NATA BOC Role Delineation (modified)

II.      Classification System of Domains, Tasks, and Knowledge and Skill Statements

This section of the report contains the domains, tasks, and knowledge and skill statements as delineated by the role delineation study panel of experts and validated with data from the role delineation study survey described later in this report. Each domain begins with a summary of athletic training literature defining the domain and describing current practice and trends.

Domain I.            Prevention

Domain II.           Clinical Evaluation and Diagnosis

Domain III.          Immediate Care

Domain IV.         Treatment, Rehabilitation, and Reconditioning

Domain V.           Organization and Administration

Domain VI.         Professional Responsibility

Performance Domain I: Prevention

Prevention is defined as the ability to discern, evaluate, and communicate risk associated with participation in athletic and physical activities. In this sense, risk is defined as “exposure to the chance of injury or loss; a hazard.”¹³⁰ Athletic activities have been classified by degree of risk,^{88, 31} and it is noteworthy that participants and/or their guardians must acknowledge that a certain degree of risk, termed the individual assumption of risk, that narrows the scope of prevention measures that can be employed by Athletic Trainers-Certified (ATC).^{44, 76}

Basic human anatomy, physiology,^{57, 123} and biomechanics^{40, 58} serve as the cornerstone for understanding injury/illness risk and mechanisms. ATCs also require knowledge related to the epidemiology¹⁰² and pathophysiology^{53, 69} of common and catastrophic injuries and illness.^{48, 84, 137} Of particular importance, the catastrophic consequences of HIV, hepatitis, and other infectious diseases must be addressed and prevented.^{80, 97} Additionally, recent attention has been given to the detrimental physiological and psychological effects of overtraining¹²⁰ as new theories¹²⁴ support long-term consequences; and while they may not be catastrophic, must be prevented or at least minimized. Injury databases are helpful in communicating statistical probabilities to appropriate individuals.^{83, 101, 104}

Recent attention to the catastrophic effects of neurological or brain injury in physical activities merits specific attention because some concepts relevant to the Prevention domain (such as risk,^{64, 138} return-to-play criteria,⁹⁰ and second-impact syndrome^{39, 81, 139}) are still subject to debate,³³ and only one text is available that addresses sports neurology.⁶⁵ Additionally, the sudden deaths of several well-known sports figures in recent years^{1, 100} emphasizes the need for ATCs to be aware of the risk and prevention of sudden death, typically because of cardiovascular failure. This means that ATCs need to know the recommendations for determining eligibility for competition in athletes with cardiovascular abnormalities.⁵

The prevention of injury and illness challenges the ATC to understand and use preventive measures to ensure the highest quality of care for every individual athlete. While the knowledge and skills in prevention are broad and overlap somewhat with the other domains of athletic training, their designation as a separate domain in the Role Delineation Study reflects the importance of and priority given to the prevention of injury and illness.

Responsibilities in Prevention in the current Role Delineation Study differ from those of previous studies in that the scope of the activities has broadened considerably in recent years. This change reflects significant progress in sports and medical research and technology, including the expanded authority of governing bodies in today’s allied health professions, the increased participation of a wide variety of individuals (especially women), and expansion in the type of events, practices, and physical activity.⁸⁸

A.  Educate the appropriate individual(s) about risks associated with participation and specific activities using effective communication techniques to minimize the risk of injury and illness.

At the same time, the variety of individuals with whom an ATC must communicate regarding risk and prevention has expanded. These individuals, termed “appropriate” in the domain, are associated with (1) the sports medicine team,^{31, 29, 126, 136} (2) the clinical setting,⁶⁷ and (3) fitness facilities.¹¹ ATCs also communicate risk because of legal considerations.^{30, 118}

Communicating the risk of participation assumes knowledge of both common and catastrophic risk, as well as their mechanisms of injury or illness. While there is merit in separating the common from catastrophic in prevention, most text resources address both types, with more attention given to common injuries or illnesses involving the musculoskeletal, neurological, and respiratory systems.^{31, 50, 67, 75, 110, 115} A few noteworthy texts address the pediatric population.^{36, 66 134}

The prevention of nutritional disorders^{12, 96, 133, 2, 10, 17} and use of dietary supplements⁸⁷ among physically active individuals have become standard activities for ATCs. Likewise, ATCs need to understand substance abuse when used for both social⁹⁸ and performance enhancement.^{8, 34} The use of pharmacological agents in the athletic training room has drawn considerable attention in risk management, whether from a safety,^{99, 103, 119} prevention,^{42, 79} or legal⁶¹ perspective. The ability to communicate these risks to appropriate individuals depends on knowledge of medical risk terminology,^{41, 51, 78} management strategies,^{30, 59, 67, 118} governing and legal bodies,^{35, 49} and most recently, federal privacy regulations^{94, 95, 111} and reimbursement issues.²⁶

B.  Interpret preparticipation and other relevant screening information in accordance with accepted guidelines to minimize risk of injury and illness.

