Archive for January, 2017

Patient Reported Outcomes in Clinical Practice

Tuesday, January 17th, 2017

Posted January 17, 2017

Beth Druvenga
M.S. Ed, LAT, ATC

By Beth Druvenga, M.S. Ed, LAT, ATC

As athletic training pushes to the forefront of healthcare professions, it is necessary for us to also change with the times. The Institute of Medicine urges healthcare educational programs to incorporate outcomes that are reported by the patient into their curriculum as to enhance clinicians’ decision making processes and drive forward patient centered care.1 Patient reported outcomes (PROs) are a valuable tool for Athletic Trainers (ATs) to add to their arsenal of evaluating their patient as a whole. With the addition of PROs into educational programs,1 this gives the student a chance to learn how and when to utilize these outcomes. It also makes it easier to analyze and interpret the results.

Many clinicians are hesitant to use PROs, especially in the fast-paced world of athletic training. Some of the greatest barriers to using PROs are time, comprehension and independence. Most clinicians and patients, report that it takes too much time to complete the surveys, and therefore, do not want to include them in their plan of care. Others report that patients don’t understand the questions and cannot properly fill out the survey without dependence on the clinician.1 How can we break through these barriers?

Initially, it may take time to walk the patient through the survey, but after they understand it, they can independently complete it at subsequent times. On the patient’s side, they can complete the survey while they are hooked up to electrical stimulation, icing or heating. This breaks down the time, comprehension and dependency barriers. It could be easily argued that recording PROs is as important to the patient’s rehab as recording objective measures of range of motion, strength and flexibility.

Once you’ve decided to use PROs, there are some things to consider for picking the correct outcome measure to use. First is to select the type of PRO. There are PROs to record the overall health related quality of life, the patient’s whole body health or information that focuses directly to one area of the body. The PRO that focused directly to one area of the body will be best suited for the outcomes most ATs will want to measure.

Once the type is determined, it’s time to decide on the quality of the PRO. In determining the quality, a clinician should look at the reliability and validity of the measure. This is to make sure that the outcome measure accurately shows change over time for the intended population and evaluates items which are important to the clinician and the patient. 2 Other elements to look at are the stability of the measure to reproduce a same score when a patient’s health status has not changed and responsiveness to detect how true the change in the score is over time.2

Along with the internal elements of the outcome measure, the measure also should be patient and clinician friendly, easy to use and score and support the goals that have been made for the patient. If you are interested in adding PROs into your practice but are still not sure where to go, http://www.orthopaedicscores.com/ is a valuable website. This resource has PROs grouped into specific categories as well as offers printable excel files.

One of the best reasons to use patient reported outcomes is to increase communication with the patient and to direct the patient’s care plan.1 Utilizing PROs in conjunction with clinician reported outcomes can enhance the rehabilitation process. Imagine the scenario of a patient returning from ACL surgery. By utilizing PROs, they will be able to see their progress from day 1 to present. As ATs, we watch our patients go through the highs and the lows of their rehabilitation process, including days where they feel like they haven’t made any progress. PROs, in conjunction with clinician reported outcomes, are valuable tools to utilize in helping patients reach their goals.

Resources

1. Snyder Valier, A. R., Jennings, A. L., Parsons, J. T., & Vela, L. I. (2014). Benefits of and Barriers to Using Patient-Rated Outcome Measures in Athletic Training. Journal of Athletic Training, 674-683.

2. Valier, A. R., & Lam, K. C. (2015). Beyond the Basics of Clinical Outcomes Assessment: Selecting Appropriate Patient-Reported Outcomes Instruments for Patient Care. Athletic Training Education Journal, 91-100.

About the Author

Beth Druvenga is an Athletic Trainer currently living in northern Virginia. She has experience working in both a collegiate and high school setting. Druvenga is originally from Iowa where she earned her Bachelor of Arts degree in Athletic Training from Central College in 2012. She graduated from Old Dominion University in 2014 with a Master of Science in Education. Her professional interests include patient-reported outcomes, psychology of injury and rehabilitation as well as using yoga to increase flexibility.

