Perceptions of Approved Clinical Instructors: Barriers in the Implementation of Evidence-Based Practice

Context: As evidence-based practice (EBP) becomes prevalent in athletic training education, the barriers that Approved Clinical Instructors (ACIs) experience in implementing it with students need to be understood. Objective: To investigate barriers ACIs face when implementing EBP concepts in clinical practice and in teaching EBP to professional athletic training students and to investigate the educational emphases to improve the barriers. Design: Qualitative study. Setting: Telephone interviews. Patients or Other Participants: Sixteen ACIs (11 men, 5 women; experience as an athletic trainer = 10 ± 4.7 years, experience as an ACI = 6.81 ± 3.9 years) were interviewed. Data Collection and Analysis: We interviewed each participant by telephone. Interview data were analyzed and coded for common themes and subthemes regarding barriers and educational emphases. Themes were triangulated through multiple-analyst triangulation and interpretive verification. Results: Barriers to EBP incorporation and educational emphasis placed on EBP were the main themes reported. Resources, personnel, and student characteristics were subthemes identified as barriers. Resource barriers included time, equipment, access to current literature, and knowledge. Coworkers, clinicians, and coaches who were unwilling to accept evidence regarding advancements in treatment were identified as personnel barriers. Programmatic improvement and communication improvement were subthemes of the educational emphasis placed on EBP theme. The ACIs reported the need for better integration between the clinical setting and the classroom and expressed the need for EBP to be integrated throughout the athletic training education program. Conclusions: Integration of the classroom and clinical experience is important in advancing ACIs\u27 use of EBP with their students. Collaborative efforts within the clinical and academic program could help address the barriers ACIs face when implementing EBP. This collaboration could positively affect the ability of ACIs to implement EBP within their clinical practices

Preparation of the Professional Athletic Trainer: A Descriptive Study of Undergraduate and Graduate Degree Programs

Context: The examination of the appropriate professional degree for preparation as an athletic trainer is of interest to the profession. Descriptive information concerning universal outcomes is needed to understand the effect of a degree change. Objective: To obtain and compare descriptive information related to professional athletic training programs and a potential degree change and to determine if any of these factors contribute to success on existing universal outcome measures. Design: Cross-sectional study. Setting: Web-based survey. Patients or Other Participants: We contacted 364 program directors; 178 (48.9%; 163 undergraduate, 15 postbaccalaureate) responded. Intervention(s): The survey consisted of 46 questions: 45 questions that dealt with 5 themes (institutional demographics [n = 13], program admissions [n = 6], program outcomes [n = 10], program design [n = 9], faculty and staff [n = 7]) and 1 optional question. Main Outcome Measure(s): Descriptive statistics for all programs were calculated. We compared undergraduate and postbaccalaureate programs by examining universal outcome variables. Results: Descriptive statistics demonstrated that 33 programs could not support postbaccalaureate degrees, and a substantial loss of faculty could occur if the degree requirement changed (553 graduate assistants, 642 potentially underqualified instructors). Postbaccalaureate professional programs had higher 2011-2012 first-time Board of Certification (BOC) passing rates (U = 464.5, P = .001), 3-year aggregate first-time BOC passing rates (U = 451.5, P = .001), and employment rates for 2011-2012 graduates employed within athletic training (U = 614.0, P = .01). Linear multiple-regression models demonstrated that program and institution type contributed to the variance of the first-time BOC passing rates and the 3-year aggregate first-time BOC passing rates (P \u3c .05). Conclusions: Students in postbaccalaureate athletic training programs performed better in universal outcome measures. Our data supported the concerns that this transition could result in the loss of some programs and an additional immediate strain on current staff due to potential staffing changes and the loss of graduate assistant positions

Approved Clinical Instructors\u27 Perspectives on Implementation Strategies in Evidence-Based Practices for Athletic Training Students

