The National Spinal Cord Injury Statistical Center estimates that approximately 17,500 spinal injuries occur annually, with an estimated 8.9% of injuries to the spine being sports related.1 Further, collision and contact sport athletes have an increased risk of sustaining a spinal injury during sports participation.1 Spine injuries can be catastrophic or significantly life-altering,2 so swift and appropriate care is essential to promote optimal outcomes. Although the incidence of spine injuries in sports may not be as high as other sports-related injuries, such as lower extremity injuries,3 the severity of the injury and potential for poor outcomes emphasizes the need for current, evidence-based knowledge of proper management and emergency care for these vulnerable patients.
Athletic trainers are often the first to treat, manage, and care for patients with a suspected spine injury. Although athletic trainers may not see spine injuries every day, preparation in the event that an emergency occurs may mean the difference between a favorable or poor outcome. In 2009, the National Athletic Trainers' Association (NATA) released a position statement on acute management of the athletes with cervical spine injury that specified best practice recommendations for athletic trainers on the appropriate care of suspected spine injured athletes.4 The recommendations were developed based on the best available evidence on appropriate strategies for management of cervical spine injuries and included areas related to prevention, planning, and rehearsal, assessment, airways, stabilization, transfer and immobilization, equipment-laden sports, and emergency department management.4 Since the release of the position statement, the evidence related to the acute management of cervical spine injuries has evolved, and there is new evidence to suggest some changes to current management practices.5–11
For example, a long-standing recommendation is to keep protective equipment on suspected spine injured athletes until arrival at the hospital.4,12,13 However, newer evidence suggests that protective equipment should be removed on-field, when appropriate.6,11 Another example relates to transporting a patient using a rigid immobilization device. There is some evidence to suggest using a rigid immobilization device may help to reduce spinal motion and prevent further injury.14 Similarly, the use of a multi-rescuer team to perform a lift and slide technique when transferring a patient on a spine board has also been suggested over the log-roll technique.7
Groups of interested stakeholders have come together to discuss the care of spine injured athletes and to explore whether updated recommendations, such as the examples above, are needed to provide care in accordance with best practices and to support positive patient outcomes. Although an initial set of recommendations was developed,5 no final consensus was made regarding updates to long-standing practices and the initial document remains controversial. Work continues related to the development of updated best practice recommendations for acute management of spine injuries. To help inform updates, it is important to understand the particulars of end users of the recommendations,15,16 such as athletic trainers, because the success of practice changes depends on their ability to understand and adopt the changes.16,17 Further, a downfall for program implementation, including practice guidelines, is lack of appreciation of end user concerns and not incorporating real-world clinical scenarios.18 A starting point to understanding end users is obtaining a general sense of their knowledge on the topic. Better understanding of end user knowledge provides insight into knowledge gaps, which may help inform education and implementation strategies on current and future practice guidelines. Purposeful efforts are needed to assess current knowledge of athletic trainers, who are key end users in spine care, to inform best practice guideline development and pave the way for implementation and education strategies. Therefore, the purpose of this study was to assess athletic trainers' baseline knowledge of best practices for the appropriate care of spine injured athletes.
A census sampling of members of the NATA was used for this study. Contact information for athletic trainers who were current members of the NATA, as of December 2016, was obtained from the NATA national office through the NATA Survey List Request Form. The request to participate in the study was sent to 27,528 athletic trainers. Athletic training students who are members of the NATA were excluded from this study because they were not certified during the time of the study. Prior to data collection, University Institutional Review Board approval for exempt research was obtained; participants' consent was implied on voluntary completion of the online survey.
The research team developed a multi-item survey entitled “The Beliefs, Awareness, and Implementation Strategies for Appropriate Care of Spine Injured Athletes” (BAISAC-Spine) to assess athletic trainers' knowledge and implementation of the best practice recommendations regarding care of spine injured athletes. The BAISAC-Spine consisted of four main sections: (1) familiarity, (2) knowledge, (3) awareness, and (4) implementation. The Qualtrics survey platform (Qualtrics Lab, Inc., Provo, UT) was used to disseminate the survey to potential participants, and the BAISAC-Spine included a variety of question types, such as multiple-choice questions, binary items (yes, no), Likert-scale items, and multi-answer questions. Participants were also asked several demographic questions related to their athletic training background, previous experience with spine injured athlete care, and previous completion of continuing education opportunities regarding spine injury management and hands-on learning experiences.
