Continuing Education Practices of Athletic Trainer’s and Confidence and Knowledge of Concussion Management A THESIS Submitted to the Faculty of the School of Graduate Studies and Research of California University of Pennsylvania in partial fulfillment of the requirements for the degree of Master of Science by Zak M. Christie Research Advisor, Dr. Linda Platt Meyer California, Pennsylvania 2013 ii iii ACKNOWLEDGEMENTS I would like to take this time to identify individuals whom have helped me throughout this research process. Without them, I would not have been able to complete my research. My family (Mom, Dad, Papou, Grandma, Dan, Cody and Kristina) without a doubt is the largest support system I have. Without their encouragement I would not have believed in myself enough to finish, words cannot describe my gratitude and love. I would also like to thank my committee members for the time and feedback that they have given me. Dr. Mike Meyer and Dr. Will Biddington provided me with incredible wisdom, and It has allowed me to be proud of this document. I want to especially thank Dr. Linda Platt Meyer, she has been an inspiration to work with, and the best chair/ mentor a graduate student could hope for. If anything I will look back at this research process with fond memories of her encouragement and direction. It fills me with encouragement that there are AT’s like my committee still promoting our profession. iv TABLE OF CONTENTS Page SIGNATURE PAGE . . . . . . . . . . . . . . . ii AKNOWLEDGEMENTS . . . . . . . . . . . . . . . iii TABLE OF CONTENTS LIST OF TABLES INTRODUCTION METHODS . . . . . . . . . . . . . . iv . . . . . . . . . . . . . . . vi . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . 4 Research Design . . . . . . . . . . . . . . 4 . . . . . . . . . . . . . . . . . 5 Preliminary Research. . . . . . . . . . . . . 5 Instruments . . . . . . . . . . . . . . . . 6 Procedures 7 Subjects . . . . . . . . . . . . . . . . Hypothesis . . . . . . . . . . . . . 8 . . . . . . . . . . . . . . . 8 . . . . . . . . . . . . . . . . . . 9 Demographic Data . . . . . . . . . . . . . . 9 Data Analysis RESULTS Hypothesis Testing . . . . . . . . . . . . . . . . . 13 Additional Findings . . . . . . . . . . . . . 16 DISCUSSION . . . . . . . . . . . . . . . . . 17 Discussion of Results . . . . . . . . . . . . 17 Conclusions . . . . . . . . . . . . . . . . 21 Recommendations. . . . . . . . . . . . . . . 21 v REFERENCES . . . . . . . . . . . . . . . . . 23 APPENDICES . . . . . . . . . . . . . . . . . 27 APPENDIX A: Review of Literature . . . . . . . . 28 Introduction . . . . . . . . . . . . . . . . 29 Etiology . . . . . . . . . . . . . . . . . 30 Validity Testing . . . . . . . . . . . . . . 33 Management Styles . . . . . . . . . . . . . . 42 Athletic Training Education . . . . . . . . . . 44 Measuring Confidence . . . . . . . . . . . . . 47 Summary . . . . . . . . . . . . . . . . . . 49 APPENDIX B: The Problem . . . . . . . . . . . . 51 Statement of the Problem . . . . . . . . . . . 52 Definition of Terms . . . . . . . . . . . . . 54 Basic Assumptions . . . . . . . . . . . . . . 54 Limitations of the Study . . . . . . . . . . . 55 Significance of the Study . . . . . . . . . . 55 APPENDIX C: Additional Methods . . . . . . . . . 57 IRB: California University of Pennsylvania (C1) . . 58 Letter to Panel of Experts (C2) . . . . . . . . 72 Concussion Knowledge and Confidence Survey (C3) . . 74 Cover Letter (C4) . . . . . . . . . . . . . 85 References . . . . . . . . . . . . . . . . . 88 ABSTRACT . . . . . . . . . . . . . . . . . 92 vi LIST OF TABLES Table Title Page 1 Range of Age . . . . . 2 Gender. . . . . . . . . . 3 Years Working as an AT . . . . . . . . . . . . . . 10 . . 10 4 Work Setting . . . . . . . . . . . . . 10 5 NATA District 11 6 Level of Education . . . . . . . . . . 11 7 Credential(s) Held . . . . . . . . . . 12 8 Independent Statistics: Independent Statistics: Independent Statistics: Independent Statistics: . . . . . . 9 . . . . . . . . . . . . . t-test group Knowledge . t-test group Knowledge . t-test group Confidence . t-test group Confidence . . . . . . . . . 14 . . . . . . . . 14 . . . . . . . . 15 . . . . . . . . 15 12 Confidence Measurement 1 . . . . . . . . 15 13 Confidence Measurement 2 . . . . . . . . 15 14 Confidence Measurement 3 . . . . . . . . 16 15 mTBI vs. Concussion . . . . . . . . . . 16 9 10 11 1 INTRODUCTION The increased worth that the public has put on athletics has increased the intensity of the games along with the risks that accompanies them. One of these risks is concussion, a form of brain injury. The Centers for Disease Control (CDC) reports that over 1.7 million people suffer from concussions annually.1 The high rate of occurrence brings attention to the people that are on the front line of concussion evaluation, management and treatment. The Athletic Trainer (AT) is the front line health care professional. Athletic training education must make ATs confident in situations when they are placed in stressful situations when dealing with concussions. There are multiple diagnostic tools that ATs can use to help in their recognition and management of concussion. These tools range from the traditional models2,3,4,5 to the newer computer-based neurocognitive testing which allows for quantitative variables. 6,7,8,9,10,11,12 These tools can contribute to the ATs’ confidence level in assessing severity and making return-to-play decisions.13,14 2 Because there is such a high rate of occurrence of concussions in athletics, it is imperative that ATs are confident in their own abilities. It is also equally important that ATs be familiar and up-to-date with the most recent concussion protocols. The most current and highly respected concussion protocol is addressed in the 2009 Zurich Consensus Statement on concussion in sport.14 Continuing education awareness stands as one of the strongest tools ATs have in regards to managing concussions properly.12-18 It is crucial that all ATs are aware and practicing current concussion management. Another important and overlooked aspect of athletic training is the level of confidence that practitioners have. Building confidence is an important aspect of clinical education. Progressing students to a confident level of medical practice should be one of the main goals of the academic institutions. A study conducted by Hecimvich and Volet19 examined the progress of chiropractic students’ confidence before and after their clinical internships. After their clinical internships, both patient communication and clinical skills increased significantly. The study highlighted the contributing factors in building confidence and found that taking a proactive, hands-on approach is the most beneficial. Confidence typically 3 increases with experience, though it is still important for newly-certified ATs to portray confidence and feel certain when dealing with concussions in the field. The purpose of this study is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. This study additionally will evaluate current knowledge of concussion protocols. By surveying ATs throughout the ten districts of the National Athletic Trainers’ Association (NATA), a better understanding can be made of what educational factors increase ATs' confidence in regards to concussion. From these conclusions, possible changes in athletic training continuing education programs can be adapted to improve confidence levels when managing concussion. This segment of the study will also allow the researcher to spot-check the profession for up-to-date practice techniques for concussion management. 4 METHODS The purpose of this is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. Additionally, this study evaluates current knowledge of concussion protocols. This section includes the following sections: Research Design, Subjects, Instruments, Procedure, and Data Analysis. Research Design A descriptive design was used for this study. The dependent variable is the confidence and knowledge of ATs in regards to concussion management. The independent variable was continued education participation that ATs have with regards to concussion. 