Context

Research is limited on the extent and nature of the care provided by athletic trainers (ATs) to student-athletes in the high school setting.

Objective

To describe the methods of the National Athletic Treatment, Injury and Outcomes Network (NATION) project and provide the descriptive epidemiology of AT services for injury care in 27 high school sports.

Design

Descriptive epidemiology study.

Setting

Athletic training room (ATR) visits and AT services data collected in 147 high schools from 26 states.

Patients or Other Participants

High school student-athletes participating in 13 boys' sports and 14 girls' sports during the 2011−2012 through 2013−2014 academic years.

Main Outcome Measure(s)

The number of ATR visits and individual AT services, as well as the mean number of ATR visits (per injury) and AT services (per injury and ATR visit) were calculated by sport and for time-loss (TL) and non–time-loss (NTL) injuries.

Results

Over the 3-year period, 210 773 ATR visits and 557 381 AT services were reported for 50 604 injuries. Most ATR visits (70%) were for NTL injuries. Common AT services were therapeutic activities or exercise (45.4%), modalities (18.6%), and AT evaluation and reevaluation (15.9%), with an average of 4.17 ± 6.52 ATR visits and 11.01 ± 22.86 AT services per injury. Compared with NTL injuries, patients with TL injuries accrued more ATR visits (7.76 versus 3.47; P < .001) and AT services (18.60 versus 9.56; P < .001) per injury. An average of 2.24 ± 1.33 AT services were reported per ATR visit. Compared with TL injuries, NTL injuries had a larger average number of AT services per ATR visit (2.28 versus 2.05; P < .001).

Conclusions

These findings highlight the broad spectrum of care provided by ATs to high school student-athletes and demonstrate that patients with NTL injuries require substantial amounts of AT services.

Key Points
  • Among 147 high schools from 26 states, 210 773 athletic training room visits and 557 381 athletic trainer services were reported during the 2011–2012 through 2013–2014 school years.

  • Common athletic trainer services were therapeutic activities or exercise (45.4%), modalities (18.6%), and athletic trainer evaluation and re-evaluation (15.9%).

  • Compared with non–time-loss injuries, patients with time-loss injuries accrued more athletic training room visits and athletic trainer services per injury. However, non–time-loss injuries required a larger average number of athletic trainer services per athletic training room visit.

Over the past 40 years, a variety of surveillance systems have documented the epidemiology of sport-related injuries.15  However, sports injury-surveillance systems have been hindered by 2 main limitations. First, most injuries included in such systems were limited to time-loss (TL) injuries, or those resulting in restriction from participation in sport-related activities for at least 24 hours.2  Second, although the athletic trainers (ATs) who contributed data to these injury-surveillance systems captured in-depth information regarding sport-related injuries, there was no provision within these systems for tracking information on the evaluations, assessments, modalities, and other services provided by ATs for injuries (hereafter termed AT services).

Few authors have attempted to quantify the nature and extent of AT services in the high school6,7  and collegiate settings.8  It is clear that AT or physician coverage in high schools is less prevalent than at the college level.9  However, data are very limited at this point as to the frequency and nature of the services provided by ATs. Systematically documenting AT services, for both TL and non–time-loss (NTL) injuries, is important to obtain a better understanding of the extent to which ATs provide care to student-athletes in the high school setting. The National Athletic Treatment, Injury and Outcomes Network (NATION) project aims to provide a comprehensive examination of all TL and NTL injuries and the associated AT services in the high school setting.5  A previous publication5  detailed the methods for documenting injuries sustained by high school student-athletes via the NATION surveillance program. The purpose of this article is to (1) describe the methods of NATION related to documenting AT services and (2) describe the care provided for TL and NTL injuries reported to NATION in 27 high school sports.