Following the development of the BAISAC-Spine, a panel of four athletic trainers, consisting of two survey research experts, a public health researcher, and a spine injury researcher assessed the survey for content appropriateness and comprehensiveness. We followed the survey validation procedure as described by Williams et al.19 Following panel review, the survey was deemed to have appropriate content for the assessment of acute care of spine injured athletes and comprehensive to address the study objectives. Due to the demographic nature of the items included within the implementation section, a reliability analysis was not warranted.
This article focuses on the knowledge section of the BAISAC-Spine survey. The knowledge section included 11 multiple-choice questions to assess athletic trainers' knowledge about the appropriate care of spine injured athletes. These questions were developed from information provided on best practice recommendations on the appropriate care of spine injured athletes.4,5,13 Each question had one correct response; participants' composite knowledge score was tabulated by awarding 1 point for a correct response and 0 points for an incorrect response. The highest achievable composite score was 11 points and a higher composite knowledge score indicated a higher level of knowledge regarding the appropriate care of spine injured athletes. Reliability of the knowledge section was assessed via Cronbach's alpha and it was determined that there was a high reliability among the questions (alpha = .83).
Contact information for potential participants was obtained from the NATA national office in March 2017. Potential participants received an initial recruitment e-mail that included the purpose of the study, the estimated time to complete the survey (approximately 15 minutes), the hyperlink to the survey webpage, a request to participate, and the contact information of the research team for any questions or concerns. The data collection period was 4 weeks and two reminder e-mails were sent to those individuals who had not completed the survey. Once a participant completed the survey (indicated by clicking “submit”), a thank you e-mail was automatically generated in Qualtrics Survey Software and immediately sent to the individual.
IBM SPSS Statistics software (version 24.0; IBM Corporation, Armonk, NY) was used for statistical analyses. Descriptive statistics included means, standard deviations, ranges, frequencies, and percentages. Frequencies and percentages of individual knowledge items were calculated overall and stratified by continuing education unit (CEU) status. We defined CEU status as self-reported participation in any continuing education courses on the appropriate care of spine injured athletes in the past 2 years (yes/no). Athletic trainers were also asked to identify if they participated in hands-on learning CEU opportunities related to spine injuries (yes/no). Independent t tests were conducted comparing: CEU status (yes/no) and composite knowledge scores and CEU opportunities with hands-on experience related to spine injuries (yes/no) and composite knowledge scores. Effect sizes were calculated with Hedges' g, where 0.5 was considered a medium effect size. Pearson correlation coefficients (r) were calculated to determine the relationship between the number of CEU credits earned on spine injury management and composite knowledge score. A P value of less than .05 was considered statistically significant.
From a census sample of 27,528 athletic trainers, 2,630 individuals accessed the survey (survey access rate = 9.6%) and 2,617 athletic trainers completed at least one part of the survey. Of the 2,617 responses, 13 participants only answered the first item confirming they were certified as an athletic trainer and 300 participants indicated they were not currently practicing as an athletic trainer; these 313 participant responses were excluded from data analysis. Thus, responses from 2,304 athletic trainers were included for data analysis. A total of 1,401 participants completed the survey in its entirety for a survey completion rate of 60.8%. Participants represented all 50 states and the District of Columbia, and consisted of 1,021 (44.3%) men, 1,261 (54.7%) women, 16 (0.7%) individuals who preferred not to report sex, and 6 (0.3%) missing responses. The average age of participants was 34.7 ± 11.1 years and they had 11.4 ± 10.2 years of experience as an athletic trainer. Additional participant demographics are displayed in Table 1.
The average composite knowledge score for all participants was 6.52 of 11 ± 1.83. Table 2 displays frequencies and percentage of individual item knowledge scores overall and stratified by CEU status. Knowledge composite scores can be found in Table 3. The top three questions athletic trainers most frequently answered correctly were “athletic training services should be provided at all sporting events” (n = 1,771/1,848, 95.8%), “all sports equipment requires proper knowledge and training for removal” (n = 1,666/1,786, 93.3%), and “injury severity is the primary factor emergency action plan activation is based on” (n = 1,565/1,847, 84.7%). The top three questions athletic trainers most frequently answered incorrectly were “a two-person technique with anterior stabilization is recommended for football helmet removal following a suspected spinal injury” (n = 410/1,772, 23.1%), “an eight-person lift with slide maneuver is recommended to maintain cervical neutrality during spine boarding in the supine position” (n = 467/1,782, 26.2%), and “emergency action plans should be reviewed prior to the start of all athletic events” (n = 609/1,850, 32.9%).