5 Subjects One-thousand ATs were asked to volunteer by taking a survey for this study. Subjects (N=1000) were randomly selected from the ten districts through the NATA database. Subjects implied informed consent with the completion and return of the survey. Participation in the study was voluntary based upon completion of the survey. The study was approved by the Institutional Review Board (Appendix C1) at California University of Pennsylvania prior to launching the survey. Preliminary Research A panel of experts was organized before any research was conducted (Appendix C2). The panel consisted of ATs with experience and knowledge of concussions and survey research construction. The panel members were sent the Concussion Knowledge Survey and instructions on their responsibilities regarding the survey. The panel members reviewed the survey instrument and cover letter. They added to the content validity and made recommendations for improvement. After reviewing the survey, the panel members 6 provided critiques and changes that were reviewed for potential revision to the instrument. Necessary changes were made to the survey based on critiques by a panel of experts. Instruments An original survey was created and entitled “Concussion Knowledge and Confidence Survey.” The survey is found in Appendix C3. The survey consists of questions regarding overall confidence level in concussion evaluation, evaluation techniques, managing tools, any deficiencies perceived by the AT, and utilized return-toplay protocols. The data was automatically collected by SurveyMonkey® and placed into spreadsheet format for the researcher to utilize in analysis. The survey consisted of 36 questions and required ten minutes to complete. Variables were measured by exploring the effects of educational experiences and current knowledge ATs have on concussion. A cover letter explaining the risks involved, informed consent and instructions of the confidence and knowledge study also accompanied the survey (Appendix C4). 7 Procedures A cover letter with a link to the concussion confidence survey was distributed via e-mail to a random sample of ATs by the NATA via SurveyMonkey.com, a web-based survey program. The researcher allowed three weeks for the ATs to complete the survey. Once a week, during the three weeks, a follow up e-mail was sent to the survey subjects explaining the study and providing a link to the survey. This e-mail was to remind the subjects the survey was still open and able to be completed. The e-mail also stated if the subject had already taken the survey, they do not need to take it again. Once the surveys were completed, the answers were submitted back through SurveyMonkey.com. The web server program automatically organized, calculated, and placed all data in an Excel spreadsheet for import to SPSS 18.0. Data analysis was then performed on the survey results after the three week submission period had passed. 8 Hypothesis The following hypothesis is based on previous research and the review of the literature. 1. There will be a difference between participants who identified themselves as likely to search for peerreviewed literature on concussion management and those participants who did not identify themselves in seeking out new literature for concussion management knowledge. Data Analysis All data will be analyzed by SPSS version 16.0 for windows at an α level of 0.05. The research hypothesis was analyzed using t-test to measure for means. 9 RESULTS The purpose of this study is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. By surveying a random sample of ATs through the NATA, the profession can identify possible trends and/ or deficiencies in regards to concussion management. Demographic Information One thousand Athletic Trainers were asked to volunteer to take an original survey for this study. Out of the 1,000 Athletic Trainers, 16.9% (N=169) responded to the survey. Table 1 represents the ages of the ATs surveyed. Table 1. Range of age Age 18-22 23-27 28-32 33-37 38-42 43-47 48-52 53-57 >57 Frequency Percentage 4 45 32 22 20 14 13 6 13 2.3 26.6 18.9 13.0 11.8 8.2 7.6 3.5 7.6 10 Table 2 represents the gender of the surveyed ATs. Table 2. Gender Gender Female Male Frequency 93 76 Percentage 55.0 45.0 Table 3 represents the range number of years practicing as a Certified Athletic trainer in this study. Table 3 Years working as an AT. Years Frequency 0-1 6 1-5 48 5-10 27 10-15 29 20-25 28 >25 31 Percentage 3.6 28.4 16.0 17.2 16.6 18.3 Table 4 represents the current work setting of the surveyed ATs in this study. Table 4 Work Setting Setting College/ University Hospital/ Clinical Occupational/ Industrial Military Performing Arts Professional Sports Public Safety Clinic/ Secondary School Hospital/ Secondary School Other Frequency 60 Percentage 35.5 14 8.3 4 2.4 0 0 4 0 0.0 0.0 2.4 0.0 43 25.4 9 35 5.3 20.7 11 Table 5 represents the NATA district that the surveyed AT is currently working . Table 5. NATA district District 1 2 3 4 5 6 7 8 9 10 Frequency 16 31 22 36 7 9 9 12 19 8 Percentage 9.5 18.3 13.0 21.3 4.1 5.3 5.3 7.1 11.2 4.7 Table 6 represents the highest level of education of the surveyed AT. Table 6. Level of education Degree Frequency Bachelors 49 Masters 108 Doctorate 11 Other 1 Percentage 29.0 63.9 6.5 0.6 12 Table 7 represents the credentials which the AT surveyed holds. Table 7. Credential(s) held Credential Frequency ATC 165 EMT 9 PA-C 0 RN 0 LPN 0 Nurse Practitioner 0 LMT 2 DC 0 DPT 2 CSCS 16 PES 9 Not Available 0 Other 34 Percentage 97.6 5.3 0 0 0 0 1.2 0 1.2 9.5 5.3 0 20.1 13 Hypothesis Testing The following hypothesis was tested in this study. The hypothesis was tested with a level of significance set at an α ≤ 0.05. A t-test was used for statistical measurement. Hypothesis: There will be a difference between participants who identified themselves as likely to search for peer-reviewed literature on concussion management and those participants who did not identify themselves in seeking out new literature for concussion management knowledge. An independent test was calculated comparing the mean score of participants who identified themselves as likely to search for peer-reviewed literature on concussion management to the mean score of those participants who did not identify themselves in seeking out new literature. Conclusion: In regards to concussion management knowledge, no significant difference was found ((t147 = .341, p>.05). The mean of the likely group (8.633 ± 1.32) was not significantly different from the mean of the nonlikely group (8.550 ± 1.29). Therefore, there is no difference between the knowledge of those individuals who are likely to seek out peer reviewed literature and those 14 who do not seek out peer reviewed literature. This is represented by Tables 8 and 9 below. Table 8. Independent t-test group statistics: Knowledge Group Number of Mean SD Not Likely Likely 40 8.55 1.29 109 8.63 1.32 Table 9. Independent t-test group statistics: Knowledge Classification t df Sig. Percentage(Equal Variances assumed) -.341 147.0 .891 No significant difference was found in regards to concussion management confidence (t(152)= .328, p>.05). The mean of the likely group (M= 11.50, SD= .983) was not significantly different from the mean of the non-likely group (M= 11.56, SD= .838) in regards to concussion management knowledge. Therefore, there is no difference between the confidence of those individuals who are likely to seek out peer reviewed literature and those who do not seek out peer reviewed literature. This is represented by Tables 10 and 11 below. 15 Table 10.Independent t-test group statistics: Confidence Group Number of Mean Std. Error Subjects (SD) Mean Not 41 11.56 .130 Likely (.838) Likely 113 11.50 .092 (.983) Table 11. Independent t-test group statistics: Confidence Classification t df Sig. Percentage(Equal Variances assumed) .328 152.0 .617 Confidence in the subjects was determined by a total of three questions, using a four point likert scale. These results are represented by Tables 12, 13, and 14 below. Table 12. How confident are you in recognizing the signs and symptoms of concussion? District Frequency Percentage Very Confident 139 89.1 Somewhat Confident 15 9.6 Not Confident 0 0.0 Very Unconfident 2 1.3 Table 13. How confident are you in describing the mechanism(s) of injury for concussion? District Frequency Percentage Very Confident 132 84.6 Somewhat Confident 24 15.4 Not Confident 0 0.0 Very Unconfident 0 0.0 16 Table 14. How confident are you in preforming a sideline evaluation of concussion? District Frequency Percentage Very Confident 128 82.1 Somewhat Confident 26 16.7 Not Confident 1 0.6 Very Unconfident 1 0.6 Additional Findings Findings that were also noteworthy to the study were found in the knowledge assessment portion of the survey. The survey asked the ATs if the terms “mild traumatic brain injury (mTBI)” and “concussion” were interchangeable terms. This resulted in n=152 responses, of these responses 68.4% answered that they were interchangeable terms. This is represented by Tables 12 below. Table 15. mTBI vs. Concussion Response Frequency True 103 False 46 Percentage 68.4 31.6 Another important finding involved the current reference that the surveyed AT used as current concussion management guidelines. This resulted in N=152 responses. In all, 52.6% (n=80) reported that they use the NATA position 17 statements as their current concussion management guidelines. Only 24.3% (n=37) reported that they use the Zurich Consensus Statement of Concussion in Sport. The Zurich Consensus Statement of Concussion is the most current guideline in concussion management. DISCUSSION The following section is divided into three subsections: Discussion of Results, Conclusions, and Recommendations. Discussion of Results This study focused on continuing education awareness and its effect on concussion management confidence and knowledge. Upon research, there were no significant findings when testing the hypothesis. The majority of the knowledge questions were answered correctly. However, some additional findings suggest that there are improvements to be made in regards to concussion knowledge. 