weight selection, progression, and frequency as recommended for progressive resistance exercise.9 Thus, suggested training regimens for muscular strength and endurance are similar in terms of sets and numbers of repetitions.99 Persons who possess great levels of strength also tend to exhibit greater muscular endurance when asked to perform repeated contractions against resistance. Isokinetic Exercise An isokinetic exercise involves a muscle contraction in which the length of the muscle is changing while the contraction is performed at a constant velocity.76 In theory, maximal resistance is provided throughout the range of motion by the machine. The resistance provided by the machine will move only at some preset speed regardless of the force applied to it by the individual.1 Thus, the key to isokinetic exercise is not the resistance, but the speed at which the resistance can be moved.1,76 Currently, only one isokinetic device is available commercially—Biodex (Figure 4–16). Isokinetic devices rely Chapter Four ■ Fitness and Conditioning Techniques

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research to support this theory. Whether changing force capability is, in fact, a deterrent to improving the ability to generate force against some resistance is debatable. In the athletic training setting, isokinetics are perhaps best used as a rehabilitative and diagnostic tool rather than as a conditioning device.1

FIGURE 4–16 During isokinetic exercise, the speed of

movement is constant regardless of the force applied by the athlete. Photo courtesy of Biodex Medical Systems, Inc.

on hydraulic, pneumatic, or mechanical pressure systems to produce constant velocity of motion. Isokinetic devices are capable of resisting both concentric and eccentric contractions at a fixed speed to exercise a muscle. A major disadvantage of an isokinetic unit is its cost. The unit comes with a computer and printing device and is used primarily as a diagnostic and rehabilitative tool in the treatment of various injuries. Isokinetic devices are designed so that, regardless of the amount of force applied, the resistance can be moved only at a certain speed. That speed will be the same whether maximal force or only half the maximal force is applied. Consequently, when training isokinetically, it is absolutely necessary to exert as much force against the resistance as possible (maximal effort) for maximal strength gains to occur. This need for maximal effort is one of the major problems with an isokinetic strengthtraining program. Anyone who has been involved in a weight-training program knows that on some days it is difficult to find the motivation to work out. Because isokinetic training does not require a maximal effort, it is easy to “cheat” and not go through the workout at a high level of intensity. In a progressive resistance exercise program, the individual knows how much weight has to be lifted with how many repetitions.55 Thus, isokinetic training is often more effective if a partner system is used as a means of motivation toward a maximal effort. When isokinetic training is done properly with a maximal effort, it is theoretically possible that maximal strength gains are best achieved through the isokinetic training method in which the velocity and force of the resistance are equal throughout the range of motion.1 However, there is no conclusive evidence-based

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Circuit Training Circuit training employs a series of exercise stations that consist of various combinations of weight training, flexibility, calisthenics, and brief aerobic exercises. Circuit training is used in the majority of fitness centers in corporate and health club settings. Circuits may be designed to accomplish many different training goals. With circuit training, the individual moves rapidly from one station to the next and performs whatever exercise is to be done at that station within a specified time period. A typical circuit consists of 8 to 12 stations, and the entire circuit is repeated three to five times. Circuit training is definitely an effective technique for improving strength and flexibility. Certainly, if the pace or the time interval between stations is rapid and if workload is maintained at a high level of intensity with heart rate at or above target training levels, the cardiorespiratory system may benefit from this circuit. However, little research evidence exists to show that circuit training is effective in improving cardiorespiratory endurance. It should be, and is most often, used as a technique for developing and improving muscular strength and endurance. Bodyweight Strengthening Exercises Bodyweight exercises are one of the more easily available means of developing strength. Isotonic movement exercises can be graded according to intensity by using gravity as an aid, by ruling gravity out, by moving against gravity, or by using the body or a body part as a resistance against gravity. Most bodyweight exercises require the individual to support the body or move the total body against the force of gravity. Push-ups are a good example of a vigorous antigravity free exercise. Bodyweight-like exercises are used in functional strength training, discussed earlier. To be considered maximally effective, the isotonic bodyweight exercises like all types of exercise, must be performed in an exacting manner and in full range of motion. In most cases, 10 or more repetitions are performed for each exercise and are repeated in sets of two or three. Some free exercises use an isometric, or holding, phase instead of a full range of motion. Examples of these exercises are back extensions and sit-ups. When the exercise produces maximum muscle tension, it is held between 6 and 10 seconds and then repeated one to three times.

Plyometric Exercise Plyometric exercise is a technique that includes specific exercises that encompass a rapid stretch of a muscle eccentrically, followed immediately by a rapid concentric contraction of that muscle to facilitate and develop a forceful, explosive movement over a short period of time.2,24 This effect requires that the time between eccentric contraction and concentric contraction be very short. It is theorized that this extra power is due to the muscle gaining potential energy. This energy dissipates rapidly, so the action must be quick. The process is frequently referred to as the stretch-shortening cycle and is the underlying mechanism of plyometric training. The greater the stretch put on the muscle from its resting length immediately before the concentric contraction, the greater the resistance the muscle can overcome. Plyometric exercises emphasize the speed of the eccentric phase.23 The rate of the stretch is more critical than the magnitude of the stretch. All movements involve repeated stretch-shortening cycles. Picture a jumping athlete preparing to transfer forward energy to upward energy. As the final step is taken before jumping, the loaded leg must stop the forward momentum and change it into an upward direction. As this happens, the muscle undergoes a lengthening eccentric contraction to decelerate the movement and prestretch the muscle. This prestretch energy is then immediately released in an equal and opposite reaction, thereby producing kinetic energy. The neuromuscular system must react quickly to produce the concentric shortening contraction to prevent falling and produce the upward change in direction. Consequently, specific functional exercises to emphasize this rapid change of direction must be used. Because plyometric exercises train specific movements in a biomechanically accurate manner, the muscles, tendons, and ligaments are all strengthened in a functional manner. An advantage of plyometric exercises is that they can help develop eccentric control in dynamic movements.80 Plyometric exercises involve hops, bounds, and depth jumping for the lower extremities and use medicine balls and other types of weighted equipment for the upper extremities (Figure 4–17). Depth jumping is an example of a plyometric exercise in which an individual jumps to the ground from a specified height and then quickly jumps again as soon as ground contact is made.24 Plyometrics place a great deal of stress on the musculoskeletal system. The learning and perfection of specific jumping skills and other plyometric exercises must be technically correct and specific to the individual’s age, activity, physical development, and skill development.72

presence of the hormone testosterone. Testosterone is considered a male hormone, although all females possess some testosterone in their systems. Females with higher testosterone levels tend to have more masculine characteristics, such as increased facial and body hair, a deeper voice, and the potential to develop a little more muscle bulk.66 Both males and females experience initial rapid gains in strength due to an increase in neuromuscular efficiency, as discussed previously.101 However, in the female, these rapid initial strength gains tend to plateau after 3 to 4 weeks. Minimal improvement in muscular strength will be realized during a continuing strength-training program because the muscle will not continue to hypertrophy to any significant degree. Perhaps the most critical difference between males and females regarding physical performance is the ratio of strength to body weight. The reduced strength-tobody-weight ratio in females is the result of their higher percentage of body fat. The strength-to-body-weight ratio may be significantly improved through weight training by decreasing the percentage of body fat while increasing lean weight.45

Strength Training in Prepubescents and Adolescents The principles of resistance training discussed previously may be applied to younger individuals. A number of sociological questions regarding the advantages and disadvantages of younger—in particular, prepubescent—individuals engaging in rigorous strength-training programs emerge, however. From a physiological perspective, experts have for years debated the value of strength training in young individuals. Recently, a number of studies have indicated that, if properly supervised, prepubescents and adolescents can improve strength, power, endurance, balance, and proprioception; develop a positive body image; improve sport performance; and prevent injuries.5,71 A prepubescent child can experience gains in levels of muscle strength without significant muscle hypertrophy.41 An athletic trainer supervising a conditioning program for a young athlete should certainly incorporate resistive exercise into the program. However, close supervision, proper instruction, and appropriate modification of progression and intensity based on the extent of physical maturation of the individual are critical to the effectiveness of the resistive exercises.71 A functional strengthening program that uses calisthenic strengthening exercises with body weight as resistance should be encouraged.

Strength Training for the Female

The Relationship between Strength and Flexibility

Strength training is critical for the female. Significant muscle hypertrophy in the female is dependent on the

It is often said that strength training has a negative effect on flexibility.86 For example, we tend to think of

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F D

FIGURE 4–17 Plyometric exercises. (A) Weighted ball double-arm rotation toss. (B) Plyoback two-arm toss with rotation.

( C) Weighted ball squat to stand extension. (D) Squat jumps. (E) Overhead weighted ball throw. (F) Weighted ball forward jump from squat. (G) Weighted ball standing rotations. (H) Double-leg lateral hop overs. (I) Depth jump to vertical jump. (J) Repeat two-leg standing long jump. (K) Three-hurdle jumps. © William E. Prentice

individuals who have highly developed muscles as having lost much of their ability to move freely through a full range of motion. Occasionally, an individual develops so much bulk that the physical size of the muscle prevents a normal range of motion. It is certainly true that strength training that is not properly done can impair movement; however, weight training, if done properly through a full range of motion, will not impair flexibility. Proper strength training probably improves dynamic flexibility and, if combined with a rigorous stretching program, can greatly enhance the powerful and coordinated movements that are essential for success in many athletic activities. In all cases, a heavy weight-training program should be accompanied by a strong flexibility program.

IMPROVING AND MAINTAINING FLEXIBILITY Flexibility is the ability to move a joint or series of joints smoothly and easily through a full range of motion.4 Flexibility can be discussed in relation to movement involving only one joint, such as the knees, or movement involving a whole series of joints, such as the spinal vertebral joints, which must all move together to allow smooth bending or rotation of the trunk.

The Importance of Flexibility Maintaining a full, nonrestricted range of motion has long been recognized as essential to normal daily living. Lack of flexibility can also create uncoordinated or awkward movement patterns resulting from lost neuromuscular control.13 In most individuals, functional activities require relatively “normal” amounts of flexibility. However, some sport activities, such as gymnastics, ballet, diving, and karate, require increased flexibility for superior performance (Figure 4–18).6

FIGURE 4–18 Good flexibility is essential to successful performance in many sport activities. © William E. Prentice

Flexibility is generally seen as essential for improving performance in physical activities. However, a review of the evidence-based information in the literature looking at the relationship between flexibility and improved performance is at best conflicting and inconclusive.90,96 Although many studies done over the years have suggested that stretching improves performance,27,57,73 several recent studies have found that stretching causes decreases in performance parameters, such as strength, endurance, power, joint position sense, and reaction times.11,38,56,65,67,89,93,102 The same can be said when examining the relationship between flexibility and the incidence of injury. Although it is generally accepted that good flexibility reduces the likelihood of injury, a true cause-effect relationship has not been clearly established in the literature.7,8,22,73,102

Factors That Limit Flexibility A number of factors may limit the ability of a joint to move through a full, unrestricted range of motion. The bony structure may restrict the endpoint in the range. An elbow that has been fractured through the joint may deposit excess calcium in the joint space, causing the joint to lose its ability to fully extend. However, in many instances bony prominences stop movements at normal endpoints in the range. Excessive fat may also limit the ability to move through a full range of motion. An athlete who has a large amount of fat on the abdomen may have severely restricted trunk flexion when asked to bend forward and touch the toes. The fat may act as a wedge between two lever arms, restricting movement wherever it is found. Skin might also be responsible for limiting movement. For example, an athlete who has had some type of injury or surgery involving a tearing incision or laceration of the skin, particularly over a joint, will have inelastic scar tissue at that site. This scar tissue is incapable of stretching with joint movement. Muscles and their tendons, along with their surrounding fascial sheaths, are most often responsible for limiting range of motion. An individual who performs stretching exercises to improve flexibility about a particular joint is attempting to take advantage of the highly elastic properties of a muscle. Over time, it is possible to increase the elasticity, or the length that a given muscle can be stretched.81 Individuals who have a good deal of movement at a particular joint tend to have highly elastic and flexible muscles. Connective tissue surrounding the joint, such as ligaments on the joint capsule, may be subject to contractures. Ligaments and joint capsules do have some elasticity; however, if a joint is immobilized for a period of time, these structures tend to lose some elasticity and shorten. This condition is most commonly seen after surgical repair of an unstable joint, but it can also result from long periods of inactivity. Chapter Four ■ Fitness and Conditioning Techniques

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of balance in strength between agonist and antagonist muscle groups is necessary to produce normal, smooth, coordinated movement and to reduce the likelihood of muscle strain caused by muscular imbalance.61

Active and Passive Range of Motion FIGURE 4–19 Excessive joint motion, or hypermobility, can predispose an individual to injury. © William E. Prentice

Neural tissue tightness resulting from acute compression, chronic repetitive microtrauma, muscle imbalances, joint dysfunction, or poor posture can create morphological changes in neural tissues that may result in irritation, inflammation, and pain. Pain causes muscle guarding to protect inflamed and irritated neural structures, and this alters normal movement patterns. Over time neural fibrosis results, decreasing the elasticity of neural tissue and preventing normal movement of surrounding tissues. It is also possible for an individual to have relatively slack ligaments and joint capsules. These individuals are generally referred to as being hypermobile. An example of hypermobility is an elbow or a knee that hyperextends beyond 180 degrees (Figure 4–19). Frequently, the instability associated with hypermobility presents as great a problem in movement as ligamentous or capsular contractures. The elasticity of skin contractures caused by scarring, ligaments, joint capsules, and musculotendinous units can be improved to varying degrees over time through stretching. With the exception of bony structure, age, and gender, all the other factors that limit flexibility also may be altered to increase range of joint motion.

Agonist versus Antagonist Muscles Understanding flexibility requires defining the terms agonist and antagonist. Most joints in the body are capable of more than one movement. The knee joint, for example, is capable of flexion and extension. Contraction of the quadriceps group of muscles on the front of the thigh causes knee extension, whereas contraction of the hamstring muscles on the back of the thigh produces knee flexion. To achieve knee extension, the quadriceps group contracts while the hamstring muscles relax and stretch. The muscle that contracts to produce a movement—in this case, the quadriceps—is referred to as the agonist muscle. The muscle being stretched in response to contraction of the agonist muscle is called the antagonist muscle. In knee extension, the antagonist muscle is the hamstring group. Some degree

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Active range of motion, also called dynamic flexibility, is the degree to which a joint can be moved by a muscle contraction, usually through the midrange of movement.98 Dynamic flexibility is not necessarily a good indicator of the stiffness or looseness of a joint because it applies to the ability to move a joint efficiently, with little resistance to motion.88 Passive range of motion, sometimes called static flexibility, is the degree to which a joint may be passively moved to the endpoints in the range of motion. No muscle contraction is involved to move a joint through a passive range. When a muscle actively contracts, it produces a joint movement through a specific range of motion. However, if passive pressure is applied to an extremity, it is capable of moving farther in the range of motion. It is essential in sport activities that an extremity be capable of moving through a nonrestricted range of motion. For example, a hurdler who cannot fully extend the knee joint in a normal stride is at a considerable disadvantage because stride length and thus speed will be reduced significantly. Passive range of motion is important for injury prevention. In many sports situations, a muscle is forced to stretch beyond its normal active limits. If the muscle does not have enough elasticity to compensate for this additional stretch, the musculotendinous unit will likely be injured.

Mechanisms for Improving Flexibility For many years the efficacy of stretching in improving range of motion has been theoretically attributed to neurophysiological phenomena involving the stretch reflex.20 However, a more recent study that extensively reviewed the existing literature has suggested that improvements in range of motion resulting from stretching must be explained by mechanisms other than the stretch reflex.22 Studies reviewed indicate that changes in the ability to tolerate stretch and/or the viscoelastic properties of the stretched muscle are possible mechanisms. Neurophysiological Basis of Stretching Every muscle in the body contains various types of mechanoreceptors that, when stimulated, inform the central nervous system of what is happening with that muscle. Two of these mechanoreceptors are important in the stretch

CROSS SECTION OF SPINAL CORD Dorsal Post. horn Ant. horn Type Ib nerve from Golgi tendon organ

Ventral

Gamma efferent fiber causes reflex relaxation Alpha motor neuron causes reflex contraction

Type Ia nerve from muscle spindle

Muscle spindle

Golgi tendon organ

FIGURE 4–20 Stretch reflex. The muscle spindle produces a reflex resistance to stretch, and the Golgi tendon organ causes a reflex relaxation of the muscle in response to stretch.

reflex: the muscle spindle and the Golgi tendon organ (Figure 4–20). Both types of receptors are sensitive to changes in muscle length. The Golgi tendon organs are also affected by changes in muscle tension. When a muscle is stretched, both the muscle spindles and the Golgi tendon organs immediately begin sending sensory impulses to the spinal cord. Initially, impulses coming from the muscle spindles along type Ia nerve fibers to the spinal cord signal the central nervous system that the muscle is being stretched. Impulses return to the muscle from the spinal cord along alphamotor neurons, causing the muscle to reflexively contract, thus resisting the stretch.64 The Golgi tendon organs respond to the change in length and the increase in tension by firing off sensory impulses that are carried to the spinal cord along type Ia nerve fibers. If the stretch of the muscle continues for an extended period of time (at least 6 seconds), impulses from the Golgi tendon organs begin to override muscle spindle impulses. The impulses from the Golgi tendon organs, unlike the signals from the muscle spindle, cause a reflex relaxation of the antagonist muscle. This reflex relaxation serves as a protective mechanism that will allow the muscle to stretch through relaxation without

exceeding the extensibility limits, which could damage the muscle fibers.10 This relaxation of the antagonist muscle during contractions is referred to as autogenic

inhibition.

In any synergistic muscle group, a contraction of the agonist causes a reflex relaxation in the antagonist muscle, allowing it to stretch and protecting it from injury. This phenomenon is referred to as reciprocal inhibition (Figure 4–21).90 The Effects of Stretching on the Physical and Mechanical Properties of Muscle The neurophysi ological mechanisms of both autogenic and reciprocal inhibition result in reflex relaxation with subsequent lengthening of a muscle. Thus, the mechanical properties of that muscle that physically allow lengthening to occur are dictated via neural input. Both muscle and tendon are composed largely of noncontractile collagen and elastin fibers. Collagen enables a tissue to resist mechanical forces and deformation, whereas elastin composes highly elastic tissues that assist in recovery from deformation.95 Unlike tendon, muscle also has active contractile components, which are the actin and myosin myofilaments.

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Dorsal

Anterior Quadriceps

Ventral –

Hamstrings Posterior

FIGURE 4–21 Reciprocal inhibition. A contraction of the agonist will produce relaxation in the antagonist.

Stretching Techniques The maintenance of a full, nonrestricted range of motion has long been recognized as critical to injury prevention and as an essential component of a conditioning program.8 The goal of any effective flexibility program should be to improve the range of motion at a given articulation by altering the extensibility of the 116

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neuromusculotendinous structures that produce movement at that joint.31,46 Exercises that stretch these neuromusculotendinous structures over several months increase the range of motion possible at a given joint.86 Ballistic Stretching Ballistic stretching involves a bouncing movement in which repetitive contractions of the agonist muscle are used to produce quick stretches of the antagonist muscle. The ballistic stretching technique, although apparently effective in improving range of motion, has been criticized in the past because increased range of motion is achieved through a series of jerks or pulls on the resistant muscle tissue.4 The concern was that, if the forces generated by the jerks are greater than A construction worker the tissues’ extensibility, has a history of multiple muscle injury may result. hamstring strains, usually Dynamic Stretching Certainly, successive, force ful contractions of the agonist muscle that result in stretching of the antagonist muscle may cause muscle soreness. For example, forcefully kicking a soccer ball 50 times may result in muscle soreness of the hamstrings (antagonist muscle) as a result of eccentric contraction of the hamstrings to control the

when lifting and moving heavy wooden beams. He is very concerned that he is likely to reinjure his hamstring. He asks the athletic trainer overseeing a work hardening program if there is anything he should be doing to minimize the chances of reinjury.

? What recommendations

should the athletic trainer make?

