Epidemiology for Athletic Trainers with Chad Starkey - How to Show Injury Risks and Rates - 208

Hey, this is Sandy. And Randy? And we're here on at Corner. Being an athlete trainer comes with ups and downs and we're here to showcase it all. Join us as we share our world in sports medicine. Welcome back to another episode of At Corner Happy last week of National Athletic Training Month. And boy, do we have something so exciting in store for you guys today. Yes, we have Chad Starkey

talking about epidemiology. So fun fact, Chad actually did not know what we were going to talk about before we just jumped into this episode. He actually said, hey, it's more authentic if if we just go, I could talk about anything, which if that could, if that shows you just a little piece of how awesome, inspiring, amazing this man is.

Yeah, absolutely, for sure. So Chad Starkey is a professor and the chair of Department of Athletic Training at Ohio University. He also serves as the director of Ohio University's online DAT program and their MSAT program. Which the DAT program is where we had the luxury of meeting Chad and that's actually also where we, the two of us have taken a class from Chad about epidemiology and injury risk,

injury rates and all that. Chad is a graduate of West Virginia University. He received his master's and doctoral degrees from Ohio University.

He has served as a Commissioner for the Commission of Accreditation of Athletic Training Education, on the Board of Directors for the Board of Certification, and as Chair of the Education Council of the National Athletic Trainers Association. From 1986 through 2018, he provided epidemiological services to the MBA and he has authored several textbooks focused on sports medicine, orthopedic diagnosis, and therapeutic modalities.

Which, by the way, I'm pretty sure we all have at least one of those textbooks. Yes. And he's served as a Co editor for the for four editions of Taber's Cyclopedic Medical Dictionary. Yeah, honestly, epidemiology is kind of a scary word. I feel like if you don't know, like, it's a big scary word if you don't really, you know, know anything about it. But hopefully after you listen to this and you listen to Chad, hopefully it's a little bit less scary how?

And especially after you realize how much data we have as athletic trainers, even through everyday documentation. You ready to get this started right? Let's do it. All right, so we figured, Chad, you'd probably really love love to start off with some cryo Breakers. We figured that would be right up your alley. So one of our first ones that we got for you is what is your athletic training muse? This is a modality rehab tool, tape, braces, etcetera.

Any tool of the trade that represents you. All of those really bad icons for our profession. If I were to have a muse, it would be probably a computer or a brain. That seriously is perfect for you and perfect for what we're going to talk about. What, But I mean, I, I get, I don't know what I'm going to, to, what we're going to talk about, but we, and it's usually based on the shortage of athletic training trainers or

the, the, the lack of staffing. We tend to go into this autopilot cookbook treat everybody that this without sitting down and problem solving each patient that we see. Yeah, I hear you. I, I, I think, yeah, I get when you get really busy, it's hard to sometimes it's easier to fall back on it. Well, I've done this before. We'll keep doing that. I do have to say, I think brain is probably the first time we've had that one. Yeah. It's the foundation.

But you can teach an 8 year old to tape an ankle, right? Yeah, that's true. Yeah, that's very true. We we way over use ice. Mm hmm. For sure. Well, if you haven't guessed already, we are talking about epidemiology. So if you can give us a story, experience, case study,

something that you would like to start us off with about epidemiology and athletic trainers, sure. I excuse me, I just hit puberty nine O 9 Eastern Daylight Time. I need to market my calendar When when we talk about sports epidemiology, it's really a dumbing down or almost a bastardization of what legitimate I I shouldn't what public health epidemiologists do we all remember the pandemic and all the epidemiologists and trying to find that bat that

started everything. We use some of those principles to again make informed decision decisions regarding patient care. It can also be extended to resource allocation, and in this case, resources are you your staff? How are you? How and where are you going to spend your time based on the implied risk of the event? What are some things that like within that kind of realm of epidemiology that the Athai Turner would be looking at? So you already kind of talked

about like possibly injury risk. What are some other elements of that that a TS could use or could calculate? Well, ideally an EMR should be able to calculate all this for you. Most of them don't, but boy, it would be really great to if you could push a button and see a change in your injury rates over time to identify differences between any two groups, be it sports or positions within a sport. Those types of data points will help people make better database decisions.