18 The hypothesis is: that there will be a difference between participants who identified themselves as likely to search for peer-reviewed literature on concussion management and those participants who did not identify themselves in seeking out new literature for concussion management knowledge. It was thought that the subject group identified as “likely to go find peer-reviewed literature” to score higher than the group identified as “not likely to find peer-reviewed literature”. There was no previous literature in reference to concussion management knowledge and confidence and its relation to continuing education awareness in the athletic training profession. Based on the researcher’s own experiences and interaction with peers, it was thought that the ATs who self-identified as “likely to go find peer-reviewed literature” to have higher concussion management confidence and knowledge then the “not likely” group. However, the difference between the groups was not significant and does not support this hypothesis. Throughout the research, there were some additional findings that are worth discussion. Research conducted by Scorza, Raleigh et al20 was reaffirmed by this study. During their study, they stated that one of the most common symptoms of concussion is headache, and that both somatic and cognitive systems can be affected. This survey 19 identified that 100.0% (n=152) of ATs identified dizziness as a common symptom, along with 99.3% (n=151) reporting headache and balance issues as a common symptom. Electronic testing prevalence was also assessed in this study. Of the subjects, 69.2% (n=108) reported that they use electronic based concussion testing in their concussion management practice. Stiller-Ostrowski17 also investigated the prevalence of electronic baseline testing; they also found that majority ATs used electronic based tools in the management of concussion. In regards to the electronic software, this study revealed that 80.2%(n=101) of the subjects used the ImPACT™ test as their electronic testing software. Eckner and Kutcher 23 state in their study that signs and symptoms of concussion do not necessarily present themselves at the time of the injury. In fact, main signs and symptoms might be delayed. This survey affirmed that the general AT population is up-to-date in regards to signs and symptoms possibly being delayed. When asked if signs and symptoms of concussion always present themselves after the mechanism of injury, 98.0% (n=149) responded correctly that the signs and symptoms do not always present after the mechanism of injury. 20 This research has shown that athletic training professionals have a competent level of concussion knowledge when compared to the Zurich Consensus Statement on concussion in sport14 the current gold-standard for concussion protocol. Of the subjects, 100.0% (n=152) indicated that special considerations should be taken when treating children or adolescents (under 18 years old) who have sustained a concussion. Of the subjects 86.2% (n=131) correctly answered false when asked if there is any equipment suggested by evidence-based research that can prevent concussion injuries. When asked about the subjects return to play protocol, 94.1% (n=143) correctly responded that it was best described as: “a step-wise progression that gradually increases the patient’s activity per every 24 hours.” It was also found that 93.3% (n=140) of ATs correctly take 24 hours between steps in their return to play protocol. The study did find some deficiencies in regards to concussion management knowledge. A large amount of the subjects answered incorrectly 68.4% (n=104) that mTBI and concussion are interchangeable terms. Harmon, Kimberly et al.21 states that : Concussions have also been referred to as mTBI While all concussions are mTBIs, not all mTBIs are concussions. Concussions are a subset of mild traumatic 21 brain injury on the less severe end of the brain injury spectrum and are generally self-limited in duration and resolution. It was also found that 52.6% (n=80) use the NATA position statements as their current concussion management reference. Conclusions The results of this study do not support the hypothesis, though they do affirm the results of previous studies identified in the literature review. The overall results indicated that ATs have a solid understanding of concussion and the many tools to manage this injury. Based on the results of this study, it may be suggested that the NATA should update its concussion management guidelines to include the most recent concussion management protocol; and in this protocol to identify the difference between concussion and mTBI. Recommendations The purpose of this study is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. After reviewing the 22 results, recommendations for future research can be made. The first recommendation that can be made is to increase the sample size; a higher response rate may allow for a better representation of the athletic training profession across the nation. Another recommendation would be to use professional memberships, which was identified as the most beneficial form of continuing education opportunities in regards to concussion management (71.6%, N=111). This could be used as a way to update the athletic training population on the most current concussion guidelines. The last recommendation would be to identify the difference between mTBI and concussion in the most recent concussion management guidelines. 23 REFERENCES 1. Centers for Disease Control and Prevention. (2010). Nutrition. Retrieved from http://www.cdc.gov/traumaticbraininjury/. Accessed July 20,2012. 2. Day JR, Hanson MR, Reding MJ. Neurocognitive Testing Following Resolution of Concussion Symptoms. IJATT 2012;17(2):9-33. 3. Ragan BG, Herrmann SD, Kang M, et al. Psychometric Evaluation of the Standardized Assessment of Concussion: Evaluation of Baseline Score Validity Using Item Analysis. Atshc 2009;1(4):180-187. 4. Falconer EK, Geffen GM, Olsen SL, et al. The rapid screen of concussion: An evaluation of the non-word repetition test for use in mTBI research. Brain Inj 2006;20(12):1251–1263. 5. Beaumont LD, Mongeon D, Tremblay S, et al. Persistent Motor System Abnormalities in Formerly Concussed Athletes. J Athl Train 2011;46(3):234-240. 6. Eckner JT, Kutcher JS, Richardson JK. Between-Seasons Test-Retest Reliability of Clinically Measured Reaction Time in National Collegiate Athletic Association Division I Athletes. J Athl Train 2011:46(4):409. 7. Allen BJ, Gfeller JD. The Immediate Post-Concussion Assessment and Cognitive Testing battery and traditional neuropsychological measures: A constructed concurrent validity study. Brain Inj 2011;25(2):179– 191. 8. Broglio SP, Ferrara MS , Macciocchi SN, et al. TestRetest Reliability of Computerized Concussion Assessment Programs. J Athl Train 2007;42(4):509-514. 9. Brown CN, Guskiewicz KM, Bieiberg J. Athlete Characteristics and Outcome Scores for Computerized 24 Neuropsychological Assessment: A Preliminary Analysis. J Athl Train 2007;42(4);515-523. 10. Thomas DG, Collins MW, Saladino RA, et al. Identifying Neurocognitive Deficits in Adolescents Following Concussion. AEM 2011;18(3):246-254. 11. Broglio SP, Ferrara MS, Pinland SG, et al. Concussion history is not a predictor of computerized neurocognitive performance. Br J Sports Med 2006;40(9):802–805. 12. Broglio SP, Macciocchi SN, Ferrara MS. Neurocognitive Performance of Concussed Athletes When Symptom Free. J Athl Train 2007;42(4):504-508. 13. Guskiewicz K, Bruce S, Cantu R, et al. National Athletic Trainers' Association position statement: Management of sport-related concussion. / Management of sport-related concussion. J Athl Train. [serial online]. July 2004;39(3):280-297. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed June 22, 2012. 14. McCrory P, Meeuwisse W, Johnson K, et al. Consensus Statement on Concussion in Sport: The 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. J Athl Train. [serial online]. July 2009;44(4):434-444. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed June 22, 2012. 