Influences of Athletic Trainers’ Return-to-Activity Assessments for Patients With an Ankle Sprain
Athletic trainers (ATs) inconsistently apply rehabilitation-oriented assessments (ROASTs) when deciding return-to-activity readiness for patients with an ankle sprain. Facilitators and barriers that are most influential to ATs’ assessment selection remain unknown. To examine facilitators of and barriers to ATs’ selection of outcome assessments when determining return-to-activity readiness for patients with an ankle sprain. Cross-sectional study. Online survey. We sent an online survey to 10 000 clinically practicing ATs. The survey was accessed by 676 individuals, of whom 574 submitted responses (85% completion rate), and 541 respondents met the inclusion criteria. The survey was designed to explore facilitators and barriers influencing ATs’ selection of pain; ankle-joint swelling, range of motion, arthrokinematics, and strength; balance; gait; functional capacity; physical activity level; and patient-reported outcome assessments when making return-to-activity decisions for patients after an ankle sprain. The survey asked for reasons that participants chose to use or not use each measure (eg, previous education, personal comfort, most appropriate, available or feasible, perceived value, and other). The survey contained 12 demographic items that characterized the sample of respondents and were examined as potential influences on the facilitators and barriers. Chi-square analysis was used to identify relationships among participant demographics and facilitators of or barriers to assessment selection. Selection of each ROAST and non-ROAST was most commonly facilitated by previous education, availability or feasibility, or perceived value. Avoidance of each ROAST was most often caused by the lack of previous education, availability or feasibility, or perceived value. The presence of facilitators and barriers was affected by various demographic variables. A variety of facilitators and barriers affected ATs’ implementation of expert-recommended assessments when determining return-to-activity readiness in patients with an ankle sprain. Some subpopulations of ATs experienced more favorable or prohibitive conditions for assessment use.Context
Objective
Design
Setting
Patients or Other Participants
Main Outcome Measure(s)
Results
Conclusions
Acute ankle sprains are often a source of prolonged hardship for physically active individuals. In addition to the high incidence of primary and recurrent injuries, acute ankle sprains are associated with a wide array of sequelae and are precursors to chronic ankle instability.1 Some impairments commonly accompanying acute ankle sprains have been directly linked to an increased risk of recurrent ankle sprains and the development of chronic ankle instability.2,3 Several impairments, such as increased ankle-joint swelling and reduced ankle-joint range of motion (ROM), balance, and patient-reported outcome (PRO) scores, are also known to persist in patients beyond their clearance for return to activity.4,5 Athletic trainers (ATs) are often responsible for managing the care of patients with an ankle sprain. Thus, their clinical evaluations and return-to-activity decisions are critical to detecting persistent impairments and avoiding long-term consequences.
The consensus of the International Ankle Consortium on rehabilitation-oriented assessments (ROASTs) provided expert consensus guidelines for ankle-sprain evaluation.6 However, recent evidence has indicated that ATs do not consistently use ROASTs when determining return-to-activity readiness for patients with an ankle sprain.7,8 Insufficiencies in ATs’ assessment protocols likely contribute to persistent impairments in these patients beyond return to activity.4,5 In preliminary work, McCann et al9 indicated that facilitators and barriers influencing ATs’ assessment methods were likely multifaceted. More specifically, time, cost, availability, awareness, perceived value, and injury severity were documented as reasons for selecting or avoiding ROASTs.9 Furthermore, ATs cited patient perceptions, previous education, and clinician experience as influences on alternative assessment (non-ROAST) selection.9 Despite valuable early findings regarding facilitators of and barriers to assessment selection, limited sample sizes associated with qualitative research prevented generalization of the results to the larger AT population.
The purpose of our study was to determine which factors facilitated or acted as barriers to ATs’ selection of specific outcome assessments when determining patients’ return-to-activity readiness after an ankle sprain. Identifying influences on ATs’ ankle-sprain assessment choices will uncover potential strategies for adopting expert-recommended guidelines. We also aimed to determine the influence of participant demographics on facilitators and barriers to reveal how well equipped the subpopulations of ATs were to implement expert-recommended guidelines.
METHODS
We used a cross-sectional, web-based survey to collect pertinent data to address our study aims. The Old Dominion University Human Subjects Review Committee deemed this study exempt research.