 

Prevent Cold Weather Illnesses This Winter

Wednesday, January 11th, 2017

Posted January 11, 2017

By Mackenzie Simmons AT, MSEd, ATC

Throughout winter, it is important to be aware of the signs and symptoms of cold weather illnesses, as well as the risk factors and preventative methods. While heat illness usually seems to be on the forefront of environmental issues, cold weather illnesses can cause the same catastrophic results. Athletic Trainers (ATs) and other healthcare professionals need to be knowledgeable in differentiating and diagnosing hypothermia, frostbite, chilblains and trench foot in athletes. A short summary of these cold weather illnesses are listed below.

Hypothermia (mild, moderate or severe) is caused by prolonged exposure to cold, wet or windy conditions, usually during endurance events or outdoor games.

Mild

- Core temperature 98.6F to 95F

- Cold extremities

- Shivering

- Pallor

Moderate

- Core temperature 94F to 90F

- Slowed respiration and pulse

- Cessation of shivering

- Dilated pupils

- Impaired mental function and motor control

Severe

- Core temperature below 90F

- Rigidity

- Severely depressed respirations

- Bradycardia

- Usually has fallen into a coma

Frostbite (mild or superficial) occurs when there is an exposure to cold temperatures, often in conjunction with wind or touching cold surfaces

Mild

- Area is firm or cold to the touch

- Limited movement

- White or blue-gray colored patches in skin

- Tingling or burning sensation

Superficial

- Area is hard or cold

- Burning, aching, throbbing or shooting pain

- White, gray, black or purple skin

- Tissue necrosis

Chilblain (or pernio) is caused when the body has prolonged exposure to cold, wet conditions.

- Red or cyanotic lesions

- Tissue necrosis

- Skin sloughing

- Swelling

Trench foot comes from prolonged exposure to cold, wet conditions; it usually occurs with the continued wearing of wet socks, wet shoes or both.

- Burning, tingling or itching

- Loss of sensation

- Cyanotic or blotchy skin

- Blisters or skin fissures

Sometimes, cold weather illnesses cannot be prevented in athletes, but there are risk factors that can predispose an athlete to getting hypothermia, frostbite, chilblain or trench foot. Listed below are a few of the risk factors for cold weather illnesses:

- Lean body composition

- Lower fitness level

- Females

- Older age

- Issues such as cardiac disease, Raynaud’s phenomenon and anorexia

- Previous cold injuries

- Low caloric intake

- Dehydration

- Fatigue

While most risk factors are genetic, there are a few that can be controlled. An AT can encourage athletes to stay properly hydrated and nourished before activity to ensure the body has enough nutrients to efficiently function. Also, make sure the athletes are at the necessary fitness level to perform the event in the cold weather. It is important to encourage the athletes to get a full night of rest leading up to the event so the body is not fatigued.

In addition to controlling the risk factors, the AT can also provide guidance on the proper clothing to wear to the event. When possible, the athlete should keep their hands, feet, toes and ears covered. Also, dressing in layers is essential to keeping warm—the first layer of clothes should allow sweat evaporation, the middle layer for insulation and then the outer layer being water and wind resistant. The AT should also monitor the wind chill before and during the event to make sure the weather is safe for activity.

Resources

Cappaert, Thomas A., et al. "National Athletic Trainers' Association position statement: environmental cold injuries." Journal of athletic training 43.6 (2008): 640-658.

 

 

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Utilization of Sport Psychology in the Rehabilitation Process

Monday, January 9th, 2017

Posted January 9, 2017

Beth Druvenga
M.S. Ed, LAT, ATC

By Beth Druvenga, M.S. Ed, LAT, ATC

“Sports are 10% physical, 90% mental,” this common phrase used in sports is easily transferred into the world of injury rehabilitation. Sport psychology has started to be incorporated into the sports medicine realm.  Athletic Trainers (ATs) are required to participate in some type of psychological or behavioral classes as part of an athletic training program curriculum. Many people have heard of collegiate or professional athletes using psychological techniques such as imagery, stress reduction and positive self-talk as part of their pre-game regimen. They have credited these techniques as helping their game excel, but what if we transferred these techniques into the athletic training facility?