During the 2011−2012 through 2013−2014 school years, NATION captured injury and AT service data for 27 high school sports during preseason, regular season, and postseason practices and competitions.5  Participating ATs, who were responsible for covering practices and competitions that occurred at home and away, were employed at 147 high schools in 26 states. These ATs were either full time or part time and were internally hired or contracted from nearby clinics or university graduate programs. Most of the high schools at which the ATs were employed were public (84.4%), coeducational (98.6%), set in nonurban areas (75.5%; rural = 37.4%, suburban = 38.1%), and enrolled fewer than 1000 students (51.0%).

Data Collection

Rather than create a custom software application, the developers embedded the NATION data-collection tools within commercially available athletic training room (ATR) software.5  Thus, the data collection is seamlessly integrated into routine ATR recordkeeping. Software vendors participating in NATION modified their software and underwent annual certification using benchmarking transmission datasets developed by the Datalys Center for Sports Injury Research and Prevention (hereafter called Datalys Center). They also embedded secure data-transmission protocols that sent deidentified records to secure Datalys Center servers on an ongoing and routine basis.5  This process is Health Insurance Portability and Accountability Act (HIPAA) compliant.

Athletic trainers completed detailed reports on each injury, including condition (eg, site, diagnosis, severity) and circumstances (eg, activity, mechanism, event type [ie, competition or practice], playing surface). They were able to view and update previously submitted information as needed during the course of a season. The data collection also captured the number of ATR visits and the number of AT services provided for each injury.

The AT service data went through the same data quality checks as the injury data, in which data were deidentified and passed through an automated verification process of consistency checks.5  Datalys Center data quality-assurance staff assisted ATs in resolving any concerns about invalid values. The ATs were not compensated for their data-collection efforts.

Definitions

Injury

Injuries that are reported in NATION must have occurred within a school-sponsored sport and must have been evaluated or provided care (or both) by an AT, physician, or other health care professional. A TL injury required the student-athlete to be restricted from participation for at least 24 hours past the day of injury. To be consistent with other surveillance systems,10  the TL injuries also included all dental injuries, fractures, and concussions, regardless of TL. Injuries restricting participation for less than 24 hours were considered NTL injuries.

Athletic Trainer Service

An AT service was defined as the application of any type of manual therapy, modality, exercise and evaluations, testing, or skill session that the player received with interaction of the AT due to the injury or illness. For example, if the student-athlete was provided a hot pack, massage, and stretching, that counted as 3 AT services. If the time spent by the AT was less than 2 minutes, the AT service was not reported.8 

Statistical Analyses

Data were analyzed using SAS Enterprise Guide software (version 4.3; SAS Institute Inc, Cary, NC). Although the injury data presented in our previous publication5  were restricted to school-sanctioned organized varsity competitions and scheduled team practices (about 97.0% of all injury data collected), AT service data are presented for additional event types, such as captain practices, scrimmages, strength and conditioning sessions, skill instruction, and junior varsity competitions. Including these additional sessions offered a more complete picture of the amount of care provided.

We compiled the number of ATR visits and AT services. Services provided by ATs were examined by categories based on previous research.6  We calculated the average number of ATR visits per injury, defined as

formula

where Σ ATR visits is the sum of all ATR visits and Σ Injuries is the sum of all injuries. We also computed the average number of AT services per injury, defined as

formula

where Σ AT services is the sum of all AT services. We last computed the average number of AT services per ATR visit, defined as

formula

where Σ AT services is the sum of all AT services and Σ ATR visits is the sum of all ATR visits. These 3 statistics were calculated overall and for TL and NTL injuries. Statistics for TL and NTL injuries were compared using independent-samples t tests.11  All t statistics yielding P values <.05 were considered statistically significant.

Over the 3-year period (2011−2012 through 2013−2014), boys' sports contributed 1185 team-seasons across 13 sports; girls' sports contributed 1141 team-seasons across 14 sports. Overall, 51 997 injuries were reported, of which 50 604 (97.3%) had AT service data captured. The sports with the largest proportions of injuries with missing AT service data were boys' basketball (10.6%), girls' softball (7.1%), boys' soccer (5.4%), and boys' baseball (5.3%).

