The phrase athletic training implies that athletic trainers (ATs) train athletes to improve baseline performance. This title, and the euphemism “trainer,” create ambiguity regarding the actual knowledge, roles, and functions of the AT. ATs are multiskilled health care professionals who deliver services in cooperation with and under the direction of physicians to provide optimal care to patients in athletics, work, and life. The AT’s education and scope of practice encompass the areas of injury prevention and risk management, clinical examination and diagnosis, emergency care, therapeutic intervention (i.e., therapeutic modalities and rehabilitation), and health care administration ( Box 35-1 ).
Prevention and health promotion
Clinical examination and diagnosis
Acute care of injuries and illnesses
Psychosocial strategies and referral
Health care administration
Professional development and responsibility
Although they are most visible when working with high school, collegiate, and professional sports teams, ATs are employed in a variety of settings including clinics, physicians’ offices, hospitals, performing arts, and the military. Athletic trainers tend to work with a highly motivated, physically active population.
ATs can bill for third-party reimbursement in many settings. However, an advantage of most ATs employed by high schools and intercollegiate athletics is the provision of capitated health care services. In the case of high schools located in poor and medically underserved areas, the presence of an AT is a cost-effective approach to the health care of these students.
The knowledge and skills used by ATs are found in many other health care professions; however, the specific collection of skills of the AT is unique. Because ATs have their roots in athletics, with a sense of urgency to return patients to competition, ATs have developed a philosophy of aggressive intervention that benefits both “athletic” and “nonathletic” patients. The AT skill set is applied according to the AT philosophy of an aggressive yet safe return to activity. The role of AT in the overall health care community is often misunderstood, in part because of the overlap of skills with other professions, the lack of understanding of the AT philosophy of care, and the misleading name, “athletic training” (K. K. Knight, C. Starkey, and D. Fandel, unpublished manuscript, 2009).
Brief History of Athletic Training
The origin of athletic training can be traced back to the ancient Olympics, when paleotribes assisted athletes with their health care. In the United States, the roots of athletic training emerged in the early 1900s, when individuals began to assist physicians and coaches in caring for the medical needs of athletes. In 1950 the National Athletic Trainers’ Association was formed to help guide the practice of athletic training, which at the time was primarily limited to collegiate and professional teams.
Similar to physical therapy and occupational therapy, the first athletic training academic programs were founded in physical education. During the past 20 years athletic training has progressed through an academic major to a formal undergraduate or graduate academic degree. The focus of classroom and clinical education was once singularly focused on athletes. Other factors that have shaped the evolution of ATs are advancements in medicine and health care that have extended the age of people participating in athletics and other forms of strenuous physical activity. Improved health care has also decreased the number of conditions that can disqualify a person from competitive athletics. In response, ATs have increased their knowledge of the unique challenges faced by people who have underlying medical or physical limitations.
Although the “traditional” athletic population remains a central theme of education, ATs have evolved to develop expertise in the care of a broad segment of the physically active population. This expanded educational base has changed the employment patterns of ATs, extending well beyond high school, collegiate, and professional team sports medicine venues.
In just over half a century, ATs have evolved from the locker room to become a health care provider recognized by the American Medical Association. Contemporary ATs incorporate current evidence and best practices to treat a physically active patient base to ensure physical readiness to return to their desired level of function after injury ( Box 35-2 ).
The emergence of academic degree programs has resulted in the development of scholars who contribute to the sports medicine knowledge base. Athletic trainers are at the forefront of research regarding the prevention and diagnosis of conditions affecting athletes and others engaged in strenuous physical activity. Athletic training researchers were among the first to question the long-term consequences of athletic-related concussions and to question the efficacy of the clinical examination techniques used to identify these conditions. Other researchers have added to the evidence base for orthopaedic diagnostic techniques, therapeutic interventions, and immediate care of musculoskeletal injuries.
Based on a strong, multidisciplinary evidence base, The National Athletic Trainers’ Association has developed position statements regarding topics such as prevention of heat illness and sudden death, the management of concussions, athletes with cervical spine injuries, and athletes with type 1 diabetes, disordered eating, and asthma. Athletic trainers also have worked with other medical organizations on consensus statements regarding heat acclimation, the prehospital care of athletes with a spine injury, and athletes with sickle cell trait. For more information, see www.nata.org/membership/membership-benefits/athletic-training-publications .
