Athletic Therapists (ATs) are commonly the first medical providers or health care professionals available onsite to evaluate any injuries that may occur during a competition or practice. They are not only crucial during competition, but also post competition during the injury management and return-to-play decision-making process. Athletic Therapists work closely with the Team Physician in order to provide the most effective therapeutic interventions and rehabilitation of injuries. Their goal is to return an athlete to competition as quickly and as safely as possible. Not only do they play a key role in injury identification, evaluation, and management, but are also critical at the sideline for screening for concussions to mitigate the risk of permanent brain damage.
One of the challenges faced by an Athletic Therapist is determining whether an athlete should be removed from activity for further evaluation after a suspected hit to the head. Although even a decade ago it was acceptable to “shake it off” and return to play, new legislations in Canada and the US and standard guidelines require athletes to be removed from competition or practice if a concussion is suspected. To properly determine the risk an Athletic Therapist should complete a post-injury assessment and compare it to a test done on the same athlete at the beginning of the season. In some sports leagues, there are multiple Athletic Therapists tending to multiple teams. A reality is that a post-injury test may not be completed by the same person who did the pre-season assessment. It is important for sports medicine teams to try to manage assessment variances in order to provide the best possible information for making return-to-play decisions.
Managing variability through diversification
The post-injury assessment includes a series of questionnaires, checklists, and physical testing that is identical to the pre-season test. A concussion can impact brain function in a variety of ways and because of the nature and physical demands of a sporting event an evaluation of concussion-related symptoms can be challenging. For example, an athlete may show concussion-like symptoms if they are dehydrated or have performed a strenuous activity, however this does not mean that the athlete will also demonstrate balance or neurocognitive impairments. Therefore it is important that an Athletic Therapist, his/her team and the team physician are all using a comprehensive battery of tests to assess brain function. Relying on any one type of test for the monitoring and decision making regarding return to play for an athlete provides an incomplete picture of the severity and breadth of the brain injury.
Managing variability through calibration meetings
Assessment variances also happen when training and communication is limited between therapy teams. It is possible to estimate and to some degree calibrate inter-rater (tester 1 vs. tester 2) reliability. For example, when testing balance at the beginning of the season, teams can grade athlete balance errors individually and after the test is complete they can compare scores. While this provides a crude measurement, it will provide insight into how much agreement exists and provides an opportunity for coaching and education. Weekly “calibration” meetings may also help – short dedicated discussions can happen and ATs can discuss why they chose the specific values they did. Where disagreements appear, the collective unit can help form some rules to help ensure calibration in the future.
Managing variability with routine
Variability can also appear as a result of intra-rater (tester 1 vs tester 1) reliability issues. For example, grading a balance video in the morning, and then watching and grading the same video in a different setting in the afternoon can generate some significant variances. With the challenges and pressures that Athletic Therapists face during a sporting event combined with subjective concussion testing, a consistent routine and method can help improve intra-rater reliability. To begin, the trainer needs the support needed from his/her therapy team to focus exclusively on the concussion assessment at hand instead of attempting to split his/her attention between the test and the active game. Reducing situational interference (distractions from the surrounding environment) and following a consistent testing structure or methodology every time can also help.
Managing variability with objectivity
Technology has enabled us to collect objective measurements where subjective grading used to take place. In his Sensorimotor Physiology lab at UBC, PhD candidate Harrison Brown developed a way to use technology to reduce variances in balance testing. He specifically looked at the balance test done in concussion assessments. By analyzing the movement of athletes performing the test and by introducing motion sensors, he was able to develop an algorithm which can objectively score an athlete’s balance. “Now it doesn’t matter whether my grandma is doing the test, my favourite doctor is or both; they’re both going to get the same score.” His technology has increased the test-retest reliability of the concussion gold-standard balance test from between 40-60% reliability to over 91% reliability.