4–7 Clinical Application Exercise

Collectively, the contractile and noncontractile elements determine the muscle’s capability of deforming and recovering from deformation.60 Both the contractile and the noncontractile components appear to resist deformation when a muscle is stretched or lengthened. The percentage of their individual contribution to resisting deformation depends on the degree to which the muscle is stretched or deformed and on the velocity of deformation. The noncontractile elements are primarily resistant to the degree of lengthening, while the contractile elements limit high-velocity deformation. The greater the stretch, the more the noncontractile components contribute.95 Lengthening of a muscle via stretching allows for viscoelastic and plastic changes to occur in the collagen and elastin fibers. The viscoelastic changes that allow slow deformation with imperfect recovery are not permanent. However, plastic changes, although difficult to achieve, result in residual or permanent change in length due to deformation created by long periods of stretching. The greater the velocity of deformation, the greater the chance for exceeding that tissue’s capability to undergo viscoelastic and plastic change.60

FIGURE 4–22 Stretching techniques. (A) Dynamic stretch for hip flexors and extensors. (B) Static stretch for

knee extensors. ( C) Slow-reversal-hold-relax PNF techniques for hamstrings. (D) Slump-stretch for sciatic nerve. (E) Myofascial stretching for hamstrings. © William E. Prentice

dynamic movement of the quadriceps (agonist muscle). Stretching that is controlled usually does not cause muscle soreness.64 This is the difference between ballistic stretching and dynamic stretching. In fact, in the athletic population, dynamic stretching has become the stretching technique of choice. The argument has been that dynamic stretching exercises are more closely related to the types of activities that athletes engage in and should be considered more functional.29,64 Thus, dynamic stretching exercises are routinely recommended for athletes prior to beginning an activity (Figure 4–22A). Static Stretching The static stretching technique is a widely used and effective technique of stretching. This technique involves passively stretching a given antagonist muscle by placing it in a maximal position of stretch and holding it there for an extended time (Figure 4–22B). Recommendations for the optimal time for holding this stretched position vary from as short as 3 seconds to as long as 60 seconds.63 Recent data indicate that 30 seconds

may be an optimal time to hold the stretch. The static stretch of each muscle should be repeated three or four times.10 Much research has been done comparing ballistic and static stretching techniques for the improvement of flexibility. It has been shown that both static and ballistic stretching are effective in increasing flexibility and that there is no significant difference between the two. However, static stretching offers less danger of exceeding the extensibility limits of the involved joints because the stretch is more controlled. Ballistic stretching is apt to cause muscle soreness, whereas static stretching generally does not and is commonly used in injury rehabilitation of sore or strained muscles.4,58 Static stretching is certainly a much safer stretching technique, especially for sedentary or untrained individuals. However, many physical activities involve dynamic movement. Thus, stretching as a warm-up for these types of activities should begin with static stretching followed by ballistic and dynamic stretching, which more closely resemble the dynamic activity. Chapter Four ■ Fitness and Conditioning Techniques

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PNF Stretching Techniques Proprioceptive neuromuscular facilitation (PNF) techniques were first used by physical therapists for treating patients who had various types of neuromuscular paralysis.78 More recently, PNF exercises have been used as a stretching technique for increasing flexibility. A number of different PNF techniques are currently be ing used for stretching, including slow-reversal-hold-relax, contract-relax, and hold-relax techniques. All involve some combination of alternating contraction and relaxation of both agonist and antagonist muscles. All three techniques use a 10-second active push phase followed by a 10-second passive relax phase repeated three times for a total of 60 seconds. Using a hamstring stretching technique as an example (Figure 4–22C), the slow-reversal-hold-relax technique would be done as follows:78 • With the patient lying supine with the knee extended and the ankle flexed to 90 degrees, the athletic trainer passively flexes the hip joint to the point at which there is slight discomfort in the muscle. • At this point, the patient begins actively pushing against the athletic trainer’s resistance by contracting the hamstring muscle. • After actively pushing for 10 seconds, the hamstring muscles are relaxed and the agonist quadriceps muscle is actively contracted while the athletic trainer applies passive pressure to further stretch the antagonist hamstrings. This action should move the leg so that there is increased hip joint flexion. • The relaxing phase lasts for 10 seconds, after which the patient again actively pushes against the athletic trainer’s resistance, beginning at this new position of increased hip flexion. • This push-relax sequence is repeated at least three times. The contract-relax and hold-relax techniques are variations on the slow-reversal-hold-relax method. In the contract-relax method, the hamstrings are isotonically contracted so that the leg actually moves toward the floor during the push phase. The hold-relax method involves an isometric hamstring contraction against immovable resistance during the push phase. During the relax phase, both techniques involve the relaxation of hamstrings and quadriceps while the hamstrings are passively stretched. The same basic PNF technique can be used to stretch any muscle in the body. The PNF stretching techniques are perhaps best performed with a partner, although they may also be done using a wall as resistance (see Chapter 16).78 Comparing Techniques Although all four stretching techniques have been demonstrated to improve flexibility, there is still considerable debate as to which technique produces the greatest increases in range of 118

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motion. In the past, the ballistic technique has not been recommended because of the potential for causing muscle soreness. However, most sport activities are dynamic in nature (e.g., kicking, running), and those activities use the stretch reflex to enhance performance.29 In highly trained individuals, it is unlikely that dynamic stretching will result in muscle soreness. Static stretching is perhaps the most widely used technique. It is a simple technique and does not require a partner. A fully nonrestricted range of motion can be attained through static stretching over time.33 The PNF stretching techniques can produce dramatic increases in range of motion during one stretching session. Studies comparing static and PNF stretching suggest that PNF stretching can produce greater improvement in flexibility over an extended training period.63,79,81 The major disadvantage of PNF stretching is that it requires a partner for stretching, although stretching with a partner may have some motivational advantages. Focus Box 4–3: “Guidelines and precautions for stretching” provides recommendations for various stretching techniques.

Stretching Neural Structures The athletic trainer should be able to differentiate between tightness in the musculotendinous unit and abnormal neural tension. When an individual performs both active and passive multiplanar movements, tension is created in the neural structures that exacerbates pain, limits range of motion, and increases radiating neural symptoms, including numbness and tingling. For example, the slump stretch position is used to detect an increase in nerve/root tension in the sciatic nerve and stretching should be done to assist in relieving tension (Figure 4–22D).

Stretching Fascia Tight fascia, the connective tissue that surrounds the musculotendinous unit, can significantly limit motion. Damage to the fascia due to injury, disease, or inflammation creates pain and motion restriction. Thus, it may be necessary to release tightness in the area of injury. Stretching of tight fascia can either be done manually or by using a firm foam roller (Figure 4–22E). Myofascial release as a treatment technique is discussed in detail in Chapter 16.

Alternative Stretching Techniques The Pilates Method of Stretching The Pilates method is a somewhat different approach to stretching for improving flexibility. This method has become extremely popular and widely used among personal fitness trainers and physical therapists. Pilates is an exercise technique devised by German-born Joseph Pilates, who established the first Pilates studio in the

FOCUS 4–3 Focus on Therapeutic Intervention Guidelines and precautions for stretching The following guidelines and precautions should be incorporated into a sound stretching program: • Warm up using a slow jog or fast walk before stretching vigorously. • To increase flexibility, the muscle must be stretched within pain tolerances and tissue healing limitations to attain functional or normal range of motion. • Stretch only to the point where you feel tightness or resistance to stretch or perhaps some discomfort. Stretching should not be painful. • Increases in range of motion are specific to whatever joint is being stretched. • Exercise caution when stretching muscles that surround painful joints. Pain is an indication that something is wrong and should not be ignored. • Avoid overstretching the ligaments and capsules that surround joints, beyond their limits of extensibility. • Exercise caution when stretching the lower back and neck. Exercises that compress the vertebrae and their disks may cause damage.

United States before World War II. The Pilates method is a conditioning program that improves muscle control, flexibility, coordination, strength, and tone. The basic principles of Pilates exercise are to make people more aware of their bodies as single, integrated units; to improve body alignment and breathing; and to increase efficiency of movement.75 Unlike other exercise programs, the Pilates method does not require the repetition of exercises but instead consists of a sequence of carefully performed movements, some of which are carried out on specially designed equipment (Figures 4–23 and 4–24). Each exercise is designed to stretch and strengthen the muscles involved. There is a specific breathing pattern for each exercise to help direct energy to the areas being worked, while relaxing the rest of the body. The Pilates method works many of the deeper muscles together, improving coordination and balance, to achieve efficient and graceful movement. Instead of seeking an ideal or perfect body, the goal is for the practitioner to develop a healthy self- image through the attainment of better posture, proper coordination, and improved flexibility. This method concentrates on correcting body alignment, lengthening all the muscles of the body into a balanced whole, and building endurance and strength without putting undue stress on the lungs and heart.75 Pilates instructors believe that problems such as soft-tissue injuries can cause bad posture, which can lead to pain and discomfort. Pilates exercises aim to correct this.

• Stretching from a seated position rather than a standing position takes stress off the low back and decreases the chances of back injury. • Stretch those muscles that are tight and inflexible. • Strengthen those muscles that are weak and loose. • Be sure to continue normal breathing during a stretch. Do not hold your breath. • Static, dynamic, and PNF techniques are most often recommended for individuals who want to improve their range of motion. • Ballistic stretching should be done only by those who are already flexible or are accustomed to stretching and should be done only after static stretching. • Stretching should be done at least three times per week to see minimal improvement. Stretching five or six times per week is recommended to see maximum results.

FIGURE 4–23 Pilates techniques using equipment. (A) Reformer. (B) Magic ring. Photos courtesy Balanced Body

Normally, a beginner sees a Pilates instructor on a one-to-one basis for the first session. The instructor assesses the client’s physical condition and asks the client about any problems and about the client’s lifestyle. Chapter Four ■ Fitness and Conditioning Techniques

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Start

End

Start

End

Start

End

FIGURE 4–24 Pilates floor exercises.

(A) Alternating arm, opposite leg extensions. (B) Push-up to a side plank. ( C) Alternating legs scissors. © William E. Prentice

The client is then shown a series of exercises that work joints and muscles through a range of motion appropriate for the client’s needs. A class in a studio might involve working on specially designed equipment that primarily uses resistance against tensioned springs to isolate and develop specific muscle groups. Mat work classes involve a repertoire of exercises on a floor mat only. This type of class has become very popular in health clubs and gyms and is often compared to other forms of body conditioning. In fact, the Pilates mat exercises are generally less strenuous than mat exercises in most other conditioning classes. Yoga Yoga originated in India approximately 6,000 years ago. Its basic philosophy is that most illness is related to poor mental attitudes, posture, and diet. Practitioners of yoga maintain that stress can be reduced through combined mental and physical approaches. Yoga can help an individual cope with stress-induced behaviors and conditions, such as overeating, hypertension, and smoking. Yoga’s meditative aspects are believed to help alleviate psychosomatic illnesses. Yoga aims to unite the body and mind to reduce stress. For example, Dr. Chandra Patel, a 120

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yoga expert, has found that persons who practice yoga can reduce their blood pressure indefinitely as long as they continue to practice yoga. Yoga consists of various body postures and breathing exercises. Hatha yoga uses a number of positions through which the practitioner may progress, beginning with the simplest and moving to the more complex (Figure 4–25).84 The various positions are intended to increase mobility and flexibility. However, practitioners must use caution when performing yoga positions. Some can be dangerous, particularly for someone who is inexperienced in yoga technique. Slow, deep, diaphragmatic breathing is an important part of yoga. Many people take shallow breaths; however, breathing deeply, fully expanding the chest when inhaling, helps lower blood pressure and heart rate.84 Deep breathing has a calming effect on the body, and it increases production of endorphins.

Measuring Range of Motion Accurate measurement of the range of joint motion takes some practice on the part of the clinician. Various devices have been designed to accommodate variations in

K L J

FIGURE 4–25 Yoga positions. (A) Tree. (B) Triangle. ( C) Dancer. (D) Chair. (E) Extended hand to big toe. (F) Big mountain. (G) Lotus. (H) Cobra. (I) Downward facing dog. (J) Static squat. (K) Pigeon. (L) Child. (M) Runner’s lunge with twist. (N) Cat. © William E. Prentice

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FIGURE 4–26 A goniometer can be used to measure joint angles and range of motion. (A) Universal goniometer. (B) Inclinometer. © William E. Prentice

the size of the joints and the complexity of movements in articulations that involve more than one joint.49 Of these devices, the simplest and most widely used is the goniometer (Figure 4–26A). A goniometer is a large protractor with measurements in degrees. By aligning the two arms parallel to the longitudinal axis of the two segments involved in motion about a specific joint, it is possible to obtain relatively accurate measures of range of movement. The goniometer has its place in a rehabilitation setting, where it is essential to assess improvement in joint flexibility for the purpose of modifying injury rehabilitation programs.91 Some clinics use an inclinometer instead of a goniometer. An inclinometer is a more precise measuring instrument with high reliability that has most often been used in research settings. However, inclinometers are affordable and can easily be used to accurately measure range of motion of all joints of the body, from complex movements of the spine to simpler movements of the large joints of the extremities, and the small joints of fingers and toes (Figure 4–26B).91

FITNESS ASSESSMENT Fitness testing provides the athletic trainer or strength and conditioning coach with information about the effectiveness of the conditioning program for an individual. Testing may be done in a pretest/posttest format to determine significant improvement from some baseline measure. Tests may be used to assess flexibility, muscular strength, endurance, power, cardiorespiratory endurance, speed, balance, or agility, depending on the stated goals of the training and conditioning program. A variety of established tests can be used to assess these parameters. Focus Box 4–4: “Fitness testing” lists various tests that can be administered, along with recommended references to consult for specific testing procedures and for in-depth testing directions. 122

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PERIODIZATION IN CONDITIONING Serious athletes no longer engage only in preseason conditioning and in-season competition. Sports conditioning is a year-round endeavor. Periodization is an approach to conditioning that brings about peak performance while reducing injuries and overtraining in the athlete through a conditioning program that is followed throughout the various seasons.93 Periodization takes into account that athletes have different conditioning needs during different seasons and modifies the program according to individual needs (Table 4–4).50

Macrocycle Periodization organizes the conditioning program into cycles. The complete training period, which could be a year, in the case of seasonal sports, or 4 years, for an Olympic athlete, is referred to as a macrocycle. With seasonal sports, the macrocycle can Sports conditioning often falls into three seasons: preseason, inbe divided into season, and off-season. a preseason, an in-season, and an off-season. Throughout the course of the macrocycle, intensity, volume, and specificity of conditioning are altered, so that an athlete can achieve peak levels of fitness for competition. As competition approaches, conditioning sessions change gradually and progressively from highvolume, low-intensity, non–sport-specific activity to lowvolume, high-intensity, sport-specific training.100 Mesocycles Within the macrocycle are a series of mesocycles, each of which may last for several weeks or even months. A mesocycle is further divided into transition, preparatory, and competition periods.100 Transition Period The transition period begins after the last competition and comprises the early part of the

Fitness testing Muscle strength, power, endurance One-repetition maximum tests Timed push-ups Timed sit-ups Chin-ups Bar dips Flexed arm hang Vertical jump Flexibility Sit-and-reach test Trunk extension test Shoulder lift test Cardiorespiratory endurance Cooper’s 12-minute walk/run 1.5-mile run Harvard step test Speed 6-second dash 10- to 60-yard dash Agility T-test Edgren side step SEMO agility test Balance Stork test Fitness testing references Baumgartner T, Jackson A: Measurement for evaluation in physical education and exercise science, Dubuque, IA, 1999, WCB/McGraw-Hill. Prentice W: Fitness and wellness for life, ed 6, Dubuque, IA, 1999, WCB/McGraw-Hill. Semenick D: Testing procedures and protocols. In Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 1994, Human Kinetics.

Preparatory Period The preparatory period occurs primarily during the off-season, when there are no upcoming competitions. The preparatory period has three phases: the hypertrophy/endurance phase, the strength phase, and the power phase. During the hypertrophy/endurance phase, which occurs in the early part of the off-season, conditioning is at a low intensity with a high volume of repetitions, using activities that may or may not be directly related to a specific sport. The goal is to develop a base of endurance on which more intense conditioning can occur. This phase may last from several weeks to 2 months. During the strength phase, which also occurs during the off-season, the intensity and volume progress to moderate levels. Weight-training activities should become more specific to the sport or event. The third phase, or power phase, occurs in the preseason. The athlete trains at a high intensity at or near the level of competition. The volume of training is decreased so that full recovery is allowed between sessions. Competition Period In certain cases, the competition period lasts for only a week or less. With seasonal sports, however, the competition period may last for several months. In general, this period involves high-intensity conditioning at a low volume. As conditioning volume decreases, an increased amount of time is spent Following the competitive on skill training or stratseason, a college football egy sessions. During the player took the months competition period, it may of December and January be necessary to establish off from intense training. microcycles, which are He played only basketball periods lasting from 1 to and occasionally rode 7 days. During a weekly an exercise bike, thus completing the transitional microcycle, conditioning period of the macrocycle. should be intense early It is now time for him in the week and should to begin the preparatory progress to moderate and phase of training. finally to light training the day before a competition. What activities should he begin with, and how The goal is to make sure should these activities that the athlete will be at progress over the next peak levels of fitness and several months? performance on days of 14 competition.

Cross Training off-season. The transition period is generally unstructured, and the athlete is encouraged to participate in sport activities on a recreational basis. The idea is to allow the athlete to escape both physically and psychologically from the rigor of a highly organized training regimen.

Cross training is an approach to training and conditioning for a specific sport that involves substituting alternative activities that have some carryover value to that sport. For example, a swimmer could engage in jogging, running, or aerobic exercise to maintain levels of cardiorespiratory conditioning. Cross training is particularly useful in both the transition and the early preparatory Chapter Four ■ Fitness and Conditioning Techniques

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4–8 Clinical Application Exercise

FOCUS 4–4 Focus on Examination, Assessment, and Diagnosis

TABLE 4–4 Periodization Training Season

Period/Phase

Type of Training Activity

Off-season

Transition period

Unstructured Recreational

Preparatory period Hypertrophy/endurance phase

Cross training Low intensity High volume Non–sport specific

Strength phase

Moderate intensity Moderate volume More sport specific

Preseason

Power phase

High intensity Decreased volume Sport specific

In-season

Competition period

High intensity Low volume Skill training Strategy Maintenance of strength and power gained during the off-season

periods. It adds variety to the training regimen, thus keeping training during the off-season more interesting and exciting. However, although cross training can be

effective in maintaining levels of cardiorespiratory endurance, it is not sport specific and thus should not be used during the preseason.

SUMMARY • Proper physical conditioning for sports participation should prepare the athlete for high-level performance while helping prevent injuries inherent to that sport. • Physical conditioning must follow the SAID principle, which is an acronym for specific adaptation to imposed demands. Conditioning must work toward making the body as lean as possible, commensurate with the athlete’s sport. • A proper warm-up should precede conditioning, and a proper cool-down should follow. It takes at least 15 to 30 minutes of gradual warm-up to bring the body to a state of readiness for vigorous sports training and participation. Warming up consists of a general, unrelated activity followed by a specific, related activity. • Cardiorespiratory endurance is the ability to perform whole-body, large-muscle activities repeatedly for long periods of time. Maximal oxygen consumption is the greatest determinant of the level of cardiorespiratory endurance. Most sport activities involve some combination of both aerobic and anaerobic metabolism. 124

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Improvement of cardiorespiratory endurance may be accomplished through continuous, interval, or speed play training. • Strength is the capacity to exert a force or the ability to perform work against a resistance. There are many ways to develop strength, including functional strength training; core stability training; and isometric, isotonic, and isokinetic muscle contraction. Isometric exercise generates heat energy by forcefully contracting the muscle in a stable position that produces no change in the length of the muscle. Isotonic exercise involves shortening and lengthening a muscle through a complete range of motion. Isokinetic exercise allows resisted movement through a full range at a specific velocity. Circuit training uses a series of exercise stations to improve strength and flexibility. Plyometric training uses a quick, eccentric contraction to facilitate a more explosive concentric contraction. • Optimum flexibility is necessary for success in most sports. Too much flexibility can allow joint trauma to occur, and too little flexibility can result in muscle

tears or strains. Ballistic stretching exercises should be avoided. The safest means of increasing flexibility are dynamic stretching, static stretching, and the proprioceptive neuromuscular facilitation (PNF) technique, consisting of slow-reversal-hold-relax, contract-relax, and hold-relax methods.

• Year-round conditioning is essential in most sports to assist in preventing injuries. Periodization is an approach to conditioning that attempts to bring about peak performance while reducing injuries and overtraining in the athlete by developing a training and conditioning program to be followed throughout the various seasons.

WEB SITES National Academy of Sports Medicine: www.nasm.org

Contains a wealth of information on fitness exercises and activities.

Stretching and Flexibility: Everything you never wanted to know: www.bradapp.com/docs/rec/stretching/ Prepared by Brad Appleton, detailed information on stretching and stretching techniques is presented, including normal ranges of motion, flexibility, how to stretch, the physiology of stretching, and the types of stretching including PNF.

National Strength and Conditioning Association: www .nsca.com This organization distributes a wealth of information relative to strength training and conditioning.

SOLUTIONS TO CLINICAL APPLICATION EXERCISES 4–1 The warm-up should begin with a 5- to 7-minute slow jog, during which the athlete should break into a light sweat. At that point, she should engage in stretching (using either static or PNF techniques), concentrating on quadriceps, hamstrings, groin, and hip abductor muscles. Each specific stretch should be repeated four times, and the stretch should be held for 15 to 20 seconds. Once the workout begins, the athlete should gradually and moderately increase the intensity of her activity. She may also find it effective to stretch during the cool-down period after the workout. 4–2 Although athletes should make every effort to maintain existing levels of fitness during the rehabilitation period, to improve their fitness to competitive levels, athletes in any sport must practice or engage in that specific activity. The football player must begin a heavy strength-training program for the upper body immediately in the postseason and must continue to progressively return to heavy lifting with the lower extremities as soon as the healing process will allow. It is essential for this player to progressively increase the intensity and variety of conditioning drills that specifically relate to performance at his position. 4–3 Because this athlete suffers from a lower-extremity injury in which weight bearing is limited, alternative activities, such as swimming or riding a stationary exercise bike, should be incorporated into her rehabilitation program immediately. If the pressure on her ankle when riding an exercise bike is too painful, she may find it helpful initially to use a bike that incorporates upper-extremity exercise. The athletic trainer should recommend that this soccer player engage in a minimum of 30 minutes of continuous training as well as some higher-intensity interval training to maintain both aerobic and anaerobic fitness. 4–4 Weight training will not have a negative effect on flexibility as long as the lifting is done properly. Lifting the weight through a full range of motion will improve strength and simultaneously maintain range of motion. A female swimmer is not likely to bulk up to the point that muscle size affects range of motion. It is also important

4–5

4–6

4–7

4–8

to recommend that this athlete continue to incorporate active stretching into her training regimen. The athletic trainer can discuss the rationale for strength and conditioning with the athlete. Helping the athlete understand why it is important to increase strength and endurance can increase her motivation. In addition to improving performance and efficiency, muscular endurance and strength are also critical in preventing athletic injuries. The athletic trainer should work with the coaches to provide a periodization program that will keep the athlete’s interest and prevent atrophy from occurring. The shot put, like many other dynamic movements in sports, requires not only great strength but also the ability to generate that strength rapidly. To develop muscular power, this athlete must engage in dynamic, explosive training techniques that will help him develop his ability. Power lifting techniques should be helpful. Plyometric exercises using weights for added resistance will help him improve his speed of muscular contraction against some resistive force. The athletic trainer should recommend that the construction worker engage in a regular, consistent flexibility program using either static or PNF stretching techniques. Stretching should be done several times a day if possible. The worker should also be instructed to engage in full range of motion strength training for the hamstrings. The athletic trainer should also explain that when the construction worker feels tightness or discomfort during a training session, he should stop the activity immediately to avoid making a hamstring strain more severe. During the early part of the preparatory period, training should be at a low intensity with a high volume of repetitions, using activities that may or may not be directly related to football. This phase may last from several weeks to 2 months. The intensity and volume of these activities should progress to moderate levels. Weight-training activities should eventually become more specific to football. Just before the preseason, the athlete should train at a high intensity, and the volume of training should decrease to allow full recovery between sessions.

REVIEW QUESTIONS AND CLASS ACTIVITIES 1. In terms of injury prevention, list as many advantages as you can for conditioning. 2. How does the SAID principle relate to sports conditioning and injury prevention? 3. What is the value of proper warm-up and cool-down to sports injury prevention? 4. Critically observe how a variety of sports use warm-up and cooldown procedures. 5. Discuss the relationships among maximal oxygen consumption, heart rate, stroke volume, and cardiac output.

6. 7. 8. 9.