Chad, if you had a perfect EMR, what would you have it track? I am going to stand up. And we got the theme of this one right here. Yeah, it it's funny how over time your history kind of forgets and most of the people watching this podcast will have no idea what that means. Let Alfie help. And then let me turn it around like that. Sports systems, Sports medicine software. When it back in 1983, this thing was developed, called the personal computer.

I took out a student loan to buy an IBMPC just because I'm a nerd and I, I, I like that kind of stuff. I taught myself how to program and I built this really bad injury reporting system medical records package. I sent it to a friend of mine who actually was an orthopedic surgeon. And the thing about it was it said body part, then you had to go to a book and type in a code and he goes, that's the stupidest thing I've ever seen in my life. Why do you why do you have it

here? And then in a book I would may or may not have been at a local establishment and I may or not, may or may or not have been playing Pac-Man. And I, I'm dead serious. I'm playing Pac-Man and I'm using this thing to move Pac-Man around the board. And then it dawned on me that if I listed the body parts on the screen and used the cursor to track them down, that gets rid of the the book. So that became software package named Alfie. Where did the name Alfie come

from in Elvis Costello? So. Oh. There you go. the IT was the first commercially successful sports medicine medical records package. I was running it out of my basement. I'd be laying on the the couch watching the Flintstones take a call and make a big chunk of

change there. Kramer products ended up buying that buying the rights to it. But in that it would give you all you hit a report section and it would give you your pie charts of OK, this is your injury distribution by whatever your dependent variable is. And that in turn led me to working with the NBA to standardize and consolidate their medical records. So you know to do the the very stuff that you all learned in in class. Wow, that's really cool, Chad. I'm old.

Is so Alfie is not around anymore. No, I don't know what happened with with Kramer products. It was probably around for 10 or 12 years. Oh wow, that's pretty. I do remember. You know, you all probably aren't old enough to remember this, but when the 2000s came, there was the Y2K bug and it did kind of get bitten by the fact that, Gee, I didn't think people would be using this from for another 17 years.

So some of the fields wouldn't take the the 2000 data, but that was on them, not me. Yeah, that's crazy. That's cool. So what sorts of fields are in there? Are we when we're looking at epidemiology, are we just looking at body parts?

Are we just looking at athletes, sports? Like what? What would you recommend for athletic trainers to look at? It all depends on your question. It it kind of like a modality. One question doesn't fit all the circumstances if you want to know, OK, I've got a staff of three, I've got 72 sports let's take a look at the rate of injuries during practice. If the the injury rate for tennis is point OOO one, you probably don't need to have someone sitting right there at practice.

So, you know, again, it goes back to that human resource allocation that we discussed right at the beginning. If your goal is to reduce injuries, you can look at, we'll use football as an example. Boy, you're finding that your defensive lineman are really having a lot of shoulder problems. Is it technique? Is it strength and conditioning or the lack thereof? So you identify the problem and then you you use some method to to correct it. You you discussed a little bit

about rate and and risk. Could you define the differences

between injury rate and injury risk? Sure, Risk is a probability of an event happening. It goes from zero to one. Or if you multiply that by 100, zero to 100. And obviously the closer to 1, the more probable it is. And, and risk is just simply the odds of an event happening. So you can do it by player, you can do it by team. And if one player gets hurt once when you do your risk calculation, that would be the same as the person getting injured five times just were you

hurt. Yes. No rate is more time or exposure based and that gives you the the I'm going to use. The word prevalence, which isn't completely appropriate, is how frequently you would expect something to happen. So for for calculating like injury rate, injury risk and kind of using that that data, how savvy do you have to be like with the computer to do this?

Is this going to take a lot of like you got to know the innards of Excel or is this something you can kind of pick up pretty quickly? In the class you all had, I believe one of the the first slides was a plus sign, a minus sign, a division sign, and a multiplication sign. If you can know, if you know how to do those four functions, you're 90% of the way to to to most of the things that that you need to know. For sure. That's awesome. That's really cool.