Athletic Training Room Visits

In total, 210 773 ATR visits were reported. The majority of ATR visits were for NTL injuries (70.0%) and participants in boys' sports (65.3%). However, this sex disparity was primarily due to football, which contributed 59.5% of all ATR visits in boys' sports. Among boys' sports, football had the highest average number of ATR visits per team (502.92) and per player (6.51; Table 1). Among girls' sports, indoor track had the highest average number of ATR visits per team (164.75) and per player (7.03; Table 1).

Table 1. 

Athletic Training Room (ATR) Visits in High School Sports by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Training Room (ATR) Visits in High School Sports by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Athletic Training Room (ATR) Visits in High School Sports by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Average Number of ATR Visits per Injury

Overall, an average of 4.17 ± 6.52 ATR visits were required per injury (Table 2). The largest average number of ATR visits required per injury in boys' and girls' sports were football (4.74) and indoor track (4.65), respectively. The average number of ATR visits per injury was higher among TL injuries than among NTL injuries, overall, by sex, and among most sports (Table 2). The only exceptions were boys' crew (P = .09), girls' crew (P = .82), girls' swimming and diving (P = .12), and girls' tennis (P = .08).

Table 2. 

Athletic Training Room (ATR) Visits for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Training Room (ATR) Visits for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Athletic Training Room (ATR) Visits for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Trainer Services

In total, 557 381 AT services were provided (Table 3). Therapeutic activities or exercise were the most common type of AT service (45.4%), followed by modalities (18.6%), AT evaluation and reevaluation (15.9%), strapping (9.3%), and neuromuscular reeducation (6.6%). The most frequent specific AT services were independent range of motion (15.2%), consultation (14.8%), ice bag (10.5%), isotonic strength (9.7%), tubing strength (8.8%), and proprioception device (5.5%).

Table 3. 

Types of Athletic Trainer Services for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Types of Athletic Trainer Services for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Types of Athletic Trainer Services for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

The majority of AT services were for NTL injuries (72.8%). Distributions of AT service types varied by sport and whether injuries resulted in time loss or no time loss (Table 4). Most AT services (64.0%) were for participants in boys' sports. Again, this was primarily due to football, which contributed 56.7% of all AT services in boys' sports.

Table 4. 

Athletic Trainer (AT) Services Provided for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Trainer (AT) Services Provided for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Athletic Trainer (AT) Services Provided for Injured Student-Athletes in High School Sports, by Injury Type, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Average Number of AT Services per Injury

Overall, an average of 11.01 ± 22.86 AT services were required per injury (Table 5). The largest average numbers of AT services per injury in boys' and girls' sports were for outdoor track (12.02) and indoor track (13.99), respectively. The average number of AT services per injury was higher among TL injuries than among NTL injuries, overall, by sex, and among most sports. The only exceptions were boys' baseball (P = .22), boys' crew (P = .81), boys' swimming and diving (P = .06), boys' tennis (P = .15), girls' crew (P = .69), girls' softball (P = .11), girls' swimming and diving (P = .81), and girls' tennis (P = .08).

Table 5. 

Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Sport, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Sport, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Sport, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

When comparing the average number of AT services per injury between TL and NTL injuries, findings by AT service type were similar (Table 6). The greatest differences were in therapeutic activities or exercise (7.96 versus 4.44, P < .001) and AT evaluation and reevaluation (4.29 versus 1.27, P < .001). The 1 exception was wound care, in which the average number of AT services per injury for NTL injuries (0.31) was larger than that for TL injuries (0.12, P < .001).

Table 6. 

Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Type of AT Service, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Type of AT Service, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014
Athletic Trainer (AT) Services per Injury and per Athletic Training Room (ATR) Visit, by Type of AT Service, National Athletic Treatment, Injury and Outcomes Network (NATION), 2011−2012 Through 2013−2014

Average Number of AT Services per ATR Visit

Overall, an average of 2.24 ± 1.33 AT services were provided per ATR visit (Table 5). The largest average numbers of AT services per ATR visit in boys' and girls' sports were for golf (4.39) and lacrosse (2.53), respectively. The average number of AT services per ATR visit was higher among NTL injuries than among TL injuries, overall and by sex (all P < .001). The average number of AT services per ATR visit varied by AT service type (Table 6). There was more AT evaluation or reevaluation and greater use of treatment modalities, such as hot or cold packs and strapping, for TL than NTL injuries.

The purpose of this study was to comprehensively document AT services provided for TL and NTL injuries in the large sample of schools included in the NATION surveillance program. To care for injured student-athletes, ATs in our study provided a variety of services that included evaluation, modalities, strapping, and wound care. The findings draw attention to the high volume of services provided by onsite ATs. Such staff may help to reduce the burden of care provided in other settings such as hospitals, emergency departments, and specialty clinics.12  Additionally, there is a large productivity gain for the parents of injured student-athletes, who would have to take time to transport their children to other service providers if ATs were not present in the schools.

Common AT Services

Our results regarding the most common services provided by ATs varied from previous results of the Athletic Training Practice-Based Research Network (AT-PBRN),6,7  which also examined the high school student-athlete population. Although therapeutic activities or exercise, AT evaluation and reevaluation, and hot or cold packs were the most common AT services used, research from the AT-PBRN demonstrated larger proportions of AT evaluation and reevaluation services (45.9%6  and 53.9%7  versus 18.6%) and smaller proportions of therapeutic activities or exercise (15.3%6  and 5.7%7  versus 45.4%). Like the AT-PBRN, our study used electronic medical record systems to collect injury and treatment data. However, differences may be attributable to varying school-related characteristics. For example, most high schools in NATION were in nonurban areas (75.5%), whereas most high schools in the study by Lam et al6  were in urban areas (71%). As a result, continued research within different high school populations will help to identify commonly used AT services.

The use of hot and cold packs may be the result of the AT practice setting. Heat is often used to warm tissue before activity, and ice (cold) treatments are commonly used to combat the effects of inflammation after activity. Most physical therapy practices work with patients who have subacute or chronic conditions, in whom activity-related inflammation is less of a concern. Therefore, usage patterns for these services appear to suggest appropriate care patterns.

According to the American Physical Therapy Association, passive physical agents, such as modalities, should be used only as an evidence-based facilitation to an active rehabilitation program (ie, therapeutic activities and exercises).13  Both our findings and those of Lam et al6  indicate that ATs are following this guideline. Our results show that the number of therapeutic activities or exercise services was more than double that of modality services. This suggests that ATs are either (1) more often than not, conducting rehabilitation without the use of modalities or (2) using modalities in conjunction with an active rehabilitation program.

Comparison With College-Level Treatment Data

Our study was similar to a previous study8  that examined AT services provided to collegiate student-athletes who sustained sports injuries during the 2000−2001 and 2001−2002 academic years. Powell and Dompier8  noted that 52.6% and 66.1% of AT services in men's and women's sports, respectively, were provided for NTL injuries. Over 3 seasons of high school sports, we found higher percentages for boys and girls (69.8% and 78.1%, respectively). Also, the average number of treatments for boys and girls was similar to that described by Powell and Dompier,8  although we estimated a lower average number of treatments for TL injuries. These differences may be attributable to variations in playing level and study period, as well as in the distributions of student-athletes by sport within the study populations. Also, because many high school student-athletes do not have access to a full-time AT,9  they may seek therapy offsite.12  This contrasts with collegiate student-athletes, who have access to a full-time AT and may receive onsite care.

Comparisons Between TL and NTL Injuries

The average number of ATR visits and AT services per injury were higher among TL than among NTL injuries. In particular, TL injuries required more therapeutic activities or exercise and AT evaluation and reevaluation. These findings emphasize the severity of injuries that result in TL, which may require further examination and more extensive rehabilitation than NTL injuries. At the same time, the average number of AT services per ATR visit was higher for NTL than for TL injuries, which highlights the amount of care that ATs provide to manage certain injuries so that they do not result in TL and the athlete is able to remain active. Many injuries require ongoing management throughout a season or high school career in spite of the athlete's ability to return to full participation. Some of the services provided for NTL injuries may be related to ongoing maintenance and prevention of reinjury.