15. Noteaert AJ, Guskiewicz KM. Current Trends in Athletic Training Practice for Concussion Assessment and Management. J Athl Train 2005;40(4):320-325. 16. Hunt TN, Trombley A. Physician Management of SportRelated Concussions at the Collegiate Level. Atshc 2010;2(5):227-234. 17. Covassin T, Elbin R, Kontos AP, et al. Immediate PostConcussion Assessment and Cognitive Testing (ImPACT) Practices of Sports Medicine Professionals. J Athl Train 2009;44(6):639-644. 25 18. McLeod TC. Register-Mihalik JK. Clinical Outcomes Assessment for the Management of Sport-Related Concussion. J SPORT REHABIL 2011;20(1):46-60. 19. Hecimovich M, Volet S. Tracing the evolution of chiropractic students' confidence in clinical and patient communication skills during a clinical internship: a multi-methods study.BMC Medical Education.June 2012;19;12:42. 20. Scorza KA, Raleigh MG, O’Connor FG. Current Concepts in Concussion: Evaluation and Management. American Family Physician. 2012;85(2):123-132. 21. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clin J Sport Med 2013;(23):1-18. 22. Martinez DE. Bloodless Concussion: The Misunderstood Injury. J Am Chiropractic Assoc 2011;(7):16-36. 23. Pelletier J. Sports injuries in contact sports: concussion and spinal injuries (invited presentation); 2005 Aug 4l Ottawa, Canada. Available from: jcp@ca.inter.net. 24. Eckner JT, Kutcher JS. Concussion Symptom Scales and Sideline Assessment Tools: A Critical Literature Update. ACSM 2010;9(1):8-15. 25. Reddy CC ,Collins MW. Sports Concussion: Management and Predictors of Outcome. ACSM 2009;8(1):10-15. 26. Purcell L, Carson J. Sport-Related Concussion in Pediatric Athletes. CLIN PEDIATR 2008;47(2):106-113. 27. DeKosky ST, Ikonomovic MD, Gandy S. Traumatic brain injury—football, warfare, and long-term effects. N Engl J Med. 2010;363(14):1293-1296. 28. Piland SG, Ferrara MS, Macciocchi SN, et al. Investigation of Baseiine Seif-Report Concussion Symptom Scores.J Athl Train 2010;45(3):273-278. 26 29. Majerske CW, Mihalik JP, Ren D, et al. Concussion in Sports: Postconcussive Activity Levels, Symptoms, and Neurocognitive Performance. J Athl Train 2008;43(3):265-274. 30. Mailer BJ, McLeod TC, Bay RC. Healthy Youth Are Reliable in Reporting Symptoms on a Graded Symptom Scale. J SPORT REHABIL 2008;17(1):11-20. 31. Fox ZG, Mihalik JP, Blackburn T, et al. Return of Postural Control to Baseline After Anaerobic and Aerobic Exercise Protocols. J Athl Train 2OO8;43(5):456463. 32. Broglio SP, Zhu W, Sopiarz K, et al. Generalizability Theory Analysis of Balance Error Scoring System Reliability in Healthy Young Adults. J Athl Train 2009;44(5):497-502. 33. NATA ATEP contempencies (2006) National Athletic Trainers’ Association (NATA). Athletic Training Educational Competencies.4th ed. Dallas,TX:NATA; 2006. 34. Covassin T, Elbin R, Stiller-Ostrowski SL. Current Sport-Related Concussion Teaching and Clinical Practices of Sports Medicine Professionals. J Athl Train 2005;44(4):400-404. 35. Hankemeier DA, Van Lunen BL. Approved Cljnical Instructors' Perspectives on Implementation Strategies in Evidence-Based Practice for Athletic Training Students. J Athl Train 2011:46(6):655-664. 36. Manspeaker S, Lunen BV. Overcoming Barriers to Implementation of Evidence-Based Practice Concepts In Athletic Training Education: Perceptions of Select Educators. J Athl Train 2011;46(5);514-522. 37. Chiang YZ, Tan KT, Chiang YN, et al. Evaluation of educational methods in dermatology and confidence levels: a national survey of UK medical students. INT J DERMATOL 2011;50(2):198-202. 27 APPENDICES 28 APPENDIX A Review of Literature 29 REVIEW OF LITERATURE Appendix A: Review of Literature Concussion awareness and its education, has progressed exponentially throughout the past decade. ATs practice evidence-based medicine. This method of practice provides the athlete/patient with the most current and effective care. Concussion has had numerous evaluative tools created to properly evaluate this potentially life-altering injury. Newer methods are used to manage concussion, and it is up to the practitioner to be aware of new strategies. Many of these strategies are highlighted in consensus statments13,14 along with other continuing education opportunities. It is crucial that ATs have experience and are confident handling these injuries along with utilizing the most recent management strategies. The purpose of this study is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. The following sections that highlight this information include (1) Etiology, (2) Validity of Assessment Models, (3) Management of Concussion, (4) 30 Athletic Training Education Styles, and (5) Measuring Confidence. Etiology of Concussion The awareness of concussion has been heightened in the sports community and the general population greatly in the past few decades with a rapid acceleration of concussionrelated injuries over the last few years. The accompanying attention is concern; concern from parents, health care practitioners, and those athletes whom are at risk of a potentially fatal injury or one that can cause lifealtering dysfunction. As certified and licensed health care professionals, it is the job of ATs to be proactive on the treatment and management of this injury. However, to properly treat an injury, one must understand the injury. The Center for Disease Control (CDC) reports that over 1.7 million people suffer from concussions annually.1 This is far more common than many would assume. As it is common knowledge, concussions are injuries to the head. Concussions are simply described as a disturbance in brain function from direct or indirect force to the head.20 This injury is described as a functional injury, rather than a structural injury and results from sheer stress to 31 the brain tissue caused by rotational or angular forces.20,23,23 It is a common misconception that the subject whom has sustained a concussion must have been struck directly in the head. Martinez also describes denial as a possible effect of concussion, making it imperative that the practitioner be aware of multiple signs and symptoms22. Pelletier23 defines concussion as a complex neuropathophysiological process affecting the brain, induced by traumatic biomechanical forces, which include a traumatic alteration in brain function that is manifested by an alteration in awareness of consciousness. These forces cause injuries to the subcortical white matter that include shearing or diffuse axonal injury that may occur with or without a focal injury. This is where many individuals make light of this injury, there is no necessary impact that must happen for the athlete to sustain a concussion. Determining whether a patient has suffered a concussion often presents the practitioner with difficulties. This is because no two concussions are the same,24,25 each concussion is unique, and many concussions do not present themselves at the time of the injury. Rather, their signs and symptoms are delayed24. Concussions have a wide variety of signs and symptoms. Scorza, Raleigh, et al20 describe headache as the most common symptom of concussion, 32 although there are a variety of clinical domains (e.g., somatic, cognitive, affective) that can be affected. As practitioners who rely on the patient to describe his/her signs and symptoms, it is important to be aware of all the possible effects of this injury. The classification of concussion based on severity remains a challenge because of problems with instruments and testers, as well as the likelihood that the injured will deny the injury24. Age groups and concussions have become an increasingly popular topic. Athletics has progressed to becoming more aggressive at younger ages, which in turn makes younger athletes more susceptible to injury. Purcell and Carson26 came to the conclusion that sports-related concussions occur most frequently in the 10-14 year age group. DeKosky, Ikonomovic, et al27 describe that there is an increase in the accumulation of proteins related to neurodegeneration caused by concussion, and it is occurring at younger ages, with force previously thought to be irrelevant to the recovery/incident of the injury. 