University of Connecticut University of UC Title Fallback Connecticut

On the Map (Training and Conditioning)

By Larry Cooper

So has anybody ever heard a story about an idea that was born in a bar or restaurant, with the initial concepts drawn on a napkin? I know I was skeptical of such tales. That was until I was part of this exact situation.

Picture three athletic trainers, one of whom had talked to both individuals, but the other two had never met before. We met at the first annual Collaborative Solutions for Safety in Sport conference in New York City in 2015. I saw this as an opportunity to finally bring a guy with previous experience using a program called Zee Maps together with an athletic trainer who is also a researcher and explain that the three of us needed to collaborate on a project to assist with collecting data on the secondary school setting. The venue where this meeting took place was a restaurant called Dos Caminos in New York City.

By the end of the evening, we had the name of the project, the data that we wanted to collect, and the questions that would be asked all jotted down on a napkin. We all found something we were passionate about and were brainstorming how we could best merge all our ideas together. We were so busy and lost in thought and dialogue that we totally lost track of time and found that the restaurant staff had cleaned the entire place and got ready for the next day before we ever knew what was going on around us. This is where the Athletic Training Locations and Services (ATLAS) project was born and started to develop its personality. The players were Ronnie Harper, EdD, ATC, co-owner of My Sports Dietitian and Head Athletic Trainer at Dutchtown High School in Geismar, La., Rob Huggins, PhD, ATC, Vice President of Research and Athlete Performance at the Korey Stringer Institute (KSI), and myself.

As of today, 71 percent of all secondary schools in the country have been mapped on the ATLAS project. Currently, NATA Districts 1, 2, and 3 are tied with 91 percent of the schools mapped in their districts.

Since that time, the ATLAS program has evolved into a living, breathing project that is just starting to realize its potential. While its original goal was to collect data on employment status, hiring practices, the number of athletic trainers at a particular secondary school, and the size of school, it has grown to push student safety initiatives, track emergency action plan (EAP) use, track trends in hiring practices, see how athletic trainers work with their team physicians, track who has AEDs, track the number of student-athletes, track what sports are offered, and more. State leaders, legislators, state and national medical associations, parent groups, and school administrators are now asking for data that helps change the landscape of athletic health care at the secondary school level.

If you haven’t taken the time to get your high school accurately mapped or taken the five-minute survey, then you are in the minority. As of today, 71 percent of all secondary schools in the country have been mapped. Currently, NATA Districts 1, 2, and 3 are tied with 91 percent of the schools mapped in their districts.

While we still have a ways to go, the ATLAS project marks the first time we’ve been able to collect information on all of the approximately 22,000 high schools across the country. Before, data collection was not as robust, and we relied on other school personnel for the information. Now, we are dealing directly with athletic trainers. This in itself has helped to increase involvement and accuracy.

While the ATLAS questionnaire consists of 27 questions total, here is a snapshot of the information requested:

• Name

• Credentials

• School name and address

• Public or private or other type of institution?

• Are you full time or part time?

• How are you employed?

• Do you have venue-specific EAPs?

• Do you have Standard Operating Procedures (SOPs)?

• Who signs off on your SOPs?

• What is the specialty of your team physician?

• Are you a Safe Sports School Award Winner?

• Are you a Gatorade Award Winner?

• Number of sports your school offers?

• How many athletes?

• Do you teach?

• What do you teach?

So you may be asking yourself: How can this benefit me? Well, do your teams ever travel out of state? Do your teams compete in state tournaments against teams that you are not familiar with? If you answered yes to either of these, the ATLAS project can be a method of communicating with the athletic trainer from a team in another state or a school on the other end of the state.

We will also be able to use the information we gather as a conduit for release of material that is of particular value to our setting. If you have read the news lately, there are many states that have had their athletic trainers’ credentials attacked. ATLAS would have been a great way to mobilize state members to contact their legislators and other stakeholders in a short period of time.