Individual Item Knowledge Question Responses by CEU Status
Composite Knowledge Scores
Knowledge by CEU
Six hundred ninety-one (48.5%) athletic trainers self-reported that they completed a CEU course on the appropriate care of spine injured athletes within the past 2 years, earning an average of 4.98 ± 7.15 CEUs (range = 0 to 90), whereas 734 (51.5%) athletic trainers indicated they had not. Of those who completed CEU courses on the appropriate care of spine injured athletes within the past 2 years, 67.8% (n = 463/683, missing = 8) reported participating in CEUs with hands-on learning on the appropriate care of spine injured athletes in the past 2 years, and 220 (32.2%) athletic trainers indicated they did not.
Respondents who had participated in CEU opportunities on appropriate care of spine injured athletes demonstrated higher composite knowledge scores (7.10 of 11 ± 1.72) than athletic trainers who did not (6.32 of 11 ± 1.71, t(1,423) = 8 .54, P < .01, Hedges' g = .45). Significantly greater composite knowledge scores were found among those who had participated in hands-on learning CEU opportunities related to the appropriate care of spine injured athletes (7.24 of 11 ± 1.70) compared to those whose CEU opportunities were not hands-on learning (6.84 of 11 ± 1.74, t(681) = 2.87, P = .004, Hedges' g = .22). However, no significant relationship was found between composite knowledge score and number of spine injury CEUs earned (r = 0.039, P = .32).
The purpose of this study was to assess athletic trainers' baseline knowledge of best practices regarding the appropriate care of spine injured athletes. Our main findings indicate that athletic trainers' knowledge regarding best practices related to the appropriate care of spine injured athletes has room for improvement. Given that there is difference of opinion and controversy around establishing a consensus regarding updated recommendations for acute spine care,5 it is not surprising that there is varied knowledge among clinicians on current practices. Composite knowledge scores were higher in athletic trainers who participated in CEU courses on appropriate care of spine injured athletes in the past 2 years and those who had taken part in hands-on learning CEU opportunities on the appropriate care of spine injured athletes. However, the number of CEU credits received was not related to composite knowledge scores.
Identifying athletic trainers' baseline knowledge on concepts related to the appropriate care of spine injured athletes is important to inform strategies, such as educational and awareness campaigns, to encourage exposure to these guidelines. Knowledge is the first step to performance of a task and implementation into clinical practice.20 Specifically, in the current study, the majority of athletic trainers correctly identified when athletic training services should be provided, which protective equipment requires proper knowledge and training for removal, and what the primary factor is for activation of an emergency action plan. These recommendations are generally seen as common practice for athletic trainers and are routinely performed in clinical practice for emergency response.
Although athletic trainers did correctly answer some of the knowledge questions, most provided incorrect responses to questions related to football helmet removal with a two-person anterior stabilization technique and using an eight-person lift for a suspected spine injury. Athletic trainers may have missed questions related to equipment removal because of the long-standing recommendation to keep equipment on until at the hospital.6,21 There is some debate regarding the appropriateness of helmet and shoulder pad removal following a suspected spine injury, which may have contributed to the responses in the knowledge survey. Some researchers recommend only facemask removal to reduce spinal movement.22,23 Swartz et al.22 conducted a study exploring cervical neck motion following facemask removal or helmet removal and found facemask removal demonstrated less motion in the sagittal, frontal, and transverse planes in comparison to helmet removal, recommending facemask removal following a suspected spinal injury. Conversely, research has shown that helmet and equipment removal is vital for suspected spine injuries because the ability to do chest compression is a priority.21 Mihalik et al.21 conducted a study on the ability to perform chest compressions in football athletes with equipment on. Chest compression depth was shallowest when full equipment was on, supporting removal of all equipment for appropriate chest compression depth and airway ventilation. Other studies recommend either helmet removal6,18 or no helmet removal24 prior to transportation.