Participants
We recruited ATs to complete the survey who met the following inclusion criteria: (1) they were certified members of the National Athletic Trainers’ Association (NATA), (2) they were in good standing with the Board of Certification, (3) they were practicing clinically at the time of data collection (ie, between April and May 2021), and (4) they had provided care to at least 1 patient with an ankle sprain that resulted in time loss from activity in the year before data collection (ie, between April 2020 and April 2021). Confirmatory questions ensured that participants met our inclusion criteria.
Instrumentation
After a thorough literature search to verify that no established survey would achieve our study aims, we developed a web-based survey hosted in the Qualtrics platform. The survey contained numerous items to help us understand the facilitators and deterrents affecting ATs’ assessment choices when providing services to patients after an ankle sprain. Specifically, participants were asked to identify which outcomes (pain; ankle-joint swelling, ROM, arthrokinematics, and strength; balance; gait; functional capacity; physical activity level; and PRO instruments) they typically used to evaluate patients after an ankle sprain to determine readiness to return to activity. Next, they were asked to respond to a series of follow-up questions to further determine which specific assessment measure(s) they used. If participants did not select a specific assessment, we assumed that the assessment was not used for return-to-activity decisions. Lastly, we asked participants why they chose to use or not use each measure (eg, previous education, personal comfort, most appropriate, available or feasible, perceived value, and other). Perceived value could have pertained to colleagues, patients, or oneself. Questions about facilitators and barriers were independent; thus, if a participant did not identify a factor as a facilitator, it was not automatically classified as a barrier and vice versa. Respondents who selected other could clarify their response in the text. Athletic trainers were also asked to respond to 12 demographic items to help us characterize them. After development, the survey went through a rigorous content validity index process; the final survey instrument was deemed valid to achieve the research aims.8
Procedures
After the validated survey was pilot tested,8 the request to participate in this study was randomly distributed to 10 000 ATs via the NATA Research Survey Service in April 2021. The data-collection period was 6 weeks, and potential participants were sent weekly reminders. Given the survey logic used to ensure that participants only responded to pertinent questions based on their experiences, the anticipated survey completion time was approximately 25 minutes.
Data Analysis
Descriptive statistics were calculated to quantify frequencies of reported facilitators of and barriers to ATs’ use of patient-rated, clinician-rated, and functional assessments. To maintain voluntary rights to respond or not respond to survey items by the participants within the exempt research classification, we included all responses for data analysis, regardless of whether participants completed the survey in its entirety. Chi-square analysis was performed to determine relationships among participant demographics and facilitators of or barriers to assessment selection. Survey data were analyzed using SPSS (version 27; IBM Corp). The level of significance was set a priori at P < .05.
RESULTS
In total, 676 ATs accessed the survey (6.8% access rate), 574 of whom submitted responses (85% completion rate). A total of 33 respondents did not meet the inclusion criteria and were eliminated from analyses. Thus, our final sample consisted of 541 respondents. Respondent demographics, rates for the evaluation of each outcome domain, rates for the selection of each assessment method, demographic influences of evaluated outcome domains, and demographic influences of selected assessment methods have been reported.8
Facilitators of Assessments
Rates of reported facilitators of the selection of patient-rated, clinician-rated, and functional assessments are described in Figures 1 through 3. Multiple factors facilitated the choice of each assessment method. Previous education was the most commonly reported facilitator of the Foot and Ankle Ability Measure (FAAM), Global Rating of Change (GROC), figure-of-8, and goniometry selection. Availability or feasibility was the most frequently cited facilitator of the numeric pain rating scale, Foot and Ankle Disability Index (FADI), pain portion of the FADI (FADI-Pain), Lower Extremity Functional Scale (LEFS), Patient-Specific Functional Scale (PSFS), general conversation, visual inspection of swelling, weight-bearing lunge test (WBLT), visual inspection of ROM, posterior talar glide test (PTGT), manual muscle testing, handheld dynamometry, Balance Error Scoring System (BESS), Star Excursion Balance Test (SEBT), foot-lift test (FLT), visual inspection of gait, jumping or hopping test, agility test, and sport-specific test selection. Perceived value was the most often mentioned facilitator of the Tegner Activity Level Scale. Facilitators of each assessment were further affected by respondent demographics.
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Patient-Rated Assessments
Facilitators of numeric pain rating scale selection varied based on ATs’ highest degree earned (
= 23.878, P = .02), educational programs completed (
= 64.263, P = .02), years of clinical practice (
= 56.319, P = .003), and familiarity with the ROAST guidelines (
= 17.956, P = .006; Appendix Table 1). Facilitators of the FADI-Pain, Tegner Activity Level Scale, FAAM, and full FADI were not influenced by participant demographics.