I hope that you can now see how and why Ronnie, Rob, and I got so busy planning the premise of this project that evening in New York City. We saw endless possibilities to benefit the secondary school setting and the athletic training profession. So next time you’re at a restaurant with a group of professional colleagues and the ideas start flying, grab a napkin and start writing. You never know what could happen.

Get on board, and help the NATA and KSI get all of the secondary schools across the country mapped. Your profession depends upon it. Go to and take the survey to get your school mapped.

Special thanks to Ronnie Harper for planting the seed and to Rob Huggins and Sarah Attanasio, ATC, Assistant Director of Research at KSI, for their continued help, support, and dedication to make this project a success.

 Larry Cooper, MS, LAT, ATC, is Head Athletic Trainer at Penn-Trafford High School in Harrison City, Pa., where he also teaches health, physical education, and sports medicine classes. Since 2012, he has served as Chair of the NATA Secondary School Athletic Trainers’ Committee. Winner of a 2016 NATA Most Distinguished Athletic Trainer Award, 2015 T&C Most Valuable Athletic Trainer Award, and 2014 NATA Athletic Training Service Award, he was inducted into the Pennsylvania Athletic Trainers’ Society Hall of Fame in 2014. Cooper can be reached at:

Source: Training and Conditioning

The Risk of Exertional Heatstroke to Young Athletes (The New York Times)


Growing up as an athlete in Louisiana, I was one of many teenagers who took to the football field for summer two-a-day practices. In the nearly tropical summer heat and humidity, we would practice and play in triple-digit temperatures – almost always in full padding. Between sessions, my teammates and I sometimes stood under cold showers for 15 minutes, wearing our full uniforms, just to try to cool ourselves down. It was in those temperatures that a player I knew collapsed and died on the field from exertional heatstroke, or EHS.

EHS is a severe form of heat-related illness and a medical emergency that can result in brain and other organ damage, or even death in some cases. According to a 2015 article in The Journal of Applied Physiology, EHS ranks as the third leading cause of sudden death in high school athletes.

EHS can occur in otherwise healthy individuals and is different from classic heatstroke, which usually affects those who are very young, elderly or have pre-existing medical conditions. Athletes and soldiers whose uniforms require heavy gear are especially vulnerable.

Treatment for EHS has evolved very little over the centuries, essentially relying on external cooling methods. Water immersion, an earlier version of cold water immersion (today’s first line treatment for EHS), was described by the Greek physician Hippocrates in 400 B.C. But even as today’s young athletes and their parents are becoming better informed about the risks of concussion and dehydration out on the field, many believe that heat is merely uncomfortable and do not recognize the dire risks it can present.

Some of this risk could be reduced if high school athletic organizations followed the lead of professional and college teams in banning two-a-day summer practices, which unnecessarily subject young athletes to the risk of exertional heatstroke.

In April, the National Collegiate Athletic Association banned two-a-day summer practices for Division I college football players, on the basis of recommendations from medical professionals, coaches and administrators. The change is intended not only to control exertion on the field and promote recovery from it, but also to minimize injuries such as concussion and lower the risk of EHS.

The National Football League banned two-a-day practices six years ago, in 2011. But many high school football players still face the risks associated with two-a-day practices. Currently, guidelines vary across state lines. While states like Iowa have banned two-a-day practices, others like Georgia and Texas ban only back-to-back two-a-day sessions and other states still allow them.

I’ve served as a physician, researcher and consultant for more than 20 years in an effort to bring wide attention to the issues and threat of concussions in football. And now I have ample grounds to believe that EHS qualifies as an issue of similar importance. While many people think of EHS as a temperature issue, it’s truly a neurological and metabolic emergency that, if not treated, can result in irreversible damage to the brain, other vital organs, or even death. According to research published in the American Journal of Preventive Medicine, the number of injuries associated with exertional heat illness in the United States – most of which involved young people playing sports – increased by more than 130 percentbetween 1997 and 2006.