33 Validity of Assessment Models Throughout the history of sports medicine, there have been dramatic changes in the way head injuries are treated. The more progress as a profession, the more are capable to address and appropriately evaluate diagnostic skills. Practicing evidence-based medicine has allowed ATs to be on top of the most recent and effective concussion assessment models. The following sub-sections address the different type of assessment models, and their reliability when addressing concussions. Computer-Based Assessment In sports medicine practice, it is becoming more common to use electronic based concussion testing as an assessment tool. These tests specifically allow ATs to make precise, quantifiable decisions when it pertains to a concussion. Eckner, Kutcher, and Richardson6 conducted a reliability study which compared manual reaction times versus the reaction time component of CogState 34 Sport(version 5.6.4) computerized neuropsychological test. The reliability study revealed that manual reaction time testing when used for baseline protocol is a reliable means of measurement when compared to computerized testing. The manual testing methods included using the weighted stick drop method as a measure of reaction time. Manual testing should be used in conjunction with computerized testing for a multifaceted approach.6,9 However, computerized testing reveals more precise measurements.6,10 Other studies also look into how precise the computerized neurocognitive testing is, and whether it should be used more frequently as a diagnostic tool. A study conducted by Thomas, Collins, Saladino, et al10 examined the detective nature of the Immediate PostConcussion Assessment and Cognitive Testing (ImPACT™) taken immediately (12 hours) after the injury. The ImPACT™ is an electronic based neurocognitive assessment tool. Results were then compared 3 to 10 days after the injury. This study aimed to find if the ImPACT™ could detect differences in head injury severity that clinical grading scales could not detect. Results suggested that computerized testing detected deficiencies that the clinical grading scale could not, and could potentially be used as a tool to determine the recovery time of the patient10. 35 As previously mentioned, health care providers rely on the patient to report his/her signs and symptoms. However, when the athlete reports he/she is asymptomatic, there are times where neurocognitive deficiencies might be present. Broglio, Macciocchi, and Ferrara12 conducted a study using the ImPACT™ test in regards to identifying deficiencies in athletes that reported they were asymptomatic. The ImPACT™ test was administered to all athletes when symptomatic, and when symptoms were reportedly resolved. Results showed there were deficiencies in at least one ImPACT™ variable when the athlete stated he/she was asymptomatic. The research suggests that using only symptom scores as the return to play protocol is not advised and that a multifaceted approach to concussion assessment is most appropriate. The ImPACT™ test is one of the more popular used electronic concussion assessment tools. Allen and Gfeller7 used a clinical study consisting of 100 undergraduate students from a small midwestern university to test the validity of the ImPACT™ test. The ImPACT™ test was compared to other traditional tests, results of the study revealed that both traditional tests along with the computerized ImPACT™ had overlapping results, and should be used in conjunction with one another. Other computer-based 36 concussion assessment tools are being used: such as the Concussion Resolution Index(CRI). Recent literature has compared the CRI to the more popular ImPACT™ test. Results have found that the tests are comparable to one another in terms of reliability; however chronic neurocognitive decrements from sport concussion may be subtle and undetectable by either of these two assessment techniques11. The ImPACT™ test is not the only computer-based concussion assessment tool which is being used. Broglio, Ferrara, Macciocchi, Baumgartner, and Elliott8 also examined test/retest validity in computerized testing. The authors conducted their subjects to complete the ImPACT™, Concussion Sentinel and Head Minder Concussion tests on three separate days. From their results, neurocognitive assessments have been shown to be sensitive to the consequences of concussion; and therefore, computerized testing has many practical advantages in athletic settings. The authors did warn practitioners to be cautious and to approach concussions with a conservative approach, placing greater focus on indexes producing higher reliability scores. The question of taking a computer-based assessment will result in a significant change of scores still remains. Brown, Guskiewicz, and Bieiberg9 investigated 37 possible trends due to gender, SAT scores and sport when evaluating an athlete for neuropsychological testing. Results concluded that computerized neuropsychological tests could possibly be affected by some of the previously mentioned factors. Traditional Concussion Assessment Traditional concussion assessments include those assessments that rely on the patient's reported signs and symptoms, these tests are generally administered via a symptom score test or another method which does not heavily revolve around a computer. Day, Hanson and Reding 2 specifically used the traditional Concussion Symptom Assessment Scale (CSAS) along with the electronic Concussion Resolution Index (CRI), to determine if they were proper indicators of neurocognitive deficiency after the patient reported no signs/symptoms. Both tests were used in conjunction with one another for baseline testing. This study showed that 35% of the athletes continued to show neurocognitive deficiencies when reporting no signs or symptoms. 38 Other traditional tools were also examined; the Standardized Assessment of Concussion (SAC) was questioned for reliability as a baseline tool. SAC testing proved to hold poor reliability, and proved too simplistic for the 76% of the subjects. Ragan, Herrmann, Kang, and Mack3 concluded that the SAC test might not be the best for cognitive testing, which diminishes the tests’ reliability when used for baseline testing. Not all traditional tests examine only patient signs and symptoms. Beaumont et al5 found that athletes with a history of concussion had altered scores in baseline balance testing. Methods included using a force platform to access center of pressure (COP) displacement, the subject was then asked to perform rapid alternating movements. Results revealed lower scores in those subjects who sustained a concussion. The authors encourage practitioners to acknowledge that baselines will vary over a period of time. The non-word repetition test (NWR) uses a method which is described as a test that requires participants to continuously repeat a group of chosen “non-words” aloud. The test aims to measure the phonological loop, which during a concussion can be impaired, therefore determining the severity of the concussion. A total 166 concussions and 39 uninjured participants were administered the NWR test. Out of these 166 subjects, 107 participants were included (46 concussions and 61 uninjured). Two studies were administered to the group of subjects. The first group was given the NWR along with the Rapid Screen of Concussion (RSC) test. The second test administered the NWR along with the Hopkins Verbal Learning Test. The NWR was found to be reliable in regards to sub-vocal rehearsal speed and was to the acute effects of concussion, thus being an effective indicator in the subtle defects concussion has on patients.4 Baseline Baseline testing is one of the most important factors when managing concussions. The nature of the injury makes it difficult to determine proper return-to-play decisions. This is where baseline testing bridges the gap between uncertainty and safe decision making. However, it is advised for health care providers to be cautious when relying on baseline testing which has been proctored over a substantial period of time due to the changing nature of the results. An investigative study constructed by Piland, Ferrara, et al.28 evaluates the influence that history of concussion, 40 sex, physical illness and acute fatigue has on selfreported baseline concussion testing. A total of six National Collegiate Athletic Association institutions were used, along with 1,065 collegiate student-athletes. Results revealed that student-athletes with previous concussion history, fatigue, physical illness and orthopedic injury had higher concussion symptom scores. However, sex did not show any significant effects on symptom scores.28 Clinicians are advised to take all of these factors into account when evaluating student-athletes. Majerske et al.29 also examined the role of activity post injury and its effect on neurocognitive tests. A cohort design was used to assess the relationship of symptom status and neurocognitive function after a concussion. A total of 95 student-athletes were used in this study. The ImPACT™ and the Colorado Concussion scale were used to determine the severity of the concussion, where the activity intensity scale was used to safely progress the student into exertional activity. Results showed the level of exertion significantly affected symptom scores and neurocognitive performance.28,29 One of