There are some athletes who still feel the stigma of psychosocial help and may not see it as the ATs “place” to employ sport psychology theories into the rehabilitation program.1 However, these interventions have been shown to have positive effects on athlete compliance to rehabilitation programs, better rates of recovery and may help alleviate stress or anxiety.4,3

As ATs, we are put into the unique role, which allows us to control many aspects of the rehabilitation process such as; creating a positive atmosphere, maintaining athlete compliance and providing social support for the injured athlete. We can easily facilitate the discussion with the athlete about how they feel regarding their injury, refer them to another healthcare professional or help them cope with their injury. ATs are on the front lines of student-athlete wellness. Having awareness and knowledge about the psychosocial aspects of the sport allows ATs to take greater care of the athlete, which will hopefully reduce injury recovery time.

Use your tools of the trade! As a professional, it is intrinsic to give our athletes feedback and cues on how to do their exercises correctly. We help set achievable goals in their rehabilitation and lift them up when they’re having a rough day in rehab. All athletes have some part of their identity associated with being an athlete. Being aware of any changes in this identity can be useful for an AT to help in identifying any issue that may appear. These are all subtle psychological interventions!1 Though subtle is sometimes best, there are some more direct ways that can be beneficial to the athlete.

Start by having the athlete write down goals for each week in a journal or on a rehab sheet. The ability to see these goals daily during rehab will ingrain in the athlete’s mind about what they have set out to do for the week and will motivate them to make progress.2 They can acknowledge their goals while doing specific exercises and visibly see their progress written out. Talking with the athlete about their motivation for recovery can also be helpful. By understanding the athletes “why” early in the recovery process, you can help remind them of this “why” during the difficult days.

Add imagery into their program. Imagery is a process which involves three steps: vividness, controllability and self-perception.5 Especially with post-surgical cases and prior to the exercise, have the athlete imagine the muscles they use to do a specific exercise (vividness). After they have done this for a few minutes, have them move on to imagining going through the exercise and completing it successfully and pain free (controllability). Then, after doing this step for a few minutes, finally have the athlete think about a time where they were performing at their best, what emotions they had and what it took for them to feel that way.5 Imagery can be used in pain management as well. Having the athlete view the pain as a “hot” color like red and change it to a “cool” color like blue, which can help reduce pain.6

Teach them positive self-talk. Athletes are quick to get down on themselves if they aren’t performing the task perfectly. Have the athlete use “I can”, or “I will” statements before tackling a tough exercise. This practice will positively engage the brain and give the athlete the boost to achieve their goal. Another way to enhance confidence is to view the setback or injury as a challenge and obstacle to overcome rather than a threat to athletic identity. Changing the perception will help the athlete remain optimistic during a potentially difficult period of life.

Create a peer to peer group.2 A peer to peer group can be led by a sport psychologist or qualified mental skills coach, which can meet to discuss the “boo’s and yay’s” of that day’s session. Athletes need to know they’re not the only one struggling with certain things. When they can dialogue with others in a controlled setting, they may find it beneficial to talk with others going through similar situations. They can also share techniques which have helped them and may  help other athletes.

Many ATs do not feel adequately equipped to walk athletes through the psychological aspects of return from injury. If this is the case, search for local sports psychologist or qualified mental skills coach, who work with adolescents or young adults. A great resource is the Association for Applied Sport Psychology, they have information for consultants in your area, as well are plenty of resources on injury/rehabilitation.

