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Context: "Tensegrity" is a structural-organization model initially described in the architecture and design fields. By applying tensegrity design principles to biological structures, scientists have developed "biotensegrity" to explain a complex systems-on-systems structural-organization philosophy for integrated human movements. Objective: To provide a brief historical overview of tensegrity and biotensegrity principles, including recommendations and benefits for integrating these structural models into athletic training education. Background: Tensegrity and biotensegrity structures require constant interaction between continuous tension and discontinuous compression elements that connect through focal adhesion points. During the 1970s and 1980s, scientists applied tensegrity concepts to biological organisms to create an integrated model of human structure and interaction. Since then, biotensegrity has grown as an accepted biological structural model capable of explaining complex and integrated human movements. Synthesis: By teaching tensegrity and biotensegrity principles, athletic training educators can provide athletic training students with a basic and consistent human body structural model. With this knowledge, students can better comprehend the integrated kinetic chain, including current and future prevention, examination, and rehabilitation paradigms. Results: Although absent from the Practice Analysis, seventh edition, and the 2020 Commission on Accreditation of Athletic Training Education curricular content standards, tensegrity and biotensegrity relate to many injury prevention, examination, treatment, and rehabilitation concepts regularly taught in professional athletic training programs. Recommendation(s): Athletic training educators should consider ways to incorporate biotensegrity models into professional athletic training programs to improve critical thinking and whole-person health care principles of athletic training students. Conclusion(s): Integrating tensegrity and biotensegrity principles into professional athletic training programs provides a structural hierarchy of human body organization that athletic training students can apply to a multitude of current and future methodical approaches.

Context: Advanced clinical practice is inherent in contemporary athletic training education, such as residency programs and Doctor of Athletic Training programs; however, as a concept, advanced clinical practice in athletic training has been poorly studied to date. Objective: To explore athletic trainers' perceptions of advanced clinical practice. Design: Cross-sectional. Setting: Online survey with open-ended questions. Patients or Other Participants: Three hundred fifty of 1992 athletic trainers accessed the survey (17.6% access rate); 321 respondents completed at least 1 open-ended question; and 196 completed the survey in its entirety (61.1% completion rate). Intervention(s): We used a 13-item survey including demographic items (9 items) and open-ended response questions (4 items). Main Outcome Measure(s): Guided by the consensual qualitative research approach, a 3-person data analysis team coded the open-ended responses. Each member coded 50 responses and a consensus codebook was developed. Two members of the team coded the remaining responses, which were confirmed by the third member. Emergent data were organized into themes and categories, and frequency counts were determined for each category. Results: Athletic trainers' definitions of advanced clinical practice were categorized into 4 emergent categories: (1) formal training and education; (2) informal training and education; (3) knowledge, skills, and behaviors; and (4) experience and uncertainty. Conclusions: The categories of formal and informal training and education focused on athletic trainers acquiring additional knowledge and skills through mechanisms such as postprofessional degree programs, residency programs, or other areas of study. The knowledge, skills, and behaviors category included areas related to specialized skills and the core competencies. These 3 categories aligned with one another to provide both the types of knowledge, skills, and behaviors that define advanced clinical practice, and the specific mechanisms through which an athletic trainer can achieve advanced clinical practice.

Context: The ''Strategic Priorities for Athletic Training Education'' promote the development of clinical specialists and advanced practice leaders; however, little is known about the characteristics of advanced practice athletic trainers. Peer health professions have formal education and training programs and specialized credentials to denote advanced practice clinicians; however, such mechanisms are only now emerging in athletic training. As training and credentialing programs advance, it is important to understand the perceived characteristics of clinicians engaged in advanced clinical practice. Objective: To explore how athletic trainers perceive the characteristics of clinicians advanced practice clinicians. Design: Cross-sectional. Setting: Self-reported online survey. Participants: Of 1992 athletic trainers invited to participate, 350 accessed the survey (17.6% access rate); 321 respondents completed at least 1 open-ended question, and 196 completed the entire survey (61.1% completion rate). Main Outcome Measures: Consensual qualitative research approach consisting of a 3-person team was used to analyze the open-ended responses. Members individually coded the initial set of responses and then met to develop a consensus codebook. Remaining responses were coded by 2 team members and were confirmed by the third member. Data were organized into themes and categories, and frequency counts were used for each category. Results: Four categories of characteristics associated with advanced practice clinicians emerged: (1) intrapersonal skills, (2) interpersonal skills, (3) discipline specific knowledge and skills, and (4) experience. Conclusions: Intrapersonal skills including lifelong learning, critical thinking, and willingness to mentor others were identified, in addition to strong communication and leadership skills. Discipline-specific knowledge and skills were also associated with advanced clinical practice, including specialized skills and advanced integration of the core competencies. Accredited Athletic Training Residency programs and Doctor of Athletic Training programs should strive to foster these characteristics within their students to facilitate the development of advanced practice athletic trainers.