Differentiate between aerobic and anaerobic training methods. How is continuous training different from interval training? How may increasing strength decrease susceptibility to injury? Compare different techniques of increasing strength. How may each technique be an advantage or a disadvantage to the athlete in terms of injury prevention? 10. Compare ways to increase flexibility and how they may decrease or increase the athlete’s susceptibility to injury. 11. Why is year-round conditioning so important for injury prevention? Chapter Four ■ Fitness and Conditioning Techniques

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REFERENCES 1. Alemany J: Comparison of acute responses to isotonic or isokinetic eccentric muscle action: Differential outcomes in skeletal muscle damage and implications for rehabilitation, International Journal for Sports Medicine 65(1):1–7, 2014. 2. Allerheiligen W: Speed development and plyometric training. In Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 2008, Human Kinetics. 3. Allerheiligen W: Stretching and warm-up. In Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 2008, Human Kinetics. 4. Alter M: The science of flexibility, Champaign, IL, 2004, Human Kinetics. 5. American College of Sports Medicine: Guidelines for exercise testing and prescription, Philadelphia, 2013, Lippincott, Williams and Wilkens. 6. Andersen J: Flexibility in performance: Foundational concepts and practical issues, Athletic Therapy Today 11(3):9, 2006. 7. Andersen J: Stretching before and after exercise: Effect on muscle soreness and injury risk, J Athl Train 40(3):218, 2005. 8. Armiger P: Preventing musculotendinous injuries: A focus on flexibility, Athletic Therapy Today 5(4):20, 2000. 9. Baker D: Generality vs. specificity: A comparison of dynamic and isometric measures of strength and speed-strength, Eur J Appl Physiol 68:350, 1994. 10. Bandy W: The effect of static stretch and dynamic range of motion training on the flexibility of the hamstring muscles, J Orthop Sports Phys Ther 27(4):295, 1998. 11. Behm D: Effect of acute static stretching on force, balance, reaction time, and movement time, Med Sci Sports Exerc 36(8):1397, 2004. 12. Berger R: Conditioning for men, Boston, 1973, Allyn & Bacon. 13. Blanke D: Flexibility. In Mellion M, editor: Sports medicine secrets, Philadelphia, 2002, Hanley & Belfus. 14. Bompa T: Periodization: Theory and methodization of training, Champaign, IL, 2010, Human Kinetics. 15. Bompa T: Serious strength training, Champaign, IL, 2012, Human Kinetics. 16. Boyle M: Functional training for sports, Champaign, IL, 2004, Human Kinetics. 17. Brooks G: Exercise physiology: Human bioenergetics and its applications, San Francisco, 2004, McGraw-Hill. 18. Brumitt J: Core assessment and training, Champaign, IL, 2010, Human Kinetics. 19. Buchheit M: High-intensity interval training, solutions to the programming puzzle, Sports Medicine 43(10):927–954, 2013. 20. Burke D: The theoretical basis of proprioceptive neuromuscular facilitation, Strength Cond 14(4):496, 2000. 21. Carter C: Training the child athlete: Physical fitness, health and injury, British Journal of Sports Medicine 45:880–885, 2011. 22. Chalmers G: Re-examination of the possible role of Golgi tendon organ and muscle spindle reflexes in proprioceptive neuromuscular facilitation muscle stretching, Sports Biomechanics 3(1):159, 2004. 23. Chimera N, Swanik K, Swanik C: Effects of plyometric training on muscle activation strategies

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and performance in female athletes, J Athl Train 39(1):24, 2004. 24. Chu D: Plyometics in sports injury rehabilitation and training, Athletic Therapy Today 4(3): 7, 1999. 25. Clark M: NASM essentials of corrective exercise training, Baltimore, MD: 2011, Lippincott, Williams & Wilkins. 26. Colston M: Core Stability, Part 1: Overview and the concept, Athletic Therapy and Training, 17(1):8–13, 2012. 27. Costa, P: Warm-up, stretching and cool-down strategies for combat sports, Strength and Conditioning Journal 33(6):71–79, 2011. 28. Cross K: Effects of a static stretching program on the incidence of lower extremity musculotendinous strains, J Athl Train 34(1):11, 1999. 29. Curtis N: Stretching and functional flexibility, Athletic Therapy Today 11(3):30, 2006. 30. Dale B: Principles of core stabilization for athletic populations, Athletic Therapy Today 10(4):13, 2005. 31. Decoster L: The effects of hamstring stretching on range of motion: A systematic literature review, J Orthop Sports Phys Ther 3(6): 377, 2005. 32. DeLorme T: Progressive resistance exercise, New York, 1951, Appleton-Century-Crofts. 33. DePino G: Duration of maintained hamstring flexibility after cessation of an acute static stretching protocol, J Athl Train 35(1): 56, 2000. 34. Enoksen E: The effect of high- vs. low-intensity training on aerobic capacity in well-trained male middle-distance runners, Journal of Strength and Conditioning Research 25(3): 812–18, 2011. 35. Eston R. Perceived exertion: Recent advances and novel applications in children and adults, Journal of Exercise Science and Fitness 7(2):11–17, 2009. 36. Ferrar K: A systematic review and metaanalysis of submaximal exercise-based equations to predict maximal oxygen uptake in young people, Pediatric Exercise Science 26(3)342–57, 2014. 37. Fleck S: Designing resistance training programs, Champaign, IL, 2003, Human Kinetics. 38. Fowles J: Reduced strength after passive stretch of the human plantarflexors, J App Physiol 89(3):1179, 2000. 39. Fradkin A: Does warming up prevent injury in sport? The evidence from randomized controlled trials? Journal of Science and Medicine in Sport 9(3):214–20, 2006. 40. Fradkin A: Effects of warming up on physical performance: A systematic review with metaanalysis, Journal of Strength and Conditioning Research 24(1):140–48, 2010. 41. Gardner P: Youth strength training, Athletic Therapy Today 8(1):42, 2003. 42. Gist N: Sprint interval training effects on aerobic capacity: A systematic review and metaanalysis, Sports Medicine 44(2):269–79, 2014. 43. Goldberg L: Strength ball training, Champaign, IL, 2006, Human Kinetics. 44. Gormley S: Effect of intensity of aerobic training on VO2max, Medicine and Science in Sports and Exercise 40(7):1336–43, 2008. 45. Gravelle B, Blessing D: Physiological adaptation in women concurrently training for strength and endurance, J Strength Cond Res 14(1): 5, 2000.

46. Gribble P: Effects of static and hold-relax stretching on hamstring range of motion using the FlexAbility LE1000, J Sport Rehabil 8(3):195, 1999. 47. Harman E: The biomechanics of resistance exercise. In Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 2008, Human Kinetics. 48. Hilbert S: Free weights versus machines, Strength Cond 21(6):66, 1999. 49. Holt L: Modifications to the standard sitand-reach flexibility protocol, J Athl Train 34(1):43, 1999. 50. Issurin V: New horizons for the methodology and physiology of training periodization, Sports Medicine 40(3):189–206, 2010. 51. Jones T: Performance and neuromuscular adaptations following differing ratios of concurrent strength and endurance training, Journal of Strength and Conditioning Research 27(12): 3342–51, 2013. 52. Kaminski T: Concentric versus enhanced eccentric hamstring strength training: Clinical implications, J Athl Train 33(3):216, 1998. 53. Karvonen M: The effects of training on heart rate: A longitudinal study, Ann Med Exp Biol 35:305, 1957. 54. Klinger T: Prescribing target heart rates without the use of a graded exercise test, Clinical Exercise Physiology 3(4):207, 2001. 55. Knight K: Isotonic contractions might be more effective than isokinetic contractions in developing muscle strength, J Sport Rehabil 10(2): 124, 2001. 56. Kokkonen J: Acute stretching inhibits strength endurance, Med Sci Sports Exerc 35(5): 11, 2001. 57. Kokkonen J: Chronic stretching improves sport specific skills, Med Sci Sports Exerc 29(5): 67, 1997. 58. Kovacs M: The argument against static stretching before sport and physical activity, Athletic Therapy Today 11(3):6, 2006. 59. Kraemer W: Strength training for sport, Cambridge, MA, 2002, Blackwell Science. 60. Kubo K: Effect of stretching training on the viscoelastic properties of human tendon structures in vivo, J App Physiol 92(2): 595, 2002. 61. Leetun D: Core stability measures as risk factors for lower extremity injury in athletes, Med Sci Sports Exerc 36(6):926, 2005. 62. Logan G: Recent findings in learning and performance. Paper presented at the Southern Section Meeting, California Association for Health, Physical Education, and Recreation, Pasadena, 1960. 63. Maddigan M: A comparison of assisted and unassisted proprioceptive neuromuscular facilitation techniques and static stretching, Journal of Strength and Conditioning Research 26(5):1238–44, 2012. 64. Mann D: Functional stretching: Implementing a dynamic stretching program, Athletic Therapy Today 6(3):10, 2001. 65. Marek S: Acute effects of static and proprioceptive neuromuscular facilitation stretching on muscle strength and power output, J Athl Train 40(2):94, 2005. 66. McArdle W: Exercise physiology, energy, nutrition, and human performance, Philadelphia, 2014, Lippincott, Williams and Wilkins.

67. McHugh M: To stretch or not to stretch: The role of stretching in injury prevention and performance, Scandinavian Journal of Medicine and Science in Sports 20(2):169–81, 2010. 68. McLaughlin J: Test of the classic model for predicting endurance running performance, Medicine and Science in Sports and Exercise 42(5):991–97, 2010. 69. Merce J: Analysis of peak oxygen consumption and heart rate during elliptical and treadmill exercise, J Sport Rehabil 10(1):48, 2001. 70. Middlesworth M: More than ergonomics: Warm-up and stretching key to injury prevention, Athletic Therapy Today 7(2):32, 2002. 71. Moreno A: The practicalities of adolescent resistance training, Athletic Therapy Today 8(3):26, 2003. 72. Moss R: Physics, plyometrics, and injury prevention, Athletic Therapy Today 7(2):44, 2002. 73. Nelson R: An update on flexibility. Natl Strength Condit Assoc J 27(1):10, 2005. 74. Okada T: Relationship between core stability, functional movement and performance, Journal of Strength and Conditioning Research 25(1):252–61, 2011. 75. Owsley A: An introduction to clinical Pilates. Athletic Therapy Today 10(4):19, 2005. 76. Parr J: Symptomatic and functional responses to concentric-eccentric isokinetic versus eccentric-only isotonic exercise, J Athl Train, 44(5): 462–68, 2009. 77. Prentice W: Get fit stay fit, ed 7, Philadelphia, 2015, F.A. Davis. 78. Prentice W: Proprioceptive neuromuscular facilitation techniques. In Prentice W, editor: Rehabilitation techniques in sports medicine and athletic training, Thorofare, NJ, 2015, Slack. 79. Puentedura E: Immediate effects of quantified hamstring stretching: Hold-relax proprioceptive neuromuscular facilitation versus

static stretching, Physical Therapy in Sport 12(3):122–26, 2011. 80. Radcliffe J: High-powered plyometrics, Champaign, IL: 2015, Human Kinetics. 81. Rubley M: Flexibility retention 3 weeks after a 5-day training regime, J Sport Rehabil 10(2):105, 2001. 82. Ryan E: Do practical durations of stretching alter muscle strength. A dose-response study, Medicine and Science in Sport and Exercise 40(8):1529–37, 2008. 83. Ryan E: Acute effects of different volumes of dynamic stretching on vertical jump performance, flexibility and muscle endurance, Clinical Physiology and Functional Imaging 34(6):485–92, 2014. 84. Ryba T: The benefits of yoga for athletes: The body, Athletic Therapy Today 11(2):32, 2006. 85. Sartor F: Estimation of maximal oxygen uptake via submaximal exercise testing in sports, clinical, and home settings, Sports Medicine 43(9):865–73. 2015. 86. Schilling B: Stretching: Acute effects on strength and power performance, Strength Cond 22(1):44, 2000. 87. Sekendiz B: Effects of Swiss-ball core strength training on strength, endurance, flexibility and balance in sedentary women, Journal of Strength and Conditioning Research 24(11):3032–40, 2010. 88. Sexton P: The importance of flexibility for functional range of motion, Athletic Therapy Today 11(3):13, 2006. 89. Siatras T: Static and dynamic acute stretching effect on gymnasts’ speed in vaulting, Ped Ex Sci 15:383, 2003. 90. Small K: A systematic review into the efficacy of static stretching as part of a warmup for the prevention of exercise-related injury, Research in Sports Medicine 16(3):213–31, 2008.

91. Soames R: Joint motion: Clinical measurement and evaluation, Philadelphia, 2002, Elsevier. 92. Swain D: Validation of a new method for estimating VO2max based on VO2 reserve, Med Sci Sports Exerc 36(8):1421, 2004. 93. Swanson J: Periodization for the multisport athlete, Strength Cond 26(4):50, 2004. 94. Talanian J: Two weeks of high-intensity aerobic interval training increases the capacity for fat oxidation during exercise in women, Journal of Applied Physiology 102(4): 1439–47, 2007. 95. Taylor D: Viscoelastic characteristics of muscle: Passive stretching versus muscular contractions, Med Sci Sports Exerc 29(12):1619, 1997. 96. Thacker S: The impact of stretching on sports injury risk: A systematic review of the literature, Med Sci Sports Exerc 36(3):371, 2004. 97. Thomas M: The functional warm-up, Strength Cond 22(2):51, 2000. 98. Van Hatten B: Passive versus active stretching, Phys Ther 85(1):80, 2005. 99. Walker M: Relationship between maximum strength and relative endurance for the emptycan exercise, J Sport Rehabil 12(1):31, 2003. 100. Wathen D: Periodization: Concepts and applications. In Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 2008, Human Kinetics. 101. Wilkerson G: Neuromuscular changes in female collegiate athletes resulting from a plyometric jump training program, J Athl Train 39(1): 17, 2004. 102. Winters M: Passive versus active stretching of hip flexor muscles in subjects with limited hip extension: A randomized clinical trial, Phys Ther 84(9):800, 2004. 103. Zentz C: Warm up to perform up, Athletic Therapy Today 5(2):59, 2000.

ANNOTATED BIBLIOGRAPHY Adler S, Beckers D, Buck M: PNF in practice: an illustrated guide, New York, 2008, Springer. A heavily illustrated text that covers all aspects of PNF. Alter M: The science of flexibility, Champaign, IL, 2004, Human Kinetics. Explains the principles and techniques of stretching and details the anatomy and physiology of muscle and connective tissue. Includes guidelines for developing a flexibility program, illustrated stretching exercises, and warm-up drills. Anderson B: Stretching, Bolinas, CA, 2010, Shelter. An extremely comprehensive best-selling text on stretching exercises for the entire body. Baechle T, editor: Essentials of strength training and conditioning, Champaign, IL, 2008, Human Kinetics. A book from the National Strength Coaches Association that explains the science, theory, and practical application of various aspects of conditioning in a very concise, easily understood text. Bishop, J: Fitness through aerobics, Philadelphia, PA, 2010, Benjamin Cummings. This text uses the most up-to-date fitness and wellness information on aerobic dance exercise. Cardinale, M. Newton, R, Strength and conditioning: Biological principles and practical applications, Hoboken, NJ, 2011, John Wiley. This book provides good scientific and practical information in the field of strength and conditioning.

Fleck, S, Kraemer, W, Designing resistance training programs, Champaign, IL, 2014, Human Kinetics. A clear, readable, state-of-the-art guide to developing individualized training programs for both athletes and fitness enthusiasts. Kovacs, M, Dynamic stretching: The revolutionary new warm-up method to improve power, performance and range of motion. Berkeley, CA, 2009, Ulysses Press. Teaches how to prepare your body for physical activity while simultaneously improving strength, power, speed, agility, and endurance. Leibenson, C. Functional training handbook, Baltimore, MD, 2014, Lippincott, Williams & Wilkins. This practical guide delivers clear, how-to information, an array of sport-specific guidelines, and key principles that foster lifelong health, mobility, and athletic development. National Strength and Conditioning Association, Developing the core, Champaign, IL, 2013, Human Kinetics. The National Strength and Conditioning Association (NSCA) brings you the authoritative resource on strengthening the core to maximize sport performance. Powers, S, Howley, E. Exercise physiology: Theory and application to fitness and performance, New York, 2011, McGraw-Hill. Written especially for exercise science and physical education students, this text provides a solid foundation in theory illuminated by application and performance models to increase understanding and to help students apply what they’ve learned in the classroom.

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Radcliffe, J, Farentinos, R, High powered plyometrics, Champaign, IL, 2015. Human Kinetics. Detailing plyometric exercises for a variety of sports, this guide explains how plyometrics work and how to incorporate plyometrics into a comprehensive strength- and power-training program. Prentice W: Fitness and wellness for life, ed 7, Dubuque, IA, 1999, WCB/McGraw-Hill. A comprehensive fitness text that covers all aspects of a training and conditioning program. Verstegen M, Williams P: Core performance: the revolutionary workout program to transform your body and your life, Mountain View, CA, 2005, Rodale Press.

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Concentrates primarily on core stabilization exercises to improve posture and improve performance in athletes. Wiksten D, Peters C: The athletic trainer’s guide to strength and endurance training, Thorofare, NJ, 2000, Slack. Layout offers ease of reference, sport-specific programs, information on n utritional supplements, and illustrations on weight training and s upplemental routines.

Nutrition and Supplements ■ Objectives When you finish this chapter you should be able to • Distinguish the six classes of nutrients and describe their major functions. • Explain the importance of good nutrition in enhancing performance and preventing injuries. • Assess the advantages and disadvantages of dietary supplements. • Discuss popular eating and drinking practices. • Discuss the advantages and disadvantages of consuming a pre-event meal.

■ Outline Nutrition Basics 130 Energy Sources 131 Regulator Nutrients 133 Nutrient Requirements and Recommendations 136

• Differentiate between body weight and body composition. • Explain the principle of caloric balance and how to assess it. • Assess body composition using skinfold calipers. • Evaluate methods for losing and gaining weight. • Recognize the signs of bulimia nervosa and anorexia nervosa.

■ Key Terms amino acids osteoporosis lactase deficiency anemia glycemic index (GI)

glycogen supercompensation obesity adipose cell body composition

Dietary Supplements 138 Eating and Drinking Practices 142 Body Composition and Weight Control 147 Summary 154

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • Clinical application scenarios covering methods of losing and gaining weight, nutrition to enhance performance and prevent injury, dietary supplements, and caloric balance and how to assess it • Click-and-drag questions covering vitamins, minerals, prevent meals, and body composition • Multiple-choice questions covering nutrients, proper nutrition to enhance performance, dietary supplements, hydration, and eating disorders • Selection questions covering nutrients and their major functions

he relation of nutrition, diet, and weight control to overall health and fitness should be an issue of critical importance to everyone. Individuals who practice sound nutritional habits reduce the likelihood of injury and illness by maintaining a higher standard of healthful living.11 We know that eating a well-balanced diet can positively contribute to the development of strength, flexibility, and cardiorespiratory endurance.66,81 Unfortunately, misconceptions, fads, and, in many cases, superstitions regarding nutrition have a significant impact on dietary habits.48 Many athletes associate successful performance with the consumption of special foods or supplements.25 An athlete who is performing well may be reluctant to change dietary habits regardless of whether the diet is physiologically beneficial to overall health.85 There is no question that the psychological aspect of allowing the athlete to eat whatever he or she is most comfortable with can greatly affect performance. The problem is that these eating habits tend to become accepted as beneficial and may become traditional when, in fact, they may be physiologically detrimental to athletic performance. Thus, many nutrition “experts” tend to disseminate nutritional information based on traditional rather than experimental information.25 The athletic trainer must possess a strong knowledge of nutrition so that he or she may serve as an informational resource for the athlete.10,46,66 SoR:A The athletic trainer should make an effort to establish a support team that includes a registered dietitian, sports nutritionist, or other health care professional with expertise in nutrition.10 SoR:A An athletic trainer working in the clinical, corporate, or industrial setting may be responsible for overseeing employee fitness or wellness programs. Providing direct nutritional counseling, organizing health fairs or

NUTRITION BASICS Nutrition is the science of the substances in food that are essential to life. Nutrients have three major functions: the growth, repair, and maintenance of all tissues; the regulation of body processes; and the production of energy.22 The nutrients are categorized into six major classes: carbohydrates, fats (often called lipids), proteins, water, vitamins, and minerals. Carbohydrates, proteins, and fats are referred to as the macronutrients: the absorbable components of food, from which The six classes of nutrients are energy is derived. carbohydrates, fats, proteins, Vitamins, minerals, water, vitamins, and minerals. and water are considered to be micronutrients, which are necessary for regulating normal body functions. They do not provide energy, but without sufficient quantities of micronutrients, the energy from macronutrients cannot be utilized. For example, certain vitamins are necessary for other vitamins to be absorbed. Most foods are actually mixtures of these nutrients. Some nutrients can be made by the body, but an essential nutrient must be supplied by the diet.85 Not all substances in food are considered nutrients. There is no such thing as the perfect food; that is, no single natural food contains all the nutrients needed for health. A summary of current percentages and recommended percentages of calories from protein, carbohydrate, and fat is shown in Figure 5–1.

45%–65%

60 50%

DIET RECOMMENDATIONS

16% Protein

34%

Fat

Protein

20%–35% 10%–35%

Fat

Carbohydrate

50 Carbohydrate

Percent of total energy intake

workshops that focus on various aspects of nutrition, and serving as a resource in disseminating information related to diet and nutrition may all be part of the responsibilities of that position.

CURRENT U.S. DIET

FIGURE 5–1 Comparison of calories from protein, carbohydrate, and fat. (Based on 2015–2020 Dietary Guidelines) 130

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ENERGY SOURCES Carbohydrates Anyone who is physically active has increased energy needs. Carbohydrates are the body’s most efficient source of energy and should be relied on to fill those needs.50 Carbohydrate intake should account for 45 to 65 percent of total caloric intake. The following sections describe different forms of carbohydrates and their role in the production of energy and the maintenance of health.13 It is important to understand that not all carbohydrates are digested and absorbed at the same rate. Sugars Carbohydrates are classified as simple (sugars) or complex (starch and most forms of fiber). Sugars are further divided into monosaccharides Carbohydrates are sugars, starches, and fiber. and disaccharides. Monosaccharides, or single sugars, are found mostly in fruits, syrups, and honey. Glucose (blood sugar) is a monosaccharide. Milk sugar (lactose) and table sugar (sucrose) are combinations of two monosaccharides and are called disaccharides. Because sugar contributes little in the way of other nutrients, the amount of sugar eaten should account for no more than 100 calories a day for women and 150 calories a day for men. Starches Starches are complex carbohydrates. A starch is made up of long chains of glucose units.

