Off the field evaluation

What is considered an essential skill for athletic trainers?

Evaluation of injuries

What are the four distinct evaluations?

1. Preparticipation (prior to start of season)

2. On-the-field assessment

3. Off-the-field assessment

4. Progress evaluation

What are the basic knowledge requirements of an athletic trainer?

Must have general knowledge of anatomy and biomechanics as well as hazards associated with particular sports

For basic knowledge requirements, what do ATs need to know regarding anatomy?

Surface anatomy

• understanding topographical anatomy

• Key surface landmarks provide examiner with indications of normal or injury structures

For basic knowledge requirements, what should ATs know about body planes and anatomical directions?

Used as points of reference

For basic knowledge requirements, what should ATs know about musculoskeletal anatomy?

• requires knowledge of structural and functional anatomy

• Encompasses bony and skeletal musculature

• Knowledge of neural anatomy is useful relative to motion, sensation, and pain

For basic knowledge requirements, what should ATs know about standard terminology?

• used to describe precise location of structures and orientation

Regarding basic information, what should an AT know about biomechanics?

• foundation for assessment

• Application of mechanical forces, which may stem from within or outside the body, to living organisms

What is pathomechanics?

Mechanical forces applied to the body due to structural deviation, leading to faulty alignment (resulting in overuse injuries)

How does having more knowledge of activity help AT’s?

Allows for more inherent knowledge of injuries associated with activity

• results in more accurate clinical diagnosis and rehab design with appropriate functional aspects incorporated for athlete’s return to activity

What should ATs be mot aware of when applying these concepts in any activity?

• proper biomechanics and kinesiology

What would happen if there is a violation of the principles when applying them to any activity?

Violation of principles can lead to repetitive overuse trauma

What is etiology?

Cause of injury or disease

What is mechanism?

Mechanical description of cause

What is the difference between mechanism and etiology?

Etiology doesnt have to be a mechanism; could just hurt to hurt; covering the big picture

Mechanism is considered the MOI (mechanism of injury); an obvious thing that caused the injury

What is pathology?

Structural and functional changes associated with injury process

What are symptoms?

Perceptible changes in body or function that indicate injury or illness (subjective)

How can ATs figure out how much pain someone is in?

Using a scale for the patient to rate their pain and signs such as a limp, wincing, face, face contortion

What is a sign?

Objective, definitive, and obvious indicator of specific condition. Examples of this would be decreased ROM, decreased strength, obvious deformity

What is degree?

Grading for injury/condition

Can be moderate or severe

Can be 1, 2, or 3

Can be a strength scale of 1-5

What is diagnosis?

Denotes name of specific condition

What is differential diagnosis?

Systematic method of diagnosing a disorder

What does a differential diagnosis do?

• refers to a list of possible causes

• Prioritizing of possibilities

• Also referred to as a hypothesis or working diagnosis

What is prognosis?

Prediction of the course of the condition

What is sequela?

Condition following and resulting from disease or injury (pneumonia resulting from flu, infection caused by a blister)

What is syndrome?

Group of symptoms and signs that together indicate a particular injury or disease (patellar femoral syndrome, medial tibial stress syndrome)

When would ATs be able to get a detailed evaluation of an athlete?

On sideline or in clinical setting

True or false: an evaluation of an athlete should be performed as soon as possible on matter the injury

False. Doesn’t have to be right away UNLESS it is an emergent situation

How do we divide an evaluation into 4 components?

HOPS

What does HOPS stand for?

H. History

O. Observation

P. Palpation

S. Special tests

Does HOPS need to be performed in this order when doing an evaluation?

No, doesn’t necessarily need to be in this order

What does history include in HOPS?

• Obtain subjective information relative to how injury occurred, extent of injury, and MOI

• Inquire about previous injuries/illnesses that may be involved as well as past treatments

What kind of questions would an AT ask for a history?

• What is the problem?

• How and when did it occur?

• Did you hear or feel something?

• Which direction did the joint move?

• Characterize the pain (not only intensity, but describing the pain)

What are some questions to consider when making an observation of the patient?

• Are there any asymmetries, postural malalignments, or deformities?

• How does the athlete move? Is there a limp?

• Are movements abnormal?

• What is the body position?

• Does the patient’s facial expressions indicate anything?

• Are there any abnormal sounds?

• Is there any swelling, heat, redness, inflammation, or discoloration?

What exactly are ATs palpating?

Bony and soft tissue

What are special tests?

• Used to detect specific pathologies

• Compare inert and contractile tissues and their integrity

• Assessment should be made bilaterally

What are AT’s testing when doing special tests on ROM?

