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Clinical Bottom Line - Effective January 2022

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An addition has been made to the “BOC Approved Providers Standards” (Standards) that will strengthen continuing professional educational content and focus on the clinical bottom line. This addition is made for two reasons:

  1. To emphasize critical aspects of Evidence Based Practice (EBP), which is concluding as a stand-alone Category at the end of 2021.
  2. This addition is part of a concerted effort by the BOC to shift the focus of BOC Approved Providers to the educational quality, and away from administrative requirements that can deter the developmental focus when creating continuing education (CE)

To be clear, under the General Standard, “Development and Structure” and Standard 1 “Evidence”, this has been added:

“Essential Element C: Clinical Bottom Line: Provide a clinical bottom line or a summary of the evidence (three to four sentences) that identifies the clinical recommendation outlined in the learning objectives.

Commentary: A clinical recommendation or a summary of evidence that addresses one or more of the following aspects of patient care:

  • Financial implications
  • Equipment needs
  • Practicality of implementation
  • Applicability to various patient populations.”

The full Standards, beginning January 2022, can be viewed here.

BOC Approved Providers have expressed some confusion about the differences between Clinical Bottom Line and Practice Gap. To clarify, the Clinical Bottom Line covers recommendations to the clinician, while Practice Gap identifies the educational need.

These two components exist for two audiences:

  • Clinical Bottom Line: For Athletic Trainers (ATs) (i.e. what they should be doing in practice).
  • Practice Gap: For BOC Approved Providers during the development of continuing education (CE) (i.e. identifying the “gap” helps a provider align their curriculum)

Note: The BOC will provide instructional resources, steps, and how-to’s, in the weeks to come so that BOC Approved Providers are comfortable and confident with Clinical Bottom Line. Many providers are already incorporating aspects of Clinical Bottom Line into their CE. The addition to the Standards merely formalizes this.


To enable BOC Approved Providers the ability to effectively implement this concept, we are providing real-life examples that demonstrate three “good” examples that include the Clinical Bottom Line and Practice Gap, along with one “not adequate” example. Reminder, as with all Standards, you will need to develop each program to these specifications. However, you will only send this to the BOC during your Annual Reports (2022 and beyond).


“GOOD”: these were all accepted by EBP panel upon initial submission:

Managing the Risk of Osteoarthritis Following Anterior Cruciate Ligament Injury Starts with ATs

A. Educational-Professional Practice Gap:

Approximately, one in three individuals with an ACL injury will develop PTOA within 10 years of injury

Currently, 40% of ATs report being unaware of the condition of PTOA and 37% believe development of PTOA following acute injury is not a major health care concern.

Additionally, ATs tend to underestimate the prevalence of PTOA following ACLR and overestimate the ability of traditional reconstruction and rehabilitation to decrease the risk of PTOA in ACL injured individuals.

ATs need to understand the risk of PTOA following ACL injury and know the most effective methods for detecting early joint changes and managing PTOA risk following ACL injury.

B. Clinical Bottom Line:

Improving long-term outcomes following ACLR is paramount for young patients at greatest risk of injury. Many of the biomechanical and biochemical changes that cause PTOA begin at or shortly after the time of injury. Therefore, ATs need to know how they can work to improve long-term health of their patients immediately following injury. Understanding the risk of PTOA following ACL injury and know the most effective methods for detecting early joint changes and managing PTOA will improve patient outcomes and make ATs more effective in prevention of long-term disability following acute injury.


Why Subacromial Impingement Does Not Exist: An Evidence-Based Look at the Shoulder

