BOC Domain 1: Risk Reduction, Wellness & Health Literacy Study Guide

Core Definitions and Overview of Risk Reduction

  • Risk Reduction: This domain encompasses all activities intended to prevent, ameliorate, treat, and/or reduce disability and death related to injuries.

  • The Risk Management Cycle: This is a continuous process of maintaining safety through four primary stages:

    1. Identify risks: Pinpointing potential hazards or predispositions.

    2. Implement interventions: Executing strategies to mitigate those risks.

    3. Review results: Assessing the effectiveness of the implemented plans.

    4. Revise plan: Updating protocols based on assessment data.

  • Key Conceptual Pairs in Risk Assessment:

    • Intrinsic Factors: Variables internal to the patient, such as medical history, demographics (age, gender), structural, mental and psychological aspects

    • Extrinsic Factors: Variables external to the patient, including environmental conditions, social factors, and sport-specific equipment or requirements.

    • Modifiable Risk Factors: Factors that can be altered through intervention, such as diet and exercise habits.

    • Static Risk Factors: Fixed variables that cannot be changed, such as age, gender, and ethnicity.

  • Educational Sub-Themes:

    1. Risk Reduction: Identifying and mitigating injury or illness risk.

    2. Wellness Promotion: A holistic approach encompassing physical, social, intellectual, emotional, mental, and spiritual health.

    3. Health Literacy: The process of educating and empowering patients to make informed, autonomous health decisions.

  • Professional Scope: Athletic Trainers (ATs) serve as community and public health advocates rather than just individual patient providers. An example includes traumatic brain injury (TBI) education initiatives that reach schools, parents, and legislators.

Task 0101: Identify Risk via Screening, History, and Surveillance

  • Pre-Participation Exam (PPE) Principles:

    • Medical History: This is considered the cornerstone of the PPE. It identifies approximately 75%75\% of medical problems. Specific focus is required for previous injuries or surgical procedures.

    • General Screening: Effective for early detection and aimed at improving the likelihood of favorable health outcomes.

  • Cardiovascular Screening:

    • Auscultation: Must be performed in both standing and supine positions and should include the Valsalva maneuver.

    • Abnormal Findings: A systolic murmur of grade 3−63-6 or louder, or any diastolic murmur, requires further investigation.

    • Pulses: Radial and femoral pulses must be palpated in both extremities to check for symmetry.

    • Youth Mortality: The leading cause of death in youth athletes is hypertrophic cardiomyopathy, followed by congenital coronary artery anomalies. Other causes include myocarditis, Marfan syndrome, valvular heart disease, dilated cardiomyopathy, premature coronary artery disease, and myocardial bridge.

    • Cardiac Auscultation Points (Mnemonic: All People Eat Tasty Muffins):

      1. Aortic: Right upper sternal border.

      2. Pulmonic: Left upper sternal border.

      3. Erb's Point: Located between the pulmonic and tricuspid areas.

      4. Tricuspid: Left lower sternal border.

      5. Mitral (Apex): Fifth intercostal space, mid-clavicular line.

    • AHA 12-Element Cardiovascular Screening:

      • Personal History: Chest pain or dyspnea during exertion, syncope, history of heart murmur, and elevated blood pressure.

      • Family History: Premature death (heart disease in relatives under 5050 years old), disability from heart disease, and specific conditions like hypertrophic cardiomyopathy, long QT syndrome, or Marfan syndrome.

      • Physical Exam: Assessment for heart murmurs, femoral pulses, Marfan stigmata, and blood pressure (taken sitting in both arms).

  • Neurologic and Pulmonary Screening:

    • Neurologic History: Screening is required if the patient has a history of concussions, seizures, cervical spine stenosis, or spinal cord injury.

    • Head/Neck Exam: Includes inspection of the head, eye gaze/vision, nose (septum symmetry/turbinates), teeth, and posterior oropharynx. Palpation of the thyroid and cervical lymph nodes is necessary.

    • Concussion and Spine Guidelines:

      • Neurapraxia (Burner/Stinger): Athlete is cleared to play unless currently symptomatic.

      • Spear Tackler's Spine: A developmental stenosis of the cervical canal, which acts as a contraindication for participation.

      • Impact History: 2−32-3 concussions with Loss of Consciousness (LOC), or 1−21-2 concussions with LOC, require further medical evaluation. Three or more concussions, or cases with delayed recovery, may result in disqualification.

    • Pulmonary Exam: Must include both inspection and auscultation of the chest.

  • General Physical Examination Details:

    • Abdominal: Patient must be supine. AT must perform auscultation for bowel sounds and palpate all four quadrants to check spleen and liver size.