During the digestion process, the starch chain is broken down and the glucose units are free to be absorbed. Food sources of starch, such as rice, potatoes, and breads, often provide vitamins and minerals in addition to serving as the body’s principal source of glucose. Many people believe that starchy foods contribute to obesity. However, most of these foods are eaten with fats from butter, margarine, sauces, and gravies that make the food more enjoyable but contribute an excess of calories. The body cannot use starches and many sugars directly from food for energy. It must obtain the simple sugar glucose (blood sugar). During digestion and metabolism, starches and diGlycolysis is the process that saccharide sugars breaks down glucose to produce energy. are broken down and converted to glucose. The glucose that is not needed for immediate energy is stored as glycogen in the liver and muscle cells. Glucose can be released from glycogen later if needed. The body, however, can store only a limited amount of glucose as glycogen. Any extra glucose is converted to body fat. When the body experiences an inadequate intake of dietary carbohydrate, it uses protein to make glucose, but the protein is then diverted from its own important functions. Therefore, a supply of glucose must be kept available to prevent the use of protein for energy. This is called the protein-sparing action of glucose. Fiber Fiber forms the structural parts of plants and is not digested by humans. Fiber is not found in animal sources of food. There are two kinds of dietary fiber: soluble and insoluble. Soluble fiber includes A dancer has been told gums and pectins; celby the choreographer in lulose is the primary her dance company that insoluble form. Sources she is slightly overweight of soluble fiber are oatand needs to lose a few meal, legumes, and some pounds. The dancer has fruits. Food sources of been watching television insoluble fi ber include and reading about how whole-grain breads and important it is to limit bran cereals. the dietary intake of fat Because it is not difor losing weight. She has gested, fiber passes through decided to go on a diet that has essentially no-fat the intestinal tract and adds and is totally convinced bulk. Fiber aids normal that this will help her lose elimination by reducing the weight. amount of time required for wastes to move through What should the the digestive tract, which athletic trainer tell her about avoiding the is believed to reduce the excessive intake of fat as a risk of colon cancer. Also, means of losing weight? increased fiber intake is thought to reduce the risk

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5–1 Clinical Application Exercise

It is recommended that the majority, about 45 to 65 percent, of the calories consumed be in the form of carbohydrates. Fat should account for between 20 to 35 percent of the total caloric intake. Only 10 to 35 percent of the caloric intake Dietary recommendations: should be protein. • Carbohydrate: 45%–65% For an athlete who • Fat: 20%–35% requires additional • Protein: 10%–35% energy during the course of a day, the extra calories consumed should be in the form of carbohydrates.82 Nutrient-dense foods are those that supply adequate amounts of vitamins and minerals in relation to their caloric value. Nutrient-dense foods supply The so-called junk adequate amounts of vitamins foods provide exand minerals in relation to caloric cessive amounts of value. calories from fat and sugar in relation to vitamins and minerals and therefore are not nutrient dense. However, many people live on junk foods that displace more nutrient-dense foods from their diet.67 This behavior is not healthful in the long run.83

of coronary artery disease. Soluble forms of fiber bind to cholesterol passing through the digestive tract and prevent its absorption, which can reduce blood cholesterol levels. Foods rich in saturated fats (meats, in particular) often take the place of fiber-rich foods in the diet, thus increasing cholesterol absorption and formation. Consumption of adequate amounts of fiber has been associated with lowered incidences of obesity, constipation, colitis, appendicitis, and diabetes. The recommended amount of fiber in the diet is approximately 25 grams per day for women and 38 grams per day for men.77 Unfortunately, the average person consumes only 15 grams per day. Fiber intake should be increased by increasing the amount of wholegrain cereal products and fruits and vegetables in the diet rather than by using fiber supplements. However, excessive consumption of fiber may cause intestinal discomfort as well as increased losses of calcium and iron.

Fats Fats are an essential component of the diet. They are the most concentrated source of energy, providing more than twice the calories per gram when compared with carbohydrates or proteins. Fat is used as a primary source of energy. Some dietary fat is needed to make food more flavorful and for sources of the fat-soluble vitamins. Also, a minimal amount of fat is essential for normal growth and development. Unfortunately, in the typical American diet, fat represents approximately 40 to 50 percent of the total caloric intake. This intake is believed to be too high and may contribute to the prevalence of obesity, certain cancers, and coronary artery disease. Intake should be limited to less than 20 to 35 percent of total calories.83 Saturated versus Unsaturated Fat Both plant and animal foods provide sources of dietary fat. About 95 percent of the fat consumed is in the form of triglycerides. Depending on their chemiFats may be saturated or cal nature, fatty unsaturated. acids may be saturated or unsaturated. The unsaturated fatty acids can be subdivided into monounsaturates and polyunsaturates. Therefore, the terms saturated, monounsaturated, and polyunsaturated are used to describe the chemical nature of the fat in foods. The triglycerides that make up food fats are usually mixtures of saturated and unsaturated fatty acids but are classified according to the type that predominates. In general, fats containing more unsaturated fatty acids are from plants and are liquid at room temperature. Saturated fatty acids are derived mainly from animal sources. Trans fatty acids (trans fat) have physical properties generally resembling saturated fatty acids, and their 132

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presence tends to harden oils. Trans fats have been used in many cookies crackers, dairy products, meats, potato chips, most junk foods, and fast foods. Trans fatty acids increase the risk of heart disease by boosting levels of bad cholesterol. Because they are not essential and provide no known health benefit, there is no safe level of trans fatty acids in the blood, and people should eat as little of them as possible while consuming a nutritionally adequate diet. There is a substantial ongoing effort by the Food and Drug Administration to eliminate trans fats from the U.S. food supply. Other Fats Phospholipids and sterols represent the remaining 5 percent of fats. One example of phospholipids is lecithin; cholesterol is the best known sterol. Cholesterol is consumed in animal foods; it is not supplied by plant sources of food. Generally, it is wise to avoid eating foods high in cholesterol. Although cholesterol is essential to many bodily functions, the body can manufacture cholesterol from carbohydrates, proteins, and especially saturated fat. Thus, there is little, if any, need to consume additional amounts of cholesterol in the diet. When low-density cholesterol (LDL) becomes too high, the risk of developing cardiovascular diseases also increases. Saturated fat can raise the amount of low-density lipoprotein (LDL) and the level of “bad” cholesterol, thus increasing the risk for heart disease. The American Heart Association recommends consuming less than 300 mg per day. Their guidelines also advise limiting saturated fats and trans fats, both of which can raise LDL cholesterol.3 One type of unsaturated fatty acid seems to serve as a protective mechanism against certain disease processes. The omega-3 fatty acids apparently have the capability of reducing the likelihood of heart disease, stroke, and hypertension. These fatty acids are found in cold-water fish.

Proteins Proteins make up the major structural components of the body. They are needed for the growth, maintenance, and repair of all body tissues. In addition, proteins are needed to make enzymes, many hormones, and antibodies that help fight infection. In general, the body prefers not to use much protein for energy; instead, it relies on fats and carbohydrates. Protein intake should be around 10 to 35 percent of total calories. Amino Acids The basic units that make up proteins are smaller compounds called amino acids. Most of the body’s proteins are made up of about 20 amino acids. Amino acids can be linked together in a wide variety of combinations, which is why there are so many different forms and uses of proteins. Most of the amino acids can be produced as needed in the body. The others cannot be made to any significant degree and therefore must be supplied by the diet. The amino acids obtained through

5–2 Clinical Application Exercise

food are referred to as the essential amino acids. The amount of protein and the levels of the individual essential amino acids are important for determining the quality of diet. A diet that contains large amounts of protein will not support growth, repair, and maintenance of tissues if the essential amino acids are not available in the proper proportions.39 Most of the proteins from animal foods contain all the essential amino acids that humans require and are called complete, or high-quality, proteins. Incomplete proteins—that is, proteins that do Proteins are made up of amino acids. not contain all the essential amino acids—usually are from plant sources of food. Beans and legumes are a potential source of protein and iron for vegetarians. Protein Sources and Need Most people do not have difficulty meeting their protein needs because the typical diet is rich in protein. Athletes need more than the recommended daily allowance (RDA) of pro A company employee tein (1.2–2.0 g/kg/BW).32 who regularly goes to the Many athletes consume corporate fitness center more than twice the complains to the athletic recommended amounts trainer that she constantly of protein. There is no feels tired and lethargic, even though she thinks advantage to consumthat she is eating well ing more protein, parand getting a sufficient ticularly in the form of amount of sleep. A protein supplements. If coworker has suggested more protein is supplied that she begin taking than needed, the body vitamin supplements, must convert the excess which the coworker claims to fat for storage. This give her more energy and conversion can create a make her more resistant to situation in which exfatigue. The employee asks cess water is removed the athletic trainer’s advice about the kind of vitamins from cells, leading to she needs to take. dehydration and possible damage to the kidneys What facts should or liver. Although this the athletic trainer is not generally a conexplain about vitamin cern in healthy adults.62 supplementation, and what recommendations should Protein supplements may he or she make? also create imbalances of the chemicals that make up proteins, the amino acids, which is not desirable. A condition of the bones, osteoporosis, has been linked to a diet that contains too much protein.4 Increased physical activity increases a person’s need for energy, not necessarily for protein.39 The increases in muscle mass that result from conditioning and training are associated with only a small increase in protein requirements, which can easily be met with

the usual diet. Therefore, an athlete does not need protein supplements.

REGULATOR NUTRIENTS Vitamins Although vitamins are required in extremely small amounts when compared with water, proteins, carbohydrates, and fats, they perform essential functions, primarily as regulators of body processes.13 Thirteen vitamins have specific roles in the body, many of which are still being explored. In the past, letters were assigned as names for vitamins. Today, most are known by their scientific names. Vitamins are classified into two groups: fat-soluble vitamins, which are dissolved in fats and stored in the body, and water-soluble vitamins, which are dissolved in watery solutions and are not stored. Table 5–1 lists the vitamins and indicates their primary functions. Fat-Soluble Vitamins Vitamins A, D, E, and K are fat soluble. They are found in the fatty portions of foods and in oils. Because they are stored in the Fat-soluble vitamins: A, D, E, body’s fat, it is posand K. sible to consume excess amounts, which can accumulate and lead to toxicity if the upper intake levels (ULs) are exceeded. Water-Soluble Vitamins The water-soluble vitamins are vitamin C, known as ascorbic acid, and the B-complex vitamins thiamin, riboflavin, niacin, B6, folate, B12, biotin, and pantothenic acid. Although vitamins are not metabolized for energy, thiamin, riboflavin, niacin, biotin, and pantothenic acid are used to regulate the metabolism of carbohydrates, proteins, and fats Water-soluble vitamins: C, to obtain energy. thiamin, riboflavin, niacin, Vitamin B6 reguB6, B12, folate, biotin, and pantothenic acid. lates the body’s use of amino acids. Folate and vitamin B12 are important in normal blood formation. Vitamin C is used for building bones and teeth, maintaining connective tissues, and strengthening the immune system. Unlike fat-soluble vitamins, watersoluble vitamins cannot be stored to any significant extent in the body and should be supplied in the diet each day.50 Antioxidants Certain nutrients, called antioxidants, may prevent premature aging, certain cancers, heart disease, and other health problems.59 An antioxidant protects vital cell components from the destructive effects of certain agents, including oxygen. Antioxidants: vitamin C, vitamin Vitamin C, vitamin E, and beta-carotene. E, and beta-carotene Chapter Five ■ Nutrition and Supplements

133

TABLE 5–1 Vitamin

Vitamins Major Function

Most Reliable Sources

Deficiency

Excess (toxicity)

Fat-Soluable Vitamins A

Maintains skin and other cells that line the inside of the body, bone and tooth development, growth, vision in dim light

Liver, milk, egg yolk, deep green and yellow fruits and vegetables

Night blindness, dry skin, growth failure

Headaches, nausea, loss of hair, dry skin, diarrhea

Normal bone growth and development

Exposure to sunlight, fortified dairy products, eggs and fish liver oils

Rickets in children— defective bone formation leading to deformed bones

Appetite loss, weight loss, failure to grow

Prevents destruction of polyunsaturated fats caused by exposure to oxidizing agents, protects cell membranes from destruction

Vegetable oils, some in fruits and vegetables, whole grains

Breakage of red blood cells leading to anemia

Nausea and diarrhea, interferes with vitamin K absorption if vitamin D is also deficient, not as toxic as other fat-soluble vitamins

Production of bloodclotting substances

Green, leafy vegetables; normal bacteria that live in intestines

Increased bleeding time

Water-Soluble Vitamins Thiamin

Needed for release of energy from carbohydrates, fats, and proteins

Cereal products, pork, peas, dried beans

Lack of energy, nerve problems

Riboflavin

Energy from carbohydrates, fats, and proteins

Milk, liver, fruits and vegetables, enriched breads and cereals

Dry skin, cracked lips

Niacin

Energy from carbohydrates, fats, and proteins

Liver, meat, poultry, peanut butter, legumes, enriched breads and cereals

Skin problems, diarrhea, mental depression, eventually death (rarely occurs in U.S.)

Skin flushing, intestinal upset, nervousness, intestinal ulcers

Metabolism of protein, production of hemoglobin

White meats, whole grains, liver, egg yolk, bananas

Poor growth, anemia

Severe loss of coordination from nerve damage

B12

Production of genetic material, maintains central nervous system

Foods of animal origin

Neurological problems, anemia

Wheat germ; liver; yeast; mushrooms; green, leafy vegetables; fruits

Anemia

Fruits and vegetables

Scurvy (rare), swollen joints, bleeding gums, fatigue, bruising

Pantothenic Energy from acid carbohydrates, fats, proteins

Widely found in foods

Not observed in humans under normal conditions

Biotin

Widely found in foods

Rare under normal conditions

Production of genetic Folate (folic acid) material C (ascorbic acid)

Formation and maintenance of connective tissue, tooth and bone formation, immune function

Use of fats

Kidney stones, diarrhea

are antioxidants. Beta-carotene is a plant pigment found in dark green, deep yellow, and orange fruits and vegetables. The body can convert beta-carotene to vitamin A. In the early 1980s, researchers reported that smokers who ate large quantities of fruits and vegetables rich in betacarotene were less likely to develop lung cancer than were other smokers.71 Since that time, more evidence has accumulated about the benefits of a diet rich in the antioxidant nutrients.71 Some experts believe that it is important to increase intake of antioxidants, even if it means taking supplements. Others are more cautious.71 Excess beta-carotene pigments circulate throughout the body and may turn the skin yellow. However, the pigment is not believed to be toxic, like its nutrient cousin, vitamin A. On the other hand, increasing intake of vitamins C and E is not without some risk. Excess vitamin C is not well absorbed. The excess is irritating to the intestines and creates diarrhea. Although less toxic than vitamins A and D, too much vitamin E causes health problems. The issue of whether athletes need to use antioxidant supplements is controversial. Currently, there is limited scientific

TABLE 5–2

evidence to recommend antioxidant supplements to athletes or other physically active individuals.57 Vitamin Deficiencies The illness that results from a lack of any nutrient, especially those nutrients, such as vitamins, that are needed only in small amounts, is referred to as a deficiency disease.13 Vitamin deficiency diseases are rare. Adequate amounts of the vitamins, as with other nutrients, can be obtained if a wide variety of foods are eaten. Vitamin supplements can cause toxic effects if large enough quantities are taken. Table 5–1 describes some of vitamins’ toxicity problems.

Minerals More than 20 mineral elements have a role in body function and therefore must be supplied in the diet. The most essential minerals are listed in Table5–2. Most minerals are stored in the body, especially in the liver and bones. Magnesium is needed in e nergy-supplying reactions; sodium and potassium are important for the transmission of nerve impulses. Iron plays a role in energy metabolism but is also combined with a protein to form hemoglobin,

Minerals

Mineral

Major Role

Most Reliable Sources

Deficiency

Excess

Calcium

Bone and tooth formation, blood clotting, muscle contraction, nerve function

Dairy products, calcium-enriched orange juice and bread

May lead to osteoporosis

Calcium deposits in soft tissues

Phosphorus

Skeletal development, tooth formation

Meats, dairy products, other protein-rich foods

Rarely seen

Sodium

Maintenance of fluid balance

Salt (sodium chloride) added to foods and sodium-containing preservatives

Iron

Formation of hemoglobin; energy from carbohydrates, fats, and proteins

Liver and red meats, enriched breads and cereals

Iron-deficiency anemia

Can cause death in children from supplement overdose

Copper

Formation of hemoglobin

Liver, nuts, shellfish, cherries, mushrooms, whole-grain breads and cereals

Anemia

Nausea, vomiting

Zinc

Normal growth and development

Seafood, meats

Skin problems, delayed development, growth problems

Interferes with copper use, may decrease high-density lipoprotein levels

Iodine

Production of the hormone thyroxin

Iodized salt, seafood

Mental and growth retardation, lack of energy

Fluorine

Strengthens bones and teeth

Fluoridated water

Teeth are less resistant to decay

May contribute to the development of hypertension

Damage to tooth enamel

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the compound that transports oxygen in red blood cells. Calcium has many important functions: It is necessary for proper bone and teeth formation, blood clotting, and muscle contraction. In general, minerals have roles that are too numerous to detail. Eating a wide variety of foods is the best way to obtain the minerals needed in the proper concentrations.55

Water Water is the most essential of all the nutrients and should be the nutrient of greatest concern to the athlete.15 It is the most abundant nutrient in the body, accounting for approximately 60 percent of the body weight, although this varies considerably (+/−10%) among individuals due to age and percent of body fat. Water is essential for all the chemical processes that occur in the body, and an adequate supply of water is necessary for energy production and the normal digestion of other nutrients. Although water does not supply any energy (calories), an adequate amount of water is needed for energy production in all cells. Water also takes part in digestion and maintenance of the proper environment inside and outside cells. Water is also necessary for temperature control and for the elimination of waste products of nutrient and body metabolism. Too little water leads to dehydration, and severe dehydration can lead to death. The Institute of Medicine determined that an adequate intake (AI) for men is roughly about 3 liters of total beverages a day and for women is about 2.2 liters of total beverages a day. The body has a number of mechanisms designed to maintain body water at a near-normal level. Too little water leads to accumulation of solutes in the blood. These solutes signal the brain that the body is thirsty while signaling the kidneys to conserve water. Excessive water dilutes these solutes, which signals the brain to stop drinking and the kidneys to get rid of the excess water. Water is the only nutrient that is of greater importance to the athlete than to those people who are more sedentary, especially when the athlete is engaging in prolonged exercise in a hot, humid environment.36 Such a situation may cause excessive sweating and subsequent losses of large amounts of water. When the body burns carbohydrate and fat for energy, it produces a great deal of heat. During exercise, that heat is lost from the body primarily by sweating. Sweating is how the body uses water to keep itself from overheating. Restriction of water during this time results in dehydration. Symptoms of dehydration include fatigue, vomiting, nausea, exhaustion, fainting, and possibly death. Electrolyte Requirements Electrolytes, including sodium, chloride, potassium, magnesium, and calcium, are electrically charged ions dissolved in body water. Among many other functions, electrolytes maintain the balance of 136

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water inside and Electrolytes: sodium, chloride, outside the cell. In potassium, magnesium, and other words,eleccalcium. trolytes, especially sodium, are essential in helping the body rehydrate quickly.2 Electrolyte replenishment may be needed when a person is not fit, suffers from extreme water loss, or has Replacing fluid after heavy just completed an sweating is far more important than replacing electrolytes. exercise period and is expected to perform at near-maximum effort within the next few hours. In most cases, electrolytes can be sufficiently replaced with a balanced diet, which can, if necessary, be salted slightly more than usual. Free access to water and sports drinks (ad libitum) before, during, and after activity should be the rule (see Chapter 6).42 In some people, electrolyte losses can produce muscle cramping and intolerance to heat. Sweating results not only in body water loss but in some electrolyte loss as well.53 Chapter 6 discusses fluid and electrolyte replacement in great detail.

NUTRIENT REQUIREMENTS AND RECOMMENDATIONS A nutrient requirement is the amount of the nutrient that is needed to prevent the nutrient’s deficiency disease. Nutrient needs vary among individuals within a population. A recommendation for a nutrient is different from the requirement for a nutrient. Scientists establish recommendations for nutrients and calories based on extensive scientific research and assessment of present dietary intakes.85 In the past, the U.S. recommended dietary allowances (U.S. RDAs) have served as the benchmark of nutritional adequacy in the United States. Over the past several years, new information has emerged about nutrient requirements that necessitated updating of the RDAs.24 RDAs have been changed to dietary reference intakes (DRIs), which are established using an expanded concept that includes indicators of good health and the prevention of chronic disease, as well as possible adverse effects of overconsumption.85 Dietary reference intakes is an umbrella term that encompasses sets of dietary recommendations that include not only recommended intakes (RDAs) intended to help individuals meet their daily nutritional requirements but also tolerable upper intake levels (ULs), which help individuals avoid harm from consuming too much of a nutrient; estimated average requirements (EARs), which are the average daily nutrient intake levels estimated to meet the requirements of half the healthy individuals in a particular age group; and AI, which is the recommended average daily intake level based on experimentally developed estimates of

nutrient intake that are used when the RDA cannot be determined.24

FOOD LABELS Over the past 20 years, food labels have provided helpful nutritional information for consumers. In 1994, a new nutritional labeling format changed the look and importance of food product packaging. People were becoming concerned about the amount of fat, cholesterol, sodium, and fiber in the typical American diet, thus producing the drive for a more health-conscious label. Health educators believe that the new format has made it easier for consumers to make more informed, healthful food selections. In 2006, the U.S. Food and Drug Administration (FDA) mandated that trans fat be added to the label. In 2016, the FDA updated the “Nutrition Facts” label for packaged foods to reflect

the latest scientific information to emphasize important elements, such as calories, serving sizes, and percentage of daily value, which are important in addressing current public health problems like obesity and heart disease.21 Figure 5–2 shows the new, redesigned Nutrition Facts label approved by the FDA. The new label will be required on most packaged food by July 2018.

MyPlate The USDA’s new food icon MyPlate, introduced in 2011, is the government’s primary food group symbol, designed to help consumers adopt healthy eating habits consistent with the 2015 Dietary Guidelines for Americans.77 (See Figure 5–3.) The intent is to help consumers think about building a healthy diet, which consists of fruit, vegetable, grain, protein, and dairy food groups.

Nutrition Facts 8 servings per container

Serving size

Amount per serving

Calories

2/3 cup (55g)

230 % Daily Value*

Total Fat 8g Saturated Fat 1g

10% 5%

Trans Fat 0g Cholesterol 0mg

Sodium 160mg

Total Carbohydrate 37g Dietary Fiber 4g

13% 14%

Total Sugars 12g Includes 10g Added Sugars

20%

Protein 3g Vitamin D 2mcg

10%

Calcium 260mg

20%

Iron 8mg

45%

Potassium 235mg

* The % Daily Value (DV) tells you how much a nutrient in a serving of food contributes to a daily diet. 2,000 calories a day is used for general nutrition advice.

FIGURE 5–2 Food label indicating nutrition information per serving.

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empower people to make healthier food choices for themselves, their families, and their children. Hopefully, this approach will help to eliminate consumer frustration over what they report as contradictory nutrition information. The newest 2015 to 2020 Dietary Guidelines for Americans form the basis of the federal government’s nutrition education programs, federal nutrition assistance programs, and dietary advice provided by health and nutrition professionals. The guidelines and recommendations help professionals and the media understand and deliver relevant nutrition information to encourage healthy eating and help Americans make healthy choices for them and their families. Focus Box 5–1 identifies the 2015 to 2020 Dietary Guidelines.

DIETARY SUPPLEMENTS FIGURE 5–3 MyPlate Icon. Source: U.S. Department of Agriculture, U.S. Department of Health and Human Serivces, 2015.