The idea of removing the football helmet prior to transport, when appropriate, is a slight shift from the 2009 NATA position statement on acute management of spinal injuries.4 Recommendations within the 2009 position statement suggest removal of existing barriers, such as facemasks, for airway exposure. Further, the 2009 position statement does allow for flexibility in care of those with suspected spine injury, including removal of equipment in certain situations, and was crafted using guiding principles for equipment removal as opposed to blanket recommendations across sports.4 Providing comprehensive education and training on proper techniques related to equipment removal is essential, especially given that there is debate on best practices in this area and there may be a change in practice that allows for equipment removal prior to transport given the right circumstances.
A common mechanism that is available for athletic trainers to gain new information is through continuing education opportunities that produce CEUs that are necessary to maintain certification. Although the effect sizes were small (0.4 and 0.2), the current study found a statistically significant difference between composite knowledge scores and recent participation in CEU courses (past 2 years) related to the appropriate care of spine injured athletes and for those who participated in hands-on learning opportunities. No relationship was found between the composite knowledge scores and the number of CEU credits earned for these courses. Although continuing education is important, the type and mode of delivery may affect the ability to retain the information and make clinical practice shifts.25,26 Educational opportunities come in a variety of formats, including didactic courses, lectures, quizzes, and instructional videos. National, regional, and local conferences are a major source for continuing educational opportunities (eg, approximately 7,900 athletic trainers attended the 2016 NATA annual clinical symposium).27 However, there is evidence to suggest a lack of knowledge retention from conferences.26 Research has shown that just providing the material for continuing education does not always lead to changes in practice.25,26 Providing material is a form of passive dissemination, and education focused on active dissemination strategies is more successful.28 Davis et al.25 reviewed the literature and found that continuing medical education courses that were interactive with activities and opportunities to practice the skills allowed for physicians to make more practice changes. What remains unknown is whether these educational opportunities drive practice changes. Identifying effective implementation strategies to share information regarding best practices, whether through educational opportunities or other avenues, is important and necessary for continual professional development.
The findings from our study are a first step to developing educational and implementation strategies to help ensure that athletic trainers are using techniques in spine care management that align with best practices. Providing guidelines to clinicians and avenues to incorporate new research into clinical practice will enable clinicians to make appropriate practice changes, but that does not equate to putting information into practice. The approach and methodology behind dissemination of information can hinder the ability of clinicians to absorb and make changes. A simple dissemination of information is not enough to drive practice change. For example, Finch et al.17 researched implementation and dissemination factors of concussion guidelines and suggested that only presenting expert concussion guidelines to clinicians does little to drive practice changes and there is a need for more purposeful and targeted marketing for content dissemination. More targeted efforts to understand the end user should help shape the implementation approach.15,16
Implementation research has been largely focused on injury prevention and incorporates the Translating Research into Injury Prevention Practice (TRIPP) framework.15 However, although its application has focused on injury prevention, the steps and philosophy apply to other areas, including guideline implementation. The TRIPP framework outlines six stages of injury prevention implementation.15 The six stages include identifying injury surveillance (stage 1), understanding why injury occurs (stage 2), identifying solutions (stage 3), assessing intervention efficacy assessment (stage 4), identifying how outcomes can be translated into action (stage 5), and implementing intervention into appropriate context (stage 6).15 Stages 5 and 6 are most relevant for findings from this study. Information from stage 5 provides researchers with the ability to answer questions related to the current state of baseline knowledge. The current study identified baseline knowledge of athletic trainers on best practices related to the appropriate care of spine injured athletes, which is helpful in understanding educational needs. Further, stage 6 is the feedback loop of implementation of strategies into the real world. Stage 6 provides insight into how current processes are applied to current practice.15 Findings from the knowledge assessment related to care of spine injured athletes can drive implementation strategies to encourage the up-take of these important care guidelines. Developing educational materials based on successful implementation strategies, such as hands-on practice and self-assessments of current practice patterns, may enhance athletic trainers' ability to uptake recommendations and change or improve practice faster than before.