the biggest uncertainties is reliability when it comes to self-reported symptom tests. It is no secret that many patients may not be honest when reporting his or 41 her scores. Mailer, McLeod, et al.30 also used a self-report baseline for a reliability test. The patients used a Graded Symptom Scale (GSS) which has been modified from the Head Injury Scale Self Report Concussion Symptoms Scale (HIS). The subject body of this baseline consisted of 126 middle school students. A survey was given to the students; it consisted of a demographic and life events questionnaire, along with GSS addressing symptom severity and length. Scores were added into a Total Symptom Score report and were found to hold very strong reliability.30 The authors’ results find that healthy youth are reliable with selfreported symptom scales. It was also found that exertional activity affects a patient’s postural stability when performing concussion assessments. Thirty-six college student-athletes were tested for the effects of fatigue on posture after aerobic and anaerobic exercises. Postural stability was accessed by the universal Balance Error Scoring System (BESS) and scores were compared to a baseline test where no exercise was performed. Fox, Mihalik, Blackburn, et al.31 revealed that balance was negatively affected after aerobic and anaerobic exercise. The BESS test was specifically examined for reliability by Brogilio, Zhu, Sopiarz, et al.32 The subjects 42 included 48 volunteers whose mean age was 20 years old (+/2.08). All subjects reported having no prior lower extremity injury. Participants were given the test a total of 5 times, each trial was given 50 days apart. Results found that the BESS held validly and should be considered being included in most clinicians’ baseline and post injury concussion testing. Management of Concussion Ultimately, management of concussion is what places pressure on the health care provider. It is imperative that all health care professionals be proficient in multiple styles of concussion management. The NATA has set Educational Competencies which identify the need for identification and management of concussion. The competencies that refer to concussion management are not specific to which management styles should be used. Noteaert and Guskiewicz15 investigated the current trends of ATs and their management and assessment of concussions. They randomly surveyed a total of 2,750 ATs whom were members of the NATA. Research findings concluded that the majority of ATs surveyed use hybrid evaluation and 43 management styles; many of these closely resembling the NATA position statement. The NATA lays out position statements to help provide guidelines for all ATs to be consistent with their decisions, and ultimately make the best decisions for the patient. The NATA position statement on management of concussion13 lists multiple grading tools for concussion, management tools, and return-to-play guidelines. These guidelines and competencies are helpful when educating ATs, though there is much gray area in the educational process. Hunt and Trombley16 investigated via survey the different management styles of concussion amongst a group of 120 team physicians. Results found that family practice physicians evaluated the most concussions per year (30%). A variety of methods were used during concussion assessment. Clinical examination and symptom checklists were reported as the most commonly used methods. Forty-eight percent reported that the clinical examination is the most important method when assessing return to play. One assessment style mentioned by the NATA position statement is the importance of baseline concussion testing.13 A survey conducted by Covassin, Elbin, Kontos, and Stiller-Ostrowski17 investigated the prevalence of neurocognitive baseline concussion testing in the high 44 school setting. The research concluded there is a high rate of baseline and post-concussion testing being used by AT’s, and that symptom scores are weighted heavier than neurocognitive test scores when returning an athlete to play. Athletic Training Education Styles Education models in Athletic Training Education are essentially up to the educator. The following section briefly overviews a few methods used to educate health care professionals. The competencies call for the athletic training education program to identify the signs and symptoms of head trauma including: loss of consciousness, change in standardized neurological function, cranial nerve assessment, and other symptoms that indicate underlying trauma. It also asks for the curriculum to explain the importance of monitoring a patient following the head injury, reviving clearance from a physician to progress the patient, and to define cerebral concussion33. Though the NATA identifies these competencies, they do not specifically designate management or assessment models. 45 This can result to the fact that each protocol can be altered by the ATs’ medical directors, within the guidelines of recent literature. However, this can put new ATs at a disadvantage in their first independent time to manage concussions. Covassin, Elbin, and Stiller-Ostrowski34 investigated the current concussion guidelines and methods being taught in a classroom, along with tracking the prevalence of the Vienna guidelines in the educational curriculum. A survey was sent program directors and ATs which addressed a variety of questions pertaining to experience and preference in education style. The majority of results showed that the NATA position statement was most widely used in managing concussions along with deciding return to play protocol. Results found that the Vienna guidelines were extremely underused. After review of the Vienna guidelines, 84% of those surveyed stated they would start teaching the guidelines in their curriculum. Hankemeier and Van Lunen35 examined the different experiences and opinions of Athletic Training instructors when implementing evidence-based practice concepts into their education program. All clinical instructors acknowledged the importance of evidence-based practice in the athletic training profession. Common themes when 46 implementing the practice included: self-discovery, promoting critical thinking, and sharing information. Program directors should be implementing evidence-based practice into the curriculum, along with encouraging clinical instructors to practice evidence-based medicine.35,37 A study by Manspeaker and Lunen36 also identified the need for evidence-based practice in Commission on Accreditation of Athletic Training Education (CAATE) programs. They concluded that educators must transition towards evidence-based medicine being taught in athletic training curriculum to provide the most relevant information to the students. Measuring Confidence As in any health care profession, evaluating one’s own personal abilities and growth is important when trying to grow as a professional. Confidence is one of the keystones for having a safe healthcare practice. It is important for 47 healthcare practitioners, to measure confidence when dealing with certain situations. However, many practitioners do not realize any deficiencies in their confidence until they are asked to reflect upon it. Measuring one’s confidence is descriptive in nature, and can be difficult to measure. However, self-reflection through confidence measurements can provide direction for continuing education, and improving the education processes. In fields such as athletic training, physical therapy, chiropractic, and osteopathy, students are exposed to real patients in a supervised, clinical situation. These clinical situations are vital as they introduce the students into situations they will eventually be placed into as a healthcare provider, ultimately building confidence in the individual. Research done by Hecimvich and Volet19 examined the progress of chiropractic students’ confidence before and after their clinical internships. Methods of their research included using two large-scale surveys and randomly interviewing a sub-sample of their subject base. Tools used to measure confidence included surveys developed by the authors: the Patient communication confidence scale, and the clinical skills confidence scale. Results revealed that before the start of their clinical 48 internships, students had more confidence in patient communication rather than their clinical skills. After their clinical internships, both patient communication and clinical skills increased significantly. The study highlighted the contributing factors in building confidence, and found that taking a proactive hand on approach is the most beneficial. Other studies investigated different educational strategies and how it affected the students’ level of