A Web site, ChooseMyPlate.gov, provides practical information to several groups, including individual Americans, health professionals, nutrition educators, and the food industry, to help these consumers build healthier diets. Resources and tools for dietary assessment, nutrition education, and other user-friendly nutrition information can also be found on this Web site. Because the American population is experiencing epidemic rates of overweight and obesity, the hope is that the online resources and tools can

Many people believe that exercise increases requirements for nutrients, such as proteins, vitamins, and minerals, and that it is possible and desirable to saturate the body with these nutrients.17 There is no scientific basis Vitamin requirements do not increase during exercise. for ingesting levels of these nutrients above DRI levels.64 Exercise increases the need for energy, not for proteins, vitamins, and minerals.13 Additionally, many athletes use nutritional supplements for performance enhancement.61,69,80 But it is important to note that attempts to enhance performance should be based primarily on proper nutrition and permanent changes in the athlete’s diet rather than relying on dietary supplementation. Thus, it is

FOCUS 5–1 Focus on Injury/Illness Prevention and Wellness Promotion 2015–2020 Dietary Guidelines for Americans* Guidelines 1. Follow a healthy eating pattern across the lifespan.

3. Limit calories from added sugars and saturated fats and reduce sodium intake.

All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.

Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in these components to amounts that fit within healthy eating patterns.

2. Focus on variety, nutrient density, and amount.

4. Shift to healthier food and beverage choices.

To meet nutrient needs within calorie limits, choose a variety of nutrientdense foods across and within all food groups in recommended amounts.

Choose nutrient-dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences

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to make these shifts easier to accomplish and maintain. 5. Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities. *From U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans, 8th ed., December 2015. Available at http://health.gov /dietaryguidelines/2015/guidelines/

Vitamin Supplements Many individuals believe that taking large amounts of vitamin supplements can lead to superior health and performance.85 A megadose of a nutrient supple ment is essentially Since the majority of supplements an overdose; the are not regulated, these over-theamount ingested counter products may contain far exceeds the banned substances. Athletes DRI levels.13 The should consult their athletic rationale used for trainer or team physician prior to such excessive in taking any supplement. takes is that if taking a pill that contains the DRI for each vitamin and mineral makes a person healthy, taking a pill that has 10 times the DRI should make that individual 10 times healthier.55 An example of a popular practice has been to take megadoses of vitamin C. Such doses do not prevent the common cold or slow aging. However, it has been shown that vitamin C reduces the duration and severity of colds. Given the low cost and safety of the vitamin, it may be worthwhile for common cold patients to test whether therapeutic vitamin C is beneficial for them on an individual basis.31 Fruits, juices, and vegetables are reliable sources of vitamin C that also supply other vitamins and minerals.55 Vitamin E protects certain fatty acids in cell membranes from being damaged.55 There is not much evidence to support the notion that this vitamin can extend life expectancy or enhance physical performance. Vitamin E does not enhance sexual ability, prevent graying hair, or cure muscular dystrophy. A person can obtain adequate amounts of vitamin E by consuming whole-grain products, vegetable oils, and nuts.

The B-complex vitamins A rowing athlete that are involved in obtaining complains of feeling energy from carbohydrates, tired lately and more fats, and proteins are often exhausted than usual abused by individuals who after workouts. She believe that vitamins proalso states that she has vide energy. B-vitamins noticed many bruises on her legs and arms. The are found in lots of energy bruises randomly appear drinks; although the pubin different places all lic often thinks it is the over her body. When B-vitamins that give them asked about her diet, she the rush, in reality it is the mentions she eats two caffeine. Any increased need meals a day and it is food for these nutrients is easily she grabs on the run. fulfilled when a person eats She cannot remember more nutritious foods while the last time she had a training.80 If athletes do not meal with vegetables or increase their food consumpquality meat. tion, they will lose weight What do you suspect because of their high level of might be wrong with caloric expenditure. her, and what is your Vitamin D is essential suggested plan of action? for intestinal absorption of calcium. A deficiency has been linked to numerous disorders including osteoporosis and autoimmune diseases. Recently, vitamin D supplementation for athletes has become controversial as there is little current evidence that vitamin D supplementation in athletes who are not vitamin D deficient helps to improve performance. For athletes who are vitamin D deficient, it is recommended that serum vitamin D concentration be monitored by a health care professional and/or nutritionist to determine the need for supplementation.57 If an individual is not eating a well-balanced diet, taking a multiple vitamin once each day would be helpful and, in fact, is recommended by many physicians to make certain that minimum DRIs are met.

Mineral Supplements Obtaining adequate levels of certain minerals can be a problem for some people.55 Calcium and iron intakes may be low for those who do not include dairy products, red meats, or enriched breads and cereals in their diet. The following sections explore some minerals that can be deficient in the diet and some suggestions for improving the quality of the diet so that supplements are not necessary. Calcium Supplements Calcium is the most abundant mineral in the body. It is essential for bones and teeth as well as for muscle contraction and the conduction of nerve impulses. However, the importance of obtaining adequate calcium supplies throughout life has become more recognized. If calcium intake is too low to meet needs, the body can remove calcium from the bones. Over time, bones become weakened and appear porous on X-rays. These bones are brittle and often break spontaneously. This condition is called osteoporosis and is Chapter Five ■ Nutrition and Supplements

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5–3 Clinical Application Exercise

essential that the athletic trainer not only become knowledgeable about the effects of nutrition on performance, but also rely on a registered dietitian or sports nutritionist to provide additional expertise.13 SoR:A The athletes need to understand the level of regulation (or lack thereof) and should not assume a product is safe simply because it is sold over the counter. Dietary supplement manufacturers are not required to provide any evidence of product efficacy. Athletes must be aware that dietary supplement labels do not require third-party verification or truth in labeling.13 SoR:A Athletic trainers should advise athletes that dietary supplements are not well regulated and may contain banned substances. Sport governing bodies should make the rules regarding banned substances and their philosophies regarding supplementation available to athletes.13 SoR:A The athletic trainers should be aware of resources to identify products known to have adverse effects.13 SoR:C (The use of various supplements for performance enhancement is discussed in Chapter 17.) NATA has published a position statement “Evaluation of Dietary Supplements for Performance Nutrition” (http://natajournals.org/doi /pdf/10.4085/1062-6050-48.1.16) that discusses the use of dietary supplements in athletes.

estimated to be eight times more common among women than men. It becomes a serious problem for women after menopause.4 (See Chapter 29.) The RDA for young adults (14 to 18 years) is 1,300 mg (an 8-ounce glass of milk contains about 300 mg of calcium). Unfortunately, about 25 percent of all females in the United States consume less than 300 mg of calcium per day, well below the RDA. High-protein diets and alcohol consumption also increase calcium excretion from the body. Exercise causes calcium to be retained in bones, so physical activity is beneficial. However, younger females who exercise to extremes, so that their normal hormonal balance is upset, are prone to develop premature osteoporosis.4 Calcium supplementation, preferably as calcium carbonate or citrate rather than phosphate, may be advisable for females who have a family history of osteoporosis. Milk products are the most reliable sources of calcium. Many people complain that milk and other dairy products upset their stomach. They may lack an enzyme, called lactase, that is needed to digest the milk sugar lactose. This condition is referred to as lactose intolerance, or lactase deficiency.13 The undigested lactose enters the large intestine, where the bacteria that normally reside there use it for energy. The bacteria produce large quantities of intestinal gas, which causes discomfort and cramps. Many lactoseintolerant people also suffer from diarrhea. Fortunately, scientists have produced the missing enzyme, lactase. Lactase is available without prescription in forms that can be added to foods before eating or can be taken with meals.

5–4 Clinical Application Exercise

Iron Supplements Iron deficiency is a common problem, especially for young females. Lack of iron can result in iron-deficiency anemia (see Chapter29).65 Iron is needed to properly form hemoglobin. With anemia, the oxygen-carrying ability of the red blood cells is reduced, so muscles cannot obtain enough oxygen to generate energy.20 Anemia leaves a person feeling tired and weak. Obviously, an athlete cannot compete at peak level while suffering from an iron deficiency. Excess intake of iron can be toxic, however, and may result in constipation. A high-school football player has become interested in bodybuilding. He is most interested in seeing an increase in muscle mass. He is religious about his weight training but has heard that increased protein intake causes muscle hypertrophy more quickly.

? What advice can the

athletic trainer give him about taking commercially produced protein supplements?

140

Protein Supplements Athletes often believe that more protein is needed to build bigger muscles.39 It is true that athletes who are developing muscles in a conditioning program need a relatively small amount of extra protein. Many athletes, particularly those who are training with heavy weights or who are bodybuilders, routinely take protein supplements

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that are commercially produced and marketed.39 It should be added that some supplements that claim to be muscle building can contain substances that are banned by different sport governing bodies. To build muscle, athletes should consume 1.2 to 1.7 grams per kilogram of body weight every day.62 This range goes from slightly above to about double the protein RDA (0.8 gram per kilogram of desirable body weight).18 Anyone eating a variety of foods, but especially protein-rich foods, can easily meet the higher amounts. Thus, athletes do not need protein supplements, because their diets typically exceed even the most generous protein recommendations. An active adult most likely requires 0.6gram per pound, or 66 percent more than the DRI.62

Creatine Supplements Creatine is a naturally occurring organic compound synthesized by the kidneys, liver, and pancreas. Free creatine can also be obtained from ingesting meat and fish that contain approximately 5 grams per kilogram. Creatine has an integral role in energy metabolism.73 There are two main types of creatine: free creatine and phosphocreatine. Phosphocreatine is stored in skeletal muscle and is used during anaerobic activity to produce ATP, with the assistance of the enzyme creatine kinase. With creatine supplementation, phosphocreatine depletion is delayed and performance is enhanced through the maintenance of the normal metabolic pathways.70 The positive physiological functions of creatine include increasing the resynthesis of ATP, thus allowing for increased intensity in a workout; acting as a lactic acid buffer, thus prolonging maximal effort and improving exercise recovery time during maximum-intensity activities; stimulating protein synthesis; decreasing total cholesterol while improving the HDL-to-LDL ratio; decreasing total triglycerides; and increasing fat-free mass.73 Oral supplementation with creatine may enhance muscular performance during high-intensity resistance exercise.84 It has been suggested that creatine supplementation may reduce the incidence of muscle cramps.27 Side effects of creatine supplementation include weight gain, due primarily to an increase in total body water,58 gastrointestinal disturbances, and renal dysfunction. There are apparently no other known long-term side effects. It has been suggested that an initial loading phase should consist of ingesting approximately 0.3 gram of creatine per kilogram of body weight per day.63 The dosage should be split over four or five times per day, with approximately 16 ounces of water per dose. The loading phase lasts for 5 days. A loading phase is not necessarily required, however. It has been shown that ingesting creatine at a much lower dose of 3 grams per day increases total muscle creatine to the same values observed with 5days of 20 grams per day; however, this takes approximately 30 days.84 Thus, the high “loading” dose is unnecessary to realize an increase in muscle creatine content. After completing the loading phase, one should take a maintenance dosage every day equal to about 0.03 gram of creatine per kilogram of body weight for

a month. Then a “wash-out” phase should last for 1 month, during which there is no supplementation.84 In August 2000, the NCAA Committee on Competitive Safeguards and Medical Aspects of Sports banned the distribution of all muscle-building substances, including creatine, by NCAA member institutions. However the use of creatine itself is not necessarily banned by other organizations.

Herbal Supplements The use of herbs as natural alternatives to drugs and medicines has clearly become a trend among American consumers. Most herbs, as edible plants, are safe to ingest as foods; as natural medicines, they are claimed to have few side effects, although occasionally a mild, allergic reaction may occur.51 Those taking herbs should also be mindful of potential interactions.43 Herbs can offer the body nutrients that are reported to nourish the brain, glands, and hormones.76 Unlike

vitamins, which work best when taken with food, herbs do not need to be taken with other foods, because they provide their own digestive enzymes.23 Herbs in their whole form are not drugs. As medicine, herbs are essentially body balancers that work with the body’s functions so that it can heal and regulate itself. Herbal formulas can be general for overall strength and nutrient support or specific to a particular ailment or condition.38 Hundreds of herbs are widely available at all quality levels. They are readily available at health food stores. However, unlike both food and medicine, no federal or governmental controls regulate the sale of herbs to ensure the quality of the products being sold.23 The consumer of herbal products must exercise extreme caution. Focus Box 5–2: “Commonly used herbs” lists the most popular and widely used herbal products sold in health food stores. Some additional potent and complex herbs,

FOCUS 5–2 Focus on Injury/Illness Prevention and Wellness Promotion Commonly used herbs The indications for using these herbs have at least minimal scientific basis in the literature. However, there is a substantial lack of strong evidence-based support for their use. Cayenne (capsaicin)—pain control; may cause stomach irritation. Cascara—used as a laxative; can cause dehydration. Dong quai—weak evidence that it can be used to treat abnormal heart rhythm, prevent accumulation of platelets in blood vessels, protect the liver, promote urination, act as a mild laxative, promote sleep, and fight infection. Echinacea—promotes wound healing and strengthens the immune system. Feverfew—weak evidence that it prevents and relieves migraine headaches, arthritis, and PMS. Garlic—weak evidence that it can be effective in treating atherosclerosis by reducing total blood cholesterol and triglyceride levels and raising HDL levels; also for use in treating hypertension, diabetes, the common cold, tuberculosis, and intestinal parasites. Garcina cambagia—used to promote loss of fat. Ginkgo biloba—weak evidence for its use in treating dementia and Alzheimer’s disease, memory impairment, eye problems, intermittent claudication, and tinnitus. Ginseng—used to prevent Alzheimer’s disease, cancer, depression, diabetes, chronic respiratory disease, menopausal symptoms, and stress; has been shown to enhance cardiovascular health by raising HDL while reducing total cholesterol levels, fertility/sexual performance, immune system function, mental performance and mood, and physical endurance.

Green tea—contains component EGCG; has traditionally been used to prevent or slow growth in a variety of cancers; not enough evidence to determine improvement in mental alertness, weight loss, lowering cholesterol levels, or protecting skin from sun damage. Guarana*—used as a stimulant because it contains large amounts of caffeine; often in weight-loss products. Kava—used to reduce anxiety and insomnia; increased risk of severe liver damage. Ma huang*(ephedrine)—derived from the ephedra plant; has been used in China for medicinal purposes, including increased energy, appetite suppression, increased fat burning, and preservation of muscle tissue from breakdown; a central nervous system stimulant drug that was used in many diet pills; in 1995, the FDA revealed adverse reactions to ephedrine, such as heart attacks, strokes, paranoid psychosis, vomiting, fever, palpitations, convulsions, and comas; banned by the FDA in 2003. Mate—central nervous system stimulant. Saw palmetto—used to treat inflamed prostate; also used as a diuretic. Senna—used as a laxative; can cause water and electrolyte loss. St. John’s wort—used as an antidepressant; also used to treat nervous disorders, depression, and seasonal affective disorder. Valerian—used to treat insomnia, anxiety, and stress. Vohimbe—used to increase libido and blood flow to sexual organs in the male. Banned by some athletic organizations and/or the FDA. However, all of these substances are readily available over the Internet. *

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such as capsicum, lobelia, sassafras, mandrake tansy, canada snake root, wormwood, woodruff, poke root, and rue, may be useful in small amounts and as catalysts but should not be used alone. Ephedrine Ephedrine is a stimulant that has been used as an ingredient in diet pills, illegal recreational drugs, and legitimate over-the-counter medications to treat congestion and asthma.57 Ephedrine is similar to an amphetamine. In December 2003, the FDA banned the use of ephedrine as a dietary supplement. For several years the FDA warned consumers about the potential dangers of using ephedrine. The NCAA, the National Football League, the National Basketball Association, minor league baseball, and the USOC have banned the use of ephedrine by their athletes. However, some companies continue to sell supplements that contain ephedrine or other stimulants despite the fact that these supplements have caused numerous problems. Ephedrine is known to produce the following adverse reactions: heart attack, stroke, tachycardia, paranoid psychosis, depression, convulsions, fever, coma, vomiting, palpitations, hypertension, and respiratory depression.57

Glucose Supplements Ingesting large quantities of glucose in the form of honey, candy bars, or pure sugar immediately before physical activity may have a significant impact on performance.72 As carbohydrates are digested, large quantities of glucose enter the blood. This increase in blood sugar (glucose) levels stimulates the release of the hormone insulin. Insulin allows the cells to use the circulating glucose, so that blood glucose levels soon return to normal.50 It was hypothesized that a decline in blood sugar levels was detrimental to performance and endurance. However, recent evidence indicates that the effect of eating large quantities of carbohydrates is beneficial rather than negative.19,72 Nevertheless, some athletes are sensitive to highcarbohydrate feedings and experience problems with increased levels of insulin. Also, some athletes cannot tolerate large amounts of the simple sugar fructose. For these individuals, too much fructose leads to intestinal upset and diarrhea. Athletes should test themselves with various high-carbohydrate foods to see whether they are affected (but not before a competitive event).50

EATING AND DRINKING PRACTICES Caffeine Consumption Caffeine is a central nervous system stimulant. Most people who consume caffeine in coffee, tea, or carbonated beverages are aware of its effect of increasing alertness 142

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and decreasing fatigue. Chocolate contains compounds that are related to caffeine and have the same stimulating effects. However, large amounts of caffeine cause nervousness, irritability, increased heart rate, insomnia, and headaches.50 Also, headaches are a withdrawal symptom experienced when a person tries to stop consuming caffeinated products.50 Although small amounts of caffeine do not appear to harm physical performance, cases of nausea and lightheadedness have been reported. Caffeine enhances the use of fat during endurance exercise, thus delaying the depletion of glycogen stores.85 This delay would help endurance performance. Caffeine also helps make calcium more available to muscles during contraction, allowing the muscles to work more efficiently. Caffeine is no longer on the banned list for Olympic athletes, but it is still on the NCAA banned substances list. It should not be present in a drug test in levels greater than that resulting from drinking five or six cups of coffee. Energy Drinks Over the last decade, consumption of energy drinks has increased dramatically, and there are now literally hundreds of energy drinks available to the consumer. Red Bull, Rockstar, AMP, Monster, and 5-hour Energy are just a few of the most common energy drinks. It must be clarified that energy drinks are different than sport drinks. Sports drinks contain no caffeine. Generally, the energy drinks contain caffeine in doses ranging anywhere from 50 mg to in excess of 500 mg, with the average between 70 and 80 mg per serving.33 They are marketed for their performance-enhancing and stimulant drug effects. An obvious risk of caffeine intoxication exists when consuming a high amount of caffeine, which can cause adverse effects including nervousness, insomnia, headache, tachycardia (increased heart rate), and rarely seizure activity or occasionally death. Problems with caffeine dependence and withdrawal have also been reported.33 Energy drinks also have a high concentration of carbohydrate, and most are carbonated. There is currently little government regulation of energy drinks, including content labeling and health warnings. Because caffeine is a drug and not a nutrient, it is not listed on the nutrition facts panel. Of even greater concern is the combined use of caffeine and alcohol. Studies suggest that such combined use may increase the rate of alcohol-related injury.

Alcohol Consumption Alcohol use is prevalent among athletes at all levels. It appears that alcohol consumption is higher among athletes when compared to non-athlete peers.13 The depressant effects of alcohol on the central nervous system include decreased physical coordination, slowed reaction times, and decreased mental alertness. Also, this drug increases the production of urine, resulting in body water losses (diuretic effect). Alcohol does provide energy for

the body; each gram of pure alcohol (ethanol) supplies seven calories. However, sources of alcohol provide little other nutritional value with regard to vitamins, minerals, and proteins. Therefore, the use of alcoholic beverages by the athlete is strongly discouraged before, during, and after physical activity.

•

Consumption of Organic, Natural, and Health Foods Many people are concerned about the quality of the foods they eat—not just the nutritional value of the food but also its safety. Organic foods are grown without the use of synthetic fertilizers and pesticides. Those who advocate the use of organic farming methods claim that these foods are nutritionally superior and safer than the same products grown using chemicals, such as pesticides and synthetic fertilizers.16 All foods (except water) are organic; that is, they contain the element carbon. Organically produced foods are often more expensive than the same foods that have been produced by conventional means. There is no advantage to consuming organic food products. They are not more nutritious than foods produced by conventional methods. Nevertheless, for some people the psychological benefit of believing that they are doing something good for their bodies justifies the extra cost. Natural foods have been subjected to little processing and contain no additives, such as preservatives or artificial flavors.16 Processing can protect nutritional value. Preservatives save food that would otherwise spoil and have to be destroyed. Both organic and natural foods can be described as health foods.

Vegetarianism Vegetarianism is an alternative to the usual American diet. All vegetarians use plant foods to form the foundation of their diet; animal foods are either Vegetarians: total totally excluded vegetarians, lactovegetarians, ovolactovegetarians, and or included in a semivegetarians. variety of eating patterns.26 People who choose to become vegetarians do so for economic, philosophical, religious, cultural, or health reasons. Vegetarianism is no longer considered to be a fad if it is practiced intelligently. However, the vegetarian diet may create deficiencies if nutrient needs are not carefully considered. Individuals who follow this eating pattern must plan their diet carefully so that their caloric needs are met.26 The types of vegetarian dietary patterns are categorized as follows. • Vegans: Individuals who do not eat red meat, fish, poultry, eggs, or dairy products are vegans or true vegetarians. This diet has been found to be adequate for most adults if they give careful consideration to obtaining enough calories; sources of vitamin B12;

•

• •

and the minerals calcium, zinc, and iron. It is not recommended for pregnant women, infants, or children because of the difficulty in consuming the quantity of plant foods necessary to meet the caloric and nutritional needs during these life stages. Lactovegetarians: Individuals who consume dairy products along with plant foods. Meat, fish, poultry, and eggs are excluded from the diet. Iron and zinc levels can be low in people who practice this form of vegetarianism. Lacto-ovo-vegetarians: People who consume both dairy products and eggs in their diet, along with plant foods. Meat, fish, and poultry are excluded. Again, iron could be a problem. Ovo-vegetarians: People who eat eggs but not dairy products. Flextarians: People who consume animal products but exclude red meats. Plant products still form an important part of the diet. This diet is usually adequate.