Our study is not without limitations. Although we assessed composite knowledge scores based on current best practice recommendation, we did not assess knowledge on all recommendations. Further, with respect to CEUs, we did not assess the type, mode, or content of the CEU opportunities, nor did we ask questions related to the quality of the CEU courses. Many clinicians engaged in CEU activities related to management and care of spine injured athletes and worked to ensure that those educational opportunities are high quality and present the most current recommendations that will be important moving forward. Finally, although the executive summary statement on the appropriate care of spine injured athletes was disseminated and made public by the NATA, it remains controversial and no official consensus statement was produced.
To provide informed implementation strategies to athletic trainers on the care of spine injured athletes, it is helpful to have an understanding of baseline knowledge. Maintaining updated guidelines on the appropriate care for spine injured athletes is important for proper management and producing the best patient outcomes given the seriousness of spinal cord injuries. Dissemination of educational materials and development of active learning strategies could enhance athletic trainers' knowledge and therefore allow athletic trainers to stay up to date on clinical practice changes.
Implications for Clinical Practice
Spine injuries can be catastrophic and staying current on best practices and management techniques can serve as a factor for swift, effective care that hopefully leads to more favorable patient outcomes. Providing awareness of a best practice guideline for any recommendation, including those related to patients with spine injury, without a purposeful, targeted plan to encourage implementation is insufficient to drive change. Real world application by athletic trainers in their own clinical setting is necessary to incorporate best practice guidelines into clinical practice.
- National Spinal Cord Injury Statistical Center. Facts and Figures at a Glance. Birmingham, AL: University of Alabama at Birmingham; 2016.
- Cantu RC, Mueller FO. The prevention of catastrophic head and spine injuries in high school and college sports. Br J Sports Med. 2009;43:981–986. doi:10.1136/bjsm.2009.067728 [CrossRef]
- Hootman JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations for injury prevention initiatives. J Athl Train. 2007;42:311–319.
- Swartz EE, Boden BP, Courson RW, et al. National athletic trainers' association position statement: acute management of the cervical spine-injured athlete. J Athl Train. 2009;44:306–331. doi:10.4085/1062-6050-44.3.306 [CrossRef]
- National Athletic Trainers' Association. NATA Releases Executive Summary of Appropriate Care of Spine Injured Athlete Inter-Association Consensus Statement. 2015. https://www.nata.org/sites/default/files/Executive-Summary-Spine-Injury-updated.pdf. Accessed May 21, 2017.
- Ellis J, Courson R, Daniels B. Spinal trauma. Curr Rev Musculoskelet Med. 2014;7:381–386. doi:10.1007/s12178-014-9235-x [CrossRef]
- Conrad BP, Rossi GD, Horodyski MB, Prasarn ML, Alemi Y, Rechtine GR. Eliminating log rolling as a spine trauma order. Surg Neurol Int. 2012;3(suppl 3):S188–S197. doi:10.4103/2152-7806.98584 [CrossRef]
- Del Rossi G, Horodyski MH, Conrad BP, Di Paola CP, Di Paola MJ, Rechtine GR. The 6-plus-person lift transfer technique compared with other methods of spine boarding. J Athl Train. 2008;43:6–13. doi:10.4085/1062-6050-43.1.6 [CrossRef]
- Del Rossi G, Horodyski M, Conrad BP, Dipaola CP, Dipaola MJ, Rechtine GR. Transferring patients with thoracolumbar spinal instability: are there alternatives to the log roll maneuver?Spine. 2008;33:1611–1615. doi:10.1097/BRS.0b013e3181788683 [CrossRef]
- Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on spine-injured patients?Am J Emerg Med. 2010;28:751–756. doi:10.1016/j.ajem.2009.03.014 [CrossRef]
- Del Rossi G, Bodkin D, Dhanani A, Courson RW, Konin JG. Protective athletic equipment slows initiation of CPR in simulated cardiac arrest. Resuscitation. 2011;82:908–912. doi:10.1016/j.resuscitation.2011.02.022 [CrossRef]
- Horodyski M. Care of the spine injured athlete. Presented at: Mid-Atlantic District Meeting. ; May 30, 2015. ; Virginia Beach, VA. .
- Horodyski M, Henry G, Courson R. Inter-association consensus statement on management of spine injuries. Presented at: National Athletic Trainers' Association 66th Clinical Symposia and AT Expo. ; June 23–26, 2015. ; St. Louis, MO. .