    • Vital Signs: Normal Blood Pressure is defined as 120/80 mmHg120/80\,mmHg.

    • Visual Acuity: Measured with a Snellen chart. Testing includes monocular and binocular vision, with and without corrective lenses. Baseball is cited as the leading cause of eye injuries.

    • Orthopedic Screen: The knee is the most commonly affected joint. The 9090-second orthopedic screen is 51%51\% sensitive and 97%97\% specific. An accurate history alone can detect over 90%90\% of musculoskeletal injuries. Evaluation should occur 4−64-6 weeks prior to the season.

  • Laboratory and Diagnostic Screening:

    • Routine labs (CBC, urinalysis, etc.) are NOT supported for all athletes.

    • Anemia: If suspected or in history, hemoglobin and ferritin levels must be measured.

    • Diabetes: Type 1 or 2 patients require individualized plans and evaluation for retinopathy, nephropathy, and neuropathy.

    • Sickle Cell Trait (SCT): Athletes at high risk due to heritage must be confirmed via exam. Those with SCT require monitoring for heat and dehydration concerns.

Task 0102: Implement Evidence-Based Risk Reduction Plans

  • ACL Injury Prevention (NATA Position Statement):

    • Mechanism: Typically noncontact or indirect contact paired with uncontrolled lower extremity biomechanics.

    • Multicomponent Training (Mnemonic: SPABF): Programs must include at least 3 of these 5 components: Strength, Plyometrics, Agility, Balance, and Flexibility.

    • Efficacy: Reduces noncontact knee injuries by 51−62%51-62\%, and up to 75%75\% in high-risk females.

    • Dosage: 2−32-3 times per week, performed during both preseason and in-season every year the athlete participates.

    • Guidelines: Supervised sessions, provide verbal feedback, and include at least 3 multicomponent exercises at progressive intensities.

  • Pediatric Overuse Injury Prevention:

    • Prevalence: Approximately 50%50\% of pediatric patients in clinics present with chronic injuries.

    • Growth-Related Conditions: Osgood-Schlatter, Sever's disease, Little League Elbow, Shoulder Instability, and Sinding-Larsen Johansson Syndrome.

    • Anatomical Risks: Leg length discrepancies, genu varum/valgum, and pelvic rotation. Hypermobility is screened using the Beighton and Horan index (scored out of 99 points).

    • Volume Guidelines:

      • Limit vigorous exercise to 16−2016-20 hours per week.

      • Increase intensity, load, or distance by no more than 10%10\% weekly.

      • Athletes should participate in only one team per sport per season and avoid year-round play of a single overhead sport.

      • Take 2−32-3 non-consecutive months off per year from a single sport.

    • Pitching Limits:

      • Ages 9−149-14: Max 7575 pitches per game; 600600 per season; 2,000−3,0002,000-3,000 per year.

      • Ages 15−1815-18: Max 9090 pitches per game; limit to two games per week.

  • Reducing Head-First Contact in Football:

    • Definitions: Head-first contact (HFC) is the intentional use of the head-down position. Spearing is the deliberate use of head-down contact.

    • Strategies: Documented education for coaches/officials/parents on HFC dangers, regulating full-contact practice time, and enforcing penalties for targeting. Helmet add-ons may overstate prevention benefits; technology like impact monitoring should be secondary to skill development.

  • Evidence-Based Practice (EBP) Five-Step Process:

    1. Define Clinical Question: Components include Patient population, Intervention, Comparison group, and Outcome (PICO).

    2. Research Evidence: Use databases to retrieve relevant articles.

    3. Critically Appraise: Requires judgment on study quality and statistical application (e.g., Numbers Needed to Treat, Likelihood Ratios, Confidence Intervals).

    4. Apply Evidence: Clinician makes the final decision based on patient preference, cost, and expertise.

    5. Evaluate Performance: Assess the usefulness of the process.

Sudden Death Prevention in Collegiate Conditioning

  • Top Three Causes of Death:

    1. Exercise-related death associated with Sickle Cell Trait.

    2. Exertional Heat Stroke.

    3. Cardiac Conditions.

  • Key Recommendations:

    • Acclimatization: The first 7−107-10 days are transitional with a work-to-rest ratio of 1:41:4.

    • Punishment: No exercise should be used as a punishment under any circumstance.

    • Medical Coverage: S&C coaches must be present always. ATs or physicians must be present for high-risk activities (sprinting, mat drills).

    • EAP: Venue-specific; sessions cannot occur if the supervisor is unfamiliar with the EAP.

    • Seizures: If a collapsed athlete has seizures, they must be treated as having sudden cardiac arrest until proven otherwise.

