Since when is rehabilitation a one size fit all?  The National Athletic Trainer’s Association Executive Council on Education describes rehabilitation proficiency as the ability to: “Select, apply and evaluate the effectiveness of therapeutic interventions using the best evidence to guide those decisions.”  This is great benchmark, in that allows creativity and ability to choose.  In my education rehabilitation has been about adapting exercise and interventions to meet patient goals without using a “cookie-cutter” approach.  I have learned to have lots of options and base my progress on patient feedback. 

In 2013, during the Scapular Summit, all the greatest minds in this area of research discussed concepts of prevention, diagnosis, and rehabilitation.1  Their lengthy and detailed conversation yielded the same questions most of us clinicians have been asking for quite some time… What comes first, the chicken (the dyskinesis) or the egg (concomitant pathology)?  Without a thorough understanding of the causative factors associated with scapular dyskinesis, it is difficult to plan for rehabilitation. 

Most clinicians focus on retraining the scapula after surgical intervention or as a means to decrease symptoms for a chronic problem.  But, what if we focused less attention on strength and more on neuromuscular control?  As part of my thesis, we are evaluating certain exercises, that are theorized in the literature, to focus specifically on the sequencing of muscle activation or that coordination of movement called neuromuscular control.  What we are finding is that uniplanar motions typical of a “cookie-cutter” approach to rehabilitation are not effective at coordinating movement and as such, we need more creative and advanced approaches to managing scapular dyskinesis.

Which of the following exercises are focused on neuromuscular control?

I, Y, T, Ws

Pushup/Pushup Plus

Wall Washes

Body Blade in Overhead/Sport Specific Position

Impulse in Overhead/Sport Specific Position

Plyo-rebounder

Theraband RC exercises (Internal Rotation, External Rotation, D1, D2, Flexion, Extension)

Weight Shifts

Theraband Rows

Theraband Serratus Punch

Prone T Ball Flip

-Austin Krause LAT, ATC

References

1.       Kibler BW, Ludewig PM, McClure PW, Michener LA, Bak K, Sciascia AD. Clinical implications of scapular dyskinesis in shoulder injury: The 2013 consensus statement from the ‘scapular summit’. Br J Sports Med. 2013;00:1-12

I recently had an encounter with the mother of one of my athletes. Her daughter had gotten injured in practice a week before but it had not been made known to the athletic training staff. When I noticed that she was sitting out at practice I asked her and her coaches what the reason was. They all informed me that she just had a headache and that was all. It seemed a little odd to me that she would be missing practice for a headache so I asked if there was a specific cause or if she had hit her head. Her response was no, that she just had a headache. I wrote off the conversation in my mind until the following week at her basketball game. During the game it was made known to me that she fell and hit her head at practice and had been experiencing headaches for three days after the incident. Immediately following the game I went to the locker room to get the real story of what had happened from the athlete and she informed me that she had in fact fallen but that she went to her family physician and had been cleared to play. Afterwards I told her that in the future it is very important that she let us know if she gets hurt so that we can help to provide her with the best care. She agreed and I thought that would be the end of it. Within a few minutes of leaving the locker room the athlete’s mother approached me and asked me to sit down to talk about the situation. I could immediately tell that this was not going to be a smooth conversation so I calmly explained what I had told her daughter. She looked at me and asked, “Why do you need to be informed if my daughter gets injured if she has her own insurance and physician?” I explained to her that while her daughter is participating in activities with the school, we (the athletic trainers) are responsible for providing medical care.

I became very confused by her questions relevance to the situation and didn’t understand what would make her so upset about the fact that I wanted to help her daughter. I took a moment to really think about this bizarre conversation. There had to be something that I was missing. And then it hit me. Somehow there had been a misunderstanding about what Athletic Trainers do and why we are working in the high school setting. I took a deep breath and attempted to start the conversation over. I explained to the mother that the Athletic Trainers are available to the athletes in case an injury or an emergency occurs. That while they are on campus or participating in athletics through the high school we are responsible for providing them care or referring them to another health care professional. In the case of needing to refer them, we first will go through whatever insurance the family has or their family physician and then if they do not have a specific request, then they will be able to see the physicians that we work under. By no means are we trying to take the place of their physician but instead we are there to work with the physician in order to provide the best care to the athlete and make sure that it is safe for their children to participate.

