Principles of Sports Medicine

Sports PTs

- "science" ^ orthopedics ^ pathophysiology ^ manual therapy ^ exercise prescription ^ protocols ^ evidence-based practice ^ anatomy/physiology ^ biomechanics - "art" ^ communication ^ adaptability ^ teamwork ^ problem solving ^ situational awareness ^ creativity ^ professionalism ^ work ethic

Sports Certified Specialist: American Board of PT Specialists

- 2961 Sports Certified Specialists as of 2022 (8.4% of all board-certified specialists; 0.5% of all physical therapists in US). - If you are board certified in sports physical therapy, you are permitted to practice only within the scope of your state physical therapy practice act. - Board certification does not grant you any additional rights or privileges.

Sports Residency Programs

- 67 APTA credentialed programs to date ◦ 11 Candidate programs - Before starting program ◦ ATC ◦ EMT ◦ Approved EMR course

Code of Ethics: Principle 5

- A PT shall achieve and maintain professional competence. ◦ 5.1 Scope of Competence ^ A PT shall practice within the scope of his/her competence and commensurate with his/her level of education, training, and experience. ◦ 5.2 Self-assessment ^ A PT has a lifelong professional responsibility for maintaining competence through on-going self-assessment, education, and enhancement of knowledge and skills

Code of Ethics: Principle 4

- A PT shall exercise sound professional judgment. ◦ A PT shall exercise sound professional judgment based upon his/her knowledge, skill, education, training, and experience.

Code of Ethics: Principle 11

- A PT shall respect the rights, knowledge, and skills of colleagues and other HCPs. ◦ 11.1 Consultation ^ A PT shall seek consultation whenever the welfare of the pt. will be safeguarded or advanced by consulting those who have special skills, knowledge, and experience.

Collegiate/Pro Sports Medicine Model

- ATC ^ Coach ^ Team MD ^ Athletes

Sports Medicine

- American College of Sports Medicine (ACSM) ◦ The knowledge concerning the motivation, responses, adaptations, and health of persons engaged in exercise ◦ The term includes all medical and paramedical professionals who are concerned with enhancing the performance and healthcare of these persons

SCS Certification: Process

- Application - Rigorous examination ◦ 200 questions ◦ 6 hours - Re-certification every 10 years ◦ Maintenance of Specialist Certification (MOSC) process began in 2016 ◦ Focuses on continuing competency of the certified specialist

Bracing vs. Taping

- Both have been demonstrated to reduce incidence of acute ankle sprains - No significant difference in effectiveness - Significant difference in cost ◦ Bracing is more cost effective if used for prophylactic purpose

Bracing: Key Points

- Bracing can be an integral part of treating MSK injuries - Single aspect of the overall rehab process (i.e., it should not take the place of rehab) - Research is inconclusive in most cases with regard to clinical efficacy

SCS Certification

- Current PT license - Current CPR certification - Emergency care requirement ◦ Acute Management of Injury and Illness Course ◦ EMT or Paramedic certification/licensure ◦ NATA certification within last 4 years - Direct patient care (2 options) ◦ 2000 hours in specialty area within last 10 years ◦ 25% (500 hrs) within last 3 years ◦ Effective 2017, 100 hours must be documented athletic venue coverage with at least 50% of hours in association with a contact sport OR ◦ Successful completion of APTA-credentialed sports clinical residency

Bracing and ACL

- Dynamic bracing system - Designed to reduce strain on ACL - Cuff and strapping configuration provide a net differential posterior force to tibia, preventing anterior movement

Role of the ATC

- Gate keeper - First line of defense for athletes - Not just a "taper" - Recognized by the American Medical Association, Health Resources Services Administration, and the Department of Health and Human Services as an allied healthcare profession

TN PT Practice Act: Can a PT in TN provide medical coverage at sporting events?

- In emergency circumstances, including minor emergencies, a licensed PT may provide assistance to a person to the best of a therapist's ability without the referral of a referring practitioner. The PT shall refer to the appropriate health care practitioner, as indicated, immediately thereafter.

Role of Sports PT

- Injury evaluation - Injury rehabilitation - Screening/pre-participation exam - Performance enhancement - Testing/functional progression - Return-to-play decision - Outreach administration ◦ Fiscal ◦ Clinical - Sideline coverage (?)