- Campbell J. International Trauma Life Support for Emergency Care Providers, 7th ed. Harlow, England: Pearson; 2012.
- Finch C. Review: A new framework for research leading to sports injury prevention. J Sci Med Sport. 2006;9:3–9. doi:10.1016/j.jsams.2006.02.009 [CrossRef]
- Finch CF. Implementation and dissemination research: the time has come!Br J Sports Med. 2011;45:763–764. doi:10.1136/bjsports-2011-090252 [CrossRef]
- Finch CF, McCrory P, Ewing MT, Sullivan SJ. Concussion guidelines need to move from only expert content to also include implementation and dissemination strategies. Br J Sports Med. 2013;47:12–14. doi:10.1136/bjsports-2012-091796 [CrossRef]
- Donaldson A, Callaghan A, Bizzini M, Jowett A, Keyzer P, Nicholson M. A concept mapping approach to identifying the barriers to implementing an evidence-based sports injury prevention programme [published online ahead of print January 20, 2018]. Injury Prevention.
- Williams RM, Welch CE, Parsons JT, Valovich McLeod TC. Athletic trainers' familiarity with and perceptions of academic accommodations in secondary school athletes after sport-related concussion. J Athl Train. 2015;50:262–269. doi:10.4085/1062-6050-49.3.81 [CrossRef]
- Titler MG. The evidence for evidence-based practice implementation. In: Hughes RG, ed. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality; 2008.
- Mihalik JP, Lynall RC, Fraser MA, et al. Football equipment removal improves chest compression and ventilation efficacy. Prehosp Emerg Care. 2016;20:578–585. doi:10.3109/10903127.2016.1149649 [CrossRef]
- Swartz EE, Mihalik JP, Beltz NM, Day MA, Decoster LC. Face mask removal is safer than helmet removal for emergent airway access in American football. J Spine. 2014;14:996–1004. doi:10.1016/j.spinee.2013.10.032 [CrossRef]
- DuBose DN, Connolly S, Hatzel B, et al. Motion created in an unstable spine during the removal of a football helmet: comparison of techniques. Athletic Training and Sports Health Care. 2015;7:242–247. doi:10.3928/19425864-20151029-05 [CrossRef]
- Aprahamian C, Thompson BM, Darin JC. Recommended helmet removal techniques in a cervical spine injured patient. J Trauma. 1984;24:841–842. doi:10.1097/00005373-198409000-00011 [CrossRef]
- Davis D, O'Brien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes?J Am Med Assoc. 1999;282:867–874. doi:10.1001/jama.282.9.867 [CrossRef]
- Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAMA. 1995;274:700–705. doi:10.1001/jama.1995.03530090032018 [CrossRef]
- Sitzler B. NATA takes over Baltimore. NATA Now. June2, 2016. https://www.nata.org/blog/beth-sitzler/nata-takes-over-baltimore
- Bayley MT, Teasell RW, Wolfe DL, et al. Where to build the bridge between evidence and practice? Results of an international workshop to prioritize knowledge translation activities in traumatic brain injury care. J Head Trauma Rehabil. 2014;29:268–276. doi:10.1097/HTR.0000000000000053 [CrossRef]
|Highest level of education (n = 2,304)|
| Bachelor's degree||464||20.1|
| Master's degree||903||39.2|
| Doctorate degree (eg, PhD, EdD)||28||1.2|
| Clinical degree (eg, DAT, DPT)||21||0.9|
| Professional degree (eg, MD, DO)||4||0.2|
|Clinical practice setting (n = 2,287)|
| Secondary school||951||41.6|
| Health or fitness club||4||0.2|
| Professional sports||48||2.1|
| Performance arts||11||0.5|
| Industrial or occupational||40||1.7|
| Amateur, recreational, or youth sports||33||1.4|
| Military, government, or law enforcement||17||0.7|
| Residential care facility or nursing home||3||0.1|
| Independent contractor||41||1.8|
| Multiple settings||32||1.4|
|Primary athletic training role (n = 2,297)|
| Athletic trainer||710||30.9|
| Head athletic trainer||719||31.3|
| Associate athletic trainer||93||4.0|
| Assistant athletic trainer||332||14.5|
| Graduate assistant athletic trainer||193||8.4|
| Educator–currently providing patient care||90||3.9|
| Physician extender||21||0.9|