Context: Understanding implementation strategies of Approved Clinibal Instructors (ACIs) who use evidence-based practice (EBP) in clinical instruction will help promote the use of EBP in clinical practice. Objective: To examine the perspectives and experiences of ACIs using EBP concepts in undergraduate athletic training education programs to determine the importance of using these concepts in clinical practice, clinical EBP implementation strategies for students, and challenges of implementing EBP into clinical practice while mentoring and teaching their students. Design: Qualitative study. Setting: Telephone interviews. Patients or Other Participants: Sixteen ACIs (11 men, 5 women; experience as a certified athletic trainer = 10 ± 4.7 years, experience as an ACI = 6.8 ± 3.9 years) were interviewed. Data Collection and Analysis: We interviewed each participant by telephone. Interview transcripts were analyzed and coded for common themes and subthemes regarding implementation strategies. Established themes were triangulated through peer review and member checking to verify the data. Results: The ACIs identified EBP implementation as important for validation of the profession, changing paradigm shift, improving patient care, and improving student educational experiences. They promoted 3 methods of implementing EBP concepts with their students: self-discovery, promoting critical thinking, and sharing information. They assisted students with the steps of EBP and often faced challenges in implementation of the first 3 steps of EBP: defining a clinical question, literature searching, and literature appraisal. Finally, ACIs indicated that modeling the behavior of making clinical decisions based on evidence was the best way to encourage students to continue using EBP. Conclusions: Athletic training education program directors should encourage and recommend specific techniques for EBP implementation in the clinical setting. The ACIs believed that role modeling is a strategy that can be used to promote the use of EBP with students. Training of ACIs should include methods by which to address the steps of the EBP process while still promoting critical thinking

An Evidence-Based Practice Educational Intervention for Athletic Trainers: A Randomized Controlled Trial

Context: As evidence-based practice (EBP) becomes a necessity in athletic training, Web-based modules have been developed and made available to the National Athletic Trainers\u27 Association membership as a mechanism to educate athletic trainers (ATs) on concepts of EBP. Objective: To assess the effect of an educational intervention on enhancing knowledge of EBP among ATs. Design: Randomized controlled trial. Setting: Web-based modules and knowledge assessment. Patients or Other Participants: A total of 164 of 473 ATs (34.7% response rate), including professional athletic training students, graduate students, clinical preceptors, educators, and clinicians, were randomized into a control group (40 men, 42 women) or experimental group (33 men, 49 women). Intervention(s): Ten Web-based modules were developed that covered concepts involved in the EBP process. Both groups completed the Evidence-Based Practice Knowledge Assessment before and after the intervention phase. During the intervention phase, the experimental group had access to the Web-based modules for 4 weeks, whereas the control group had no direct responsibilities for the investigation. The knowledge assessment consisted of 60 multiple choice questions pertaining to concepts presented in the 10 modules. Test-retest reliability was determined to be good (intraclass correlation coefficient [2,1] = 0.726, 95% confidence interval = 0.605, 0.814). Main Outcome Measure(s): Independent variables consisted of group (control, experimental) and time (preassessment, postassessment). Knowledge scores were tabulated by awarding 1 point for each correct answer (maximum = 60). Between-group and within-group differences were calculated using a 2 × 2 repeated-measures analysis of variance (P ≤ .05), post hoc t tests, and Hedges g effect size with 95% confidence intervals. Results: We found a group × time interaction (F1,162 = 26.29, P \u3c .001). No differences were identified between the control (30.12 ± 5.73) and experimental (30.65 ± 5.93) groups during the preassessment (t162 = 0.58, P = .84). The experimental group (36.35 ± 8.58) obtained higher scores on the postassessment than the control group (30.99 ± 6.33; t162 = 4.55, P = .01). No differences were identified among time instances within the control group (t81 = 1.77, P = .08); however, the experimental group obtained higher scores on the postassessment than the preassessment (t81 = 7.07, P \u3c .001). Conclusions: An educational intervention consisting of 10 Web-based modules was an effective mechanism to increase knowledge of foundational EBP concepts among ATs. However, it is not known whether ATs are integrating EBP into daily clinical practice. Researchers should determine whether increased knowledge of EBP affects the daily clinical decision making of ATs

Health-Related Quality of Life in Individuals With Chronic Ankle Instability

Context: Individuals with chronic ankle instability (CAI) have reported decreased global and regional function. Despite the identification of functional deficits in those with CAI, more research is required to determine the extent to which CAI influences the multidimensional profile of health-related quality of life. Objective: To determine whether global, regional, and psychological health-related outcomes differ between individuals with and without CAI. Design: Case-control study. Setting: Laboratory. Patients or Other Participants: Twenty-five participants with CAI (age = 21.9 ± 2.5 years, height = 170.8 ± 8.6 cm, mass = 69.8.0 ± 11.7 kg) were sex- and limb-matched to 25 healthy participants (age = 22.0 ± 2.1 years, height = 167.4 ± 9.1 cm, mass = 64.8 ± 11.2 kg). Main Outcome Measure(s): Both groups completed the Disablement in the Physically Active Scale, the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport, the Tampa Scale of Kinesiophobia-11, and the Fear-Avoidance Beliefs Questionnaire. Dependent variables were scores on these instruments, and the independent variable was group. Results: Compared with healthy individuals, those with CAI reported decreased function on the Disablement in the Physically Active Scale, FAAM, and FAAM-Sport (P \u3c .001) and increased fear of reinjury on the Tampa Scale of Kinesiophobia-11 and Fear-Avoidance Beliefs Questionnaire (P \u3c .001). In the CAI group, the FAAM and FAAM-Sport demonstrated a significant relationship (r = 0.774, P \u3c .01). Conclusions: Individuals with CAI reported decreased function and increased fear of reinjury compared with healthy control participants. Also, within the CAI group, there was a strong relationship between FAAM and FAAM-Sport scores but not between any other instruments. These findings suggest that health-related quality of life should be examined during the rehabilitation process of individuals with CAI