The Prevention domain categorizes risk into three general areas: (1) physiological or health related, (2) environmental (including facilities), and (3) equipment related. Each area requires a preparticipation evaluation based on existing guidelines and current state of practice.

Preparticipation health and fitness screening prior to physical activity has become one of the single most important prevention measures to reduce the incidents of catastrophic injury or illness.¹⁹ While the 2002 Arnheim & Prentice ³¹ text provides a general overview of the components involved in preparticipation screening as do other athletic training texts, only a few noteworthy references exist relating to disqualifying criteria¹²¹ and cardiovascular screening.¹¹⁶ The value of preparticipation examination information for children is addressed in journal articles.^{28, 37, 85, 86} Likewise, preparticipation criteria exist for special populations that require special considerations, including pregnant women,³² physically disabled athletes, ⁴⁵ and individuals with chronic diseases and disabilities.^{22, 134} Cardiovascular,^{15, 77} respiratory,^{73, 122} diabetic,¹⁶ and drug⁷⁴ screening guidelines have been published that specifically address these medical concerns in the athletic population, rather than in the general population.

C.  Instruct the appropriate individual(s) about standard protective equipment by using effective communication techniques to minimize risk of injury and illness.

D.  Apply appropriate prophylactic/protective measures by using commercial products or custom-made devices to minimize risk of injury and illness.

Risk associated with sport and physical activities can be addressed through the application of standard or commercial protective/prophylactic equipment and products. This aspect of prevention is well documented in most athletic training textbooks. However, other references supplement these texts and are discussed in the following paragraphs. Prevention requires that the ATC be knowledgeable about these products: their intended purpose,^{3, 27, 70, 114, 127} limitations,^{43, 128} and capabilities for protection in specific sports and physical activities;⁵⁵ the rules governing their use; and the guidelines, standards,¹⁰⁶ and/or recommendations for their use by a host of governing bodies. Additionally, the health⁶³ and legal risks of using,¹²⁵ reconditioning,⁵⁶ and/or altering the structure^{35, 49} of these products in any way must also be identified.

 E.  Identify safety hazards associated with activities, activity areas, and equipment by following accepted procedures and guidelines in order to make appropriate recommendations and to minimize the risk of injury and illness.

ATCs have long had responsibility for identifying safety hazards in activity areas and equipment. Other professionals, such as athletic directors, facility and equipment managers, and game officials also share this responsibility.^{11, 91} Thus, policies and procedures for identifying and correcting hazards must be known by all ATCs.⁶ Knowledge of the facilities and/or equipment required for specific activities as well as the rules governing play or participation in those areas and with the equipment are required.^{102, 105} Common hazards, such as surface, obstructions, moisture, foreign bodies, lighting, and broken equipment, must be identified and corrected.^{31, 91} ATCs may soon be active in identifying safety hazards related to the newly popular sports of mountain biking⁷¹ and snowboarding.¹²⁹ Transmission of infectious diseases is also included in this aspect of the Prevention domain.¹³²

F.   Maintain clinical and treatment areas by complying with safety and sanitation standards to minimize risk of injury and illness.

Numerous local, state, national, federal, and institutional bodies have established standards and regulations to ensure safe and sanitary conditions in treatment and clinical areas used by ATCs and other healthcare professionals.^{97, 107, 108, 109, 112, 113} It is the responsibility of the ATC to know and comply with these standards and regulations. Additionally, ATCs are required to comply with the guidelines of any and all manufacturers of equipment used in those areas.^{24, 49} Safety standards are further enhanced with the recent availability of automated external defibrillators in health and fitness facilities.²⁰

 G. Monitor participants and environmental conditions by following accepted guidelines to promote safe participation.

Environmental and ambient conditions can impose additional risk on individuals participating in outdoor activities.³⁸ Risk is even greater when participants present with conditions that predispose them to environmental injury or illness.^{22, 122} ATCs must identify, monitor, and control the risk imposed by the environment, especially for at-risk participants. Established standards and policies and procedures can assist the ATC in this task.^{4, 7, 8, 89, 92, 93}

H.  Facilitate physical conditioning by designing and implementing appropriate programs to minimize injury risk.

With an increase in the number of participants and activity events, and with the presence of ATCs in non-traditional roles, the importance of designing and implementing physical conditioning programs cannot be underestimated. This component of prevention is essential to reduce the risk of injury or illness, yet attention given this area may be declining with the advancing specialization of other healthcare professionals. ATCs are required to know the physiological adaptations to exercise^{38, 62} and the components of safe and effective physical conditioning^{13, 14, 19, 72} and strength training^{21, 25, 68, 117} programs. The ATC should also be aware of the potential for overtraining.^{47, 120} Knowing and complying with legal considerations for designing and implementing conditioning programs is also the responsibility of the ATC.⁶⁰

I.    Facilitate healthy lifestyle behaviors using effective education, communication, and interventions to reduce risk of injury and illness and promote wellness.