So when you're using this data to bring to administrators, how

would you put that in a way that makes it digestible for them? Pictures. OK, I I. I mean, if you're, if you're looking to an article or if you're looking at something on the the web and there's all of these words, but there's a graph that explains it, Which one are you going to be more drawn to and which one is going to leave more of a lasting impact on you for? Sure. Definitely the pictures. How far is your drive from home to your work? 10 minutes. For some of us, it's 32 an hour.

OK, so in your 10 minutes or you're 32 an hour, how many billboards do you go pass? A ton. Yeah, Randy gets a ton. Tell me, Tell me one of them. Well, I see a lot of injury attorney billboards and accident attorney billboards on the way to work. Next time you drive into work and don't become overly distracted doing this it It is really really rare to see a billboard that has more than 7 words on it. Oh I'm I'm all in now. I want to see this. I, I, I mean, I could believe that for sure.

And it it's, it's a combination. It's usually the visual that that draws your attention to it. And then the, the few words put all that in into context. So your injury attorney lawyers probably have a big old cigar there in their mouth. Yes, for sure. It it you know what, it is usually a picture of themselves. There's one with the dog. There is the one with the dog, that's right. The dog is an attorney. It's a very smart maybe. Maybe a partner? It's a mascot.

Junior associate? Maybe so you kind of alluded to this as far as just kind of like the EMR component, but like kind of what's the easiest way to start collecting this data?

Like sometimes when you hear like calculating injury risk, injury rate, it seems like there might be a lot of work to it. So what's kind of just the easy way to just get going? A lot of it is going to be dependent on which EMR you use and you know what, what fields those Emrs collect. The other thing that some Emrs will do this, others don't you you'll need to a way to calculate exposures days is the

easiest way to do that. But when I was doing the stuff with the NBAI had the luxury of being able to say, oh, Sandra Harris played 732 minutes so far. Well, there's your denominator, and it's a very precise denominator. The more general you get, the more the less applicable your your outcomes are. So for a sport like basketball, it's a lot easier to calculate the number of minutes that someone's playing.

But for a sport more like football or soccer, you know, you don't really have that data as readily available. How would you go about finding exposures in those? Sports in in that case you would use appearances in the game. Now, the the problem with doing that is if you 2 are on a soccer team, you both appear in a game that's one, that's two

exposures, one each. But if Randy plays 30 seconds and Sandra plays, I don't know how long a soccer game is soccer matches, but we'll say 45 minutes, you know, they both count as an exposure, but one exposure's like that the other ones. So and that's kind of the the the problem with using larger chunks for for your epic. Have you ever taken this data to a coach and made any changes? No, but when I was doing this, remember I was working with the athletic trainers in the league office.

So we did use data for decision making purposes. Wow, that's really cool. Especially at at that level of sport. Like that's really awesome. And the reason why I haven't is almost my whole career has been here in geekdom, but I have helped. It's our athletic training staff do this in class. I I try to help you know how to put this stuff together so so you can use it. For sure.

You know, another thing that I was kind of thinking of is I've seen a lot of epidemiological studies on just kind of looking at like injury rates across like like I've seen some from like NCAA that looked at cross country injuries over like the last 10 years. If you're in a place that like,

hey, maybe you just don't have the time to necessarily collect as much like that exposure data. Is it possible to use the those epidemiological studies to help kind of decision making or do you need it still a little more personalized? You can use large scale epidemiological studies to make

inferences. And in your case, if you're using cross country, if you find if that 10 year study said, well, here's the average rate of injury in cross country and you're way up here that that gives you a metric to to say, you know, at least identify that a problem exists. For sure. That brings up a really good point because from even from my football season last year to this year's season, we had drastically different injury

rates. Even in in position group, it was significantly more the second season and obviously there were a lot of factors that went into that. But looking into what a normal injury rate is for some of these athletes, looking at the first season, it was not really that the second season was so much more injury prone.