Postprofessional Athletic Training Students\u27 Perceptions Concerning the Health Care Competencies

Context: Over a decade ago, the Institute of Medicine indicated that all health care professionals should be educated in several health care competency areas (quality improvement, health care informatics, interprofessional education and collaborative practice, evidence-based practice, and patient-centered care). Despite this initiative, athletic training has only recently incorporated these competencies throughout education. Objective: To assess postprofessional athletic training students\u27 perceived abilities and importance regarding 6 core competencies. Design: Cross-sectional. Setting: Self-reported paper survey. Patients or Other Participants: A total of 221 from a convenience sample of 258 postprofessional athletic training students (85.7%) completed the survey (82 males, 138 females; age = 23.29 ± 2.05 years). Main Outcome Measure(s): The survey consisted of several concept statements for each competency, and perceptions were collected via Likert-scale items (range 1-4). Composite perceived ability and importance Likert-scale scores were achieved by tabulating all values and then averaging the scores back to the Likert scale. Higher scores indicated that participants perceived themselves to have greater ability and that the concepts were more important for implementation in clinical practice. Results: Overall, postprofessional athletic training students perceived they were able to implement the concepts of the competencies into their daily practice and perceived all of the competencies to be moderately to extremely important for implementation. However, while participants globally perceived they were able to implement the competencies, they disagreed or strongly disagreed they were able to implement some concepts, particularly within health care informatics and patient-centered care, as a part of their clinical practice. Conclusions: Postprofessional athletic training students recognize the importance of the core competencies and perceive they are able to implement these competencies throughout clinical practice. However, as postprofessional athletic training students continue to advance their skills as clinicians, the benefits of health care informatics and incorporating real-time electronic patient data to support their clinical decisions should be emphasized

Landing Technique Affects Knee Loading and Position During Athletic Tasks

Anterior cruciate ligament (ACL) injuries have been reported to occur with the ankle in a dorsiflexed position at initial contact. Few studies have attempted to quantify the biomechanical parameters related with such landing patterns during athletic tasks. Objectives- The purpose of this study was to evaluate the effects that two landing techniques have in lower extremity biomechanics while performing two tasks. Design- Single-group repeated measures design. Methods- Twenty female soccer athletes from a Division 1 institution performed two landing techniques (forefoot and rearfoot) during two unanticipated tasks (sidestep cutting and pivot). Repeated measures analyses of variance were conducted to assess differences in the kinematic and kinetic parameters between landing techniques for each task. Results: The forefoot landing technique had significantly higher internal knee adductor moment than the rearfoot for both the pivot and sidestep cutting task (p \u3c 0.001 and p = 0.003, respectively). For the sidestep cutting task, participants had increased knee valgus angle with the rearfoot, whereas for the pivot they had increased knee valgus with the forefoot landing technique (p \u3c 0.05). Conclusions- The results of this study highlighted that there are inherent differences in biomechanical outcomes between foot-landing techniques. The forefoot landing technique increasingly affects knee adduction moment loading, which can potentially place a higher strain on the ACL. Essentially, the demands of the landing technique on lower extremity biomechanics (e.g., hip and knee) are task dependent

A Feedback Inclusive Neuromuscular Training Program Alters Frontal Plane Kinematics