| Athletic trainering intern/fellow/resident||17||0.7|
| Dual profession||35||1.5|
| Director of program/area director||18||0.8|
|Decision-making authority on policies/procedures (n = 2,304)|
|Continuing education on appropriate management of spine-injured athletes in past 2 years (n = 2,304)|
Individual Item Knowledge Question Responses by CEU Status
|Question||Response Choices||Overall||CEU||No CEU|
|When should athletic training services be provided?||All sporting events||1,771||95.8||668||96.8||696||94.8|
|All contact sporting events||74||4.0||22||3.2||36||4.9|
|When should EAP be reviewed?||Prior to the start of all athletic events||609||32.9||250||36.2||236||32.2|
|Prior to the start of each calendar month||54||2.9||15||2.1||23||3.1|
|Prior to the start of each calendar year||257||13.9||77||11.1||117||15.9|
|Prior to the start of each new sport season||930||50.3||349||61.6||358||48.8|
|What primary factor should the activation of an EAP be based on?||Availability of athletic training staff||123||6.7||46||6.6||40||5.5|
|Availability of EMS personnel||53||2.9||20||2.9||21||2.9|
|When is it recommended that protective equipment be removed following a suspected spinal injury?||Prior to spine boarding the athlete||1,130||61.2||505||73.3||399||54.4|
|After spine boarding the athlete||181||9.8||64||9.3||67||9.1|
|In the ambulance||9||0.5||0||0||4||0.5|
|At the hospital||526||28.5||120||17.4||263||35.9|
|What is the recommended number of trained rescuers for protective equipment removal?||2||135||7.3||39||5.6||62||8.4|
|Which sports protective equipment requires proper knowledge and training for removal?||Helmets and face masks||115||6.4||31||4.5||57||7.8|
|Eye wear and headgear||0||0||0||0||0||0|
|Should pads and chest protectors||5||0.3||2||0.2||3||0.4|
|All sports equipment||1,666||93.3||656||95.2||674||91.8|
|When should a rigid cervical collar be applied?||Prior to spine boarding the athlete||1,321||73.9||522||75.7||511||69.6|
|After spine boarding the athlete||442||24.7||160||23.2||210||28.6|
|In the ambulance||3||0.2||1||0.1||0||0|
|At the hospital||21||1.2||7||1.0||13||1.8|
|Which of the following statements is true of manual in-line stabilization?||Manual in-line stabilization should be applied until EMS arrives||433||24.3||146||21.2||190||25.9|
|Manual in-line stabilization should continue even after rigid collar is applied||1,092||61.2||443||64.3||438||59.7|
|Manual in-line stabilization should only be applied if rigid collar is not applied||236||13.3||13.2||99||13.5|
|Manual in-line stabilization should be applied at the discretion of EMS||22||1.2||9||1.3||6||0.8|
|Which of the following techniques is recommended to maintain cervical neutrality during spine boarding in the supine position?||8-person lift with slide maneuver||467||26.2||236||34.3||146||19.9|
|6-person lift with slide maneuver||720||40.4||279||40.5||309||42.1|
|4-person log roll maneuver||591||33.2||173||25.1||277||37.7|
|2-person log roll maneuver||4||0.2||1||0.1||3||0.4|
|Which of the following techniques is recommended for football helmet removal following a suspected spinal injury?||3-person technique with anterior stabilization||683||38.5||280||40.8||274||37.6|
|2-person technique with posterior stabilization||237||13.4||87||12.7||99||13.6|
|2-person technique with anterior stabilization||410||23.1||182||26.5||147||20.2|
|3-person technique with posterior stabilization||442||24.9||138||20.1||208||28.6|
|Which of the following techniques is recommended for football should pad removal?||Elevated torso technique||765||43.8||360||52.8||263||36.7|
|Full body lift technique||465||26.6||174||25.5||187||26.1|
|Single arm technique||249||14.2||62||9.1||141||45.7|
|Double arm technique||269||15.4||86||12.6||126||17.8|
Composite Knowledge Scores
|Score||Percentage (Score / 11 * 100)||Academic Grade Equivalent||N (%)|
|< 6.00||< 45.5%||–||525 (28.3)|