Context: The use of point-of-care ultrasound (POCUS) is increasingly becoming a standard of care for sports medicine and orthopedic physicians. As such, there will be increased demand for athletic trainers to have knowledge and skills in diagnostic ultrasound. Objective: To provide key considerations for integration of diagnostic ultrasound into athletic training education and address challenges and barriers to such integration. Background: Advancements in designing portable, user-friendly ultrasound units have enabled clinicians to perform POCUS as an adjunct to the physical exam, resulting in improved patient care. Increased demands for POCUS across medicine have prompted medical schools to integrate diagnostic ultrasound throughout the curriculum, providing athletic training education programs a framework to consider within their curriculum. Synthesis: Integrating diagnostic ultrasound throughout the curriculum provides focused experiences to prepare, conduct, and link imaging to clinical and physical exam skills. Diagnostic ultrasound has a role in visualizing structures in an anatomy course, as an adjunct to physical exam in medical conditions, orthopedic exam, and diagnosis courses, and as a visual feedback tool in rehabilitation courses, thus enabling it to be integrated throughout existing curriculum. Barriers to diagnostic ultrasound include cost, time, and faculty expertise. Results: Cost sharing or use of ultrasound simulators can overcome cost barriers. Use of online educational modules to deliver content virtually is effective and allows face-to-face time to be spent in hands-on experiential learning. Finally, developing interprofessional partnerships to ''teach the teacher'' is an effective model in teaching faculty about diagnostic ultrasound. Recommendation(s): Educational programs should consider ways to overcome barriers and integrate diagnostic ultrasound into curriculum equipping future athletic trainers with knowledge and skills for POCUS, thus increasing their effectiveness on a health care team. Conclusion(s): Proactive integration of diagnostic ultrasound into athletic training education will equip graduates to add value to a health care team.

Context: The use of point-of-care diagnostic ultrasound is increasing in health care, specifically among sports medicine clinicians as an adjunct to the physical exam. Given the role of athletic trainers in interdisciplinary sports medicine teams, athletic training educational programs should consider integrating this noninvasive imaging modality into curricula. Objective: To provide a framework for integrating diagnostic ultrasound imaging content into existing athletic training curricula. Background: A phased approach to incorporating ultrasound imaging into existing courses with minimal disruption is important for adoption. Foundational knowledge for skill performance begins with early exposure to ultrasound concepts and is followed by phased integration of hands-on ultrasound imaging into athletic training courses. Description: Content delivery considerations, such as online modules and technology needs, to enhance hands-on learning is discussed. Examples of integrating diagnostic ultrasound imaging throughout the curriculum, including anatomy, clinical assessment, and manual therapy courses, are provided. Clinical Advantage(s): Integrating ultrasound throughout curricula teaches students how to use and interpret ultrasound images as an adjunct to physical exam, enhancing the athletic trainer's value on a health care team and improving clinical practice. Ultrasound imaging can also be used as a valuable feedback mechanism during the performance of hands-on athletic training skills, including special tissue tests and manual therapy techniques. Conclusion(s): Following initial exposure to ultrasound imaging, the inclusion of diagnostic ultrasound instruction in athletic training curricula can expose students to ultrasound imaging, basic concepts, transducer characteristics, and image interpretation, which is a valuable adjunct to clinical practice.

