Importance of Coaching Education in High School Athletics

Coaches and athletic trainers in many ways share a common goal, and that is to see their athletes’ succeed both on and off the playing field; however, for this success to happen safely, coaches and athletic trainers must work together. A good working relationship and communication are the first keys to success when it comes to the health of an athlete, whether it be preventing, recognizing, or treating both injuries and illnesses. In a high school setting, athletic trainers may not be able to cover all events, so coaches are in some ways an extra set of eyes and ears that an athletic trainer can utilize, so it is imperative they are up-to-date with the most recent evidence-based guidelines.

One recent guideline that has come through the Connecticut governmental pipeline is the new mandatory concussion education law that began July 1, 2014. This law requires all high schools in the State of Connecticut to educate every one of their student-athletes, parents, and coaches on multiple different aspects of concussion education, including, but not limited to:

• The recognition of signs and symptoms of a concussion
• The nature and risks of a concussion, and continuing play after sustaining a concussion
• Current best practices in the prevention and treatment of a concussion

Another law that has recently been approved as well is the mandatory sudden cardiac arrest awareness education program for high schools. Much like the concussion law, this will mandate education of student-athletes, parents, and coaches on sudden cardiac arrest topics that focus on prevention, recognition, treatment, and return to play.

With these ever-changing guidelines regarding sports safety, it is crucial that coaches remain educated and informed to make sure they are providing the best care for their athletes. With injuries and illnesses being very unpredictable, a coach may end up finding themselves as one of the only first responders during an emergent event. As a coach you must ask yourself; are you prepared? Are you equipped with the knowledge needed to properly manage the situation? Does the team have policy and procedures to properly manage the situation?

1st Youth Sport Safety Governing Bodies Meeting

Last week, the staff of KSI were joined by leaders within youth sport national governing bodies (NGBs) at the National Football League (NFL) Headquarters in New York City holding the first annual Youth Sport Safety Governing Bodies (YSSGB) meeting. The meeting was sponsored by OneBeat CPR + AED, Kestrel, and Mission AthleteCare and hosted by the NFL. The purpose of this two-day meeting was to bring together the top youth sport NGBs together to discuss policies and considerations to make sports safer. Present at this year’s meeting included 9 different NGBs: US Tennis Association, USA Football, US Soccer, US Lacrosse, USA Wrestling, USA Track and Field, USA Hockey, MLB Digital Academy, and the US Olympic Committee. The focus of this year’s meeting was to educate the attendees on different safety considerations: heat illness, sports-related concussions, cardiac conditions, and emergency action planning.

The first day of the meeting (“Kestrel Heat Stress Tracker Day”), focused on Heat Illness Considerations, presented by the KSI COO Dr. Douglas Casa, and Sports-Related Concussions, presented by Dr. Jason Mihalik. Both Dr. Casa’s and Dr. Mihalik’s presentations sparked some great comments and dialogue from all in attendance. Coaching education and certifications were the main topics of interest during Thursday’s conversations; including how the different NGBs have already implemented educational programs and obstacles that were experienced by other NGBs who have yet to instrument one. For example, USA Football shared their structure of educational program where they train and educate ‘Master Trainer” who can subsequently educate their peers in the local area (“Train the Trainer” framework). USA Hockey spoke on their SafeSport program, where coaches are required to complete a set of educational course to receive coaching certificate.

The second day of the meeting (“OneBeat CPR + AED Day”), focused on Cardiac Conditions, presented by Dr. Fred Brennan, and Emergency Action Plans, presented by Dr. Robert Huggins. These presentations also focused on the importance of sports-specific pre-participation exam (PPE) and ways to ensure athlete’s safety from the planning stage (“be proactive, not reactive!”). Dr. Brennan eluted to the importance of a comprehensive and uniform PPE before sports participation. In order to have a good idea of athlete’s health history and assess the athletes’ readiness to safely participate in the athletics, a comprehensive PPE is imperative piece of information that can identify athletes who may be at-risk. Additionally, uniformity in PPEs will allow the athlete’s health history to be shared across sports, which would be beneficial in multi-sport athletes, or for sport tournament and camp hosts who may have had limited access to participant’s medical record traditionally.