• Active

• Passive

• Normal versus abnormal endpoints

• Goniometric measures versus digital inclinometers

• Report in angles or loss of ROM

• Resistive MMT (manual muscle test)

How do you describe resistive ROM?

Resisting through ROM (concentric and eccentric)

How do you describe restrictive ROM?

Holding isometric

How does the grading out of 5 MMT scale work?

5/5 is equal ROM, 3/5 is able to move against gravity but not against resistance

How do we take gravity out of the picture for someone that scores a 3/5 on the MMT?

Have the patient lay on their side

What areas can be assessed for special testing of neurological and circulation assessments?

Brain

• cerebral, cranial nerve, and cerebellar function

Sensory and motor function

• dermatome - area of skin innervated by a single nerve

• Myotome - muscle or group of muscles innervated by a specific motor nerve

Reflex testing - involuntary response to a stimulus

• deep tendon: caused by stimulation of stretch reflex

• Superficial: stimulation of skin that causes reflexive muscle contraction

• Pathological: superficial reflex indicative of upper motor neuron lesion

  • Babinski’s sign, chaddock’s, Oppenheimer’s, and Gordon’s

Referred pain

What are special tests used for?

• Testing joint stability

• Testing functional performance

  • Used to determine athlete’s readiness to participate or continue participation

• Other tests

  • Postural

  • Gait

  • Anthropometric

What is the use of a diagnosis?

• Use of clinical or scientific methods to establish cause and nature of patient’s illness or injury and subsequent functional impairment due to the pathology

• Forms basis for patient care

Who is credible to make a medical diagnosis?

A physician

What is a medical diagnosis?

The ultimate determination of patient’s physical condition

Why might the medical diagnosis might not always be the “correct” determination?

The physician only sees the athlete in a snapshot and usually on the athlete’s best day

Clinical diagnosis identifies what aspects associated with pathology?

Clinical diagnosis identifies pathology and limitations/disabilities

What does the SBAR reporting method stand for?

S. Situation

B. Background

A. Assessment

R. Recommendation

What should be considered in the S portion of the SBAR reporting method?

Situation

• identify yourself and location

• Identify patient (name, age, sex)

• State diagnosis (suspected or definitive); or what you think is going on

• State reason for transfer or handover (e.g. unavailable diagnostics or therapeutics)

What should be considered in the B portion of the SBAR reporting method?

Background

• Relevant past medical and surgical history

• Recent changes in status (level of consciousness)

• Recent vital signs

• Management or interventions provided

• Relevant psychosocial factors (panic attack, no insurance, no transportation, no family support)

What should be considered in the A portion of the SBAR reporting method?

Assessment

• state the diagnoses or conditions (if diagnostic uncertainty); if haven’t already done so

• State severity of illness (stable or critical)

• State patient trajectory (worsening or improving)

• Report response to interventions provided

What should be considered in the R portion of the SBAR reporting method?

Recommendation

• State your recommendations and concerns (e.g. transfer for specialist consult or frequent monitoring)

• State timeline for recommendations (e.g. transfer or intervention needed in next hour)

• State contingency plans (e.g. if patient transfer is delayed, then I will…)

How do athletic trainers document injury evaluation information?

• completing accurate documentation is critical

• Clear, concise, and accurate records are necessary for third-party billing

• While the process is cumbersome and time-consuming, athletic trainers must be proficient and able to generate accurate records based on the evaluation performed

Why is documenting not the strong point for AT?

This is because athletic trainers are not billing insurance so the documentations are not as specific

What are some important aspects of SOAP notes?

• Record keeping can be performed systematically

• Outline subjective and objective findings as well as immediate and future plans

• Allow for subjective and objective information, assessment and development of a plan to be implemented

What does the acronym SOAP notes stand for?

S. Subjective

O. Objective

A. Assessment

P. Plan

What is the difference between HOPS and SOAP?

HOPS is for evaluation, SOAP is for documentation

What does the S portion of SOAP notes consider?

Subjective

• Statements made by patient: primarily history information and patient’s perceptions including severity, pain, and MOI

This portion lines up with the History in HOPS

What does the O portion of SOAP notes consider?

Objective

• Findings based on athletic trainer’s evaluation

Observation, palpation, and special tests from HOPS lines up with this section

What does the A portion of SOAP notes consider?

Assessment

• Athletic trainer’s professional opinion regarding impression of injury

• May include suspected site of injury and structures involved along with rating severity

What does the P portion of SOAP notes consider?