Pre-Event Nutrition The importance and content of the pre-event meal has been heatedly debated among coaches, athletic trainers, and athletes.30 The trend has been to ignore logical thinking about what should be eaten before competition and to upholding the tradition of “rewarding” the athlete for hard work by serving foods that may hamper performance. For example, the traditional steak-and-eggs meal before football games is great for coaches and athletic trainers; however, the athlete gains nothing from this meal. The important point is that too often people are concerned primarily with the pre-event meal and fail to realize that the nutrients consumed over several days before competition are much more important than what is eaten 3 hours before an event. (See Focus Box 5–3: “The pregame meal.”) The purpose of the pre-event meal should be to maximize carbohydrate stored in the muscles as well as blood glucose. It has been suggested that the athlete consume carbohydrates 3 to 4 hours before practice or competition.30 But it has also been suggested that consuming carbohydrates immediately before competition causes an increased release of insulin, which increases the rate at which muscles burn carbohydrate, thus lowering blood glucose levels (hypoglycemia). Different carbohydrates are digested and absorbed at different rates. The glycemic index (GI) is a scale that indicates how much different types of carbohydrate effect blood glucose levels.9 Consuming foods that have a low to medium GI prior to an event is recommended because they produce only small fluctuations in blood glucose and insulin levels and release energy more slowly over a longer time period. Ingesting carbohydrates that have a high GI within an hour of exercise may actually lower blood glucose. Figure 5–4 lists the glycemic index range for common foods. Chapter Five ■ Nutrition and Supplements

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FOCUS 5–3 Focus on Injury/Illness Prevention and Wellness Promotion The pregame meal • Try to achieve the largest possible storage of carbohydrates (glycogen) in both resting muscle and the liver. This storage is particularly important for endurance activities but may also be beneficial for intense, short-duration exercise. • A stomach that is full of food during contact sports is subject to injury. Therefore, the type of food eaten should allow the stomach to empty quickly. Carbohydrates are easier to digest than are fats or proteins. A meal that contains plenty of carbohydrates leaves the stomach and is digested faster than a fatty meal. It would be wise to replace the traditional steak-andeggs pre-event meal with a low-fat one containing a small amount of pasta, tomato sauce, and bread. • Foods should not cause irritation or upset to the gastrointestinal tract. Foods high in cellulose and other forms of fiber, such as whole-grain products, fruits, and vegetables, increase the need for defecation. Highly spiced foods and gas-forming foods

Additionally the foods selected should minimize gastrointestinal distress and should be foods that the individual athlete prefers. It is also critical to make certain that the athlete is appropriately hydrated.

Low Glycemic Index (70) White bread White rice Corn flakes Baked potato Watermelon Popcorn Sports drinks

FIGURE 5–4 Glycemic Index Food Recommendations for Pre-Event Meals. 144

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(such as onions, baked beans, or peppers) must also be avoided because any type of disturbance in the gastrointestinal tract may be detrimental to performance. Carbonated beverages and chewing gum also contribute to the formation of gas. • Liquids consumed should be easily absorbed and low in fat content and should not act as a laxative. Whole milk, coffee, and tea should be avoided. Water intake should be increased, particularly if the temperature is high. • A meal should be eaten approximately 3 to 4 hours before the event or before exercising. This timing allows for adequate stomach emptying, but the individual will not feel hungry during activity. • The athlete should not eat any food that he or she dislikes. Most important, the individual must feel psychologically satisfied by any pre-event meal. If not, performance may be impaired more by psychological factors than by physiological factors.

Athletes should be encouraged to become conscious of their diets. However, no experimental evidence exists to indicate that performance may be enhanced by altering a diet that is basically sound. A nutritious diet may be achieved in many ways, and the diet that is optimal for one athlete may not be the best for another. In many instances, the individual is the best judge of what he or she should or should not eat in the preevent meal or before exercising. It seems that a person’s best guide is to eat whatever he or she is most comfortable with. Liquid Food Supplements Liquid food supplements (e.g., Gatorade G Series Recover Shake, Sustagen) have been recommended as effective pre-event meals and are being used by secondary-school, college, university, and professional teams with some indications of success.62 These supplements supply from 225 to 400 calories per average serving. Athletes who have used these supplements report elimination of the usual pregame symptoms of dry mouth, abdominal cramps, leg cramps, nervous defecation, and nausea. Under ordinary conditions, it usually takes approximately 4 hours for a full meal to pass through the stomach and the small intestine. Pregame emotional tension often delays the emptying of the stomach; therefore, the undigested food mass remains in the stomach and upper bowel for a prolonged time, even up to or through the actual period of competition, and frequently results in nausea, vomiting, and cramps. This unabsorbed food mass is of no value to the athlete. Team physicians who

have experimented with the liquid food supplements say that a major advantage of the supplements is that they clear both the stomach and the upper bowel before game time, thus making available the caloric energy that would otherwise still be in an unassimilated state. There is merit in the use of such food supplements for pregame meals.62

Recommendations for Restoring Muscle Glycogen after Exercise When the time period between exercise sessions is relatively short (less than 8 hours), the athlete should begin consuming carbohydrates to restore supplies of muscle glycogen as soon as possible after the workout to maximize recovery between sessions.37 Ideally, the foods should have a high glycemic index. Given that complete muscle glycogen restoration takes at least 20 to 24 hours, athletes should not waste time. They should ingest approximately 0.45 to 0.55 grams of carbohydrate per pound of body weight for each of the first 4 hours after exercise or until they eat their next large meal. During this period, nutrient-rich carbohydrate foods, such as fruits and vegetables or a high-carbohydrate drink, are recommended.37 Over a 24-hour period, carbohydrate intake should range from 2.3 grams to as much as 5.5 grams per pound of body weight, depending on the intensity of the activity.37 Pasta, potatoes, oatmeal, and sports drinks are recommended. It has been suggested that adding a small amount of protein (15 to 25 grams) to a carbohydrate supplement enhances aerobic endurance performance above that which occurs with carbohydrate alone, and stimulates muscle protein synthesis and repair. Peanut butter and tuna are recommended as good sources of protein.

Eating Fast Foods Eating fast food is a way of life in American society. Athletes, especially young athletes, have for the most part grown up as fast-food junkies. Furthermore, travel budgets and tight schedules dictate that fast food is a frequent choice for coaches on road trips.66 Aside from occasional problems with food flavor, the biggest concern in consuming fast foods, as can be seen in Table 5–3, is that 40 to 50 percent of the calories consumed are from fats. To compound this problem, these already sizable meals are often “supersized” at a more affordable price for those who want maximum fat, salt, and calories in a single sitting. On the positive side, most fast-food restaurants now offer healthy menu items such as whole-wheat breads and rolls, salad bars, and low-fat milk products. Nutrition information can be found at the point of purchase, on the Web site, or using an App for smartphones. Focus Box 5–4: “Tips for selecting fast foods” provides suggestions for eating more healthfully at fast-food restaurants. 67

Low-Carbohydrate Diets For many years, it was recommended that fat intake be limited as a means of controlling weight. More recently, the recommendation was to severely limit the intake of carbohydrate in the diet.79 There are many versions of a low-carbohydrate diet, all of which recommend a strict reduction in the consumption of carbohydrates. Most “low-carb” diets replace carbohydrates with a high-fat and moderate-protein diet. The low-calorie and lowfat diets that have been recommended for years have failed to realize that dietary fat is not necessarily converted into body fat. However, c arbohydrates are readily converted into fat. In a high-carbohydrate meal, the increased blood glucose stimulates insulin production by the pancreas. Insulin allows blood glucose to be used by the cells, but it also causes fat to be deposited, and it stimulates the brain to produce hunger signals. Thus, there is a tendency to eat more carbohydrates, and the cycle repeats. It has been shown that most overweight people became overweight due to a condition called hyperinsulinemia—elevated insulin levels in the blood. Restricting carbohydrate intake halts this cycle by decreasing insulin levels. Carbohydrate restriction also increases the levels of glucagon, which is a hormone that causes body fat to be burned and aids in removing cholesterol deposits in the arteries. Severely restricting carbohydrate intake puts the body into a state of ketosis, in which blood glucose levels stabilize, insulin level drops, and because the body is burning fat, fairly rapid weight loss occurs.79 However, if an individual is an athlete or is physically active they need carbohydrates and should instead focus on making carbohydrates readily available to working muscles. This does not happen when consuming a low-carbohydrate diet.

Glycogen Supercompensation (Carbohydrate Loading) Because the quantity of glycogen stored in a muscle directly affects the endurance of that muscle, many athletes preparing for endurance events engage in a practice called glycogen super compensation also known as carbohydrate loading.50 For endurance events, maximizing the amount of glycogen that can be stored, especially in muscles, may make the difference between finishing first or at the end of the pack. Athletes can increase glycogen supplies in muscle and liver by reducing the training program a few days before competing and by significantly increasing carbohydrate intake during the week before the event.43 Several studies have investigated effects of endurance training, pre-event carbohydrate-loading protocols (that range from one to seven days pre-event), and supplementing carbohydrate during an endurance event. By reducing training before the competition, the athlete can eliminate any metabolic waste products that may hinder performance. The high-carbohydrate diet restores glycogen levels in muscle and the liver. Chapter Five ■ Nutrition and Supplements

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TABLE 5–3

Examples of Fast-Food Choices and Nutritional Value Food

Calories

Protein Carbohydrate Fat (g) (g) (g)

Calories from fat

Cholesterol Sodium (mg) (mg)

Hamburgers McDonald’s hamburger

250

520

Dairy Queen single hamburger w/cheese

400

160

930

Hardee’s Original 1/3 Pound Thickburger

860

540

105

1,630

Wendy’s double hamburger, white bun

800

—

105

1,530

McDonald’s Big Mac

540

260

1,040

Burger King Whopper sandwich

650

340

910

In-n-Out cheeseburger with onion

480

240

1,000

540

240

990

Burger King chicken sandwich

660

360

1,170

Dairy Queen chicken sandwich

600

270

1,250

Chicken Arby’s crispy chicken sandwich

Church’s Crispy Nuggets (5 pieces)

162

190

759

Kentucky Fried Chicken Original Recipe Bites (6)

200

660

470

117

1,240

Fish Burger King Fish Filet Sandwich Long John Silver’s Fish

470

207

1,210

Bojangles Filet of Fish Sandwich

335

144

645

380

230

1,130

Others Hardee’s Jumbo Chili Dog Taco Bell Burrito Supreme

390

120

1,090

Arby’s roast beef sandwich (regular)

350

110

950

Hardee’s roast beef sandwich (regular)

300

130

850

French fries Arby’s french fries

400

260

1,200

McDonald’s french fries (medium)

380

170

270

Wendy’s french fries (medium)

420

—

460

730

115

210

310

Shakes Dairy Queen (vanilla, medium) McDonald’s Vanilla

530

140

160

Chocolate

560

150

240

Strawberry

550

150

160

210

—

Soft drinks Coca-Cola

—

Sprite

Diet Coke

210

—

Dr Pepper

260

—

Sprite Zero Mountain Dew

290

—

105

Pepsi

269

—

Diet Pepsi

FOCUS 5–4 Focus on Injury/Illness Prevention and Wellness Promotion Tips for selecting fast foods

5–5 Clinical Application Exercise

• Limit deep-fried foods, such as fish and chicken sandwiches and chicken nuggets, which are often higher in fat than plain burgers are. If you are having fried chicken, remove some of the breading before eating. • Order roast beef, turkey, or grilled chicken, where available, for a lower-fat alternative to most burgers. • Choose a small order of fries with your meal rather than a large one, and request no salt. Add a small amount of salt yourself if desired. If you are ordering a deep-fat-fried sandwich or one that is made with cheese and sauce, skip the fries altogether and try a plain baked potato (add butter and salt sparingly) or a dinner roll instead of a biscuit, or try a side salad to accompany your meal. • Choose regular sandwiches instead of “double,” “jumbo,” “deluxe,” or “ultimate” sandwiches. And order plain types rather than those with the works, such as cheese, bacon, mayonnaise, and special

Glycogen supercompensation may be accomplished over a 6-day period divided into three phases. In phase 1 (days 1 and 2), training should be hard and dietary intake of carbohydrates restricted. During phase 2 (days 3 through 5), training is cut back and the individual eats plenty of carbohydrates. Studies have indicated that glycogen stores may be increased from 50 to 100 percent, theoretiA recreational runner has been training to run his cally enhancing endurfirst marathon. He feels ance during a long-term good about his level of event. Phase3 (day6) is conditioning but wants the day of the event, durto make certain that he ing which a normal diet does everything that must be consumed. he can do to maximize Additional suggested his performance. He is carbohydrate-loading proconcerned about eating tocols focus on the benthe right type of foods efits that can occur, withboth before and during the out a glycogen-depletion marathon to help ensure that he does not become period, in as little as excessively fatigued. one to three days, provided that training during What recommendations loading days does not should the athletic trainer deplete already stored make regarding glycogen glycogen. A 3-day modisupercompensation, the pre-event meal, and food fied carbohydrate-loading consumption during the regimen on days 1 and 2 event? involves tapered training with 10 to 12 grams of

sauce. Pickles, mustard, ketchup, and other condiments are high in sodium. Choose lettuce, tomatoes, and onions. • At the salad bar, load up on fresh greens, fruits, and vegetables. Be careful of salad dressings, added toppings, and creamy salads (potato salad, macaroni salad, coleslaw). These can quickly push calories and fat to the level of other menu items or higher. • Many fast-food items contain large amounts of sodium from salt and other ingredients. Try to balance the rest of your day’s sodium choices after a fast-food meal. • Alternate water, low-fat milk, or skim milk with a soda or a shake. • For dessert, or a sweet-on-the-run, choose low-fat frozen yogurt where available. • Remember to balance your fast-food choices with your food selections for the whole day.

carbohydrate per kilogram of body weight. Day 3 is a rest day again with 10 to 12g CHO/kg/BW, prior to competition on day 4. It has been recommended that glycogen supercompensation not be done more than two or three times a year. Glycogen supercompensation is only of value in long-duration events that produce glycogen depletion, such as a marathon.50

Fat Loading Some endurance athletes have used fat loading in place of carbohydrate loading. Their intent was to have a better source of energy at their disposal. The deleterious effects of this procedure outweigh any benefits that may be derived. Associated with fat loading is cardiac protein and potassium depletion, causing arrhythmias and increased levels of serum cholesterol as a result of the ingestion of butter, cheese, cream, and marbled beef.

BODY COMPOSITION AND WEIGHT CONTROL Gain or loss of weight often poses a problem because an individual’s ingrained eating habits are difficult to change.27 The athletic trainer’s inability to adequately supervise the athlete’s meal program in terms of balance and quantity further complicates the problem. An intelligent and conscientious approach to weight control requires a team approach between the athlete, coach, athletic trainer and, if at all possible, a registered dietitian Chapter Five ■ Nutrition and Supplements

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5–6 Clinical Application Exercise

or sports nutritionist.75 The athletic trainer should be skilled and appropriately trained in the use of the various body composition assessment techniques and should periodically track an athlete’s body composition to make certain that individual goals of that athlete are met.76 Such understanding allows individuals to better discipline themselves as to the quantity and kinds of A female softball player foods they should eat.29 has a problem controlling her weight. Her body fat percentage has been measured at 25 percent and she asks the athletic trainer what she needs to do to be able to lose some weight quickly and then to maintain her body weight thereafter.

Body Composition

Desirable body weight is most often determined by consulting age-related height and weight charts, such as those pub lished by life insurance companies. Unfortunately, these How should the athletic charts are inaccurate betrainer respond? cause they involve broad ranges and often fail to take individual body types into account. Health and performance, rather than body weight, may best be determined by body composition.34 Body composition refers to both the fat and nonfat components of the body. The portion of total body weight that is composed of fat tissue is referred to as the percentage of body fat. The total body weight that is composed of nonfat or lean tissue, which includes muscles, tendons, bones, and connective tissue, is referred to as lean body weight. Body composition measurements provide an accurate determination of precisely how much weight an individual may gain or lose.50 The average college-age female has between 20 and 25 percent body fat. The average college-age male has between 12 and 15 percent body fat. Male endurance athletes may get their fat percentage as low as 8 to 12 percent, and female endurance athletes may reach 10 to 18 percent. Body fat percentage should not go below 3 percent in males and 12 percent in females, because below these percentages the internal organs tend to lose their protective padding of essential fat, potentially subjecting them to injury.7 Being overweight and being obese are different conditions.8 Being overweight implies having excess body weight relative to physical size and stature. Being overweight may not be a problem unless a person is also overfat, which means that the percentage of total body weight that is made up of fat is excessive. Obesity implies an excessive amount of body fat, much greater than what would be considered normal. Females with body fat above 30 percent and males with body fat above 20 percent are considered to be obese.7 Two factors determine the amount of fat in the body: the number of fat, or adipose, cells and the size of

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each adipose cell. Proliferation, or hyperplagia, of adipose cells begins at birth and continues to puberty. It is thought that after early adulthood the number of fat cells remains fixed, although some evidence suggests that the number of cells is not necessarily fixed.50 Adipose cell size also increases gradually, or hypertrophies, to early adulthood and can increase or decrease as a function of caloric balance. In adults, weight loss or gain is primarily a function of the change in cell size, not cell number. Obese adults tend to exhibit a great deal of adipose cell hypertrophy. The adipose cell stores triglyceride (a form of liquid fat). This liquid fat moves in and out of the cell according to the energy needs of the body, which are determined to some extent by activity type. The greatest amount of fat is used in activities of moderate intensity and long duration. The greater the amount of triglyceride contained in the adipose cell, the greater the amount of total body weight composed of fat. One pound of body fat is made up of approximately 3,500 calories stored as triglyceride within the adipose cell.

Assessing Body Composition Body composition assessments should be used to determine body weight and body composition goals that are safe for the athlete.76 SoR:B Methods for assessing body composition most commonly used by athletic trainers are measurement of skinfold thickness;12 hydrostatic, or underwater, weighing; DXA measurements; BOD POD measurements; measurement of electrical impedance; and, assessing body mass index. For all of these assessment techniques the athlete should be in a hydrated state.76 SoR:B Skinfold Measurements The method of measuring the thickness of skinfolds is based on the fact that about 50 percent of the fat in the body is contained in the subcutaneous fat layers and is closely related to total fat. The remainder of the fat in the body is found around organs and vessels and serves a shock-absorptive function. The skinfold technique measures the thickness of the subcutaneous fat layer with a skinfold caliper (Figure 5–5), at very specific locations, using a well-defined technique.68 Its accuracy is relatively low; however, expertise in measurement is easily developed, and the time required for this technique is considerably less than for the others. It has been estimated that error in skinfold measurement is plus or minus 3 to 5 percent.12 Researchers have offered several different techniques for measuring body composition via skinfolds. A technique proposed by Jackson and Pollack,34 which measures the thigh, triceps, suprailiac, abdomen, and chest skinfolds, is widely used.50 Hydrostatic Weighing Hydrostatic (underwater) weighing involves placing a subject in a specially designed underwater tank to determine body density. Fat tissue is

FIGURE 5–5 Sites and techniques for measuring body composition. (A) Thigh. (B) Triceps. (C) Suprailiac. (D) Abdomen. (E) Chest. © William E. Prentice

less dense than lean tissue. Therefore, the more body fat present, the more the body floats (buoyancy) and the less it weighs in water. Body composition is calculated by comparing the weight of the submerged individual with the weight before entering the tank. If done properly, this technique is very accurate. Unfortunately, the tank and equipment are expensive and generally not available to most athletic trainers. In addition, this technique has other drawbacks. It is time-consuming (especially for large groups), and subjects must exhale completely and hold their breath while under water. Many individuals have fears about this aspect of the technique. BOD POD The BOD POD Body Composition System uses the relationship between pressure and volume to derive the body volume of a subject seated in a fiberglass chamber. The principle is similar to hydrostatic weighing except, instead of using water to measure body volume,

the BOD POD uses air displacement to measure body volume. Bioelectrical Impedance This technique involves the measurement of resistance to the flow of electrical current through the body between selected points.35 It is based on the principle that electricity will choose to flow through the tissue that offers the least resistance, or impedance. Fat is generally a poor conductor of electrical energy, whereas lean tissue is a fairly good conductor. Thus, the higher the percentage of body fat, the greater the resistance to the passage of electrical energy. Very simply, this method predicts the percent body fat by measuring bioelectrical impedance.35 Bioelectrical impedance measures can be affected by levels of hydration; if the body is dehydrated, the measurement will tend to overestimate percent body fat relative to measurements taken when there is normal hydration.35 The equipment available for taking these Chapter Five ■ Nutrition and Supplements

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measurements is fairly expensive and generally includes computer software. Dual Energy X-ray Absorptiometry (DXA) This new DXA technology is the most recent and the most accurate technique of assessing body composition, but it is fairly expensive, costing around $300 per test. The instrument uses total body X-ray technique to look at the density of the body and can then estimate the amount of lean and fat tissue.

Determining Body Mass Index A relatively easy way to determine the extent of overweight or obesity is to use a person’s body weight and height measurements to calculate body mass index (BMI).50 BMI is a ratio of body weight to height. This technique represents a method for measuring health risks from obesity using height/weight measurements. BMI might not be useful for athletes who have a high lean mass and low fat mass, making it appear that an athlete is overfat when in fact he or she has a low percent of body fat but high muscle mass. Health problems associated with excess body fat tend to be associated with a BMI of more than 25. A BMI of 25 to 30 indicates that a person is overweight. A BMI of 30 or more indicates a state of obesity.50 Focus Box 5–5: “Determining body mass index” will help you calculate BMI.

FOCUS 5–5 Focus on Examination, Assessment, and Diagnosis Determining body mass index 1. Weigh yourself to determine your body weight in pounds. 2. Divide your weight in pounds by 2.2 to determine kilograms. 3. Measure your height in inches. 4. Multiply your height in inches by 2.54 and divide by 100 to convert your height to meters. 5. Multiply your height in meters by your height in meters to get your height in meters squared. 6. Divide your weight in kilograms by your height in meters squared to determine your BMI. 1. Divided by 2.2 = Weight (lbs) Weight (kg) 2. Times 2.54 divided by 100 = Height (in) Height (m) 3. Times = Height (m) Height (m) Height (m2) 4. Divided by = Weight (kg) Height (m2) Body mass index

Assessing Caloric Balance Changes in body weight are almost entirely the result of changes in caloric balance.40 Caloric balance =

Number of calories consumed – Number of calories expended

If more calories are consumed than expended, this positive caloric balance results in weight gain. Conversely, weight loss results from a negative caloric balance, in which more calories are expended than are consumed. Caloric balance may be calculated by maintaining accurate records of both the number of calories consumed in the diet and the number of calories expended for metabolic needs and in activities performed during the day. Caloric Consumption Caloric balance is determined by the number of calories consumed regardless of whether the calories are contained in fat, carbohydrate, or protein. There are Positive caloric balance leads differences in the to weight gain; negative caloric caloric content of balance leads to weight loss. these foodstuffs: Carbohydrate = 4 calories per gram Protein = 4 calories per gram Fat = 9 calories per gram Alcohol = 7 calories per gram 150

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Estimations of caloric intake for college athletes range between 2,000 and 5,000 calories per day. Estimations of caloric expenditure range between 2,200 and 4,400 calories on average. Energy demands will be considerably higher in endurance-type athletes, who may require as many as 7,000 calories per day.50 Caloric Expenditure Calories may be expended by three processes: basal metabolism, work (any activity that requires more energy than sleeping), and excretion. When estimating caloric expenditure, it is first necessary to determine the amount of calories (energy) needed to support basal metabolism. This is the minimal amount of energy required to sustain the body’s vital functions, such as respiration, heartbeat, circulation, and maintenance of body temperature during a 24-hour period. The basal metabolic rate (BMR) is the rate at which calories are spent for these maintenance activities. BMR is most accurately determined in a laboratory through a measurement process known as indirect calorimetry, which measures a person’s oxygen uptake. Measurement of BMR using this procedure is generally done as soon as the subject awakes, in a quiet, warm environment, and after a 12-hour fast. Once BMR has been determined, it is necessary to calculate the energy requirements of all physical activities done in a 24-hour period. This is the second component of energy needs, referred to as work. There is a wide variation

in energy output for work. It is determined by the type, intensity, and duration of a physical activity. Body size is also a factor; heavier people expend more energy in an activity than do lighter people. Specific energy expenditures may be determined by consulting charts that predict the energy used in an activity based on (1) the time spent in each activity in minutes and (2) the metabolic costs of each activity in kilocalories per minute per pound (kcal/min/lb) of body weight.