confidence. Chiang, Tan, Chiang, Burge, Griffiths, and Verbov37 investigated the impact of different educational methods on confidence levels in dermatology among UK medical students. Premise for their research being that the high coincidences of skin conditions make dermatology education a necessary part of the medical curriculum. Methods included using survey based research to establish: educational experience in dermatology, and confidence levels in the British association of dermatologists core curriculum learning outcomes, confidence measurements were rated uses a five point Likert scale. Results found that students who received education from dermatologists, dermatology specialized nurses and expert patient, held higher levels of confidence. Education in clinical settings and small group settings also revealed the highest levels 49 of confidence. The authors established that clinical experiences and small group learning settings are the most effective in regards to developing confidence. Summary The research is very heavy in terms of evaluating, diagnosing and managing concussions. There are multiple tools that the ATs are presented with to make the correct clinical impression in conjunction of giving the best possible care. Tools range from the newly-developed computerized neurocognitive assessments to the more traditional self-symptoms scores. The NATA, along with other recent literature, outlines these standards both in competencies for the student and position statements for the practicing AT. Studies show that educators in athletic training are able to identify and adapt to their students learning models. However, there is little literature known on the relation between concussion management confidence and its relation to the AT’s continuing education awareness. 50 51 APPENDIX B The Problem 52 STATEMENT OF THE PROBLEM The athletic trainer has to be familiar and current with the new and established concussion management guidelines. As the intensity of athletics increases, so does the potential of concussion, which if not treated properly, can be life altering. Being familiar with the current guidelines and putting them to practice in a confident fashion is also extremely crucial. The most up to date information is constantly changing. Continuing education is the tool athletic trainers’ have to keep current with new practices, the awareness of the athletic trainer in regards to continuing education may relate to his/her knowledge of concussion and possibly his/her confidence in managing concussion. The purpose of the literature review is to discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. It is important to examine this relationship because concussion is a potentially life threatening injury and are very common in athletics. It would be beneficial for Athletic Training Education Programs to evaluate the comfort level and experience level of new athletic trainers because alterations in curriculum can be made if research finds 53 that the general subject population feels ill prepared. Additionally, it would be beneficial for athletic trainers to know where many of their newly certified peers stand when dealing with concussions. 54 Definition of Terms The following definitions of terms will be defined for this study: 1) Concussion – A complex neuro-pathophysiological process affecting the brain, induced by traumatic biomechanical forces, which include a traumatic alteration in brain function that is manifested by an alteration in awareness of consciousness. 2) Continuing Education - An instructional program that brings participants up to date in a particular area of knowledge or skills. 3) Confidence - Belief in oneself and one's powers or abilities. 4) Athletic Training Competencies - A set of required teaching guidelines an ATEP has to follow. 5) Baseline Concussion Testing - A pre-season exam used to assess a patients’ balance, brain function, and any concussion symptoms. Basic Assumptions The following are basic assumptions of this study: 1) The subjects will be honest when they complete their demographic sheets. 2) Subjects will not receive outside help from any other 55 individual or outside source on any question. 3) The sample is a representation of the population of athletic trainers. Limitations of the Study The following are possible limitations of the study: 1) The response rate of the survey could be low due to busy schedules of the athletic trainers. 2) As with any anonymous survey, answers might not be answered honestly by the subjects. Significance of the Study Athletic Trainers should possess all the current knowledge when it comes to concussion. The injury has proven to be an issue that is frequent in the athletic training profession. By assessing the athletic training profession’s current knowledge level, any possible deficiencies may be detected by this study. If any deficiencies are identified, it would allow for an extravagant learning opportunity for both continuing education practice and athletic training education curriculums. Continuing education opportunities can also be improved depending on the results of this study. Continuing education awareness for the athletic trainer in regards to 56 concussion management may reveal opportunities to improve educational programs. The significance of this study aims to improve the athletic training profession by identifying the relation between continuing education awareness, current knowledge and the confidence the athletic trainer has in regards to concussion management. 57 APPENDIX C Additional Methods 58 APPENDIX C1 Institutional Review Board – California University of Pennsylvania 59 60 61 62 63 64 65 66 67 68 69 70 71 Institutional Review Board California University of Pennsylvania Morgan Hall, Room 310 250 University Avenue California, PA 15419 instreviewboard@calu.edu Robert Skwarecki, Ph.D., CCC-SLP,Chair Dear Mr. Christie: Please consider this email as official notification that your proposal titled "Continuing Education Participation Effecting Concussion Management Confidence in Athletic Trainers” (Proposal #12-037) has been approved by the California University of Pennsylvania Institutional Review Board as submitted. The effective date of the approval is 2-11-2013 and the expiration date is 2-10-2014. These dates must appear on the consent form. Please note that Federal Policy requires that you notify the IRB promptly regarding any of the following: (1) Any additions or changes in procedures you might wish for your study (additions or changes must be approved by the IRB before they are implemented) (2) Any events that affect the safety or well-being of subjects (3) Any modifications of your study or other responses that are necessitated by any events reported in (2). (4) To continue your research beyond the approval expiration date of 2-10-2014 you must file additional information to be considered for continuing review. Please contactinstreviewboard@calu.edu Please notify the Board when data collection is complete. Regards, Robert Skwarecki, Ph.D., CCC-SLP Chair, Institutional Review Board 72 APPENDIX C2 Panel of Experts Letter 73 Hello, My name is Zak Christie, I am a graduate Athletic Trainer at California University of Pennsylvania. I am conducting research with Dr. Linda Meyer and am using a survey. You were highly recommended as an expert in the field of concussion. I am asking for you to sit on my panel of experts for this survey. Please let me know if you are NOT able to assist me with this survey. If you are able to assist, I kindly ask if you would please reply no later than Monday, November 23, 2012. Either way, thank you for your time; I greatly appreciate it. Thank you for your time and consideration. Very Respectfully, Zak Christie 74 APPENDIX C3 Concussion Knowledge and Confidence Survey 75 76 77 78 79 80 81 82 83 84 85 APPENDIX C4 Cover Letter 86 3/18/2013 Dear Fellow Certified Athletic Trainer: My name is Zachary Christie and I am currently a graduate student at California University of Pennsylvania pursing a Master of Science in Athletic Training. Part of the graduate study curriculum is to complete a research thesis through conducting research. I am conducting survey research to determine the current knowledge level of concussion and the educational factors effecting confidence in certified athletic trainers. This Data will allow the Athletic Training profession to further our own knowledge in regards to concussion management. Certified athletic trainers whom are members of the National Athletic Training Association are being asked to participate in this research; however, your participation is voluntary and you do have the right to choose not to participate. You also have the right to discontinue participation at any time during the survey without penalty; however your data