The goal of this first annual YSSGB meeting was to integrate top youth sport NGBs together to discuss safety policies and strategies to implement them to ensure youth sport safety. With the raising awareness and societal concerns over sports related safety issues, sports NGBs are continuing to add more emphasis on protecting the health and safety of athletes. The ability to ensure that all athletes, amongst all sports, receive the best and safest environment to participate in their sports will be a goal that we continue to strive for. The ability to bring together these top personnel within their respective organizations to discuss these topics was unheard of and never done before. While each of us is doing our best to get there, we need to now work together to accomplish the goal. We believe that our first meeting allowed the NGBs to establish a ground to continue our discussion to make sports safer.

“If you want to go fast, go alone. If you want to go far, go together.” 

Evidence Based Practice

This past weekend, January 9-12, was the 67^th Annual Eastern Athletic Trainers’ Association (EATA) Meeting and Clinical Symposium in Philadelphia, PA. A great addition to this year’s program was the opportunity for the attendees to listen to four Evidence-Based Practice (EBP) talks. The EBP sessions covered topics on the integration of qualitative research in athletic training as it pertains to work-life balance, the adaptations of the nervous system after ACL reconstruction, targeted rehabilitation strategies of ankle injuries using sensory feedback, and using injury surveillance on clinical decision making. These sessions allowed the Athletic Trainers and students that attended the conference learn about current topics in our profession that are supported by evidence-based research.

Evidence based practice in Athletic Training is a three-pronged approach to optimize patient care. The incorporation of best research evidence, clinical expertise, and patient values and preferences allows Athletic Trainers as clinicians to provide the best care to their patients and athletes.

Best research evidence incorporates the ever-evolving field of scientific research to guide the clinician on the appropriate clinical decisions and practices to enhance patient outcomes. Clinical expertise is derived from a clinician’s personal observations, reflection, and judgment, which are also needed to translate scientific results into treatment of individual patients. Patient preferences provide the clinician information based on their attitudes and beliefs and is a driving force of using the evidence and turning it into practice.

The opportunity to sit in on these EBP talks was important, not only for the Athletic Trainers to improve their clinical practice, but to also meet recent requirements for Athletic Trainers to maintain their certification. The Board of Certification, the organization that oversees the credentialing of Athletic Trainers in the United States, has made modifications on the requirements for Athletic Trainers obtaining their required continuing education units (CEUs) for maintenance of their certification. Athletic Trainers are now required to obtain 10 of their 50 bi-annual CEUs as EBP.

KSI is currently developing an EBP course for Athletic Trainers and other medical professionals to become educated on preventing sudden death in sport and physical activity, which will further add to the current EBP topics that Athletic Trainers can choose from. It is essential that Athletic Trainers, as medical professionals, stay up-to-date on the most current evidence-based research in order to improve overall patient-centered outcomes.

 

State-by-state Secondary School Athletic Trainer Map

Four years ago the National Athletic Trainers’ Association (NATA) and the Korey Stringer Institute (KSI) embarked a large scale project, known as the CATCH-ON study, which we have posted about back in November of 2013 and again in June of 2014 in our blog where we called public and private high schools all across the United States. KSI successfully called over 20,000 schools if you don’t include technical, magnet, and charter schools. The NATA wanted to determine how many schools all across the country have Athletic Trainers (AT), if the AT was part-time, full-time, working in a clinic, etc., and they also wanted to know questions like “How many athletes are in your school?”, “If you don’t have an AT, why?”, and “What type of medical coverage do you have?” Lastly, potentially the most important question we asked of each school and the reason for writing today was “What is your zip code?” Yes….that’s right, your zip code!