ATC Responsibilities

- Injury recognition and evaluation - Injury management and emergency care - Injury rehabilitation - Program organization and administration - Education/counseling - Extraneous duties

Domains of Athletic Training

- Injury/illness prevention and wellness promotion - Examination, assessment, and diagnosis - Immediate and emergency care - Therapeutic intervention - Healthcare administration and professional responsibility

Patient Education (Bracing)

- MUST accompany use of a brace - Observe patient applying brace - Observe how the brace acts during movement - Provide information on brace hygiene

Ask Relevant Questions (Clinical Sports PT)

- Mechanism of Injury? - Contact or non-contact? - Past medical history of injury? - Aggravating/alleviating? - Risk factors (intrinsic/extrinsic)? - Single or multi-sport? - What is their role/position? - Prior level of function? - Current limitations? - Goals?

Bracing and Ankle Sprains

- Most common injury in sports - Estimated 28,000 ankle injuries occur in US each day - High recurrence rate - Bracing/taping commonly used to prevent recurrence

Detrimental Effects (of Bracing)

- Muscle atrophy/inhibition (?) ◦ No definitive answer - Predisposition to injury of another joint (?) ◦ Evidence of increased load/force to other joints in the kinetic chain, but no definitive evidence that this leads to increased risk of injury - Performance impairments (?) ◦ May induce premature muscle fatigue by reducing perfusion ◦ Increased energy expenditure ◦ Decreased proprioception

Maintaining Certification: Continuing Education Requirements

- NATA-BOC requirements ◦ 50 CEU's every 2 year reporting period ◦ Minimum of 10 EBP CEU's ◦ Maintenance of CPR certification - State requirements ◦ TN—same as NATA ◦ Other states may vary

Guide to PT Practice

- PTs practice in a broad range of inpatient, outpatient, and community based settings, including the following: ◦ Athletic facilities (collegiate, amateur, and professional) ◦ Fitness centers and sports training facilities - APTA has endorsed the concepts of primary care - For acute MSK and neuromuscular conditions, triage and initial exam are appropriate PT responsibilities

Sports Medicine Team

- Physician(s) - Certified athletic trainer - Coaches - Athlete - Specialist MD's - Sports physical therapist - Chiropractor - Strength and conditioning specialist - Sports psychologist - Dentist - Nutritionist - Exercise physiologist - Biomechanist - Nurse

Sports PT Competency Areas

- Rehabilitation and return to activity - Acute injury management - Medical and surgical considerations - Injury prevention - Sports performance enhancement - Professional roles and responsibilities

Proposed Mechanisms (Bracing)

- Restrict motion - Correct alignment - Displace forces to other tissues - Provide cushioning - Provide proprioceptive input - Placebo effect

Athletic Training Certification: National Certification Examination - Combination of 175 scored and unscored (experimental) items including:

- Stand-alone multiple-choice questions - Stand-alone alternative items (drag-and-drop, text based simulation, multi-select, hot spot, etc.) - Focused testlets ◦ A 5-item focused testlet consists of a scenario followed by 5 key/critical questions related to that scenario ◦ Each focused testlet may include multiple-choice questions and/or any of the previously described alternative item types

ATC Practice Settings

- Students (27%) - College/university (19%) - High school (18%) - Clinical (17%) - Professional (2%) - Emerging settings (2%) ◦ Industrial/occupational health ◦ Military ◦ Performing arts ◦ Public safety

Bracing and Ankle Sprains: Fewer et al

- Studied effect of ankle braces on LE muscle activation in patients with CAI - Demonstrated decreased muscle activity during common rehab exercises (forward lunge, star excursion balance anterior reach and posterolateral reach) ◦ Lateral gastroc ◦ Peroneus longus ◦ Rectus femoris ◦ Gluteus medius

TN Athletic Training Practice Act

- and, in carrying out these functions the athletic trainer is authorized to use physical modalities, such as heat, light, sound, cold, electricity, or mechanical devices related to prevention, recognition, evaluation, management, disposition, rehabilitation, and treatment - an athletic trainer shall practice only in those areas in which such athletic trainer is competent by reason of training or experience that can be substantiated by records or other evidence found acceptable by the board in the exercise of the board's discretion