Education and Regulation
ATs must graduate from a professional bachelor’s or master’s degree program accredited by the Commission on Accreditation of Athletic Training Education. The educational content of an AT program is defined by the Athletic Training Education Competencies, whereas the Role Delineation Study defines base entry-level practice. Box 35-1 presents the content area required in the professional preparation of ATs. More than 70% of ATs possess advanced degrees, including accredited postprofessional programs. Many ATs are dual credentialed, most often in conjunction with the fields of physical therapy, physician’s assistant, and/or strength and conditioning/performance enhancement.
Graduation from a professional program is a requisite to sit for the Board of Certification, Inc. (BOC) examination as an entry-level athletic trainer. The “ATC” designation indicates that a person has passed the BOC examination, but the actual practice credential, typically “LAT” or “AT,” is granted by the state.
The BOC examination serves as the common examination for the 48 states that currently regulate the practice of athletic training ( Table 35-1 ). Licensure is required in 39 states, whereas 4 states have certification, 4 have registration, and 1 has exemption. Only two states, California and Alaska, do not regulate AT practice.
|Licensure||Licensure restricts practice to persons who have meet the licensing board’s requirements. The practice act describes the athletic trainer’s scope of practice. Unlicensed persons are prohibited from practicing athletic training.|
|Certification||Similar to state licensure, persons must meet minimum educational requirements and pass a state examination (the Board of Certification, Inc., examination is often recognized for this purpose). However, state certification only provides title protection; it does not limit uncertified persons from practicing.|
|Registration||Registration may or may not have educational or examination requirements. By registering with the state, title protection is granted.|
|Exemption||Exemption excludes a person from the standards of other licensed professions (e.g., physician assistant, physical therapy, or nursing).|
Athletic Trainer Scope of Practice
A unique aspect of athletic training is that, in many instances, ATs follow their patient throughout the continuum of care, from preinjury (prevention) through the diagnostic and intervention stages to the return-to-activity decision. This section presents an overview of the AT’s role and function. The actual scope of practice within each state may differ from the description provided in this section. Physicians who direct AT practice should consult the state’s AT practice act for applicable regulations. Specific scope of practice questions should be directed to the state practice board.
These domains are tied together through the use of evidence-based practice. Many ATs are world-class scholars who have emerged as leaders in the diagnosis and management of concussion, heat illness, cervical spine trauma, and therapeutic interventions. ATs also consume research produced by physicians, physical therapists, and other professions who address the needs of persons who are physically active.
Injury Prevention and Health Promotion
The basis of injury prevention and risk management is ensuring the individual’s physical readiness to participate in strenuous activity, ensuring a safe playing/work environment, and developing and implementing emergency action plans (EAPs). Another form of injury prevention is ensuring the safe return to activity after an injury has been sustained.
Through use of a written health questionnaire and physical examination, the preparticipation physical examination identifies a person’s physical readiness to engage in selected activities. During a routine preparticipation physical examination, the following aspects of the patient’s general health should be examined:
Personal medical history
Family medical history
Abdominal and gastrointestinal
Baseline concussion tests
Baseline strength and range of motion
ATs work with physicians, administrators, and attorneys to develop EAPs. The EAP describes the standard of care and the procedures to follow in the event of foreseeable emergent situations (e.g., cardiac arrest, cervical spine injury, and heat illness), inclement weather (e.g., heat or lightning), or other possible venue-specific contingencies.
Patient education is the most encompassing method of injury prevention and risk management. When working with high school–aged patients (or younger), patient education also includes the athlete’s parent(s) or legal guardian. The AT is often the primary source for information regarding concussions, heat illness, sickle cell trait, and nutritional and hydration needs. This role also extends to bridging the gap between the patient, the patient’s family, and the physician regarding the potential outcomes of surgery or other interventions for an injury or illness (and, likewise, the possible consequences of not following the physician’s advice).
Clinical Examination and Diagnosis
ATs are in a unique position because they often perform the first examination of an injury, usually minutes after its onset. The immediate (on-field) examination first rules out life- or limb-threatening conditions, fractures, or dislocations. The on-field examination ultimately culminates in the decision about how to remove the athlete from the playing field (e.g., assisted or unassisted) and whether the condition requires that the athlete be immediately transported to a hospital for emergency care.
The clinical examination relies on obtaining a medical history and performing a functional assessment, inspection, palpation, and assessment of joint and muscle function to form a differential diagnosis. Joint-specific stress tests, selective tissue tests, and, when applicable, neurologic and vascular tests are used to rule in or rule out various pathologies, resulting in a working clinical diagnosis.
The AT triages the athlete and determines if a referral is indicated. Once a diagnosis has been established, the AT may consult with the physician to determine the appropriate course of care ( Fig. 35-1 ).