A. Educational-Professional Practice Gap:

Shoulder pain accounts for nearly 4.5 million visits to physicians, with well over half being diagnosed with subacromial impingement at a medical cost exceeding one billion dollars a year in the United States (Paavola et al., 2018). As such, arthroscopic subacromial decompression surgery has seen a large rise in the past two decades, including a 91% increase in England of 52 per 100,000 people in 2016-17, New York seeing 102 per 100,000 in 2006, and Florida with 130 per 100,000 in 2007 (Jones et al., 2019). In cases of subacromial impingement, the patient typically presents with shoulder pain brought on by flexion, abduction, and/or external rotation, which has been reasoned to occur due to tears in the rotator cuff tendons, typically the supraspinatus (Barreto, Braman, Ludewig, Ribeiro, & Camargo, 2019; Dunn et al., 2014), secondary to rubbing or compression on the acromion (Beard et al., 2018; Kukkonen et al., 2018; Paavola et al., 2018). Therefore, surgery has been utilized to smooth the undersurface of the acromion, remove bone spurs, remove the bursa and other soft tissue, and release the coracoacromial ligament, to alleviate the proposed mechanical process of impingement (Beard et al., 2018; Kukkonen et al., 2015; Paavola et al., 2018). While conservative care is typically utilized, a recent Danish study consisting of over 3,000 patients with subacromial shoulder pain showed 16% of those who were in non-operative care had not performed any exercise (Clausen et al., 2021). Aside from surgery, it is also not uncommon to see patients receive passive modalities or be undertreated when it comes to shoulder pain, even though passive modalities such as dry needling (Pérez-Palomares et al., 2017), cupping (Charles et al., 2019), ultrasound, acupuncture, iontophoresis, laser therapy (Gebremariam et al., 2013) and kinesio tape (Kocyigit et al., 2016) have all been shown to be no more effective against sham treatments for shoulder pain. There appears to be a gap between practice and evidence, and this presentation can be a step in the right direction to open dialogue and implement evidence into practice.

B. Clinical Bottom Line:

There is high-quality evidence shown that subacromial decompression surgery, for those with atraumatic rotator cuff tears, does not outperform either diagnostic arthroscopy, exercise therapy, or active monitoring (Beard et al., 2018; Kukkonen et al., 2015; Paavola et al., 2018). Additionally, in examining traumatic rotator cuff tears, evidence shows that physiotherapy can lead to similar functional outcomes for tears less than 1.5-2cm (Ranebo et al., 2020; Moosmayer et al., 2019). It would stand to reason that the removal of the bone and other soft tissue is not justified in those suffering with subacromial shoulder pain. These findings should be discussed with patients, as it is often thought of as a quick fix to a pathoanatomical issue. An extensive and appropriate exercise therapy intervention should be exhausted before looking at surgical options.


Evidence-Based Treatment of the Cervical Spine: An Update

A. Educational-Professional Practice Gap:

Neck pain is the fourth highest disorder in terms of disability as measured by years of life lost. Typically, those with neck problems are less healthy than those without. Adults with low back and/or neck pain reported more comorbid conditions, exhibited more psychological distress (including serious mental illness), and engaged in more risky health behaviors than adults without either condition. It also has a financial impact, since these symptoms result in extended periods of sick leave from work and high utilization of health care services. As the prevalence of neck pain continues, interventions must be directed to recognize the more prevalent cervical pathologies seen in musculoskeletal practice and identify interventions for the cervical spine. The guidelines provide an evidence-based educational tool to assist the practitioner in delivering optimum efficacious treatment of and functional recovery from cervical spine disorders.

B. Clinical Bottom Line:

In patients with neck pain, there is little evidence to indicate traditional modalities can improve neck pain. ATs could still integrate these modalities into a treatment plan as they are relatively benign but should consider other therapeutic interventions to help improve the patient’s neck pain. Mobilization and/or manipulation when used in conjunction with exercise, improve neck pain. But when done alone, neither manipulation nor mobilization improve pain. ATs should consider integrating mobilization, manipulation, and exercise into the treatment plan of someone with neck pain, particularly those with whiplash associated disorder. Dry needling can improve myofascial trigger points. ATs who are trained in this technique can consider integrating this into the treatment plan for a patient with neck pain who has been found with trigger points on assessment.


“Not Adequate” example: (denied by EBP panel):

No Title

A. Educational-Professional Practice Gap:

The main barbell lifts (squat, bench press, deadlift, and overhead press) are a foundational pillar for any strength training program. While most strength coaches and ATs are taught how to coach these movements, very few are skilled in the ability to modify them for patients with shoulder, back, knee, or hip pain. While the evidence shows that modification of range of motion, external load, tempo, and exercise selection can have a profound effect on modulating the pain experience, there is clearly a gap on what parameters to prioritize and in what order. (Gap is not identified within the content provided. Explain the overall educational need for this program and identify one specific practice gap. What is the gap between available evidence and current clinical practice?)

B. Clinical Bottom Line:

Helping a client overcome musculoskeletal pain during strength training involves more than just adding more foam rolling, stretching, or modalities. It requires a structured approach of knowing how to modify the parameters of the lift itself and the programming prescription. (No Clinical Bottom Line provided. Content provided does not answer the clinical question. Content should reflect the evidence. Content should answer the clinical question and be pulled from the references. Ask: What do the references say that answers your clinical question? Ask: What is your final take home point and recommendation? What should ATs be doing based on the preliminary conclusions? What barriers may they face in implementing your recommendation based on the literature?)


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