TN Athletic Training Practice ACT: Athletic trainers may treat:

- athletic injuries

CAATE Description of the Professional: Athletic Trainers

- healthcare professionals who collaborate with physicians to optimize activity and participation of patients and clients - encompasses the prevention, diagnosis, and intervention of emergency, acute, and chronic medical conditions involving impairment, functional limitations, and disabilities

TN Athletic Training Practice ACT: Athletic Trainer

- means a person with specific qualifications as set forth in this chapter, who, upon the advice, consent, and oral or written prescriptions or referrals of a physician licensed under this title, carries out the practice of prevention, recognition, evaluation, management, disposition, treatment, or rehabilitation of athletic injuries

TN Athletic Training Practice ACT: Athletic Injury

- means any injury sustained by a person as a result of such person's participation in exercises, sports, games, or recreation requiring physical strength, agility, flexibility, ROM, speed, or stamina, or comparable athletic injury that prevents such person from participating in such activities

TN PT Practice Act: Can a PT in TN provide medical coverage at sporting events? - Emergency Medical Care

- means bona fide emergency services provided after the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in: (i) Placing the patient's health in serious jeopardy (ii) Serious impairment to bodily functions (iii) Serious dysfunction of any bodily organ or part

TN PT Practice Act: Can a PT in TN provide medical coverage at sporting events? - Emergency Circumstances

- means instances where emergency medical care is called for

TN PT Practice Act: Scope of Practice and Supervision - Supervision of PT Assistive Personnel, "Onsite Supervision"

- means the supervising PT must: ◦ (i) be continuously onsite and present in the department or facility where assistive personnel are performing services ◦ (ii) be immediately available to assist the person being supervised in the services being performed ◦ (iii) maintain continued involvement in appropriate aspects of each treatment session in which a component of treatment is delegated to assistive personnel

Strength and Conditioning Parameters: Power

- reps: 1-5 - sets: 3-5 - rest: 2-6 min - load: 45-60% 1RM

Strength and Conditioning Parameters: Strength

- reps: 1-5 - sets: 4-7 - rest: 2-6 min - load: 80-90% 1RM

Strength and Conditioning Parameters: Endurance

- reps: 12 or more - sets: 2-4 - rest: 30-60 s - load: 40-60% of 1RM

Strength and Conditioning Parameters: Hypertrophy

- reps: 6-12 - sets: 4-8 - rest: 1-2 min - load: 60-80% 1RM

Needs Analysis (Clinical Sports PT)

- types of loads? - training/competition schedule? - work/rest ratio? - planes of movement? - performance aspects? - what joints are involved? - energy systems? - biomechanics?

Bracing and ACL - 4 Points of Leverage

◦ 1—anterior thigh cuff/posterior thigh strap ◦ 2—posterior calf cuff/anterior tibial strap ◦ 3—posterior distal thigh strap ◦ 4—anterior proximal tibial strap

The Clinical Sports PT: DOs

◦ Ask relevant questions ◦ Perform needs analysis ◦ Apply exercise prescription appropriately ◦ Provide clear, safe parameters ◦ Offer management strategies

Bracing and ACL - Functional Braces

◦ Attempts to control tibial displacement ◦ Commonly prescribed following ACL reconstruction ◦ Original ACL brace—"derotation" brace ◦ Evidence - Limited evidence supporting clinical efficacy - Similar long-term results with regard to knee laxity, functional tests, ROM, strength, and outcome scores - Evidence of lower subjective instability ratings in ACL-deficient patients ^ Especially in quad-deficient patients

Bracing and Ankle Sprains: Rehabilitative, Functional, and/or Prophylactic

◦ Attempts to limit ROM that would stress lateral ligaments ◦ Stirrup braces ◦ Semi-rigid braces ◦ Hinged braces ◦ Lace-up braces ◦ Sleeves

Athletic Training Certification: NATA-BOC Requirements

◦ Bachelor's degree minimum (??) - Most are in the process of converting to Master's level programs ◦ CPR or EMT certification ◦ Graduate of accredited program ◦ Board exam (BOC)