With each zip code, we at KSI were able to map each school that we called all across the country and state-by-state in a software program called ZeeMaps. The ZeeMaps software utilizes Google Maps and allows you to create your own custom maps. So what did we do? We first created maps (as seen below for the state of New York) for each state based on the results of the calling for both public and private schools separately. If a high school had an AT it was categorized as “green” while those without were “red”, and schools that did not respond to our survey were defaulted as “black.”

We knew that maps like these would be convenient in identifying the strategies to promote athletic training services in the secondary school settings. In fact, the information included in these maps were immediately demanded by the NATA as they were in the process of combining forces with the National Football League (NFL) Foundation to launch the NFL Foundation’s AT Grant Initiative (http://www.nata.org/nata-news-blog/latest-nfl-foundations-grant-initiative), where the NFL the NATA and the Professional Football Athletic Trainers’ Society have teamed up to get AT services provided in the 31 NFL cities at high schools that need it the most. The NFL Foundation agreed to provide a $1 million dollars and NATA $125,000 towards the initiative, and currently 16/32 teams have applied. In order for the NFL and NATA to identify which high schools their clubs should reach out to, they looked to KSI’s expertise and our ZeeMaps.

KSI provided the Athletic Trainer ZeeMaps to any NFL club head Athletic Trainer or community relations director so that they could identify (1) which high schools in their areas did not have AT’s, and (2) which schools they would be able to coordinate AT services to.

The feedback on these maps was fantastic. KSI and NATA will continue to work on this initiative to gather more data to enhance the maps so that state athletic training associations could be more informed about their own state’s numbers. Specifically, the state athletic training associations wanted to see to what the employment status is for each high school (as depicted below for Missouri) by utilizing the map’s function to select out Full Time and Part Time . Furthermore, continuing this project will help the NATA keep tabs on what the job market is like for ATs and most importantly help them reach their goal in getting AT services into every high school across the country.

We plan on releasing the ZeeMaps for public access in the spring of 2015.

11 Ways to Improve Concussion Guidelines- Reflection from Hartford Courant article series

Last week, the Hartford Courant featured a four-day series on issues surrounding the risks and the recent heightened awareness of concussions in sport. The societal concern over sport related concussions seems to have accelerated as the National Football League, National Collegiate Athletic Association, and the military put more focus on setting guidelines and rule changes to better manage concussions and to provide adequate time and a plan to return concussed athletes back to the playing field.

Currently, all fifty states have a concussion law in place to address the concussion issues in high school sports; however, the details of the law in each state varies greatly, and much could be done (and should be done) to enhance the law to effectively minimize the risk of brain injuries that could have been prevented. Many state high school athletic associations also have guidelines set for their school’s athletics program.

The Korey Stringer Institute (KSI), a not-for profit organization that is housed at the University of Connecticut, works to advocate for the safety and prevention of sudden death in sport and physical activity. KSI endorses the following eleven criteria for concussion policies that follow minimum best practices that should be included in the guidelines for each state’s athletic associations and written into the legislative laws surrounding concussion:

1. Schools should develop an EAP for handling potentially life-threatening injuries and a referral plan for concussions
2. Use certified helmets/equipment
3. The pre-participation exam should include concussion specific questions
4. Preseason education for personnel, coaches, and athletes (should be tailored to the group being taught, strongly recommend educational materials for parents) on basics of concussion (i.e. that helmets do not prevent cerebral concussions, signs and symptoms, treatment, testing options, return to play considerations)
5. High school athletes suspected of sustaining a concussion are not permitted to return to a practice, game, or activity involving exertional activity on the same day.
6. Athletes suspected of a concussion are not permitted to return to participation until written release from a licensed physician or athletic trainer
7. No child/adolescent should return to sport/activity unless he/she has managed to return to school
8. Implementation of a graduated return to participation protocol (see Zurich/AMSSM example, at least 5 steps, no more than 2 in one day)
9. Comprehensive medical-management plan for acute care of a potential head or cervical spine injury
10. Limiting the number of contact by monitoring the number of hits made or sustained and also keeping track of total practice time
11. Strict enforcement to remove head contacts out of the game by placing rules such as suspension from the game once intentional head contact is witnessed.