It is vital for EHS to be identified as early as possible, so that the person can be removed from the hot and humid environment and be treated. EHS occurs when the core body temperature rises to dangerous levels – 104 degrees Fahrenheit or greater. Such a high core body temperature, even for a short period of time, can cause permanent damage to the brain, liver, kidneys and other organs.

It’s particularly ominous when the central nervous system becomes involved; there is the potential for progression to coma and death. For those who survive, long-term and potentially irreversible neurological damage can occur, affecting cognition, movement, coordination and sensory systems. I’ve personally seen how such nervous system deficits can devastate patients, impairing everything from performing basic tasks to engaging in social interactions with friends. These effects often strike young, active patients who are in the prime of their lives. And because the effects of heat are cumulative, people who have had other heat stress experiences are more likely to experience heat illnesses – like EHS – again, and should take particular caution when exerting themselves in hot or humid conditions.

As a physician dedicated to the practice of sports medicine and as a former athlete, I’m committed to raising awareness of EHS and ensuring that parents, coaches, athletic trainers and others are prepared to recognize EHS and respond.

The Korey Stringer Institute, named for the Minnesota Vikings player who died of exertional heatstroke in 2001 at age 27, offers useful guidance on its website. In addition to a high core body temperature, the signs and symptoms of exertional heatstroke include fainting or dizziness, vomiting, confusion and disorientation and unusual behavior like aggression. Exertional heatstroke is a medical emergency, and fast treatment is critical.

If you see anyone exhibiting the signs and symptoms of EHS, call 911 immediately and initiate rapid cooling, ideally with an ice bath. It’s important to remember that seemingly healthy people can be at risk.

If organizations that represent high school athletes consider adopting the N.C.A.A.’s complete ban on two-a-day practices, they may help prevent fatalities like that of the player I knew years ago in Louisiana.

Julian Bailes is director of the department of neurosurgery and co-director of the NorthShore University HealthSystem Neurological Institute.

Source: The New York Times

NSCA 40th Annual National Conference

Courteney Benjamin MS, CSCS

Associate Director of Communication and Assistant Director of Athlete Performance and Safety

Members of KSI had the opportunity to travel to Las Vegas, Nevada for the 40th annual National Strength and Conditioning Conference
where strength and conditioning coaches, personal trainers, sport scientists, sport nutritionists, and health enthusiasts gathered to present, network, and honor certain outstanding members.


We were fortunate to attend a lecture given by this year’s Sport Scientists of the Year, Shawn M, Arent, and Dave DiFabio from Polar, whom we had the opportunity to work with in the past. They discussed the use of wearable technology and how coaches and sport scientists should start thinking about applying the knowledge we gather from this data to practice.

Ryan Curtis, Yasuki Sekiguchi, and I presented some of the recent research findings from the KSI. I presented a poster titled, “Analysis of Women’s Cross Country Lab Tests Results and Training Over the Course of a Competitive Fall Season” on Thursday (7/13/17). I examined the change in lactate testing, VO2 max and training of the UCONN Women’s Cross Country team during their fall season. The major finding of this study was the vOBLA (velocity at onset of blood lactate) was significantly higher during the middle of the season while VO2 max did not change throughout the season. During my presentation, I was very excited to reconnect with two of my former colleagues from Florida State University. Daniel Shaefer was the former director of strength and conditioning at FSU and is now working on is PhD at the University of Wisconsin-Madison. Jon Jost was the former FSU director of strength and conditioning and recently accepted a position with Gatorade. I am hopeful that we will get an opportunity to collaborate on future research. I also had the fortune to meet Kristen Holmes-Winn, from WHOOP, who funded the research Ryan and I presented at this conference.