Context: Altered diaphragm function is linked to decreased core stabilization, postural changes, and decreased function. Two clinical tests used to assess breathing are the Hi-lo and lateral rib expansion (LRE) tests. It is currently unknown how breathing classification based on these tests differ and how their results are affected by varying test positions. Objective: To compare the results of breathing tests when conducted in varying test positions. Design: Prospective cross-sectional study. Setting: University laboratory. Participants: A total of 50 healthy adults (females 31 and males 29; age 29.3 [4.1] y; height 170.0 [10.4] cm; weight 70.7 [15.1] kg). Intervention(s): Hi-lo and LRE tests in supine, seated, standing, and half-kneeling body positions. All tests were recorded and later scored by a single examiner. A generalized estimating equations approach with breathing test and body position as factors was used for analysis. Pairwise comparison with Bonferroni correction was used to adjust for multiple tests. Statistical significance was set at P = .05, 2 tailed. Main Outcome Measures: Hi-lo and LRE tests were scored based on the presence or absence of abdominal excursion, LRE, and superior rib cage migration. Following scoring, results were classified as functional or dysfunctional based on observation of these criteria. Results: A significant breathing test x test position interaction (P c .O l) was noted, as well as main effects for test (P c .O l) and test position ( P c .01). All Hi-lo test positions identified significantly more dysfunctional breathers in positions of increased stability demand (P < .01), except between standing and halfkneeling positions (P= .52). In the LRE test, all positions were similar (P > .99) except for half-kneeling, which was significantly different from all other positions (P<.01). Conclusions: The Hi-lo test and LRE tests assess different breathing mechanics. Clinicians should use these tests in combination to gain a comprehensive understanding of a person's breathing pattern. The Hi-lo test should be administered in multiple testing positions. [ABSTRACT FROM AUTHOR]

The effective use of electronic records (ie, electronic health records or electronic medical records) is essential to professional initiatives and the overall advancement of the athletic training profession. However, evidence suggests that comprehensive patient care documentation and widespread use of electronic records are still limited in athletic training. The lack of formal training and education for clinicians and students is often cited as a primary barrier to electronic record use. Other health care disciplines have used academic electronic health record (AEHR) systems to address these barriers with promising results. To identify common challenges associated with the effective use of electronic records in clinical practice, discuss how an AEHR system can address these challenges and encourage more effective use of electronic records, and describe strategies for deploying AEHRs in the athletic training profession. The AEHR is an electronic records system specifically designed for educational use to support simulation learning among all types of learners (eg, practicing clinicians, students). Mimicking the form and function of an electronic health record, the AEHR offers various educational tasks, including patient care documentation projects, critical reviews of standardized patient cases, and assessments of patient care data for quality improvement efforts. Recent evidence suggests that the use of an AEHR can improve knowledge and enhance skills. Specifically, AEHR use has been associated with enhanced attitudes toward electronic health record technology, increased informatics competencies, and improved documentation skills. Also, the use of an AEHR has been associated with improved critical thinking and decision-making skills. This tool appears to be valuable for health professions education, and athletic training stands to benefit from its use to better train and upskill clinicians and students alike for clinical practice. Although the implementation of an AEHR will require much time and large-scale coordinated efforts, it will be a worthy investment to address current challenges and advance the athletic training profession. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Research has shown a link between poor core stability and chronic, nonspecific low back pain, with data to suggest that alterations in core muscle activation patterns, breathing patterns, lung function, and diaphragm mechanics may occur. Traditional treatment approaches for chronic, nonspecific low back pain focus on exercise and manual therapy interventions, however it is not clear whether breathing exercises are effective in treating back pain. Focused Clinical Question: In adults with chronic, nonspecific low back pain, are breathing exercises effective in reducing pain, improving respiratory function, and/or health related quality of life? Summary of Key Findings: Following a literature search, 3 studies were identified for inclusion in the review. All reviewed studies were critically appraised at level 2 evidence and reported improvements in either low back pain or quality of life following breathing program intervention. Clinical Bottom Line: Exercise programs were shown to be effective in improving lung function, reducing back pain, and improving quality of life. Breathing program frequencies ranged from daily to 2-3 times per week, with durations ranging from 4 to 8 weeks. Based on these results, athletic trainers and physical therapists caring for patients with chronic, nonspecific low back pain should consider the inclusion of breathing exercises for the treatment of back pain when such treatments align with the clinician's own judgment and clinical expertise and the patient's preferences and values. Strength of Recommendation: Grade B evidence exists to support the use of breathing exercises in the treatment of chronic, nonspecific low back pain. [ABSTRACT FROM AUTHOR]