Starting next year, Connecticut Interscholastic Athletic Conference (CIAC) will introduce a new guideline to limit the total number of regular season football games, including the playoffs, to ten. CIAC is also drafting a guideline to mandate at least four to five days between the three-playoff games, but the number of days is still yet to be determined.

Just like the state of Connecticut, many states are striving to make improvements in their concussion laws every year to reflect the evidenced-based practice and recent research findings. However, unless the laws and guidelines are reinforced and mandated by the high school athletics associations with strict penalties for violating the law, we are unlikely to change the behavior of coaches, parents and athletes. In addition, the public must understand that the risk of concussion is inherent in every sport, not just football. The false sense of security among athletes parents and coaches of non-football sports may put themselves at a greater risk from complications from concussions due to lack of recognition, prevention, and management plans.

In the desperate need to better recognize and prevent sport related concussions, many research groups and companies have introduced potential ways to quantify and monitor the impacts from collisions. However, consumers must be sensible to the fact that there currently is no device or technology that could detect or prevent concussions. Many companies are aware of their limitations in their products and often have disclaimers, but those may not be obvious to the consumers and provide them with misleading information that could lead to a false sense of security. Thus including parents in concussion education becomes essential in providing them with good knowledge to make appropriate decisions for their children’s safety.

We are at a time where we have the momentum to make changes to make sports safer. The state legislators and state high school athletics associations have the duty to keep the laws and guidelines up-to-date with the current evidence-based medicine, and the duty to ensure that everyone is adherent to them. We must continue to make more effort to ensure that correct information is being delivered to the coaches, parents and athletes via education, and that the education is leading a behavioral change for better and safer game.

1st Sports Safety Symposium in Japan

The first annual Sports Safety Symposium in Japan was held in Tokyo, Japan on December 29^th, 2014. This symposium was hosted by Sports Safety Japan, a not-for-profit organization based in Tokyo whose mission is to bring awareness of sports safety to Japanese society and promote safer sports via education.

Speakers at the symposium came from various backgrounds: Mr. Koichiro Mochizuki, a lawyer from Toranomon law firm who has worked numerous cases related to sudden death in sports; Dr. Ryo Uchida, a professor from Nagoya University who is known for the work that investigated the Judo related deaths in youth athletes; Mr. Katsuhiro Ichihara, ATC, who presented the importance of emergency action plans along with his personal experience in working with major and minor league baseball; and Mr. Yutaka Saho ,ATC, the COO of Sports Safety Japan, who presented his future visions and initiatives to fulfill the organization’s mission to promote safer sports.

Yuri Hosokawa, MAT, ATC from the Korey Stringer Institute was also one of the speakers who spoke at the symposium. She presented “lessons learned” from how sports organizations and athletics associations in the United States have evolved to ensure athlete safety and provided examples of initiatives that KSI and other organizations have done and are currently working on to promote sports safety in sport and physical activity.

Similar to what we are observing in the U.S. after the lawsuit filed by the NFLPA against the NFL regarding concussions sustained by retired players and the long term health effects of those injuries, Japanese society is also starting to realize the lack of education and the false sense of security that made people believe “nothing bad will happen”. That is not the case anymore. Athletic trainers, teachers, parents, school board administrators, and coaches in Japan are now starting to raise questions; how can we make sports safer? Why do similar deaths occur in youth sports? What can we do better to prevent deaths from happening again? Was it really an accident that could not have been prevented?

The Sports Safety Symposium was the first of its kind to be held in Japan. It was an eye-opening event for KSI to learn that many issues and obstacles addressed in the symposium were similar to what we are seeing in the U.S., too. #Strive2Protect

Korey Stringer Institute Summer Fellowship Program

Do you want to gain more experience in exercise science research? Do you want to be part of advocacy initiatives aimed at making sports safer? If so, then the Korey Stringer Institute Summer Fellowship program may be right for you.