Once I was able to explain our role as physician extenders, the mood of the conversation immediately changed. The mother quickly said that in the future her daughter would let us know about any injuries she may have and that she was sorry for the misunderstanding. As we parted ways a huge weight was lifted off my shoulders. For the rest of the night I kept thinking about all the different ways that conversation could have gone. Her question about why we needed to be informed clued me in to the fact that despite our efforts as clinicians to educate the athletes and their parents on what it is that Athletic Trainers do, there was still one parent in the stands that didn’t know. This mother was acting in a way as to protect her daughter and make sure that she was properly taken care of. She just didn’t know that her and I were on the same page. And at the end of the day, a little patience and education got us a long way.

-Rachael Kirkpatrick LAT, ATC

A major public health issue in today’s society is mental health. In the collegiate and secondary school setting, student-athletes have stressors from coaches, parents, scouts, athletic departments, the media, as well as the pressure they put on themselves to excel. Mental health issues are unique to more common injuries sustained during competition. Athletes tend to feel comfortable seeking help for orthopedic injuries, but there seems to be a stigma behind seeking help for mental illnesses. This is where the role of the athletic trainer becomes vital to athlete safety.


I recently was in a situation where an athlete’s loved one attempted suicide. As athletic trainers, it is in our nature to intervene and support the athlete in any way possible. In this particular situation, the athlete had also sustained an injury in a game the night before and we had set up a plan to begin rehabilitation on the injury the next day. When I heard the news, my mindset and plan of action shifted from rehabilitating the orthopedic injury to ensuring the athlete was in a stable state of mind.


A key component of handling mental illness in sport is developing policies and procedures for athletes to seek mental help much like they seek guidance for their physical health. In 2013, the NATA released an inter-association task force consensus statement titled, “Recommendations for Developing a Plan to Recognize and Refer Student Athletes with Psychological Concerns at the Collegiate Level.” In the secondary school setting, athletic trainers may also use this resource to help identify behaviors to monitor that reflect physiological concerns.

In my transition to practice, I have learned that it takes a team based approach to keep an athlete safe. In this particular case, athletic trainers, counselors, social workers, school administration, and coaches all worked together with a common goal of ensuring this athlete was healthy, physically and mentally.

Consensus Statement:  www.nata.org/sites/default/files/psychologicalreferal-summary.pdf

Emma Nye LAT, ATC 

The transition from an undergraduate athletic training student to a newly certified athletic trainer is daunting. One day you are a student feeling confident about graduation, getting a job and stepping out into the workforce then suddenly the pressure of being a certified athletic trainer overwhelms you. The realization that you are now in charge can cause an array of emotions. I remember feeling nervous, excited, overwhelmed, confident and frustrated all in the course of my first week. Every individual has a truly unique transition to practice but just remember you are not alone.

I am the first athletic trainer to ever be at Turkey Run High School. My transition has been quite the journey. The transition to being in charge, making decisions by myself, and proving myself are typical concerns of any entry level athletic trainer and I was prepared to deal with these aspects. However, I was not necessarily prepared for the comprehensive integration of all my athletic training knowledge and skills. A lot of effort, energy, and time went into developing the athletic training program. I can remember drafting emergency action plans, developing my own system for SOAP notes, creating athlete medical files, creating and defending a budget, building relationships and trust as well as educating about my the profession. Although all these things seem silly and easy now, I was not truly ready for this responsibility.

Looking back now I have many people to thank and advice to give for other transitioning professional. My biggest piece of advice is to remember that you are never alone. It does not matter whether you seek out previous mentors, preceptors, and professors or newly formed relationships, people are willing to help.  The outreach and support of my fellow athletic trainers just shows how truly great the profession is. We are all in this together and working for the greater good.

Ashley Crossway LAT,ATC

In my last year of undergraduate as an athletic training student my head Athletic Trainer asked me, “What are you most afraid of next year?” I responded saying, “I’m mostly afraid of having the responsibility of someone’s life in my hands.”

People commonly associate athletic trainers with carrying around water, taping ankles, and handing out ice bags, which is just a tiny fraction of what we are capable of as medical professionals.  The most important skill of an Athletic Trainer is being able to save lives! All Athletic Trainers are required to be CPR and AED certified, proficient in several spine boarding techniques, able to recognize signs and symptoms of heat illnesses, asthma attacks, concussion injuries, sickle cell and seizure episodes, and many more injuries and illnesses.