Clinician-Rated Assessments
Facilitators of figure-of-8 selection varied based on ATs’ highest degree earned (
= 25.050, P = .02; Appendix Table 2). Facilitators of visual inspection of swelling selection differed based on ATs’ years of clinical practice (
= 49.899, P = .01) and familiarity with the ROAST guidelines (
= 14.254, P = .03; Appendix Table 2). Facilitators of goniometry selection varied based on ATs’ gender (
= 15.163, P = .02; Appendix Table 2), whereas facilitators of WBLT selection varied based on ATs’ educational programs completed (
= 60.008, P = .04; Appendix Table 2). Facilitators of PTGT selection differed based on ATs’ years of clinical practice (
= 44.917, P = .04; Appendix Table 2). Facilitators of manual muscle testing varied based on ATs’ gender (
= 17.533, P = .007), educational programs completed (
= 99.471, P < .001), and familiarity with the ROAST guidelines (
= 14.828, P = .02; Appendix Table 2). Facilitators of visual inspection of ROM and handheld dynamometry selection were not affected by demographics.
Functional Assessments
Facilitators of BESS selection differed based on ATs’ gender (
= 24.091, P < .001), age (
= 40.419, P = .02), years of clinical practice (
= 83.820, P < .001), and familiarity with the ROAST guidelines (
= 13.625, P = .03; Appendix Table 3). Facilitators of SEBT selection varied based on ATs’ age (
= 37.289, P = .041) and years of clinical practice (
= 60.043, P < .001; Appendix Table 3). Facilitators of visual inspection for gait varied based on ATs’ gender (
= 15.401, P = .02; Appendix Table 3). Facilitators of jumping or hopping tests were influenced by age (
= 47.318, P = .003; Appendix Table 4). Facilitators of agility tests were affected by educational programs completed (
= 68.526, P = .006; Appendix Table 5). Participant demographics did not influence facilitators of the FLT and sport-specific test.
Barriers to Assessments
Rates of reported barriers to selecting patient-rated, clinician-rated, and functional assessments are provided in Figures 4 through 6. Multiple barriers limited the selection of each expert-recommended assessment. A lack of previous education was the most often reported barrier to selecting the FADI, Tegner Activity Level Scale, FAAM, FADI-Pain, figure-of-8, WBLT, PTGT, SEBT, and FLT. Low perceived value and other were the most typically described barriers to selecting the numeric pain rating scale and BESS. Low availability or feasibility was the most frequently noted barrier to the selection of handheld dynamometry.
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Citation: Journal of Athletic Training 59, 2; 10.4085/1062-6050-0628.22
Patient-Rated Assessments
Barriers to using the FADI-Pain varied based on familiarity with the ROAST guidelines (
= 49.695, P < .001; Appendix Table 4) and educational programs completed (
= 104.786, P < .001; Appendix Table 5). Barriers to using the FAAM (
= 15.945, P = .01) and full FADI differed based on familiarity with the ROAST guidelines (
= 20.169, P = .003; Appendix Table 4). Barriers to using the numeric pain rating scale and Tegner Activity Level Scale were not affected by participant demographics.
Clinician-Rated Assessments
Barriers to using figure-of-8 (
= 14.050, P = .03), WBLT (
= 15.034, P = .04), and handheld dynamometry (
= 14.351, P = .045) varied based on ATs’ familiarity with the ROAST guidelines (Appendix Table 4). Barriers to handheld dynamometry selection (
= 27.747, P = .02) further differed based on the highest degree earned (Appendix Table 5). Barriers to using the PTGT were not influenced by demographics.
Functional Assessments
Barriers to using the SEBT varied based on familiarity with the ROAST guidelines (
= 21.149, P = .002; Appendix Table 4) and educational programs completed (
= 103.890, P < .001; Appendix Table 5). Barriers to using the BESS, FLT, and visual inspection of gait were not affected by demographics.