The Korey Stringer Institute seeks talented undergraduate and graduate athletic training students to apply for an 8-week research and advocacy fellowship. This fellowship will be hosted at the University of Connecticut in Storrs, CT.

Candidates will be selected based on the strength of their application and desire to pursue a career field related to preventing sudden death in sport. Successful candidates will demonstrate academic excellence, quality recommendations and strong communication skills.

Number of Fellowships: 1 Fellow will be selected for the summer of 2015

Fellowship Amount: Stipend of $5000 dollars paid on a bi-weekly basis (Fellows will be responsible for housing)

Fellowship Term: 8-weeks beginning in mid-June 2015

Eligibility: (1) Junior or Senior undergraduate athletic training students OR certified athletic trainer graduate students, (2) US Citizenship OR appropriate work visa

Application Information: Application materials are due by February 1, 2015.

Required Materials: (1) Complete Fellowship Application Form, (2) Cover Letter, (3) Resume (Including research, advocacy or clinical experience) 3 letters of recommendations, (4) Transcript verifying eligibility

 For more information and application form, visit: http://ksi.uconn.edu/ksi/?LinkServID=0418444B-D7D7-F971-E687AFA7E1FDC8C4

Lightning Emergency Action Plan

A lot of scenarios in preventing sudden death in sports require annual or semi-annual planning to be adequately prepared. Lightning emergencies, however, require daily vigilance to ensure that everything is being done to prevent catastrophic injury. In 2013 the NATA released a new position statement that covers Lightning preparedness and there are some important items to note from this document.

When it comes to lightning awareness and monitoring, these are daily steps that you need to ensure safety. Gone are the days of the flash-bang count. Now the presumption is that if you can hear thunder, lightning risk is imminent. While you can buy advanced equipment that monitors your fields, the ultimate decision should be based off close weather monitoring and on-site vigilance. It is incredibly important to have these criteria determined before any event, as hesitation can be very costly.

Whenever it is determined that lightning risk is elevated, all activities should be stopped immediately and individuals should be evacuated to safe structures. The key thing to remember with safe structures is that they need to be enclosed and grounded. Common mistakes are using pavilions or dugouts for evacuation structures, when these locations may actually put you more at risk. Finally, for large events you must consider extra time for evacuation of players, coaches and fans if there is not an adequate structure nearby.

First aid for lightning strikes can seem paradoxical, in that the mantra is to “Treat those who appear dead first”. Due to then nature of a lightning injury these individuals need to be treated rapidly to reverse their conditions. After any lightning strike it is extremely important to also rapidly evacuate victims and bystanders alike because there is always potential for a second strike.

Unfortunately there are a lot of myths about lightning that are perpetuated that must be overcome to ensure lightning safety. The ideas that lightning cannot strike when the sky is clear or that lightning does not strike the same place twice creates situations where individuals risk their own safety. In addition, there is no truth to the myths that lightning always strikes from the sky or that a car is a safe structure. Athletic trainers represent a great resource to educate coaches and athletes alike about lightning safety and avoid some hazardous pitfalls.

Lightning safety is a true test as to whether your emergency policies are adequate because they require daily vigilance and excellent procedures to ensure safety. For more information on lightning safety, visit ksi.uconn.edu.

Heat Safety Pledge

Mission Athletecare, a newly announced partner of the Korey Stringer Institute, has started a new effort to promote safety in high school athletics. They’ve created a pledge to provide $1,000,000 in cooling products to schools who create a safer playing environment for their athletes. Using current best practices recommendations, KSI has determined six pillars which prepare athletic programs for exercise in hot weather. You can find details on how to qualify here.