It was, it was really that our, our first year, I mean, we were all so undefeated and we were, we were the, the, IT really does make a difference when you are the bigger football players. And so we really had a low injury rate the first year. We started out talking about the the big picture of epidemiology and, and what you see in the movies in and on TV and stuff. Finding patient zero and figuring out how something spreads and trans what the with orthopedic injuries they

obviously are not communicable. Ultimately that boils down to bad luck. Someone goes in for a layup, comes down and they have their leg just a little bit out of position, puts it in the vulnerable spot, there goes the ACL. So if one of the things that we need to accept and really one of the reasons, primary reasons why we exist as a profession is that when you have 2300 LB people running into each other, eventually an injury's going to

happen. For. Sure. And and you know, there are certainly the freak injuries that that happened. There's somebody sitting on the bench and gets hit by a foul ball in the head and suffers a concussion that you know, bad things unfortunately do happen and we could not prevent every injury. Definitely not. For sure now. Now when I look at my injury stats, all I'm going to see is a stat stat sheet of bad luck. That's the first thing that's going to pop in my head now.

Oh yeah, the whole concept of being injury prone, yes, there. Yeah. I can't remember it right now, but somebody did a a really nice article, that research article that does show that some people just genetically are at an increased risk of injury. Wow, that is really fascinating. Yeah. When we genetic cell is a really big influence, especially we were with ACL injuries.

I was just thinking that this was an internal study that was, we didn't publish it, but we, we me went through, I probably had almost 20 years of data at this point. And I went through and I identified every set of biological brothers that played in the NBA. And in every case, if one one of the siblings tore an ACL, the other one did. Wow. Wow, that's. Interesting. And if one or if one sibling did not rupture an ACL, the other

one didn't. So now that that only includes at the professional level, we didn't, I didn't go back and look at high school or college, but it was still really an intriguing fact. And I'll ask why students in the classroom, how many people here have ruptured an ACL? Depending on how active the class hands will go up. And then I'll say, OK, of those that did, who have we who have you have had a sibling rupture in ACL and not everybody's hands stays up, but it's like, Oh yeah.

That's interesting. I, I feel like it was, I feel like this was a quite a few years ago now, but like, I think it was like a session at NATA or something. They were talking about certain genes and like like a certain up regulation, down regulation of genes kind of led to or kind of hinted at possibly being an increased risk of ACL tear. So yeah, I have heard of that for sure.

Well, just recently one of my athletes tore their ACL and I said, hey, you know, it was, I believe it was their right leg. So I was like, well, you're not going to be able to drive. So I was like, hey, do you have like, can you call your parent to pick you up? And they're like actually my parents on on the way to take my brother to ACL surgery right now. He. Boils down, it boils. Down to you get to say thanks

mom and dad. I was like, you guys get to do rehab together, Yeah. The brothers at rehab together stay together. So we've kind of hinted at this again, just kind of like the class that you do teach on this and you know, we've, we've been like very lucky to actually take this class, but kind of where can someone kind of learn more

about epidemiology if they're not able to like take a class? What I would recommend is getting on the Google OR and not to discriminate if you're a Bing person, and search Zack Kerr. Kerr, who is at University of North Carolina Chapel Hill. He's not an athletic trainer, but he is without a doubt the most active sports epidemiologist out there. Now he is is provided so much information to the athletic training profession regarding sports epidemiology.

He he works with Dataless, who does the the NCAA and the high school study, does all their statistical analysis. You know, it's really cool to see this all come together because as we've talked about before there as an athletic trainer and in our profession, we do collect so much data. But it's really what do we do with that rather than it just sitting in a computer or software somewhere. How can we actually utilize that to show our value to help

decrease injury risk to etcetera, etcetera? And again, this is probably a workload issue. Mm Hmm. But athletic trainers aren't always the best at maintaining good records. And I think that if you take an athletic trainer that works in the private for profit setting versus you all, there's more. There's suddenly the demand, the expectation that those clinically, these people document everything that they do, be it the diagnostics or intervention.

But that shows the, the word that shows what, what people are getting out of it. We, we don't do quite as good of a job in the quote UN quote traditional setting this we should. And you know, anytime you generalize like that, you're generally wrong. But I I think to the it's an area that I think everybody can improve it. For sure, yeah.

And you know, that's what I kind of tell my students like when I'm kind of teaching them the concepts of, of epidemiology and kind of calculating injury rate is just this like we as athletic trainers are exposed to so many opportunities to collect data.