Yasuki Sekiguchi presented a poster titled “Heartrate Variability between Starters and Nonstarters throughout a Collegiate Soccer Season.” During this study, HRV and training load metrics were monitored over the course of D1
college soccer season. The relationship between these variables were examined for all players, starters, and nonstarters. The major finding of this research was that acute:chronic training load ratio might be used to explain the changes in HRV over the course of a Division 1 male soccer team

Ryan Curtis did an oral presentation on Saturday (7/15/17) titled “Relationship between Sleep, Training Load and Fitness in Collegiate Soccer.” Overall this study illustrated that sleep quality may be more sensitive to increased training load than sleep quantity. Collegiate athletes with increased training loads have increased light sleep but not REM sleep or overall sleep duration.

Outside of the conference, we had a fantastic time exploring the Las Vegas strip and the beautiful hotel hosting us and the conference, Paris Las Vegas. I am extremely thankful to the NSCA and KSI for the opportunity to collaborate and learn from others in the field while making memories that will last a lifetime. I look forward to attending this event next year and present the results from our upcoming projects.


Protecting our young student-athletes through health and safety policies

By: William M. Adams, PhD, LAT, ATC; Vice President of Sport Safety

Every year, we are plagued with the news of young athletes dying or suffering catastrophic injuries while playing the sports that they love. While being multi-causal, the most likely culprits are sudden cardiac arrest, head injuries and exertional heat stroke. While death during sport (or physical activity) cannot be 100% prevented, there are some key strategies that can be taken to ensure that these risks are mitigated. Factors such as appropriate healthcare coverage during training and competition, venue-specific emergency action plans, access to an automated external defibrillator and heat acclimatization for preseason practices are effective means to mitigate risk. Below is an explanation of these fundamental policies and procedures that should be implemented at all levels of sport to ensure the health and safety of our athletes on the playing field.

1. Access to appropriate healthcare. Having access to appropriate healthcare (i.e. athletic trainers, sports medicine physician or other healthcare providers trained in sports medicine), is a vital aspect for any athletics program. These individuals are trained in the recognition, evaluation, treatment and return to activity of sport related emergencies. Having these individuals onsite for all sanctioned practices and competitions where the risk of sudden death is high ensures that, in the event of an emergency, prompt care can be given, which helps optimize the outcomes for the athlete.

2. Emergency Preparedness. In addition to having access to appropriate healthcare for all sanctioned training and competition, having a regularly rehearsed, venue-specific emergency action plan (EAP) allows all members associated with any athletics program to have a plan in place in the event of an emergency from occurring. Having a well-established EAP dictates the roles and responsibilities of each member of the athletics team and minimizes the time to point of care services during emergency situations.

3. Immediate Access to an Automated External Defibrillator (AED). Sudden cardiac arrest is the number one medical condition resulting in death during participation in sport or physical activity. The utilization of an AED during a cardiac event is an effective method to ensure survival; however, the chances of survival decrease roughly 10% for every minute defibrillation is delayed. With sudden cardiac arrest being the number 1 reason causing athletes to die during sport, having this life-saving device within 1-3 minutes of any venue hosting training or competition minimizes the time from defibrillation. Evidence shows that when an AED is utilized within one-minute of sudden cardiac arrest, survival is as high as 90%, thus justifying the need to have an adequate number of AEDs to service an athletics program at any and all institutions.

4. Heat Acclimatization. Exercise in hot environmental conditions not only adds additional stress on the body (both cardiovascular thermoregulatory strain), but exercise in the head can greatly increase the risk of exertional heat stroke if an individual is not accustomed to exercising in such conditions. Heat acclimatization, the physiological adaptations that occur following repeated bouts of exercise improves ones ability to exercise in the heat. Adaptations such as increased sweat rate, decrease exercising body temperature and heart rate and earlier onset of sweating allow for a greater ability to mitigate the risk of exertional heat stroke. The method of becoming heat acclimatized is a gradual progression of exercise duration, intensity and the wearing of protective equipment (i.e. football equipment, field hockey goalie equipment, etc.). This method has proved effective at both the NCAA and high school levels especially for football with only 2 football players dying from exertional heat stroke during August preseason practices since the 2003 implementation of the policy (saving 25-30 lives in the process). At the high school level, there have been zero exertional heat stroke deaths since any state athletics association has mandated this policy.