Clinical Scenario: Shoulder pain is a common musculoskeletal complaint and is often associated with shoulder impingement. The annual incidence of shoulder pain is estimated to be 7% of all injuries, and is the third-most-common type of musculoskeletal pain. Initial treatment of shoulder impingement follows a conservative plan and emphasizes rehabilitation programs as opposed to surgical interventions. Shoulder rehabilitation programs commonly focus on strengthening the muscles of the shoulder complex and, more specifically, the rotator cuff. The rotator cuff is a primary dynamic stabilizer of the glenohumeral joint, using both eccentric and concentric contractions. The posterior rotator cuff, including teres minor and infraspinatus, works eccentrically to decelerate the arm during overhead throwing. Exercises to strengthen the rotator cuff and the surrounding dynamic stabilizers of the shoulder girdle vary and include activities such as internal and external rotation, full-can lifts, and rhythmic stabilizations. Traditionally, shoulder rehabilitation programs have focused on isotonic concentric contractions. Common strengthening exercises typically involve movements that result in shortening the muscle length while simultaneously loading the muscles. However, recent attention has been given to eccentric exercises, which involve lengthening of the muscle during loading, for the treatment of a variety of different tendinopathies including those of the Achilles and patellar tendons. The eccentric, or lengthening, motion is thought to be beneficial for people who are involved in activities that place eccentric stress on their shoulder, such as overhead throwers. Based on studies related to the Achilles tendon, eccentric exercise may positively influence the tendon structure by increasing collagen production and decreasing neovascularization. The changes that occur as a result of eccentric exercises may improve function, strength, and performance and decrease pain more than concentric programs, producing better patient outcomes. Although eccentric strength training has been shown to provide strength gains, there are no clear guidelines as to the inclusion of this form of exercise training in shoulder rehabilitation programs for the purposes of improving function and decreasing pain. Focused Clinical Question: Does adding an eccentric-exercise component to the rehabilitation program of patients with shoulder impingement improve shoulder function and/or decrease pain? [ABSTRACT FROM AUTHOR]

Clinical Scenario: Appropriate movement patterns during sports and physical activities are important for both athletic performance and in jury prevention. The assessment of movement dysfunction can assist clinicians in implementing appropriate rehabilitation programs after injury, as well as developing injury-prevention plans. No gold standard test exists for the evaluation of movement capacity; however, the Functional Movement Screen (FMS) has been recommended as a tool to screen for movement-pattern limitations and side-to-side movement asymmetries. Limited research has suggested that movement limitations and asymmetries may be linked to increased risk for injury. While this line of research is continuing to evolve, the use of the FMS to measure movement capacity and the development of intervention programs to improve movement patterns has become popular. Recently, additional research examining changes in movement patterns after standardized intervention programs has emerged. Clinical Question: Does an individualized training program improve movement patterns in adults who participate in high-intensity activities? [ABSTRACT FROM AUTHOR]

Context: The use of point-of-care ultrasound (POCUS) is increasingly becoming a standard of care for sports medicine and orthopedic physicians. As such, there will be increased demand for athletic trainers to have knowledge and skills in diagnostic ultrasound. Objective: To provide key considerations for integration of diagnostic ultrasound into athletic training education and address challenges and barriers to such integration. Background: Advancements in designing portable, user-friendly ultrasound units have enabled clinicians to perform POCUS as an adjunct to the physical exam, resulting in improved patient care. Increased demands for POCUS across medicine have prompted medical schools to integrate diagnostic ultrasound throughout the curriculum, providing athletic training education programs a framework to consider within their curriculum. Synthesis: Integrating diagnostic ultrasound throughout the curriculum provides focused experiences to prepare, conduct, and link imaging to clinical and physical exam skills. Diagnostic ultrasound has a role in visualizing structures in an anatomy course, as an adjunct to physical exam in medical conditions, orthopedic exam, and diagnosis courses, and as a visual feedback tool in rehabilitation courses, thus enabling it to be integrated throughout existing curriculum. Barriers to diagnostic ultrasound include cost, time, and faculty expertise. Results: Cost sharing or use of ultrasound simulators can overcome cost barriers. Use of online educational modules to deliver content virtually is effective and allows face-to-face time to be spent in hands-on experiential learning. Finally, developing interprofessional partnerships to ''teach the teacher'' is an effective model in teaching faculty about diagnostic ultrasound. Recommendation(s): Educational programs should consider ways to overcome barriers and integrate diagnostic ultrasound into curriculum equipping future athletic trainers with knowledge and skills for POCUS, thus increasing their effectiveness on a health care team. Conclusion(s): Proactive integration of diagnostic ultrasound into athletic training education will equip graduates to add value to a health care team. [ABSTRACT FROM AUTHOR]