As I come to an end of my first semester as a certified Athletic Trainer I have learned how important all of our proficiencies, practicals, and mock scenarios have prepared me. Thankfully I have not had any life threatening injuries thus far in my young career, knock on wood, but I know that if the event were to occur I would be prepared and confident in my actions to help the athlete/patient. I still fear the possibility of having someone’s life in my hands, but I am no longer afraid to respond and act in these life threatening situations.

Check out these awesome Athletic Trainers who used their life saving skills!

http://espn.go.com/high-school/lacrosse/story/_/id/7344390/athlete-advocates-safety-field

http://www.jrn.com/ktnv/news/Local-athletic-trainer-saves-teens-life-with-AED-device-233099031.html

A couple weekends ago the Drug Enforcement Administration (DEA) began an investigation into the National Football League’s (NFL) adherence to the Controlled Substance Act. In May, approximately 1,300 former NFL players filed a lawsuit against the league, claiming that some team’s medical staff violated state and federal laws pertaining to drug dispensing. Past players claim receiving countless illegal injections or pills of powerful drugs such as Percocet, Toradol, Novocain, amphetamines, sleeping pills or muscle relaxers. On November 16th, the DEA surprised traveling teams by conducting personal interviews with physicians and checking for documentation that allows the physician to practice in the visiting state. The goal of this investigation is not to arrest medical professionals but to determine whether state and federal regulations are being followed.

The prevalence of prescription or over-the-counter (OTC) drug usage within athletics is uncomfortably high. One article published online by The Washington Post stated, “a 2010 study of 644 league veterans from the Washington University School of Medicine found that retired NFL players misuse opioids at a rate more than four times that of their peers. A significant percentage reported either overusing painkilling opioid drugs within the past 30 days or taking the drugs without a prescription — or both.”

As an athletic trainer who works with football, I see the great physical, mental and emotional toll a sport takes on one’s body. I doubt I could find a football player, or any collegiate athlete, who does not feel sport related discomfort on a daily basis. But that is one of the costs of participating in high-level athletics. Where I believe the law and ethical lines get crossed is when an athlete needs copious amounts of medication to get through the day. Are we really doing our job to protect our athletes if he or she needs prescription strength ibuprofen or a narcotic to perform? I understand the need for returning athletes to play as fast as possible but at what expense? Do our athletes understand the effects he or she may experience five, ten or fifteen years later after routinely taking medication? Do they even know what they are taking?

These are some of the questions and complaints that sparked the DEAs investigation. I feel that this lawsuit has and will continue to keep athletic trainers and other medical professionals accountable for the drugs he or she handles. After reviewing the NATA’s Consensus Statement: Managing Prescriptions and Non-Prescription Medication in the Athletic Training Facility I am reminded of my role in the distribution of prescriptions or OTC drugs. Here are some key facts to remember:

-Athletic trainers work under a physician’s license and cannot dispense medications. We are able to administer a single dose of an OTC drug, but even so, it needs to be under the direction of a physician, whether it be via a verbal or written order.

-While traveling, one should have a signed formulary stating what OTC and/or prescription(s) that is to be managed by the athletic trainer. (The physician also needs documentation that he or she has practice rights within the visiting states)

-Documentation of what drugs are distributed should be recorded in the athletic training facility. Records should include: patient’s name, injury/illness, medication given, dose, quantity, lot number and date.

-All drugs should be kept in a locked metal cabinet that is environmentally controlled and accessible only to necessary medical staff members.

-Educate athletes on the drugs being consumed, why it’s prescribed, what the dosage is, and potential side effects.

We need to do a better job of advocating for the health of our athletes, educating athletes on later effects of decisions made now and documenting when medications are given out. #TogetherWeMustDoBetter

Check out the articles and NATA Consensus statement below:

http://www.sbnation.com/nfl/2014/11/17/7231649/nfl-dea-investigation-drug-abuse-painkillers

http://www.washingtonpost.com/sports/redskins/federal-drug-agents-launch-surprise-inspections-of-nfl-teams-following-games/2014/11/16/5545c84e-6da5-11e4-8808-afaa1e3a33ef_story.html

http://www.nata.org/sites/default/files/ManagingMedication.pdf

Kelly Brock LAT, ATC