In the college/university setting, seek out your psychology or kinesiology professors. They may have an interest in the area of sport psychology and would be willing to provide guidance and expertise. Seek out workshops, lectures and continuing education that touch upon applying psychology into the athletic training facility. As ATs, we are uniquely taught and equipped to handle many different and difficult facets of injury, rehabilitation and return to play. We have an overflowing toolbox, but adding sport psychology training may prove to be a welcome addition.

**Huge thank you to my brother Joel Druvenga, a Master Resilience Trainer-Performance Expert with Comprehensive Soldier and Family Fitness at Fort Riley Army Base. He has a Bachelor of Arts in Psychology, Master of Education in Counseling with an emphasis in Sport Psychology.  He is also working toward a Doctor of Education in Kinesiology. He provided me with valuable insight into the realm of sport psychology and utilizing it in the sports medicine world, and added some great edits to this blog post.**

References

1. Arvinen-Barrow, M., Massey, W. V., & Hemmings, B. (2014). Role of Sport Medicine Professionals in Addressing Psychosocial Aspects of Sport-Injury Rehabilitation: Professional Athletes' Views. Journal of Athletic Training, 764-772.

2. Granito, V. J., Hogan, J. B., & Varnum, L. K. (1995). The Performance Enhancement Group Program: Integrating Sport Psychology and Rehabilitation. Journal of Athletic Training, 328-331.

3. Hamson-Utley, J. J., Martin, S., & Walters, J. (2008). Athletic Trainers' and Physical Therapists' Perceptions of the Effectiveness of Psychological Skills Within Sport Injury Rehabilitation Programs. Journal of Athletic Training, 258-264.

4. Heaney, C. A. (2006). Recommendations for Successfully Integrating Sport Psychology Into Athletic Therapy. Sport Psychology & Counseling, 60-62.

5. Richardson, P. A., & Latuda, L. M. (1995). Therapeutic Imagery and Athletic Injuries. Journal of Athletic Training , 10-12.

6. Taylor, J., & Taylor, S. (1997). Psychological approaches to sports injury rehabilitation. Gaithersburg: Aspen Publishers.

About the Author

Beth Druvenga is an Athletic Trainer currently living in northern Virginia. She has experience working in both a collegiate and high school setting. Druvenga is originally from Iowa where she earned her Bachelor of Arts degree in Athletic Training from Central College in 2012. She graduated from Old Dominion University in 2014 with a Master of Science in Education. Her professional interests include patient-reported outcomes, psychology of injury and rehabilitation as well as using yoga to increase flexibility.

 

 

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Nutrition, Recovery and Injury Prevention for Basketball Players

Tuesday, January 3rd, 2017

Posted January 3, 2017

Desi Rotenberg
MS, LAT, ATC

By Desi Rotenberg, MS, LAT, ATC

Basketball is a sport that requires several complex movement patterns, both within the individual and the team. Before an exercise specialist can create a training and nutrition program for any sport, it is important to first fully understand the game as a whole. This includes, but is not limited to, the specific movement patterns required to optimize performance as well as how to decrease overall time to fatigue in-game and during off-court training. Coupling movement patterns with a deliberate hydration plan and nutrition plan can optimize performance, while ensuring the athlete’s body can handle the strenuous mental and physical demands of the sport itself.

Nutrition

Basketball requires a combination of movements that include strength, endurance, power, agility, quickness and proprioception. While a single game lasts between 32 and 48 minutes, depending on the level, the actual exercise time may only be a fraction of that time. A single player will undergo 1 high intensity run every 21 seconds and spends nearly 60 percent of their playing time undergoing low intensity activity .2

In order for each player to maximize their performance on the court, they must ensure they have properly fueled the energy systems needed. The training needs of the sport will also need to be taken into consideration: the average basketball player trains between 2-3 hours per day, 4-6 days per week.2 Additionally, it is estimated that the average basketball player runs between 1 and 3 miles per game. These values have only been confirmed at the professional level with state-of-the-art tracking technology. Currently, the record belongs to Jimmy Butler, who ran an average of 2.74 miles per game during the 2015-2016 NBA season.