And if you're, if you're documenting like your EMR has like just a ton of data, that is definitely usable if you have the time to do so. And some you have to pull out manually and some of them depending on what EMR you use like you can create those reports like you were talking about. Definitely depends on your question. AI can be used for good or evil. I'm working on the evil part, but I I can see in the very near future you tell your computer Sandra Harris, right?

ACL rupture, blah, blah blah. It'll sort all that. Put it into the Mr. for you and then a using our data, calculate the rate of ACL injuries, OK, now calculate that rate male versus female or football versus basketball. So the, the good aspect of AI are, are those type of things that will make the use of our time more effective. You don't have to to sit there and and and figure it out yourself. I was going to say, man, that would cut down so much time for me.

That would be fantastic. Only if you use it for evil. I think that kind of leads into if time's a little tight, how can you analyze the data either with AI, without AI, if you're like, do we just need to focus on the time to document or like what advice do you have for athletic trainers who you're right, the workload is just that much Well. First of all, we we have the legal obligation to document this anyway, so. Absolutely. That that needs to be where your your emphasis is.

It shouldn't be that challenging time wise to again if your EMR is set up for it or you downloaded into Excel to go through it and and make those calculations for. Sure. Now some of these the numbers become a little bit unstable if your N is less than 30. So are we really limited by that or how do you recommend if you

have like a smaller? That the the the low N is is most usually effects confidence intervals, so if you have something with the low end you could use the odds ratio for relative risk calculations. Nice. You ready for an action? Yes, I think it's time for this is Sandra's favorite part because she's all about action and what can we do right now. So what can an AT do today that

can change their practice? And athletic trainers listening on their way to work right now, they're going to go into their into their office and they're going to change something today. But first of all, I hope they have a nice day. Keep things in perspective. The one thing we you've heard, the expression garbage in, garbage out.

The more accurate what you document, both in terms of detail and being sure that you capture everything, gives you that foundation of data that you could use to withdraw later on for. Sure, I like that. That's what, again, that's what I try to tell my students.

Like whatever you're getting out of your like EMR or whatever data you're trying to look up is, is only as good as what's being put in. So you know, that should kind of be like your kind of expectation of like if you've put in a lot into your EMR and a lot into that kind of data usage, like you should be able to get a lot out of it. Or if you only put kind of limited like you, it might kind of limit what you're able to actually pull out of it.

And it was the other thing we spoke about is OK, if when you identify the body part, if you go leg, that's by the end of the season, you're going to have a whole lot of leg. As a matter of fact, I bet you you have twice as many legs as you have people. And then if you go leg, knee, you're going to take the end from here down to here and then you go knee. We'll, we'll, we'll show the PCL

some love here, the PCL. So what you say, if you drill down too deep it, you're not going to get that end to make the the really rational conclusion from it. A lot of this is just the eyeball test too. If your your your men's team has one ACL rupture over the last five years and your women's team has 22, you you, you don't need to take a class to figure out that's not right. Yeah, yeah, that, you know, that's. A good way to say in southeast eastern Ohio, that ain't right.

That's a good way of putting it for sure. There are times you could kind of just look at it and just be like something weird's going on, yeah. And then you can take that something weird and build it into a more scientific hypothesis for sure, but it takes the weirdo factor to kind of trigger that. Yeah, that's true. And look at that. Science started by weird. Weird science. Yeah, see there. You go. Finally, a movie reference somebody gets.

Honestly, also talking about just streamlining, 'cause you kind of brought it, brought it up. If you just put something in the notes of your EMR, right, it's going to be a lot more difficult to pull out later. But if you use like your drop down features or we created a sign in on an iPad that goes directly to an Excel file. So then we can take that data and do whatever we want with that and we can. Sort of by sport or whatever I can use that to then put into my EMR.

So really if you, if you find a system that works for you and you're streamlining, it's going to be a lot easier than looking in like every SOAP note you've written, like clicking the person's name, clicking open, clicking notes, clicking the and then and then reading through and trying to find some piece of data. If you streamline, streamline the process, it's going to be a lot easier on you on the back end to find the time to do all these things. Yes. A1 day AI.