5–7 Clinical Application Exercise

Methods of Weight Loss An individual has several ways to go about losing weight: dieting, increasing the amount of physical exercise, or a combination of diet and exercise. Weight loss through An ice hockey attackman dieting alone is difficult, has an excellent level of and in most cases dieting fitness and has superb alone is an ineffective skating ability and stick means of weight conwork. He is convinced that trol. Long-term weight the only thing keeping control through dieting him from moving to the alone is successful only next level is his low body 2 percent of the time.13 weight. In recent years, he About 35 to 45 percent has engaged in more weightof weight decrease due training activities to improve to dieting results from a his muscular endurance and, to a lesser extent, to increase loss of lean tissue. The his strength. minimum caloric intake should not go below What recommendations 1,000 to 1,200 calories should the athletic trainer per day for a female make for him to be and not below 1,200 to successful in his weightgaining efforts? 1,400 calories per day for a male.44

Weight loss through exercise involves an80 to 90 percent loss offat tissue with almostno loss of lean tissue. Weight loss through exercise alone is almost as difficult as losing weight through dieting. However, exercise not only results in weight reduction but also may enhance cardiorespiratory endurance, improve strength, and increase flexibility.7 For these reasons, exercise has some distinct advantages over dieting in any weight-loss program. The most efficient method of decreasing the percentage of body weight that is fat is through some combination of diet and exercise.76 A moderate caloric restriction combined with a moderate increase in caloric expenditure results in a negative caloric balance. This method is relatively fast and easy compared with either of the other methods because habits are being moderately changed. In any weight-loss program, the goal should be to lose 1.5 to 2 pounds per week. Weight loss of more than 4 to 5 pounds per week may be attributed to dehydration as opposed to a loss of body fat.7 A weight-loss program must emphasize the long-haul approach. It generally takes a long time to put on extra weight, and there is no reason to expect that true loss of excess body fat can be accomplished in a relatively short time. The American College of Sports Medicine has made specific recommendations for weight loss that are identified in Focus Box 5–6: “Key Recommendations for Weight Loss and Weight Maintenance.”1

Methods of Weight Gain The aim of a weight-gaining program should be to increase lean body mass—that is, muscle as opposed to body fat. Muscle mass should be increased only by muscle work combined with an appropriate increase in dietary intake. Muscle mass cannot be increased by the intake of any special food or vitamin.41

FOCUS 5–6 Focus on Healthcare Administration and Professional Responsibilities Key recommendations for weight loss and weight maintenance* • Lose weight to lower blood pressure, total cholesterol, LDL-cholesterol, triglycerides, and blood glucose, and to raise low levels of HDL-cholesterol. • Use the BMI to assess overweight and obesity and waist circumference measurement to assess abdominal fat content. • The initial goal of weight-loss therapy should be to reduce current body weight by about 10 percent. • The combination of a reduced-calorie diet and increased physical activity is recommended. • Low-calorie diets with reduced fat and carbohydrates that create a deficit of 500 to 1,000 kcal/day will help achieve a weight loss of 1 to 2 pounds per week.

• Physical activity for 30 to 45 minutes, 3 to 5 days a week should be part of a comprehensive weight-loss therapy, and weight-control program • Weight loss should be about 1 to 2 pounds per week for a period of 6 months. • A weight-maintenance program should be a priority after the initial 6 months of weight-loss therapy. • Weight maintenance should employ the combination of a low-calorie diet, increased physical activity, and behavior modification. * Adapted from https://www.nhlbi.nih.gov/health/educational/lose_wt /recommen.htm

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The recommended rate of weight gain is approximately 1 to 2 pounds per week.41 Each pound of lean body mass gained represents a positive caloric balance. This positive balance is an intake in excess of an expenditure of approximately 2,500calories. One pound of fat represents the equiv alent of 3,500 calories; lean body tissue contains less fat, more protein, and more water and represents approximately 2,500 calories. To gain 1 pound of muscle, an excess of approxi How should the athletic mately 2,500 calories is trainer respond to this needed; to lose 1 pound request? of fat, approximately 3,500 calories in excess of in take must be expended in activities. Adding 500 to 1,000 calories daily to the usual diet will provide the energy needs of gaining 1 to 2pounds per week and fuel the increased energy expenditure of the weight-training program. Weight training must be part of the weightgaining program. Otherwise, the excess intake of energy will be converted to fat.41 A tennis coach observes that one of her players has lost a significant amount of weight. Along with this loss of weight, the athlete’s level of play has begun to decrease. The coach becomes seriously concerned when another player tells the coach that she thinks her room-mate was purposely throwing up after a team meal on a recent road trip. After briefly questioning the athlete about her eating habits, the coach asks the athletic trainer to become involved in dealing with this situation.

DISORDERED EATING Disordered eating can be defined as a spectrum of abnormal eating behaviors, ranging from mild food restriction and occasional binge eating and purging to severe conditions of bulimia nervosa and anorexia nervosa. Disordered eating is a multifactorial disorder that includes social, familial, physiological, and psychological components. It appears that depression and difficulty expressing one’s feelings develop in response to experiencing family conflict, lack of family cohesion, childhood physical and emotional abuse, and neglect. These factors may influence whether an individual develops a problem eating behavior as well as the severity of the disorder. Individuals who engage in disordered eating behaviors, as well as individuals at risk for developing these behaviors, may benefit from interventions that address adaptive ways to cope with depression.49 In the athletic population, the incidence of disordered eating behaviors and pathological eating disorders is significantly higher than in the general population.87 This relatively high incidence in athletes has been attributed to the athlete’s attempt to control body weight or body composition in an effort to improve his or her performance. There is strong evidence that disordered eating, eating disorders, and 152

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amenorrhea occur more frequently in sports that emphasize leanness.56 In addition to the emotional stress and social pressures characteristic of eating disorders, there are also serious physiological effects, which can compound one another and ultimately affect the athlete’s overall health and performance. Athletes with disordered eating should be referred to a mental health practitioner for evaluation, diagnosis, and recommendations for treatment.56 A brief physiological screening test (consisting of four measurements and a 14-item questionnaire) has been developed to detect eating disorders in female collegiate athletes.6 Athletic trainers working with young athletes, particularly active females, should be educated about these disorders and work within their resources to develop strategies for prevention and management.75,78 Links to the NATA position statement “Preventing, detecting and managing eating disorders in athletes” can be found at http://www.nata.org/sites/default/files /PreventingDetectingAndManagingDisorderedEating.pdf.

Binge Eating At some point in time just about everyone overeats, such as at Thanksgiving when you have seconds and even thirds of just about everything on the table. But if this overeating becomes a recurrent problem that a person usually does in secret with strong feelings of guilt or shame about not being able to control these episodes, this behavior may be considered a binge eating disorder. Individuals who have binge eating disorder will continue to eat when they are not hungry, or will eat so much they are uncomfortable or even nauseated. They simply cannot stop eating even though the urge to quit is there; they will often eat alone and try to eat very quickly in an attempt to hide their problem. People with a binge eating disorder become depressed and develop anxiety and seem to obsess about losing and/or gaining weight even though their weight may be normal. Binge eating disorders may occur in 5 percent of the population and are more likely to occur in females (60 percent) than in males (40 percent).45 To be officially classified as having a binge eating disorder, an individual worries about eating a larger amount of food at one time than a normal person would consume within a 2-hour period, often when he or she is bored or depressed. Binge eating episodes occur at least two times a week for 6 months.45 Bulimia Nervosa The bulimic person is commonly female, ranging in age from adolescence to middle age. It is estimated that 1 out of every 200American girls, ages 12 to 18 years (1 to 2 percent of the population) will develop patterns of bulimia nervosa, anorexia nervosa, or both.5 Certainly, bulimia can be found in males as well. The bulimic individual typically gorges herself with thousands of calories after a period of starvation and then purges herself through induced vomiting and further fasting or through the use of laxatives or diuretics. This secretive bingeeating–purging cycle may go on for years.

FOCUS 5–7 Focus on Injury/Illness Prevention and Wellness Promotion Identifying the individual with an eating disorder An individual with an eating disorder may display the following signs: • Social isolation and withdrawal from friends and family • A lack of confidence in athletic abilities • Ritualistic eating behavior (e.g., organizing food on plate) • An obsession with counting calories • An obsession with constantly exercising, especially just before a meal • An obsession with weighing self • A constant overestimation of body size • Patterns of leaving the table directly after eating to go into the restroom • Problems related to eating disorders (e.g., malnutrition, menstrual irregularities, or chronic fatigue) • A family history of eating disorders

Typically, the bulimic patient is white and belongs to a middle-class or upper-middle-class family. She is perfectionistic, obedient, overcompliant, highly motivated, successful academically, well liked by her peers, and a good athlete.75 She most commonly participates in gymnastics, track, and dance. Male wrestlers and gymnasts may also develop bulimia nervosa. (See Focus Box 5–7: “Identifying the individual with an eating disorder.”) Binge-purge patterns of eating can cause stomach rupture, disruption of heart rhythm, and liver damage. Stomach acids brought up by vomiting cause tooth decay and chronically inflame the mucous lining of the mouth and throat. It must be made clear that binge eating associated with an eating disorder is different from overeating. Everyone overeats from time to time, such as at parties or on holidays. This may occur due to stress but more often due to celebration of an event or because the food tastes great. Bingeing is a loss of control, such as when eating a couple of cookies turns into finishing the entire bag, then looking for ice cream or leftover pizza. The person cannot stop eating, then feels guilty and tries to purge by vomiting. The bulimic experiences this scenario repeatedly. Anorexia Nervosa It has been estimated that 30 to 50 percent of all individuals diagnosed as having anorexia nervosa also develop some symptoms of bulimia nervosa. Anorexia nervosa is characterized by a distorted

body image and a major concern about weight gain. As with bulimia nervosa, anorexia nervosa affects mostly females. It usually begins in adolescence and can be mild without major consequences or can become life threatening. As many as 15 to 21 percent of individuals diagnosed as anorexic ultimately die from this disorder. Despite being extremely thin, the individual sees herself as too fat. These individuals deny hunger and are hyperactive, engaging in abnormal amounts of exercise, such as aerobics or distance running.74 In general, the anorexic individual is highly secretive, and the athletic trainer must be sensitive to eating problems. Early intervention is essential. Any individual with signs of bulimia nervosa or anorexia nervosa must be confronted in a kind, empathetic manner by the athletic trainer. Individuals with eating disorders must be referred for psychological or psychiatric treatment. Unfortunately, simply referring an anorexic person to a health education clinic is not usually effective. The key to the treatment of anorexia nervosa seems to be getting the patient to realize that a problem exists and that he or she could benefit from professional help. The individual must voluntarily accept such help if treatment is to be successful.7 Anorexia Athletica Anorexia athletica is a condition specific to athletes that is characterized by several of the features common to anorexia nervosa, but without the self-starvation practices. Athletes with anorexia athletica may exhibit a variety of signs, including disturbance of body image, a weight loss greater than 5 percent of body weight, gastrointestinal complaints, primary amenorrhea, menstrual dysfunction, absence of medical illness explaining the weight reduction, excessive fear of becoming obese, bingeing or purging, compulsive eating, and/or restriction of caloric intake. Female Athlete Triad Syndrome Female athlete triad syndrome is a potentially fatal problem that involves a combination of an eating disorder (either bulimia or anorexia), amenorrhea, and osteoporosis (diminished bone density).54,60 Severe undernutrition impairs reproductive and skeletal health and menstrual irregularities and low bone mineral density increase stress fracture risk.56 The incidence of this syndrome is uncertain; however, some studies have suggested that eating disorders in female athletes may be as high as 62 percent in certain sports, with amenorrhea being common in at least 60 percent of female athletes.32 However, the major risk of this syndrome is that the bone lost in osteoporosis may not be regained.52 Screening for this syndrome should occur at the preparticipation exam or annual health screening exam, and athletes with one component of the triad should be evaluated for the others.56 Multidisciplinary treatment should include a physician (or other health care professional), a registered dietitian, and, for athletes with disordered eating or an eating disorder, a mental health practitioner.56 Chapter Five ■ Nutrition and Supplements

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SUMMARY • The classes of nutrients are carbohydrates, fats, proteins, vitamins, minerals, and water. Carbohydrates, fats, and proteins provide the energy required for muscular work during activity and play a role in the function and maintenance of body tissues. Vitamins are substances in food that have no caloric value but are necessary to regulate body processes. Vitamins are either fat soluble (vitamins A, D, E, and K) or water soluble (B-complex vitamins and vitamin C). Minerals are necessary in most physiological functions of the body. Water is the most essential of all the nutrients and should be of great concern to anyone involved in physical activity. • A nutritious diet consists of eating a variety of foods in amounts recommended in MyPlate. A diet that meets those recommended amounts does not require supplementation. • Protein supplementation during weight training is not necessary if a nutritious diet is maintained. Many males and especially females may require calcium supplementation to prevent osteoporosis. It may be necessary to supplement the diet with extra iron to prevent iron-deficiency anemia. • Organic or natural foods have no beneficial effect on performance. Vegetarian diets can provide all the essential nutrients if the diet is well thought out and properly prepared. • The pre-event meal should be higher in carbohydrates, easily digested, eaten 3 to 4 hours before an event, and psychologically pleasing.

• Glycogen supercompensation involves maximizing resting stores of glucose in the muscles, blood, and liver before a competitive event. • Body composition indicates the percentage of total body weight composed of fat tissue versus the percentage composed of lean tissue. The size and number of adipose cells determine percent body fat. Percent body fat can be assessed by measuring the thickness of the subcutaneous fat at specific areas of the body with a skinfold caliper. • Changes in body weight are caused almost entirely by a change in caloric balance, which is a function of the number of calories taken in and the number of calories expended. Weight can be lost either by increasing caloric expenditure through exercise or by decreasing caloric intake. Diets generally do not work. The recommended technique for losing weight involves a combination of moderate calorie restriction and a moderate increase in physical exercise during the course of each day. Weight gain should be accomplished by increasing caloric intake and engaging in a weight-training program. It is possible to gain weight and lose fat, thus changing body composition. Muscle weighs more than fat. • Anorexia nervosa is a disease in which a person suffers a pathological weight loss because of a psychological aversion to food and eating. Bulimia nervosa is an eating disorder that involves bingeing and subsequent purging. Anorexia athletica is similar to anorexia nervosa without starvation. Female athlete triad syndrome is a combination of an eating disorder, amenorrhea, and osteoporosis.

WEB SITES National Athletic Trainers Association Position, Official, Consensus, and Support Statements Evaluation of Dietary Supplements for Performance Nutrition (February 2013) www.natajournals.org/doi /pdf/10.4085/1062-6050-48.1.16 Safe Weight Loss and Maintenance Practices in Sport and Exercise (2011) www.nata.org/sites/default/files/JAT-46-3-16 -turocy-322-336.pdf Preventing, Detecting, and Managing Disordered Eating in Athletes (2008) www.nata.org/sites/default/files/PreventingDetectingAnd ManagingDisorderedEating.pdf Fluid Replacement for Athletes (2000) http://www.nata.org/sites/default/files /FluidReplacementsForAthletes.pdf

Academy on Nutrition and Dietetics: www.eatright.org

Provides informative nutritional tips as well as gateways to nutrition and related sites.

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American Heart Association: www.americanheart.org

Complete with comprehensive nutrition guidelines, the American Heart Association is a great resource for health practitioners and laypersons.

Center for Food Safety and Applied Nutrition—FDA: www.fda.gov/AboutFDA/CentersOffices/OfficeofFoods /CFSAN/default.htm Timely fact sheets and press releases are available from the Food and Drug Administration.

Female Athlete Triad Coalition: www.femaleathletetriad.org Promotes optimal health and well-being for female athletes, active girls, and women.

Fitness and Sports Nutrition http://fnic.nal.usda.gov /lifecycle-nutrition/fitness-and-sports-nutrition A variety of fitness and sports nutrition topics and resources from organizations and institutes that specialize in sports medicine and exercise science research.

Food and Nutrition Information Center: www.fnic.nal .usda.gov/ This site is part of the information centers at the National Agricultural Library and offers access to information on healthy eating habits, food composition, and many additional resources.

Gatorade Sports Science Institute: www.gssiweb.com

This Web site provides information for coaches, athletic trainers, physicians, nutritionists, and others in the field of sports medicine, sports nutrition, and exercise science.

(or know someone who has), NEDA has information that may help.

National Institutes of Health Office of Dietary Supplements: www.ods.od.nih.gov Gives a current overview of individual vitamins, minerals, and other dietary supplements.

SuperTracker: www.supertracker.usda.gov

From the U.S. Department of Agriculture, get your personalized nutrition and physical activity plan, track your foods and physical activities to see how they stack up, and get tips and support to help you make healthier choices and plan ahead.

MyPlate: www.choosemyplate.gov

Government Web site designed to help consumers adopt healthy eating habits consistent with the 2010 Dietary Guidelines.

National Eating Disorders Association: www .nationaleatingdisorders.org

U.S. Dietary Guidelines: www.health.gov/dietaryguidelines

This site details the revised 2015 U.S. Dietary Guidelines for Americans.

Get answers to any questions about eating disorders and their prevention. If you have an eating disorder

SOLUTIONS TO CLINICAL APPLICATION EXERCISES 5–1 The important consideration for weight control is the total number of calories that are consumed relative to the total number of calories expended. It makes no difference whether the calories consumed are carbohydrates, fat, or protein. Fat contains more than twice the number of calories than either carbohydrates, or protein contains, so an athlete can eat significantly more food and still have about the same caloric intake if the diet is high in carbohydrates. This dancer should be told that it is also essential to consume at least some fat, which is necessary for the production of several enzymes and hormones. 5–2 For a person who is truly consuming anything close to a wellbalanced diet, vitamin supplementation is generally not necessary. However, if taking a one-a-day type of v itamin supplement makes her feel better, there is no harm. Vitamins do not provide energy. Her tiredness could be related to a number of medical conditions (e.g., mononucleosis). An iron-deficiency anemia may be detected through a laboratory blood test. The athletic trainer should refer this individual to a physician for blood work. 5–3 This athlete should be referred to the team physician and nutritionist. From her history, the athletic trainer can assume she is not consuming enough iron by not eating meats or other nutritious foods. Iron is essential for hemoglobin formation and energy formation. In addition, since she is not eating vegetables in a well-balanced diet, she is not receiving an adequate amount of vitamin K, which is found in green, leafy vegetables. Vitamin K is important in blood coagulation. 5–4 A small amount of protein (slightly above to about double the protein DRI) is needed for developing muscles in a training program. However, an athlete can easily get these necessary higher amounts by eating a variety of foods, especially protein-rich foods. Thus, athletes do not need protein supplements, because their diets typically exceed protein recommendations. 5–5 The amount of glycogen that can be stored in the muscle and liver can be increased by reducing the training program a few days

before competing and by significantly increasing carbohydrate intake during the week before the event. Nutrients consumed over several days before competition are much more important than what is eaten 3 hours before an event. The purpose of the pre-event meal should be to provide the competitor with sufficient nutrient energy and fluids for competition while taking into consideration the digestibility of the food. Glucose-rich drinks taken at regular intervals are beneficial for highly intense and prolonged events that severely deplete glycogen stores. 5–6 The athletic trainer should recommend that this athlete set a goal of 18 to 20 percent body fat. If the softball player needs to lose weight, she must consume fewer calories than she is burning off, and this is not something that can be achieved in a short period of time. It also must be explained that weight control is simply a matter of achieving caloric balance and making lifestyle changes in terms of eating and exercise habits to achieve caloric balance. 5–7 This athlete must understand the importance of adding lean tissue muscle mass rather than increasing his percentage of body fat. His caloric intake must be increased so that he is in a positive caloric balance of about 500 calories per day. Additional caloric intake should consist primarily of carbohydrates. Additional supplementation with protein is not necessary. It is absolutely essential that this athlete incorporate a weight-training program using heavy weights that will overload the muscle, forcing it to hypertrophy over a period of time. 5–8 Treating eating disorders is difficult even for health care professionals specifically trained to counsel these individuals. The athletic trainer should approach the individual, not with accusation but with support, showing concern about her weight loss and expressing a desire to help her secure appropriate counseling. Remember that the athlete must first be willing to admit that she has an eating disorder before treatment and counseling will be effective. Eliciting the support of close friends and family can help with treatment.

REVIEW QUESTIONS AND CLASS ACTIVITIES 1. What is the value of good nutrition in terms of performance and injury prevention? 2. Ask coaches of different sports about the type of diet they recommend for their athletes and their rationale behind the diet. 3. Have a nutritionist talk to the class about food myths and fallacies. 4. Have each member of the class prepare a week’s food diary; then compare it with other class members’ diaries.

5. What are the daily dietary requirements, according to MyPlate? Should the requirements of the typical athlete’s diet differ from those requirements? If so, in what ways? 6. Debate the value of vitamin and mineral supplements. 7. Describe the advantages and disadvantages of supplementing iron and calcium. 8. Is there some advantage to pre-event nutrition? Chapter Five ■ Nutrition and Supplements

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9. Are there advantages or disadvantages in a vegetarian diet for the athlete? 10. What is the current thinking on the value of creatine as a nutritional supplement? 11. What is the primary concern of using herbs?

12. Discuss the importance of monitoring body composition. 13. Explain the most effective technique for losing weight. 14. Contrast the signs and symptoms of bulimia nervosa and anorexia nervosa. If an athletic trainer is aware of an individual who may have an eating disorder, what should he or she do?