DISCUSSION
Our aim was to identify factors influencing ATs’ selection or avoidance of assessment methods when making return-to-activity decisions for patients with an ankle sprain. One of our primary findings was that a lack of previous education was the most frequently cited barrier to participants’ selection of most ROASTs. A preliminary qualitative analysis similarly indicated that a lack of awareness was a barrier to ATs’ implementation of ROASTs.9 The results of other authors were similar: fewer than half of ATs were familiar with the ROAST guidelines,8 and 38% of ATs were unaware of the NATA’s position statement on the management of ankle sprains.10 Across other allied health professions, a lack of knowledge has been identified as a barrier to using various outcome tools.11 This lack of awareness or previous education has been directly linked to ATs’ incomplete evaluation of expert-recommended outcome domains and assessment methods when determining return-to-activity readiness for patients with an ankle sprain.8
We found that ATs who were unfamiliar with the ROAST guidelines were more likely to cite a lack of previous education as a barrier to using the FAAM, FADI, handheld dynamometry, and SEBT. Furthermore, ATs who completed a professional undergraduate program and those with a bachelor’s degree were more likely to cite a lack of previous education as a barrier to the FADI-Pain and handheld dynamometry, respectively. A lack of training was also reported to be a barrier to PROs use among the 8% to 20% of ATs who did not use them.12,13 A high level of education has been implicated as a facilitator of the use of outcome assessments among health care providers.11
Some ATs’ previous education was a prominent facilitator of both ROASTs and non-ROASTs. For example, we determined that those who completed postprofessional education programs indicated greater availability of the numeric pain rating scale and WBLT than those who completed a professional program. In addition, respondents who completed a postprofessional master’s program were less likely to cite a lack of previous education as a barrier to FADI use. Furthermore, we discovered that younger, less experienced ATs were more likely to identify previous education as a facilitator of the PTGT, BESS, and SEBT. Although we cannot definitively determine the causal rationale, this may suggest that these assessment measures are being discussed more readily in professional education programs. Also, ATs—and particularly female ATs—familiar with the ROAST guidelines were less likely to cite previous education as a facilitator of non-ROASTs, such as goniometry and manual muscle testing.
Across other facilitators of ROASTs and non-ROASTs, availability or feasibility was the most frequently noted reason. McCann et al9 reported that time and cost were common barriers to using some ROASTs. Others have shown that insufficient time was among the most prominent barriers to ATs’ use of PROs and implementation of evidence-based practice.13,14 Although some of our respondents found ROASTs to be available and feasible, ATs also selected most non-ROASTs primarily for their availability or feasibility. Whereas ATs with master’s degrees found the figure-of-8 to be more feasible than those with a bachelor’s degree, ATs with a professional master’s degree viewed the numeric pain scale as less feasible than ATs with a doctor of athletic training degree. In addition, ATs who completed undergraduate or master’s degree athletic training programs were more likely to see the WBLT as feasible than ATs who completed a professional athletic training internship. Handheld dynamometry was the least facilitated assessment by its availability. In fact, handheld dynamometry was the only ROAST with availability or feasibility as the primary barrier, likely because it is the only ROAST that requires costly equipment.
A lack of personal comfort was also attributed to some ATs’ avoidance of handheld dynamometry. Athletic trainers with previous knowledge of the ROAST guidelines were less likely to view a lack of comfort with handheld dynamometry as a barrier to its use. We found that personal comfort was also related to the selection of non-ROASTs. For example, >80% of ATs who assessed ankle strength indicated that their comfort led to the selection of manual muscle testing as their preferred assessment measure. The use of other non-ROASTs, such as general conversation and visual inspection of swelling and ROM, were also heavily influenced by the personal comfort of ATs. Furthermore, ATs without knowledge of the ROAST guidelines were more prone to identify personal comfort as a reason for selecting visual inspection of swelling but not for the figure-of-8.
Most ATs who used a given ROAST did not cite perceived value as a facilitator. Similarly, most ATs who did not use a given ROAST did not acknowledge perceived value as a barrier. However, the perceived value was commonly selected as a facilitator of multiple non-ROASTs, including the LEFS, PSFS, general conversation, goniometry, manual muscle testing, jumping or hopping tests, agility tests, and sport-specific tests. The higher or lower perceived value of outcomes has been linked to increased or decreased clinical use in previous works.11 Other researchers have demonstrated that administration and colleagues were not barriers to ATs’ implementation of evidence-based practice.14 In our study, the perceived value represented that of colleagues, patients, or respondents themselves, so we cannot determine which source most strongly influenced that perception.