Nonetheless, a basketball player’s diet must reflect that of the short-term, high intensity movements coupled with long-term low intensity energy demands. The table below illustrates the nutritional requirements for basketball players at the high school and post-secondary levels:

  Men Women
Calories

2,500-3,000 (High school)

3,000-3,500 (Post-Secondary)

2,200-2,700 (High School)

3,500-4,000 (Post-Secondary)

Protein

1.4-1.7 g/kg

1.4-1.7 g/kg

Carbohydrate

2.7-4.5 g/kg

2.7-4.5 g/kg

It is recommended athletes eat a high carbohydrate, low fat meal roughly 3-4 hours prior to the start of a practice or competition. A small snack should be consumed 1-2 hours prior to the start. This snack should be relatively high in carbohydrate (juice, cereal bar or bagel) and have some protein (peanut butter, milk, cheese or yogurt) in order to prepare the athlete’s body for the energy need required. The protein will help initiate the athlete’s muscle recovery following completion of the practice or competition. Less than 1 hour prior to the start of the practice or competition, the athlete should consume a sports drink. This will help prime the athlete’s short-term energy system and contribute to hydration, which will help prevent fatigue.

During the practice or competition, it is recommended the athlete drink water or colored sports drinks that are kept at a cool temperature. This will prevent dehydration and exercise-induced hypoglycemia. Basketball players should be taking breaks and consuming either water or a sports drink roughly every 15-20 minutes during play.1

Injury Prevention

According to a 2016 study by Bird and Markwick published in the International Journal of Sports Physical Therapy, injury prevention within the basketball population is a combination of the ability to recognize poor movement patterns and the theoretical likelihood to predict future injury incidents.3  A meta-analysis of basketball injury prevalence showed amongst high school basketball players, an injury will occur 2.08 times per every 1,000 exposures in boys  and 1.83 per times per 1,000 exposures in girls.3 An exposure being an opportunity for an injury to occur within practice or in-game. Concurrently at the collegiate level, the injury rate substantially rises: 9.9 times per 1,000 exposures in men and 7.68 times per 1,000 exposures in women.3

Furthermore, as expected, the lower extremity was the most common region of the body to have sustained injury amongst basketball players. Ankle sprains during landing accounted for nearly 45 percent of all lower extremity injuries. In females, knee injuries that occur during a cutting or rotational movement account for nearly 30 percent of all injuries amongst high school and collegiate basketball players.3

As mentioned above, given the knowledge we have about the specific injuries that occur within the sport, we can begin to predict future injury occurrences. Bird and Marwick explain it as “injury prevention through prediction; an approach that is used to assess fundamental movement qualities in order to identify and predict overall injury risk.”3

Recent research suggests that movement screens are moving away from the traditional isolated muscle strength assessment tests. They are moving towards an integrated approach that evaluates fundamental movements related to the assessment of “an athlete’s movement competency, or the fundamental mechanics required over a period of time within a specific sport.”3 In simple terms, the assessment should focus on the fundamentals, which can then be continuously trained to ensure a safe, yet effective improvement in overall sport performance.

Below are a few of the functional assessment tools utilized by this study and their practical applications. Each test is scored on a scale of 1-3 (1 being can not complete without major flaws; 2 being can complete but with some flaws and 3 can execute with technical proficiency).3

1. Hop and Jump Variation Assessment

a. A good way to assess neuromuscular control using single leg hopping, hopping for distance and timed hop.

b. Practical Application: These assessments will allow the practitioner to visualize any neuromuscular control deficits, muscular strength deficits or imbalances, knee position and trunk position/compensation.3

2. Landing Error Scoring System

a. Known as the “Drop Box Vertical Jump test;” evaluates 17 jump-landing characteristics

b. Practical Application: Considered a reliable screening tool in the identification and prediction of non-contact ACL injuries through the evaluation of landing mechanics.3

3. Tuck Jump Assessment

a. Allows for evaluation of the ability of the hip, knee and ankle to absorb force during take-off and landing, specifically targeting the stretch-shortening cycle.

b. Practical Application: The ability to identify and predict lower extremity dysfunction such as high risk landing patterns, knee loading patterns and neuromuscular control within the hip, ankle and knee in conjunction with the trunk.