REFERENCES 1. American Heart Association: 2013 ACC/ AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults, Circulation 129(25): S46–S48, 2014. 2. American College of Sports Medicine: The physiological and health effects of oral creatine supplementation, Med Sci Sports Exerc 32(3):706, 2000. 3. American College of Sports Medicine: Position stand on the appropriate intervention strategies for weight loss and prevention of weight regain for adults, Med Sci Sports Exerc 33(12):2145, 2001. 4. Anderson J: Nutrition and bone in physical activity and sport. In Wolinsky I, Hickson J, editors: Nutrition in exercise and sport, Boca Raton, FL, 1998, CRC Press. 5. Beals K: Disordered eating among athletes: A comprehensive guide for health professionals Champaign, IL, 2004, Human Kinetics. 6. Black D: Physiologic screening test for eating disorders/ disordered eating among female collegiate athletes, J Athl Train 38(4): 286, 2003. 7. Bonci C, et al.: National Athletic Trainers’ Association position statement: Preventing, detecting and managing disordered eating in athletes, J Athl Train 43(1):80, 2008. 8. Brownell K: Food and addiction: A comprehensive handbook, New York, 2014, Oxford University Press. 9. Brukner P: Maximizing performance: Nutrition. In P. Brukner (ed.), Clinical sports medicine, ed 3, Sydney, Australia, 2010, McGraw-Hill. 10. Buell J, et al.: National Athletic Trainers Association position statement: Evaluation of dietary supplements for performance nutrition, Journal of Athletic Training 48(1):124–36, 2013. 11. Burke L: Clinical sports nutrition, Sydney, Australia, 2014, McGraw-Hill. 12. Brzycki M: What’s the most accurate way to measure body composition? Fitness Management 20(2):45, 2004. 13. Byrd-Bredbenner C: Perspectives in nutrition, New York, 2008, McGraw-Hill. 14. Campbell B: Pre-exercise carbohydrate supplementation does not suppress rate of fatigue during resistance exercise in trained females, Medicine and Science in Sport and Exercise 44:596, 2012. 15. Casa D, et al.: National Athletic Trainers’ Association position statement: Fluid replacement for athletes, J Athl Train 35(2):212, 2000. 16. Clark N: Organic foods, American Fitness 25(5):34, 2007. 17. Clark N: Nancy Clark’s sports nutrition guide book, Champaign, IL, 2013, Human Kinetics. 18. Coleman E: Protein requirements for athletes, Clinical Nutrition Insight 38(9):1–3, 2012. 19. Coyle E: Highs and lows of carbohydrate diets, Sports Science Exchange 17(2):1, 2004.

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20. Dubnov G: Prevalence of iron depletion and anemia in top-level basketball players, Int J Sport Nutr Exerc Metab 14(1):30, 2004. 21. Food and Drug Administration: Changes to the Nutrition Facts Label, 2016, U.S Department of Health and Human Services. http://www .fda.gov/Food/GuidanceRegulation/GuidanceDocumentsRegulatoryInformation/LabelingNutrition/ucm385663.htm 22. Friedman-Kester K: The function of functional foods, Athletic Therapy Today 7(3):46, 2002. 23. Friedman-Kester K: Herbal remedies are drugs, too! Athletic Therapy Today 7(4):40, 2002. 24. Friedman-Kester K: RDAs, RDIs—R U confused? Athletic Therapy Today 6(3):56, 2001. 25. Froiland K: Nutritional supplement use among college athletes and their sources of information, Int J Sport Nutr Exerc Metab 14(1):104, 2004. 26. Fuhrman J: Fueling the vegetarian athlete, Current Sports Medicine Reports, 9(4):233–41, 2010. 27. Gorinski R: In pursuit of the perfect body composition: Do dietary strategies make a difference? Athletic Therapy Today 6(6):54, 2001. 28. Greenwood M: Cramping and injury incidence in collegiate football players are reduced by creatine supplementation, J Athl Train 38(3):216– 19, 2003. 29. Gutgesell M: Weight concerns, problem eating behaviors, and problem drinking behaviors in female college athletes, J Athl Train 38(1):62, 2003. 30. Hale C: The precompetition meal, Athletic Therapy Today 6(3):21, 2001. 31. Hemila H: Vitamin C for preventing and treating the common cold, The Cochrane Library DOI: 10.1002/14651858.CD000980.pub4, 2013. 32. Hostetter K: The need for qualified intervention for the female athlete triad syndrome patient, Athletic Therapy and Training, 15(3):29–33, 2010. 33. Hoyte C: The use of energy drinks, dietary supplements, and prescription medications by United States college students to enhance athletic performance, Journal of Community Health 38(3):575–80, 2013. 34. Jackson A: Generalized equations for predicting body density of women, Med Sci Sports Exerc 12:175, 1980. 35. Kemble D: Accuracy of bioelectrical impedence analyzers in college athletes: Does hydration matter? Journal of Strength and Conditioning Research, 24(1):1, 2010. 36. Kleiner S: Fluids for performance, Athletic Therapy Today 5(1):51, 2000. 37. Kleiner S: Postexercise-recovery nutrition, Athletic Therapy Today 6(2):40, 2001. 38. Kleiner S: Performance herbs. In S. Kleiner (ed.), Power eating, 2nd ed. Champaign, IL, 2013, Human Kinetics. 39. Kleiner S: Protein power, Athletic Therapy Today 7(1):24, 2002. 40. Kleiner S: Top-ten rules for healthy weight control, Athletic Therapy Today 7(2):38, 2002.

41. Litt A: Tactics for gaining weight. In Litt A, editor: Fuel for young athletes, Champaign, IL, 2004, Human Kinetics. 42. Lopez R: Exercise and hydration: Individualizing fluid replacement guidelines, Strength and Conditioning Journal 34(4):49–54, 2012. 43. Martin M: Drug-herb interactions: Are your athletes at risk? Athletic Therapy Today 10(1): 15, 2005. 44. Martinsen M: Preventing eating disorders among young elite athletes: A randomized controlled trial, Medicine and Science in Sport and Exercise 46(3):435–47, 2014. 45. Mason T: Profiles of binge eating: The interaction of depressive symptoms, eating styles, and body mass index, Eating Disorders 22(5):450– 60, 2014. 46. Massad S, Headley S: Nutrition assessment: Considerations for athletes, Athletic Therapy Today 4(6):6, 1999. 47. Maughn R: Dietary supplements for athletes: Emerging trends and recurring themes, Journal of Sport Sciences 29(1): 56–57, 2011. 48. Maughn R: Sports nutrition, Malden, MA, 2002, Blackwell Scientific. 49. Mazzeo S, Espelage D: Association between childhood physical and emotional abuse and disordered eating behaviors in female undergraduates: An investigation of the mediating role of alexithymia and depression, Journal of Counseling Psychology 49(1):86, 2002. 50. McArdle W, Katch F, Katch V: Sports and exercise nutrition, Philadelphia, 2013, Lippincott, Williams and Wilkins. 51. McVicar J: The complete herb book. Westport, CT, 2008, Firefly Books. 52. Merrick M: Osteoporosis and the female athlete, Athletic Therapy Today 6(3):42, 2001. 53. Meyer N: Fueling for fitness: Food and fluid recommendations for before, during, and after exercise, ACSM’S Health & Fitness Journal 16(3):7–12, 2012. 54. Mountjoy M: The IOC consensus statement: Beyond the female athlete triad-relative energy deficiency in port, British Journal of Sports Medicine 48:491–97, 2014. 55. Mueller K: The athlete’s guide to sports supplements, Champaign, IL, 2013, Human Kinetics. 56. Nattiv A, et al.: The female athlete triad, Medicine and Science in Sport and Exercise 39(10)1867–82, 2007. 57. Powers M: Ephedra and its application to sport performance: Another concern for the athletic trainer? J Athl Train 36(4):420, 2001. 58. Powers M: Creatine supplementation increases total body water without altering fluid distribution, J Athl Train 38(1):44, 2003. 59. Powers S: Antioxidant and vitamin D supplements for athletes: Sense or nonsense? Journal of Sports Sciences, 29 (1 Supplement): S47–S55, 2011. 60. Rauh M: Relationships among injury and disordered eating, menstrual dysfunction, and low bone mineral density in high school athletes: A prospective study, J Athl Train 45(3):243–52, 2010.

61. Ray T: What you need to know about performance-enhancing supplements, Athletic Therapy Today 11(2):56, 2006. 62. Reimers K: The role of liquid supplements in weight gain, Strength Cond 17(1):64, 1995. 63. Rodriguez N: Introduction of protein summit 2.0: Continued exploration of the impact of highquality protein on optimal health, American Journal of Clinical Nutrition 101(6):13175–195, 2015. 64. Rosenbloom C: Risky business: Dietary Supplement use by athletes, Nutrition Today 50(5):240–46, 2015. 65. Sandstrom G: Iron deficiency in adolescent female athletes—Is iron status affected by regular sporting activity? Clinical Journal of Sports Medicine 36(1):37–44, 2012. 66. Sawyer T, editor: A guide to sport nutrition: For student-athletes, coaches, athletic trainers, and parents, Champaign, IL, 2003, Sagamore. 67. Schlosser E: Fast food nation: The dark side of the all-American meal, New York, 2012, Harper Perennial. 68. Selkow N: Subcutaneous thigh fat assessment: A comparison of skinfold calipers and ultrasound imaging, J Athl Train 46(1):50–54, 2011. 69. Smith-Ryan A: Sports nutrition and performance enhancing supplements, Ronkonkoma, NY, 2013, Linus Learning.

70. Smith-Ryan A: The effect of creatine loading on neuromuscular fatigue in women, Medicine and Science in Sport and Exercise, 46(5)990–97, 2014. 71. Snyder M: The antioxidant counter: A pocket guide to the revolutionary ORAC scale for choosing healthy foods, Berkeley, 2011, Ulysses Press. 72. Spriet L: Nutritional strategies to influence adaptations to training, Journal of Sports Sciences 22(1):127, 2004. 73. Stout J: Essentials of creatine in sports and health, Clifton, NJ, 2010, Humana Press. 74. Sundgot-Borgen J: Eating disorders in athletes. In Sundgot-Borgen J, editor: Nutrition in sport, Oxford, England, 2000, Blackwell. 75. Turk J, Prentice W: Collegiate coaches’ knowledge of eating disorders, J Athl Train 34(1): 19, 1999. 76. Turocey P, et al.: National Athletic Trainers Association position statement: Safe weight loss and maintenance practices in sport and exercise, Journal of Athletic Training 46(3):322–36, 2011. 77. U.S. Department of Health and Human Services and U.S. Department of Agriculture: 2015 – 2020 Dietary Guidelines for Americans, 8th ed., 2015.

78. Vaughn J: Collegiate athletic trainers confidence in helping female athletes with eating disorders, J Athl Train 39(1):71, 2004. 79. Vinci D: Navigating the low-carb craze, Athletic Therapy Today 10(1):20, 2005. 80. Vinci D: Negotiating the maze of nutritional ergogenic aids, Athletic Therapy Today 8(2): 28, 2003. 81. Vinci D: The training room: Developing a sports-nutrition game plan, Athletic Therapy Today 7(5):52, 2002. 82. Vinci D: What’s for lunch? Athletic Therapy Today 8(1):50, 2003. 83. Weil A: Eating well for optimal health: The essential guide to food, diet and nutrition, London, 2008, Sphere. 84. Wilder N: The effects of low-dose creatine supplementation versus creatine loading in collegiate football players, J Athl Train 36(2): 124, 2001. 85. Williams M: Nutrition for health, fitness and sports, Boston, 2009, McGraw-Hill. 86. Winterstein A, Storrs C: Herbal supplements: Considerations for the athletic trainer, J Athl Train 36(4):425, 2001. 87. Zawila L: The female, collegiate, cross-country runner: Nutritional knowledge and attitudes, J Athl Train 38(1):67, 2003.

ANNOTATED BIBLIOGRAPHY Clark N: Sport nutrition guidebook: Eating to fuel your active lifestyle, Champaign, IL, 2008, Human Kinetics. Provides real-life case studies of nutritional advice given to athletes; also provides recommendations for pregame meals.

Maughan R: Sports nutrition, IOC Medical Commission, 2014, Wiley Blackwell. A practical guide to eating for health and performance based on a consensus statement from the International Olympic Committee.

Dunford M, Doyle J: Nutrition for sport and exercise, Belmont, CA, 2014, Cengage Learning. Integrates nutrition and exercise physiology principles, emphasizing scientific reasoning and examining evidence for current nutritional recommendations.

Rosenbloom C, Coleman E: Sports nutrition: A practice manual for professionals, Chicago, IL, 2012, Academy of Nutrition & Dietetics. This book is a go-to source for specific evidence-based information on different sports nutrition topics.

Fink H, Burgoon L, Mikesky A: Practical applications in sports nutrition, Sudbury, MA, 2009, Jones and Bartlett. Provides an introduction to sports nutrition including general nutrition concepts and a thorough explanation of athletic performance and consultation skills. Girard–Eberle S: Endurance sports nutrition, Champaign, IL, 2014, Human Kinetics. A guide for selecting the optimal foods, drinks, and supplements to train longer, recover more quickly, avoid injuries, and achieve performance goals in any endurance endeavor.

Smith-Ryan A, Jose, A: Sports nutrition and performance enhancing supplements, Ronkonkoma, NY, 2013, Linus Learning. A focused resource that provides the latest sports nutrition science, and refutes many positions held so dearly by the antisupplement crowd. Williams M: Nutrition for fitness and sport, Boston, 2009, McGraw-Hill. Thorough coverage of the role nutrition plays in enhancing health, fitness, and sport performance. Current research and practical activities incorporated throughout.

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Environmental Considerations ■ Objectives When you finish this chapter you should be able to • Describe the physiology of hyperthermia. • Recognize the clinical signs of heat stress and how they can be prevented. • Identify the causes of hypothermia and the major cold disorders and how they can be prevented. • Examine the problems that high altitude might present to the athlete, and explain how they can be managed. • Review how an athlete should be protected from exposure to the sun.

■ Outline Hyperthermia 159 Hypothermia 171 Altitude Sickness 173

• Describe precautions that should be taken in a lightning storm. • List the problems that air pollution presents to the athlete and how they can be avoided. • Discuss what effect circadian dysrhythmia can have on athletes and the best procedures for handling this problem. • Compare the effect of synthetic versus natural turf on the incidence of injury.

■ Key Terms hypothermia hyponatremia circadian dysrhythmia

hypothermia acclimatization SPF

Overexposure to Sun 174 Lightning Safety 175 Air Pollution 176 Circadian Dysrhythmia (Jet Lag) 178 Synthetic Turf 179 Summary 179

■ Connect Highlights Visit connect.mcgraw-hill.com for further exercises to apply your knowledge: • Clinical application scenarios covering physiology of hyperthermia, clinical signs of heat stress, high altitude management, circadian dysrhythmia, protection of exposure to the sun, precautions of inclement weather, and playing surfaces • Click-and-drag questions covering heat conditions, clinical signs of heat stress and prevention, environmental conditions, and air quality • Multiple-choice questions covering recognition and prevention of hyperthermia and heat illnesses, inclement weather, sun exposure, circadian dysrhythmia, and playing surfaces • Selection questions covering hyponatremia, lightning safety, and prevention of heat illnesses

ne of the primary responsibilities of the athletic trainer in preventing injuries is to make certain that the practice and playing environment is as safe as it can possibly be. Certainly no one has control over the weather. However, the potential dangers of having athletes engage in practices or competitions when adverse weather or environmental conditions exist cannot be ignored. Ignoring or minimizing the potential threat to the health and well-being of athletes who practice or compete under adverse environmental conditions can have serious legal consequences should a situation arise that results in injury to an athlete. Environmental stress can adversely affect performance and in some instances can pose a serious health threat.47 The environmental categories that are of concern to athletic trainers, particularly those involved in outdoor sports, are hyperthermia, hypothermia, altitude, exposure to the sun, lightning storms, air pollution, and circadian dysrhythmia (jet lag).

HYPERTHERMIA Hyperthermia is a condition in which, for one reason or another, body temperature is elevated. Over the years, hyperthermia has caused a number of deaths in athletes at the secondary-school, collegiate, and professional levels.64 It is vitally important that the athletic trainer and the coaching staff have knowledge about temperature and humidity factors to assist them in planning practice. The athletic trainer must clearly understand when environmental heat and humidity are at a dangerous level and must make recommendations to the coaches accordingly to prevent the occurrence of heat-related illnesses.97,99 In addition, the athletic trainer must recognize and properly manage the clinical signs and symptoms of heat-related illnesses. It is the responsibility of the athletic trainer to educate relevant personnel, including coaches, administrators, security guards, EMS staff, and athletes, about preventing exertional heat-related illnesses and the policies and procedures that must be followed should they occur.17,29 SoR:C

Heat Stress Regardless of the level of physical conditioning, athletes must take extreme caution when exercising in hot, humid weather. Prolonged exposure to extreme heat can result in heat illness.17,29 Heat stress is preventable, but each year many athletes suffer illness and even death from a heatrelated cause.48 Anyone who engages in exercise in hot, humid environments is particularly vulnerable to heat stress.33 Some athletes have medical conditions such as sickle-cell trait (see Chapter 29) which make them more susceptible to the dangers of exercising in hot humid conditions. Young athletes and elderly are particularly susceptible to heat stress.122 Although heat-related illnesses most often occur in hot, humid, sunny conditions, an individual training or

competing in a cold environment may also be susceptible if he or she becomes dehydrated or if protective equipment does not allow heat dissipation through the sweating mechanism.26 The physiological processes in the body will continue to function only as long as body temperature is maintained within a normal range.23 The maintenance of normal temperature in a hot environment depends on the body’s ability to dissipate heat. Body temperature can be affected by five factors, described in the following sections. Metabolic Heat Production Normal metabolic function results in the production and radiation of heat.78 Consequently, metab Heat can be gained or lost olism always causes through: an increase in body heat that depends on • Metabolic heat production the intensity of the • Conductive heat exchange • Convective heat exchange physical activity. The • Radiant heat exchange higher the metabolic • Evaporative heat loss rate, the more heat produced. Conductive Heat Exchange Physical contact with other objects can result in either a heat loss or a heat gain. A football player competing on artificial turf on a sunny August afternoon experiences an increase in body temperature simply by standing on synthetic turf. Convective Heat Exchange Convection occurs when a mass of either air or water moves around an individual. Body heat can be either lost or gained, depending on the temperature of the circulating medium. A cool breeze tends to cool the body by removing heat from the body surface. Conversely, if the temperature of the circulating air is higher than the temperature of the skin, body heat increases. Radiant Heat Exchange Radiant heat from sunshine causes an increase in body temperature. Obviously, the effects of this radiation are much greater in the sunshine than in the shade.45 On a cloudy day, the body also emits radiant heat energy; thus, radiation may result in either heat loss or heat gain. During exercise the body attempts to dissipate heat produced by metabolism by dilating superficial arterial and venous vessels, thus channeling blood to the superficial capillaries in the skin. Evaporative Heat Loss Sweat glands in the skin allow water to be transported to the surface, where it evaporates, taking large quantities of heat with it. When the temperature and radiant heat of the environment become higher than body temperature, the loss of body heat becomes highly dependent on the process of sweat evaporation. The rate of sweating is critical for an athlete to dissipate heat. A normal person can sweat off about 1 quart of water per hour for about 2 hours. However, Chapter Six ■ Environmental Considerations

159

FOCUS 6–1 Focus on Injury/Illness Prevention and Wellness Promotion Variations in sweat rates Sweat rates can vary considerably from one athlete to another and are determined by a number of factors: • Athlete’s height and weight (heavier athletes sweat more) • Degree of acclimatization (well-acclimated a thletes sweat earlier and more) • Fitness level (fit athletes sweat more) • Hydration status (athletes who begin activity well hydrated sweat earlier) • Environmental conditions • Clothing • Intensity and duration of activity • Heredity

certain individuals can lose as much as 2 quarts of water (4 pounds) per hour.88 Focus Box 6–1: “Variations in sweat rates” identifies the factors that influence sweat rates. Sweating does not cause heat loss. The sweat must evaporate for heat to be dissipated. But the air must be relatively free of water for evaporation to occur. Heat loss through evaporation is severely impaired when the relative humidity reaches 65 percent and virtually stops when the humidity reaches 75 percent.78

Preventing Heat Illness The athletic trainer should understand that heat illness is preventable if he or she exercises some common sense and caution.18 Athletes should be encouraged to hydrate properly before, during, and after exercise, sleep at least 7 hours per night in a cool environment, eat a balanced diet, and allow 2 to 3 hours for food, fluids, electrolytes, and other nutrients to be digested and absorbed before the next practice to maximize recovery.8,29 SoR:C An athlete can only perform at an optimal level when dehydration and hyperthermia are minimized by the ingestion of ample volumes of fluid during exPrevention of hyperthermia: ercise and when • Appropriate hydration commonsense pre • Unrestricted fluid and electrolyte cautions are used replacement to keep cool.5,89,122 • Gradual acclimatization (See Focus • Identification of susceptible Box 6–2: “NATA individuals recommendations • Appropriate uniforms for preventing heat • Weight records illness.” A link to • Monitoring of the heat index the NATA position 160

Part Two ■ Risk Management

statement “Exertional heat illnesses” can be found at http://natajournals.org/doi/pdf/10.4085/1062-6050-50 .9.07. The following factors should be considered when planning a training or competitive program that is likely to take place during hot weather. Hydration Athletes should always begin activities in a well-hydrated state.17,29,34 It is essential that the athlete be aware of the importance of ingesting sufficient fluids throughout the 24-hour period preceding exercise, to make certain that he or she is appropriately hydrated. Hydration status can be assessed by measuring body weight changes before and after exercise sessions, monitoring urine color and comparing with a color chart, measuring urine specific gravity (USG) using a refractometer (see Chapter 13), measuring urine volume, or using a combination of these factors.29 Perhaps the easiest way to check this is to monitor the color of the urine. The urine should appear to be light yellow (the color of lemonade). If it is completely clear, this may indicate overhydration. Dark urine (the color of cider) indicates dehydration. The hydration process should involve ingesting small quantities of fluid at regular intervals throughout the day rather than drinking a huge volume all at once.66 It has been recommended that an athlete drink 17 to 20 fluid ounces of water or a sports drink 2 to 3 hours before exercise and drink another 7 to 10 fluid ounces of water or a sports drink 10 to 20 minutes before exercise.89 Hyponatremia It is possible for an athlete to overhydrate. Hyponatremia is a condition involving a fluid/electrolyte disorder that results in an abnormally low concentration of sodium in the blood.29 It is most often caused by ingesting so much fluid before, during, and after exercise that the concentration of sodium is decreased.110 It can also occur due from having too little sodium in the Hyponatremia occurs with low diet or in ingested blood sodium levels. fluids over a period of prolonged exercise.85 An individual with a high rate of sweating and a significant loss of sodium, who continues to ingest large quantities of fluid over a several-hour period of exercise (as in a marathon or triathlon), is particularly vulnerable to developing hyponatremia.104 Hyponatremia can be avoided completely by making certain that fluid intake during exercise does not exceed fluid loss and that sodium intake is adequate.85 The signs and symptoms of exertional hyponatremia are a progressively worsening headache; nausea and vomiting; swelling of the hands and feet; lethargy, apathy, or agitation; and low blood sodium (

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References