Our findings document the enormous volume of care and management that ATs provide to student-athletes. At the same time, it is important to realize that not all high schools have access to ATs.9  These results may not be representative of the typical US high school setting. If no AT is available, then high school student-athletes and their parents are forced to seek care elsewhere in the health care system, which results in more inconvenience and greater costs, difficulties in care coordination, and challenges in communicating an athlete's participation limitations to coaches. In some settings, the evaluation and management of acute injuries may thus fall upon coaches or part-time volunteer health care providers, who may have varying levels of first-aid knowledge.14,15 

Numerous factors may have influenced the reported AT services documented in this study. Overall staffing and athlete-to-AT ratios may limit the amount of hands-on treatment, such as manual therapy, that can be provided. Barriers may also exist because of the cost of certain equipment, such as ultrasound. Some high school ATRs may also be restricted by size; if only a few tables are available, athletes may have to share them while receiving different services. In addition, the services ATs can provide may be limited by the practice act in their state and standard operating procedures. At the same time, the AT services reported in this study may not include those services outsourced to other health care practitioners, such as physical therapists and chiropractors. For example, we found low use of manual therapy by ATs in the high school setting. The ATs, physicians, and parents may send student-athletes to other health care providers for such services, or they may not have the time and staff resources to provide manual therapy and instead give student-athletes activities they can perform on their own. Future researchers may benefit from examining outsourced services in addition to in-house AT services to better describe the care injured student-athletes receive. Qualitative findings could better describe the barriers to providing certain types of services. Furthermore, examining differences in the provision of AT services by full-time, part-time, and outreach ATs is warranted.

Other limitations exist in our study. Our injury definition was designed to collect the range of injuries that are seen by ATs and other team medical staff. However, it is possible that our definition did not account for some injuries, particularly those that student-athletes felt did not require presentation to ATs. Our data collection of AT services may have also missed other aspects of care and management provided to injured student-athletes, including prevention initiatives and emergency transport. As noted earlier, our findings may not be generalizable to high school sports programs without access to ATs. Both our study and the previous studies6,7  examining care in the high school sports setting addressed schools with onsite ATs. Recent investigators9  noted that 55% of high school student-athletes have access to a full-time AT. Our study did not account for outsourced services, differences within the type of AT coverage (eg, full time versus part time versus outreach, larger versus smaller staff sizes), or duration of care. We did not assess barriers (eg, cost) to providing certain types of AT services. Surveying ATs regarding their practice patterns may have provided information about what their ideal injury-management protocol would have been had such barriers not been present. Finally, although these findings suggest the benefits of having an onsite AT, future researchers must directly compare sport settings with and without AT coverage to determine their effect on the care of injured athletes.

A wide variety of AT services are used to care for athletes with sport-related injuries sustained in the high school setting. Although AT services vary by sport and between TL and NTL injuries, our results suggest that NTL injuries require substantial AT services and highlight the extensive volume of care that ATs provide to student-athletes. These data also suggest that ATs use appropriate forms of care such as therapeutic activities and exercise, the volume of which is likely driven by the high number of ATR visits per AT. Future investigation is needed to examine barriers to providing services and differences by AT employment status and to explore the long-term effects of providing AT services on injured student-athletes.

This study would not have been possible without the assistance of the many high school athletic trainers who participated in the program. This project was funded by the National Athletic Trainers' Association Research and Education Foundation (NATAREF) and the Central Indiana Corporate Partnership (CICP) Foundation in cooperation with BioCrossroads. The content of this report is solely the responsibility of the authors and does not necessarily reflect the views of the NATAREF, CICP Foundation, or BioCrossroads.

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