-Anterior cruciate ligament (ACL) neuromuscular training programs have demonstrated beneficial effects in reducing ACL injuries, yet further evaluation of their effects on biomechanical measures across a sports team season is required to elucidate the specific factors that are modifiable. The purpose of this study was to evaluate the effects of a 10-week off-season neuromuscular training program on lower extremity kinematics. Twelve Division I female soccer players (age: 19.2 ± 0.8 years, height: 1.67 ± 0.1 m, weight: 60.2 ± 6.5 kg) performed unanticipated dynamic trials of a running stop-jump task pretraining and posttraining. Data collection was performed using an 8-camera Vicon system (Los Angeles, CA, USA) and 2 Bertec (Columbus, OH, USA) force plates. The 10-week training program consisted of resistance training 2 times per week and field training, consisting of plyometric, agility, and speed drills, 2 times per week. Repeated measures analyses of variance (ANOVAs) were used to assess the differences between pretraining and posttraining kinetics and kinematics of the hip, knee, and ankle at initial contact (IC), peak knee flexion (PKF), and peak stance. Repeated measures ANOVAs were also used to assess isometric strength differences pretraining and posttraining. The alpha level was set at 0.05 a priori. The training program demonstrated significant increases in left hip extension, left and right hip flexion, and right hip adduction isometric strength. At IC, knee abduction angle moved from an abducted to an adducted position (-1.48 ± 3.65 degrees to 1.46 ± 3.86 degrees, p = 0.007), and hip abduction angle increased (-6.05 +/- 4.63 degrees to -10.34 ± 6.83 degrees, p = 0.007). Hip abduction angle at PKF increased (-2.23 ± 3.40 degrees to 6.01 ± 3.82 degrees, p = 0.002). The maximum knee extension moment achieved at peak stance increased from pretraining to posttraining (2.02 ± 0.32 to 2.38 ± 0.75 N.m.kg-1, p = 0.027). The neuromuscular training program demonstrated a potential positive effect in altering mechanics that influence the risk of incurring an ACL injury

Autologous Blood and Platelet-Rich Plasma Injections in the Treatment of Achilles Tendinopathy: A Critically Appraised Topic

Clinical Scenario: Achilles tendinopathy is a painful condition commonly affecting the general and athletic population. It presents with localized pain, stiffness, and swelling in the midportion of the Achilles tendon. The physical stress placed on the tendon results in microtrauma, which leads to subsequent inflammation and degeneration. While it is not surprising that this condition affects the physically active, nearly one-third of Achilles tendinopathy cases occur in sedentary individuals. Etiology for this condition stems from a change in loading patterns and/or overuse of the tendon, resulting in microscopic tearing and degenerative changes. There are numerous causes contributing to the maladaptive response in these patients, such as mechanical, age-related, genetic, and vascular factors. The treatment for these patients is typically load management and eccentric strengthening of the gastrocnemius soleus complex. Unfortunately, conservative treatment can lead to surgical intervention in up to 45% of cases. A relatively new phenomenon in the treatment of this condition is the use of autologous blood injections (ABI) and platelet-rich plasma injections (PRPI). This need for a less invasive treatment fostered more investigation into ABI and PRPI to treat these nonresponsive patients. However, the evidence concerning the effectiveness of these treatments in patients with Achilles tendinopathy has not been synthesized. Focused Clinical Question: In patients with Achilles tendinopathy, how do variations of ABI and PRPI compared with a placebo and/or eccentric training affect pain and function

Measures of Functional Performance and Their Association With Hip and Thigh Strength

Context: Insufficient hip and thigh strength may increase an athlete\u27s susceptibility to injury. However, screening for strength deficits using isometric and isokinetic instrumentation may not be practical in all clinical scenarios. Objective: To determine if functional performance tests are valid indicators of hip and thigh strength. Design: Descriptive laboratory study. Setting: Research laboratory. Patients or Other Participants: Sixty-two recreationally athletic men (n = 30, age = 21.07 years, height = 173.84 cm, mass = 81.47 kg) and women (n = 32, age = 21.03 years, height = 168.77 cm, mass = 68.22 kg) participants were recruited. Intervention(s): During session 1, we measured isometric peak force and rate of force development for 8 lower extremity muscle groups, followed by an isometric endurance test. During session 2, participants performed functional performance tests. Main Outcome Measure(s): Peak force, rate of force development, fatigue index, hop distance (or height), work (joules), and number of hops performed during the 30-second lateral-hop test were assessed. The r values were squared to calculate r 2. We used Pearson correlations to evaluate the associations between functional performance and strength. Results: In men, the strongest relationship was observed between triple-hop work and hip-adductor peak force (r2 = 50, P ≤ .001). Triple-hop work also was related to hip-adductor (r2 = 38, P ≤ .01) and hip-flexor (r2 = 37, P ≤ .01) rate of force development. For women, the strongest relationships were between single-legged vertical-jump work and knee-flexor peak force (r2 = 0.44, P ≤ .01) and single-legged vertical-jump height and knee-flexor peak force (r2 = 0.42, P ≤ .01). Single-legged vertical-jump height also was related to knee-flexor rate of force development (r2 = 0.49, P ≤ .001). The 30-second lateral-hop test did not account for a significant portion of the variance in strength endurance. Conclusions: Hop tests alone did not provide clinicians with enough information to make evidence-based decisions about lower extremity strength in isolated muscle groups