4. Weight Bearing Lunge Test

a. Correct landing technique can be visualized through ankle dorsiflexion range of motion

b. Practical application: can be a predictor of ankle injuries caused by poor force absorption within the ankle due to a lack of ROM.3

5. Star Excursion Test

a. Used to assess static and dynamic balance and neuromuscular control that involves single leg balance in 8 different directions. This will allow for the assessment of “ankle dorsiflexion, knee flexion, overall knee and hip range of motion, and proprioception.”3 Considered a reliable and predictive measure of lower extremity injuries within high school basketball players.4

b. Practical application: The ability to identify and/or predict chronic ankle instability, ACL deficiencies and patellofemoral pain.

Sleep and Recovery

Furthermore, a 2011 study by Mah, et al. out of the Stanford Sleep Disorder Clinic, investigated the effects of sleep extension on specific measures of athletic performance as well as the effect of sleep on reaction time, mood and daytime sleepiness in collegiate basketball players. It was noted an athlete who receives 79.7 additional minutes of sleep (~1.2 hours) per night, can see substantial improvements in performance in strenuous physical requirements, cardiorespiratory functioning and psychomotor tasks that include memory, learning ability and reaction time.5

Sleep extension will be predominantly critical within the collegiate and professional athletic population. This is due to the frequent travel across several time zones and into several different locations within the United States in a relatively short period of time. It was noted in this same study that collegiate basketball players travel on average of 2-3 times per month, with trip duration lasting anywhere from 3-5 days.5  This study reinforces the notion that at any level and within any sport, athletes require additional sleep in order to ensure optimal performance.

Through the use of a predictive model, the practical application of nutritional requirements, injury prevention and sleep extension can ensure optimal performance within the sport of basketball at any age level. Often times these aspects of athletic competition go unnoticed and only come to the forefront following an injury, burnout, nutrient deficiencies or an incident that is secondary to 1 of these occurrences. While there are specialists geared towards nutrition, sleep and injury prevention at the professional and collegiate levels, it will be important for high school athletic coaches and staff to understand the correlation between proper nutrition, proper sleep, injury prevention and overall performance and success within the sport in general.

Resources

1. Academy of Nutrition and Dietetics, (2016). “Fueling Basketball Players.” https://www.nutritioncaremanual.org/vault/2440/web/files/SNCM/Client%20Education%202014/Basketball%20Players-4-2014.pdf. Accessed: December 5, 2016.

2. McInnes, S. E., Carlson, J. S., Jones, C. J., & McKenna, M. J. (1995). The physiological load imposed on basketball players during competition. Journal of sports sciences, 13(5), 387-397.

3. Bird, S. P., & Markwick, W. J. (2016). Musculoskeletal Screening and Functional Testing: Considerations for Basketball Athletes. International Journal of Sports Physical Therapy, 11(5), 784.

4. Plisky, P. J., Rauh, M. J., Kaminski, T. W., & Underwood, F. B. (2006). Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. Journal of Orthopaedic & Sports Physical Therapy, 36(12), 911-919.

5. Mah, C. D., Mah, K. E., Kezirian, E. J., & Dement, W. C. (2011). The effects of sleep extension on the athletic performance of collegiate basketball players. Sleep, 34(7), 943-950.

About the Author

Desi Rotenberg, originally from Denver, Colorado, graduated with his bachelor's degree in 2012 from the University of Northern Colorado. He has been a BOC Certified Athletic Trainer since 2012 and earned his master's degree in Exercise Physiology from the University of Central Florida in 2014. He currently is a high school teacher, teaching anatomy/physiology and leadership development. Along with being a teacher, he wears many hats, such as basketball coach, curriculum developer and mentor. He has been a contributor to the BOC Blog since the summer of 2015.