Task 0103 & 0104: Health Literacy and Wellness Promotion

  • Anabolic-Androgenic Steroids (AAS) Abuse:

    • Class: Schedule III controlled substances.

    • Therapeutic Use: Hypogonadism, certain anemias, and bone health preservation.

    • Abuse Effects:

      • Psychiatric: Mania, irritability, depression upon withdrawal.

      • Male: Decreased endogenous testosterone, hypogonadism, ED, gynecomastia.

      • Female: Virilization (deep voice, clitoral hypertrophy, hirsutism), menstrual dysfunction (often permanent).

    • Skeletally Immature: Causes premature epiphyseal closure.

  • Dietary Supplements:

    • Dietary changes should be the first intervention before supplements.

    • Supplements do NOT require third-party verification; ATs must warn athletes regarding potential contamination or banned substances.

  • Dimensions of Wellness: Social, Emotional, Spiritual, Environmental, Occupational, Intellectual, and Physical.

  • Mindfulness and Meditation: Training in present-moment awareness can reduce serum cortisol, heart rate, and blood pressure, while improving immune response and emotional regulation.

  • Wellness Program Development:

    1. Identify a need.

    2. Set clear, measurable goals.

    3. Develop the intervention plan (logistics/curriculum).

    4. Implement (emphasize adaptability).

    5. Evaluate results.

  • Populations and Exercise Recommendations:

    • Children: 6060 minutes of moderate/vigorous activity daily.

    • Adults: 3030 minutes/day aerobic activity, ≥5≥ 5 days/week.

    • Older Adults: Same as adults plus balance exercises; use large-print handouts.

Management of Type 1 Diabetes

  • Care Plan Components: Glucose monitoring, insulin dosages, correction doses, glucagon instructions, and emergency contacts.

  • Insulin Administration: Must be subcutaneous; AVOID intramuscular injection as muscle contraction accelerates absorption.

    • Heat (Saunas, Hot Packs): Increases absorption.

    • Cold (Ice, Cold Whirlpools): Decreases absorption.

  • High-Yield Values:

    • Assess HbA1c every 3−43-4 months.

    • Renal glucose threshold = 180 mg/dL180\,mg/dL (10 mmol/L10\,mmol/L).

    • Extreme ambient temperatures (<36\,^{\circ}F or >86\,^{\circ}F) reduce insulin action.

    • Replace infusion sets every 2−32-3 days.

Task 0105: Environmental Safety

  • Lightning Safety:

    • Safe Locations: Fully enclosed buildings with wiring/plumbing or fully enclosed metal vehicles.

    • Unsafe Locations: Picnic shelters, dugouts, tents, towers, or near bodies of water.

    • Flash-to-Bang & 30-Minute Rule: Suspend activities when a storm is within 55 nautical miles (66 miles / 9.26 km9.26\,km). Activities may resume 3030 minutes after the last lightning strike or sound of thunder.

    • Death Mechanisms: Ground current (50−55%50-55\%), Side flash (30−35%30-35\%), Upward leader (10−15%10-15\%), Contact/Direct (3−5%3-5\% each).

  • Cold Injuries:

    • Hypothermia: Mild (95−98.6 ∘F95-98.6\,^{\circ}F); Moderate/Severe (<95\,^{\circ}F). Stop shivering indicates worsening severity. Treat by heating the trunk only to avoid "afterdrop."

    • Frostbite: Rewarm in water at 98−104 ∘F98-104\,^{\circ}F. Do NOT rub or use dry heat.

    • Chilblain (Pernio): Inflammatory response to cold-wet conditions after 1−51-5 hours.

    • Trench Foot: Nerve/vessel damage after 1212 hours to 44 days of wet exposure.

    • Heat Loss Mechanisms: Radiation (exposed skin), Convection (wind), Conduction (direct contact), Evaporation (sweat/breathing).

Sport Epidemiology

  • Definitions:

    • Prevalence: Total number of current cases.

    • Incidence: Frequency count of new cases in a specific timeframe.

    • Incidence Rate Formula: Incidence Rate=Frequency of EventsParticipants×Exposures\text{Incidence Rate} = \frac{\text{Frequency of Events}}{\text{Participants} \times \text{Exposures}}.

    • Relative Risk: Used in cohort studies to compare injury rates between groups.

    • Odds Ratio: Used in retrospective case-control studies.

  • Validity:

    • External Validity: Extent to which findings generalize to the general population.

    • Internal Validity: Extent to which cause-and-effect can be established (affected by bias and blinding).

  • Injury Severity: Time loss injuries are defined as those restricting participation for at least 2424 hours.