will be discarded. The California University of Pennsylvania Institutional Review Board has reviewed and approved this project. The approval is effective (2/11/2013 and expires 2/10/2014). All survey responses are anonymous and will be kept confidential, and informed consent to use the data collected will be assumed upon return of the survey. Aggregate survey responses will be housed in a password protected file on the CalU campus. Minimal risk is posed by participating as a subject in this study. I ask that you please take this survey at your earliest convenience as it will take approximately 10 minutes to complete. If you have any questions regarding this project, please feel free to contact the primary researcher, Zak Christie at CHR8755@CalU.edu. You can also contact the faculty advisor for this research, Linda Platt Meyer, EdD, LAT, ATC at Meyer@calu.edu. Thanks in advance for your participation. Please click the following link to access the survey (www.surveymonkey.com/s/RXRJMYZ). Thank you for taking the time to take part in my thesis research. I greatly appreciate your time and effort put into this task. 87 This student survey is not approved or endorsed by NATA. It is being sent to you because of NATA’s commitment to athletic training education and research. Sincerely, Zachary Christie LAT, ATC California University of Pennsylvania 250 University Ave California, PA 15419 CHR8755@CalU.edu 88 REFERENCES 1. Centers for Disease Control and Prevention. (2010). Nutrition. Retrieved from http://www.cdc.gov/traumaticbraininjury/. Accessed July 20,2012. 2. Day JR, Hanson MR, Reding MJ. Neurocognitive Testing Following Resolution of Concussion Symptoms. IJATT 2012;17(2):9-33. 3. Ragan BG, Herrmann SD, Kang M, et al. Psychometric Evaluation of the Standardized Assessment of Concussion: Evaluation of Baseline Score Validity Using Item Analysis. Atshc 2009;1(4):180-187. 4. Falconer EK, Geffen GM, Olsen SL, et al. The rapid screen of concussion: An evaluation of the non-word repetition test for use in mTBI research. Brain Inj 2006;20(12):1251–1263. 5. Beaumont LD, Mongeon D, Tremblay S, et al. Persistent Motor System Abnormalities in Formerly Concussed Athletes. J Athl Train 2011;46(3):234-240. 6. Eckner JT, Kutcher JS, Richardson JK. Between-Seasons Test-Retest Reliability of Clinically Measured Reaction Time in National Collegiate Athletic Association Division I Athletes. J Athl Train 2011:46(4):409. 7. Allen BJ, Gfeller JD. The Immediate Post-Concussion Assessment and Cognitive Testing battery and traditional neuropsychological measures: A constructed concurrent validity study. Brain Inj 2011;25(2):179– 191. 8. Broglio SP, Ferrara MS , Macciocchi SN, et al. TestRetest Reliability of Computerized Concussion Assessment Programs. J Athl Train 2007;42(4):509-514. 9. Brown CN, Guskiewicz KM, Bieiberg J. Athlete Characteristics and Outcome Scores for Computerized 89 Neuropsychological Assessment: A Preliminary Analysis. J Athl Train 2007;42(4);515-523. 10. Thomas DG, Collins MW, Saladino RA, et al. Identifying Neurocognitive Deficits in Adolescents Following Concussion. AEM 2011;18(3):246-254. 11. Broglio SP, Ferrara MS, Pinland SG, et al. Concussion history is not a predictor of computerized neurocognitive performance. Br J Sports Med 2006;40(9):802–805. 12. Broglio SP, Macciocchi SN, Ferrara MS. Neurocognitive Performance of Concussed Athletes When Symptom Free. J Athl Train 2007;42(4):504-508. 13. Guskiewicz K, Bruce S, Cantu R, et al. National Athletic Trainers' Association position statement: Management of sport-related concussion. / Management of sport-related concussion. J Athl Train. [serial online]. July 2004;39(3):280-297. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed June 22, 2012. 14. McCrory P, Meeuwisse W, Johnson K, et al. Consensus Statement on Concussion in Sport: The 3rd International Conference on Concussion in Sport Held in Zurich, November 2008. J Athl Train. [serial online]. July 2009;44(4):434-444. Available from: SPORTDiscus with Full Text, Ipswich, MA. Accessed June 22, 2012. 15. Noteaert AJ, Guskiewicz KM. Current Trends in Athletic Training Practice for Concussion Assessment and Management. J Athl Train 2005;40(4):320-325. 16. Hunt TN, Trombley A. Physician Management of SportRelated Concussions at the Collegiate Level. Atshc 2010;2(5):227-234. 17. Covassin T, Elbin R, Kontos AP, et al. Immediate PostConcussion Assessment and Cognitive Testing (ImPACT) Practices of Sports Medicine Professionals. J Athl Train 2009;44(6):639-644. 90 18. McLeod TC. Register-Mihalik JK. Clinical Outcomes Assessment for the Management of Sport-Related Concussion. J SPORT REHABIL 2011;20(1):46-60. 19. Hecimovich M, Volet S. Tracing the evolution of chiropractic students' confidence in clinical and patient communication skills during a clinical internship: a multi-methods study.BMC Medical Education.June 2012;19;12:42. 20. Scorza KA, Raleigh MG, O’Connor FG. Current Concepts in Concussion: Evaluation and Management. American Family Physician. 2012;85(2):123-132. 21. Harmon KG, Drezner J, Gammons M, et al. American Medical Society for Sports Medicine Position Statement: Concussion in Sport. Clin J Sport Med 2013;(23):1-18. 22. Martinez DE. Bloodless Concussion: The Misunderstood Injury. J Am Chiropractic Assoc 2011;(7):16-36. 23. Pelletier J. Sports injuries in contact sports: concussion and spinal injuries (invited presentation); 2005 Aug 4l Ottawa, Canada. Available from: jcp@ca.inter.net. 24. Eckner JT, Kutcher JS. Concussion Symptom Scales and Sideline Assessment Tools: A Critical Literature Update. ACSM 2010;9(1):8-15. 25. Reddy CC ,Collins MW. Sports Concussion: Management and Predictors of Outcome. ACSM 2009;8(1):10-15. 26. Purcell L, Carson J. Sport-Related Concussion in Pediatric Athletes. CLIN PEDIATR 2008;47(2):106-113. 27. DeKosky ST, Ikonomovic MD, Gandy S. Traumatic brain injury—football, warfare, and long-term effects. N Engl J Med. 2010;363(14):1293-1296. 28. Piland SG, Ferrara MS, Macciocchi SN, et al. Investigation of Baseiine Seif-Report Concussion Symptom Scores.J Athl Train 2010;45(3):273-278. 91 29. Majerske CW, Mihalik JP, Ren D, et al. Concussion in Sports: Postconcussive Activity Levels, Symptoms, and Neurocognitive Performance. J Athl Train 2008;43(3):265-274. 30. Mailer BJ, McLeod TC, Bay RC. Healthy Youth Are Reliable in Reporting Symptoms on a Graded Symptom Scale. J SPORT REHABIL 2008;17(1):11-20. 31. Fox ZG, Mihalik JP, Blackburn T, et al. Return of Postural Control to Baseline After Anaerobic and Aerobic Exercise Protocols. J Athl Train 2OO8;43(5):456463. 32. Broglio SP, Zhu W, Sopiarz K, et al. Generalizability Theory Analysis of Balance Error Scoring System Reliability in Healthy Young Adults. J Athl Train 2009;44(5):497-502. 33. NATA ATEP contempencies (2006) National Athletic Trainers’ Association (NATA). Athletic Training Educational Competencies.4th ed. Dallas,TX:NATA; 2006. 34. Covassin T, Elbin R, Stiller-Ostrowski SL. Current Sport-Related Concussion Teaching and Clinical Practices of Sports Medicine Professionals. J Athl Train 2005;44(4):400-404. 35. Hankemeier DA, Van Lunen BL. Approved Cljnical Instructors' Perspectives on Implementation Strategies in Evidence-Based Practice for Athletic Training Students. J Athl Train 2011:46(6):655-664. 36. Manspeaker S, Lunen BV. Overcoming Barriers to Implementation of Evidence-Based Practice Concepts In Athletic Training Education: Perceptions of Select Educators. J Athl Train 2011;46(5);514-522. 37. Chiang YZ, Tan KT, Chiang YN, et al. Evaluation of educational methods in dermatology and confidence levels: a national survey of UK medical students. INT J DERMATOL 2011;50(2):198-202. 92 ABSTRACT TITLE: CONTINUING EDUCATION AWARNESS EFFECTING CONCUSSION MANAGEMENT CONFIDENCE IN ATHLETIC TRAINERS RESEARCHER: Zak M Christie, LAT, ATC ADVISOR: Dr. Linda Platt Meyer PURPOSE: To discuss the continuing education practices of AT’s along with their concussion management confidence and knowledge. DATE: May, 2013 Design: Descriptive Survey Settings: Population-Based Survey Participants: One-thousand ATs were asked to volunteer. Subjects were randomly selected from the ten districts through the NATA database. The final response rate was 169. INTERVENTIONS: The dependent variable is the confidence of ATs in regards to concussion management. The independent variable is continued education awareness that ATs have with regards to concussion. RESULTS: There was no significance found in the hypothesis. However there were additional findings which could lead to further research in concussion knowledge throughout Athletic Trainers. CONCLUSIONS: Based on the results of this study, we can conclude that continuing education awareness does not relate to concussion management knowledge and confidence.