Clinical Application
Current evidence indicates that ATs must conduct thorough evaluations of patients with an ankle sprain to ensure that all relevant impairments are addressed. To accomplish this, ATs might need to foster conditions that promote the use of and eliminate barriers to best-practice guidelines. According to our data, enhanced education or awareness is a critical factor that affects ATs’ use of the ROAST guidelines when making return-to-activity decisions. Advanced education can be attained through the completion of higher degrees and more advanced educational programs. It can also be achieved through participation in symposia and workshops and the consumption of contemporary literature. Accordingly, familiarity with the ROAST guidelines reduced educational and comfort-related barriers to ROAST implementation. More importantly, ATs with knowledge of the ROAST guidelines were generally more likely to use ROASTs.8
Availability or feasibility also heavily affected ROAST use by ATs. Given that time is a common factor affecting feasibility, ATs with limited time might benefit from using abbreviated versions of ROASTs. For example, the Quick-FAAM retains 12 of 29 items from the original instrument while still providing a valid, reliable assessment of self-reported ankle function.15–17 Simplifying the SEBT to the anterior-reach direction has exhibited the ability to predict subsequent ankle sprains18 and identify postural control asymmetries at return to activity after an ankle sprain.4 Although most of the ROASTs have low associated costs, handheld dynamometry is the lone recommended technique that requires access to expensive equipment. Most handheld dynamometers range in cost from $300 to $1200. If a handheld dynamometer is unaffordable, ATs should consider low-cost, portable dynamometers and crane scales.19,20 Many portable dynamometers are priced between $100 and $200, and various crane scales are available for <$50. When combined with straps, belts, or chains, these alternative devices can be arranged to quantify lower extremity strength with excellent validity and reliability.19,20
Limitations
Several limitations were present in this study, including those previously described.8 As with all survey data, the self-reported nature of this data collection assumes participant honesty in responding. In asking participants about their use of recommended guidelines in clinical practice, we acknowledge the potential that acquiescence bias might have influenced their answers. In addition, some of our answer options regarding facilitators and barriers encompassed multiple subcomponents. For example, previous education could have included knowledge acquired from classroom instruction, clinical education, symposia, workshops, or self-directed learning, and we did not collect information about the specific educational content taught in participants’ completed education programs. Availability or feasibility likely included considerations for time, cost, access, or available space. Perceived value reflected the respondents’ perspectives regarding themselves, their patients, and their colleagues. Thus, our response options made it difficult to establish more specific facilitators and barriers that could have influenced ATs’ assessment selection. We sought to examine comparable demographic variables across participants, and we opted to focus on educational programs completed. We did not collect further information about professional development, continuing education, or specialty certifications obtained, which might have contributed to previous education or awareness. We included other as a response option when asking respondents to identify facilitators and barriers to using each assessment. Those who selected other had the opportunity to clarify their response in text, but a low rate of follow-up responses prevented us from fully analyzing and interpreting that variable.
CONCLUSIONS
Multiple facilitators and barriers influenced the assessments selected by ATs when determining return-to-activity readiness for patients with an ankle sprain. Previous education was a frequent facilitator of expert-recommended assessments, but a lack thereof was the most common barrier to their use. Availability or feasibility was the most often cited facilitator of the majority of assessments, regardless of whether experts recommended them. Various respondent characteristics further influenced facilitators and barriers, signifying that some subpopulations of ATs experienced more favorable or prohibitive conditions for assessment use.
Rates of influences on the use of patient-rated assessments. Abbreviations: FAAM, Foot and Ankle Ability Measure; FADI, Foot and Ankle Disability Index; FADI-Pain, pain portion of the FADI; GROC, Global Rating of Change; LEFS, Lower Extremity Functional Scale; PSFS, Patient-Specific Functional Scale; Tegner, Tegner Activity Level Scale.
Rates of influences on the use of clinician-rated assessments. Abbreviations: HHD, handheld dynamometry; MMT, manual muscle testing; PTGT, posterior talar glide test; ROM, range of motion; WBLT, weightbearing lunge test.
Rates of influences on the use of functional assessments. Abbreviations: BESS, Balance Error Scoring System; SEBT, Star Excursion Balance Test.
Rates of barriers to the use of patient-rated assessments. Abbreviations: FAAM, Foot and Ankle Ability Measure; FADI, Foot and Ankle Disability Index; FADI-Pain, pain portion of the FADI; Tegner, Tegner Activity Level Scale.
Rates of barriers to the use of clinician-rated assessments. Abbreviations: HHD, handheld dynamometry; PTGT, posterior talar glide test; WBLT, weightbearing lunge test.
Rates of barriers to the use of functional assessments. Abbreviations: BESS, Balance Error Scoring System; SEBT, Star Excursion Balance Test.
Contributor Notes