Although individuals who participate in sports or regular physical activities are likely to improve their overall health, they may remain at risk for other leading causes of death because of non-healthy lifestyle behaviors. The negative influence of non-healthy lifestyle behaviors (such as smoking, poor diet, and stress on the cardiovascular system), may negate any positive changes made through regular exercise program participation. As a healthcare team member, ATCs are obligated to educate and encourage wellness and healthy lifestyle behaviors in the individuals they treat. Many nutrition and exercise-related texts are available;^{113, 133} however, publications specifically addressing methods for how the ATC should implement wellness promotion into daily practice are relatively less abundant.^{18, 54, 82} Intervention strategies for reducing substance abuse among clients are also available.^46,52

Performance Domain II: Clinical Evaluation and Diagnosis

The responsibilities of Athletic Trainers-Certified (ATC) in evaluation and diagnosis of injuries and conditions follow standardized clinical practice in the area of diagnostic reasoning and medical decision making. There are four basic types of evaluations described in the athletic training literature: 1) the preparticipation evaluation performed prior to physical activity to determine possible medical conditions that might limit or endanger the participant; 2) the on-field evaluation that emphasizes the immediate course of acute care and determination of emergency situations; 3) the off-field evaluation that involves a more detailed evaluation of the involved body part, typically performed in the athletic training room or clinic; and 4) a progress evaluation performed to determine the progress of the rehabilitative process or determination of return to play.^{1, 2} Understanding the pathomechanics and predisposing factors of an injury assists ATCs in their evaluation of the injury, illness, or condition.^3-5 In the absence of a physician, the ATC’s diagnosis is critical to the proper management of the injury, illness, or condition.^{1, 2, 6}

The literature uses the terms evaluation and assessment interchangeably. Assessment generally refers to the process of determining the nature and severity of an injury. By comparison, evaluation is the systematic process that allows the athletic trainer to make judgments during the assessment.^1-7 Diagnosis is the determination of a disease or condition by a scientific evaluation of physical signs, symptoms, history, laboratory test results, and procedures. Arriving at a diagnosis involves the application of the scientific method of formulating objective conclusion about the individual’s condition.⁸ The initial step in medical decision making process for the athletic trainer includes recognizing the site, nature, and severity of the injury.⁷ This step includes recognizing such matters as the mechanics of injury, the posture of the individual, and other external factors that may have an effect on the injury or condition. Recognition may take place prior to the formal assessment and continues throughout the entire process as various signs and symptoms are revealed.⁷

The literature supports the use of a standardized format for the process in the initial evaluation, whether it is the on-field primary assessment or off-field initial assessment.  Most sources suggest using the History, Inspection/Observation, and Palpation and Special Tests format in performing an evaluation leading to a diagnosis.^{1, 7, 9-11} Through this method, data is collected, hypotheses are formed, and objective conclusions are reached to accept or reject a possible diagnosis. It is possible to have more than one differential diagnosis until more data is collected using special tests, laboratory tests, etc. This list of possibilities may expand or contract during the evaluation.

The ATC is competent in the recognition, evaluation, and assessment of athletic injuries, illnesses, and conditions. This process includes the knowledge and ability to perform the following seven tasks.

A.  Obtain a history through observation, interview, and/or review of relevant records to assess the pathology and extent of the injury, illness or condition.

The medical history is one of the most important aspects of assessing an injury or illness.^{2, 11-13} The history should include an interview of the athlete to determine the chief complaint, areas and amount of discomfort or pain, any unusual symptoms, and whether there is a reduced ability to perform specific motor skills. ^{12, 14} Several authors indicate that acquiring knowledge of the specific mechanism of injury and understanding the mechanisms associated with the activity are the most important objectives during the history-taking process.^{1, 2, 13, 15} Recognizing various symptoms revealed during the history helps to guide the rest of the evaluation process.^{2, 7-8, 14-16}

The on-the-scene history differs from the history taken in a controlled environment. On the scene, the individual may not always be able to give a coherent interview and an account may be needed from bystanders. A primary history should include the location of pain, presence of radicular symptoms, mechanism of injury, associated sounds and symptoms, and any relevant previous injury history to the body part.²

The history of general medical conditions requires a more thorough investigation into the symptoms, duration, and exacerbation of the condition. Cultural factors must also be taken into consideration when completing a medical history. ^{3, 4, 8, 14-16} Because the athletic trainer has taken on a greater role in the general healthcare of the athlete, ATCs must be familiar with evaluation of general medical conditions as well as orthopedic injuries. ATCs must also recognize the differences in injuries for various populations such as the adolescent participant, the female participant, the mature individual, and t