Bracing - Review of Literature: Level V Evidence

◦ Bracing increased objective measures for RTS as well as self-report of better knee function ◦ Concluded that bracing had positive effects post-ACLR, which may assist in reducing kinesiophobia when returning to pre-injury activity

Fellowships: Criteria

◦ Completed a residency program in a related specialty area ◦ An American Board of Physical Therapy Specialties board-certified specialist in a related area of specialty. ^ Orthopedic manual therapy ^ Performing arts ^ Sports division IA ^ UE athlete

Athletic Training Certification: Clinical Education Experiences

◦ Completed over a minimum of 2 academic years ◦ Must address the continuum of care ◦ Must include, but not limited to: - Individual and team sports - Sports requiring protective equipment - Patients of different sexes - Non-sport patient populations (e.g., outpatient clinic, ER, primary care office, industrial, military) - Conditions other than orthopedics (e.g., primary care, internal medicine, dermatology)

Bracing and Ankle Sprains: NATA Position Statement

◦ Conservative management and prevention of ankle sprains ◦ Recommend ankle bracing or taping for athletes with history of previous ankle sprains ◦ Prevention should include balance/NM training, LE strengthening, and addressing any DF ROM deficits

Bracing and ACL - Rehabilitative Braces

◦ Control ROM and varus/valgus stresses post-injury or post-op ◦ Protect the repair ◦ Prevent flexion contracture ◦ Evidence - Mixed reviews - No long-term benefit to post-op bracing with regard to activity level, subjective outcome, or knee laxity - Moderate evidence for preventing flexion contractures

Bracing and Ankle Sprains: Farwell et al

◦ Critically appraised topic ◦ Moderate evidence to support use of ankle braces to reduce incidence of acute ankle sprains in adolescent athletes

Athletic Training Certification: Accredited Curriculum - Competency Categories

◦ Evidence-based practice ◦ Prevention and health promotion ◦ Clinical examination and diagnosis ◦ Acute care of injury and illness ◦ Therapeutic interventions ◦ Psychosocial strategies and referral ◦ Healthcare administration ◦ Professional development and responsibility

Bracing - Review of Literature: Level I Evidence

◦ May have some benefit with regard to improving kinematics/kinetics ◦ Limited evidence to support that functional brace wear decreases rate of reinjury after ACLR ◦ Does not appear to improve knee function and stability following ACLR

Bracing - Review of Literature: Level III Evidence

◦ No beneficial effect on clinical outcomes or complication rates ◦ Patients using a rigid brace had limited flexion early on in rehab

The Clinical Sports PT: DON'Ts

◦ Overlook "the basics" ◦ Make decisions blindly ◦ Get too fancy ◦ Under-load athletes ◦ Treat with cookie-cutter approach

Categories of Bracing: Prophylactic

◦ Prevent or reduce risk of injury

Sports Medicine Team: Key Points

◦ Primary responsibility is to the athlete ◦ Each team member must be competent in area of expertise ◦ Communication between team members is essential ◦ Mutual respect

Categories of Bracing: Rehabilitative

◦ Provide protection and controlled ROM during rehab period

Categories of Bracing: Functional

◦ Provide stability to injured tissue while allowing some level of participation

Bracing - Evidence: Ankle Sprains

◦ Systematic reviews found the use of ankle bracing decreases incidence of sprains - Most effective in those with previous injuries ◦ Superior to NM training in decreasing incidence but not severity of recurrent ankle sprains ◦ Long-term bracing has not been found to affect peroneal latency ◦ Short-term bracing has not been found to affect speed, agility, and kicking performance in healthy soccer players

TN PT Practice Act: Scope of Practice and Supervision - Supervision of PT Assistive Personnel

◦ The PT may delegate to the PTA, assistive personnel, and clinical students selected acts, tasks, or procedures that fall within the scope of their education or training. ◦ PT aides, other assistive personnel, and clinical students shall at all times perform patient care activities under the on-site supervision of a licensed PT or PTA ◦ "Other assistive personnel" means other trained or educated health care personnel (other than PTA or PT aide), who perform specific delegated tasks related to physical therapy under the supervision of a PT. At the discretion of the supervising PT, and if properly credentialed and not prohibited by any other law, "other assistive personnel" or "other support personnel" may be identified by the title specific to their training or education.