Plan

• Includes first-aid treatment, referral information, goals (short- and long-term), and examiner’s plan for treatment

What are some ways athletic trainers can use the SBAR to communicate for hand-off?

For immediate emergency, a phone call would be necessary

For a non-immediate emergency, and email would suffice

• This is based on the physician’s communication preference

How does a progress SOAP note differ from an evaluation SOAP note?

S - How are the since last visit (not going into full medical history)

O - Changes noted since last visit (going into physical assessment; swelling, bruising, doing too much)

A - How do you feel their progress is going since last visit

P - Updates to plan since last visit (adjusting as needed)

What are some additional diagnostic tests that physicians have access to?

• Plain film radiographs (X-ray)

• Arthroscopy

• Positron emission tomography (PET)

• Computed tomography (CT scan)

• Bone scan

• DEXA scan

• Magnetic resonance imaging (MRI)

• Ultrasonography

• Arteriogram/Venogram

• Echocardiography

• Electrocardiography (ECG)

• Electromyography (EMG)

• Synovial fluid analysis

• Blood testing

How can plain film radiographs (X-ray) be used for diagnostic testing?

• Used to determine presence of fractures, bone abnormalities, and dislocations

• Can be used to rule out diseases (neoplasm)

• Occasionally used to assess soft-tissue factors

How can arthroscopy be used for diagnostic testing?

• Invasive technique that uses a fiber-optic arthroscope to assess joint integrity and damage

• Can also be used to perform surgical procedures

• Go in surgically to use a camera to look around

• Can also indicate that there is surgery needed so they can look to see what else is going on

What are some other uses for ultrasonography?

• MSK US

• Doppler

How is pulse oximetry used?

• Used for assessing breathing by indirectly measuring the oxygen saturation of arterial blood

Where is the pulse oximetry placed?

• Device is placed directly over a spot where there is a strong pulse, such as the tip of the finger

How does pulse oximetry work?

• Combines two beams of light with different wavelengths

• Ratio of red/infrared light that has passed through the finger is calculated

How is pulse oximetry used in hospitals?

Used in hospitals to monitor oxygen saturation and pulse rate in patients that have some type of respiratory difficulty

How can pulse oximetry help athletes?

• Can help athletes build awareness of their breathing rates and technique, which together can help maintain oxygen saturation levels above 95 percent during high-intensity training

How is urinalysis used?

• Used to assess specific gravity, pH, presence of ketones, hemoglobin, proteins, nitrates, red and white blood cells, bacteria, electrolytes, hormones, and drug levels

How does urinalysis work?

• Using dip-and-read test strips provide fast, accurate results for a number of things including, specific gravity, WBCs, nitrate, pH, protein, glucose, ketones, bilirubin, and blood

What do the strips for a urinalysis look like and how are they used?

• Large area on strip is impregnated with reagents that change color when dipped in urine

• Strips are then compared to color comparison charts

What can a urinalysis test also be used for regarding athletes?

• Can also test if an athlete is on drugs or has diabetes

What is a glucometer?

• Handheld device used to determine the approximate concentration of glucose in the blood

What is a glucometer used for?

• Commonly used by patients who have hypoglycemia or diabetes

• Provides immediate feedback on levels of blood glucose

What is a normal blood glucose level when taking a reading from a glucometer?

A normal blood glucose level is less than 100 mg/dl (when fasting and less than 140 mg/dl 2 hours after eating)

How often should a patient test their blood glucose with a glucometer?

• Patients usually repeat this test several times per day

How is a peak flow meter used?

• Used to assess peak expiratory flow rate or the ability to quickly expire air from the lungs

Who is a peak flow meter generally used for?

• Used in patients who have a condition that obstructs airflow through the bronchii

What is the measurement for peak flow meter?

Peak expiratory flow is measured 1/min

Is there a degree of variability when using a peak flow meter?

Yes, there is a high degree of variability in peak flow measurement

What is necessary for reassessment when using a peak flow meter?

• Requires readings to be taken using the same peak flow meter, by the same clinician

When would an ergonomic risk assessment (ERA) be used?

• If working in a clinic or industrial setting, an athletic trainer may be called upon to perform this assessment

What is the ergonomic risk assessment (ERA) used for?

• Involves evaluation of factors within a job that increase risk of someone suffering a workplace-related ergonomic injury

  • Assesses aspects and movements that could be modified to reduce risk

Why is injury prevention and intervention through ergonomic control measures and injury statistics important?

• Improve efficiency (time and resources)

• Reduce time lost due to injury

• Reduce decreases in productivity

• Consider how changes could impact physical requirements and demands