AT Accountability

Good morning!

Today I want to talk about accountability and how it applies to athletic training. We all know there are an unlimited number of ways to achieve the same set of rehab goals, so I don’t believe accountability can relate to our individual treatment philosophies and approaches. In my opinion, I see two qualities that can measure the “success” of an athletic trainer in their dealings with patients. Those two qualities being; patient relationship & trust, and the ability to effectively progress a patient back to unrestricted activities. Each of those qualities exist on a spectrum. You can have great relationships or you might struggle to make strong connections with your patients. At the same time you could resolve all injuries effectively and quickly, or you might have patients who keep coming back for the same old thing. For the benefit of our patients, I would think we all strive to make positive connections and get them back to being healthy as effectively as possible. So here is my question I want to address; with so many ways to get to the same end result, how do we “measure” our effectiveness? To what standard do we hold ourselves accountable?

Gray Cook talks about the need for clinicians to own up to their patient outcomes and I completely agree. Some of you might’ve jumped ahead of me, screaming at your screen “Patient Recorded Outcome Measures! Duh!” I would agree. But I might also argue that PROMs are not often very applicable to the athletic setting. In a hospital or orthopedic clinic, PROMs are an obvious way of measuring treatment effectiveness. Most commonly PROMs are simple surveys that the patient will complete on their own accord. Surveys like the “Disabilities of the Arm, Shoulder, and Hand” (DASH), or the “Foot and Ankle Outcome Score” (FAOS) are two popular ones. These surveys provide a patient-based interpretation of their recovery/level of disablement. The information from PROMs can greatly influence the clinician’s decision on treatment or rehab when implemented correctly. The issue I see is that not all PROMs are geared towards athletics, and many of them specifically target the postoperative patient which is the minority of patients treated in the average collegiate athletic training room. The other potential issue I see is that most patient surveys that ask about shoulder-related activities of daily living (reaching for the top shelf, putting on a shirt, pouring a glass of water) don’t address an athlete’s recovery towards something in the high physical demands of sport, something like throwing a 90mph fastball.

In the weight room, athlete progress can be measured a number of different ways. You could consider a measurement of one-rep-max weights for a particular movement. Maybe introduce a Rated Perceived Exertion (RPE) scale to identify the athlete’s impression of the workout. Body weight, Body Mass Index (BMI), Body Fat % are several other “markers” that could be used to assess progress of training in the weight room. Unfortunately, none of these measurements would identify the progression of an injured athlete returning to unrestricted participation. So if PROMs aren’t always applicable and weight room “measurables” aren’t indicative of injury healing, then what can I use to assess my treatment effectiveness?

I began on a quest to find a way to measure treatment effectiveness with my patients. At first I needed to consider all of the factors that play a role in athlete recovery/training. I started thinking about how big of an impact sleep and nutrition can have. I considered an athlete with an upper body injury that might still be performing lower body workouts in the weight room which could affect (positively or negatively) his/her return to full participation. Non-athletic related events can also affect an athlete’s recovery, the stress of exams or trouble with a significant other for example. So how can I isolate the effectiveness of my treatment protocol, and/or combine all of these elements into consideration for tracking the progression of an athlete back to 100%?

After trying to make sense of calculations that might include every factor I could think of (sleep, nutrition, stress, etc.), I reflected on a Dr. Seuss quote, “Sometimes the questions are complicated and the answers are simple.” So I used the simplest answer I could think of to track the effectiveness of my treatments, I just asked my patients to rate them. I started asking my patients for a rating before treatment and a rating after treatment. I used a 0-100 scale in increments of 5. For example I might ask a baseball athlete with shoulder impingement “Using increments of 5 on a 0-100 scale, how are you feeling today in relation to your shoulder?”. I ask this question when they first come into the athletic training facility and again when they leave. With this broad-strokes approach, the athlete is able to take all of the relevant factors into consideration on their own accord. If s/he only slept 4hrs the night before, most likely their rating will drop and reflect that to some extent. I am continuing to collect data to determine a relative scale within the 0-100 range. I anticipate that 75/100 might be lower limit of “I can play through it” but that could change. Using this scale I was able to track athlete progress as well as the effectiveness of my treatments (the difference of their pre/post rating reflects the “effectiveness” of treatment for that day). When an athlete plateaued for a several days, I would reevaluate our treatment plan and if necessary set up an appointment with the team physician. I believe this system kept me accountable to the needs of my patients and I hope to continue tracking these values.

I would love to hear your feedback on this! Do you consistently use any PROM-type measurements? What do you think about accountability in athletic training? How do you evaluate your effectiveness with your patients? Any thoughts on this system I created?

-MD
@MarkDomATC