• Pillar 1: Thermometer- A wet bulb globe thermometer is on site at school and used to determine activity modifications based on environmental conditions. It is school policy to modify work to rest cycles based on environmental conditions.
• Pillar 2: Certification- All coaching staff is certified in first aid, cardiopulmonary resuscitation and the use of an automated external defibrillator. Additionally, education is provided related to preventing sudden death in sport.
• Pillar 3: Athletic Trainer- An athletic trainer is employed at your school and is on-site during practices and events.
• Pillar 4: Emergency Action Plan- A specific emergency action plan for each athletic facility has been developed where sports games and practices occur. This plan is reviewed with the healthcare team every year.
• Pillar 5: Heat Acclimatization Guidelines- School has adopted nationwide high school preseason heat acclimatization guidelines set forth by the National Athletic Trainers’ Association.
• Pillar 6: Water Stations/Body Cooling- Adequate water is available and placed at various stations around the athletic fields for all sports. At water stations, body cooling is standard practice. This can be as simple as encouraging players to remove equipment during rest breaks as using ice/cold towels.

Schools who qualify for the pledge will receive $1,000 in EnduraCool cooling products for your school to add to their arsenal of ways to stay cool. Mission wants to reward schools which place value on heat safety by putting in place the best policies to prevent and handle environmental heat stress. If you know of a school who may qualify, pass on the message, and have an administrator and athletic trainer contact Mission for further details.

Hyponatremia- Mechanism and Prevention

With the recent death of a high school football player suspected of dying from hyponatremia after consuming 4 gallons of fluid after a football practice, it becomes essential to establish individualized hydration plans.

Hyponatremia, or water-intoxication in laymen’s terms, is a medical condition in which the sodium levels in the blood fall dangerously low, and if not treated for immediately, can be fatal. This is most commonly seen in long endurance events such as marathons, especially in runners with finish times greater than 4 hours, but can also occur in any sport. 

Hyponatremia can occur two ways: 1) athletes drink too much water (or other drinks low in sodium) than what they can lose via sweat or 2) athletes lose too much sodium in their sweat. Hyponatremia can be suspected if an athlete finishes a race or practice weighing more than when they started, but with the latter case above, it is not always the case.

All athletes have individualized hydration needs. Each person varies in their sweat rate during exercise and the concentration of sodium they lose via sweat. Since these measures vary in all persons, it is essential to establish individualized hydration strategies for each individual athlete. Below are some steps that can be used to find out individual hydration needs during exercise:

1) Before a workout, make sure you are hydrated (light colored urine) as being dehydrated will affect normal sweat rate

2) Take a nude body weight before the workout.

3) Exercise for 1 hour (mode and intensity of exercise would be something you would typically do on a normal basis)

4) During the one-hour workout refrain from drinking fluids as this will affect sweat rate. If water is consumed weigh the water before and after the workout and record the difference

5) After the workout take another nude body weight and calculate the difference between pre and post exercise. If water is consumed during exercise subtract the water weight from the post exercise weight.

6) For every 2.2 pounds a person loses it will equate to 1 liter of fluid loss (sweat loss). For example, if someone loses 5 pounds in 1 hour their sweat rate is 5/2.2=2.27 liters/hour.

7) A persons sweat rate is the amount of fluid they will need to replace during exercise. For heavy sweaters it is not uncommon to be unable to drink everything you lose during the workout and fully replacing fluid losses will have to occur after exercise.

As with sweat rates, sodium needs during exercise are also individualized. If you notice that after a workout you have white rings outlining the areas of sweat on your clothes or if you have white streaks on your face, you may be a “salty sweater.” In these cases, you may need to consume more sodium either in your diet or in your fluid during exercise. Although sports drinks do contain electrolytes, the concentration of electrolytes in the sports drinks do not completely prevent hyponatremia from occurring, so it may be necessary to add more salt to these drinks.

Individualized hydration plans not only add a safety precaution, but can also help maximize athletic performance. Starting an athletic event hydration, minimizing fluid losses, during, replacing fluids after exercise are important to keep the body functioning optimally. For those that are heavy sweaters or other situations where athletes are unable to replace fluid losses during exercise, replacing fluids post exercise is essential. Drinking fluids that contain carbohydrates and electrolytes post exercise will help restore electrolyte losses that occur during exercise in addition to helping retain the fluid that is consumed.