Yeah. And again, that would be in a perfect example. OK, take these SOAP notes, identify the body parts, identify the intervention. Nice. Our university has some pretty harsh policies on use of AII. Encourage our students to to use it. I think that's one thing that I've kind of noticed is I think I feel like people should at least get comfortable using it as a tool to kind of help, you

know? And I told tell them when I was a kid, there was a device that was invented that was going to destroy humanity as we knew it. That was called the calculator. People are going to have calculators and they're not going to know how to do math. Well, no. Having the calculator just makes the application of math easier. You don't have to remember your multiplication tables. The calculator obviously does that for you. Then the the teacher would say, yeah, but you're not always

going to have a calculator. Let me see if she's still alive yet or not. I do remember that argument all the time. I think math is now much more usable by more people and it's going to be the same thing with AI and information. I mean, calculating all this data without a calculator I can't even imagine. But I, if you go to like Gemini and you say, OK, I've got 142 athletes, there were seven wrist fractures, but calculate the, the you know, the risk grade, etcetera for it.

It may need more data than my quick little stem there, but it it can do it for you now. Nice, that's interesting. That's really cool. I I didn't even think of yeah. I'm telling you how to cheat for my class now that you're done. Hey, we're hey, we're already took the class. We're good. Is this is this not a good time to bring up that after I did my assignment I used AI to double check that I made the proper conclusions? Did you really? I did.

I don't remember that. I'm completely fine with that. I think she congratulated for that. I would say it's encouraged. But you still didn't pass. You mean AI didn't pass? Yeah, I did. I can develop an AI program to do this and we can call it ChatGPT you. Heard something? You heard it here first. Yeah, well, I'm going to retire from this job here and go do that. Do I think we just we just had our we just found our first AI infused ATHI training EMR. Alfie makes a comeback.

What's Alfie's last name? It must start with an I. No for because IP systems. There we go. Yeah, IP stood for idiot proof. That's pretty funny. I like that. Sweet. So just to wrap things up there, we just talked about some data that we've turned into value. Like I think in the episode we we talked about like the sign in sheets. But also, for example, something that I use is my injury report.

So like every day I create an injury report for or every, every practice day, I should say, I create an injury report for football. And at the end of the season, the last two seasons, I've been able to take those because it's already in an Excel document and I just put them in a new Excel. And then I'm able to really filter out things and, and figure out what injuries, what sides of injuries, the positions and, and just really like whatever I put into it.

Like we've said, an episode is really what you get out of it. Yeah, for sure. I think that again, that's like I said during the the interview is that's one of the most important things that I teach the athletic training students is like the data you get is only as good as like what you put in, right. So if you're trying to ask a specific question, right, you got to make sure you have the

data to kind of help you. Or if you're just thought of that question and you haven't collected that data, now you know where to start and like, oh, well, here's what I'm thinking. Here's how I should collect that data. Yeah, exactly. So it's a lot more accessible than I think people think, for sure. It just takes a minute to get started. And then once, once you really get started, then you're going to be like, oh, I could look into this. I could look into this, I could

look into this. Just opens a Pandora box of data. For real, so if you guys are new here, we do every episode as either interviews like this one. We do other episodes as stories from real life athletic trainers about various topics all around the world, athletic trainers from all around the world, which is really exciting. And then we also do education episodes, which Randy heads and those ones are worth category AC us. Thank you so much to athletic training chat and clinically

pressed. If you're interested in looking at those C us, we actually have a sale running. We have some free ones, but we also have a sale running through the end of national Athletic training month. So you can use code NATM 25 for 25% off those. C us. There's also still a couple more days of NATM. So because of that, we are still running our giveaway if you're listening to this as it comes out. So enter our giveaway with Medco to win a Merritt Mueller kit and some podcast merch.

Super exciting. And then if you're interested in more Cus, you can also use code 80 corner for $101.00 off Medbridge. It is a reporting year. Yes, it is. So if you guys are interested in sending your stories or just chatting with us, head over to our Instagram at 80 Corner podcast where you can do a bunch of the things that I already talked about. We also have a bunch more links and stuff down below in the podcast description. So I think that's all my fine

print. Thank you for helping us showcase athletic training behind the tape. Bye.