Source: Training and Conditioning

Football’s Silent Killer Forces Players and Teams to Make Tough Choices (Bleacher Report)

By Mike Tanier

At first, the condition feels like fatigue.

“It’s like a regular tired feeling,” according to Jerraud Powers, who played defensive back for eight NFL seasons with it.

If the player tries to power through, as football players so often do, the symptoms rapidly get worse.

“There’s constant cramping,” said former Ravens receiver Devard Darling, who lost his twin brother to the condition. “Once it starts, it usually doesn’t stop.”

“For someone who doesn’t have it, if they are running 20 ‘110s’ [sprints], they are dying on the 18th one.” Powers continued.

Then he corrected himself. “Not dying, you know. They are just physically exhausted.”

 For those with sickle cell trait, which has killed 11 college football players since 2000, according to the Lincoln Journal Star, the exhaustion comes sooner. “If you have a flare-up, you might feel it on the eighth or ninth sprint,” Powers explained.

The athlete’s body demands a break. But his mind—and his coach—may have other plans: No football player wants to appear weak or out of shape. So he keeps going.

If he doesn’t stop when the flare-up occurs, his own blood cells rapidly start trying to kill him. They form into crescent shapes and clog the blood supply to his muscles. The muscles die due to lack of oxygen. They dump their contaminants into the bloodstream, which, according to Dr. Kimberly Harmon of the University of Washington, interrupts the electrical system in the heart and causes cardiac arrest.

“There’s a point of no return,” according to Dr. Harmon. “And where that is differs for everybody.”

Pushed past this point of no return, the athlete literally, suddenly works himself to death.

The sickle cell trait can kill an otherwise-healthy, well-conditioned person in minutes. It affects 1 million to 3 million Americans (and roughly 1 in 12 African-Americans) overall, as well as countless pro, college and prep athletes.

Powers (No. 8) knew he had SCT while at Auburn but didn't come to understand its affect on his ability to train until he was in the NFL.

Powers (No. 8) knew he had SCT while at Auburn but didn’t come to understand its affect on his ability to train until he was in the NFL.Wesley Hitt/Getty Images

Most know they have it. But SCT is still a cause of confusion and controversy. And many young athletes still don’t know all the risks.

Deceptively dangerous

Jerraud Powers thought he was just out of shape.

“I’d be tired, and trying to figure it out,” he said. “I’m doing the same workouts with everybody else, but I’m the only one that’s dying. I would think, ‘Oh my God, I’m not gonna make it.’

“I just thought, ‘maybe I just need to stay and do some extra stuff to get in better shape.'”

Powers knew he possessed the sickle cell trait. He just did not know it could affect him. The symptoms and dangers of sickle cell disease are well-known. But the trait is just a genetic marker, not the disease itself, and until recently doctors believed it was nearly harmless. Powers was told from an early age that the trait would only impact his life if he had a child with a woman who also possessed it: That baby would be at a very high risk for the much more serious disease.

So Powers, then in high school, worked out in the sweltering Alabama heat with no safety precautions. When he got to Auburn, he talked to strength-and-conditioning coaches about his workout woes. “We talked about everything but the trait,” he said.

It wasn’t until Powers began playing for the Arizona Cardinals four years ago that he was informed by an independent doctor about the symptoms of sickle cell trait and the perils he unknowingly faced as a younger athlete.

The risk of sudden death among college football players possessing SCT was 37 times higher than the risk among the players without the trait, according to research conducted by Harmon at the University of Washington looking at college athletes from 2004 to 2008. The mortality rate among college football players with SCT was one in 827 in the mid-2000s, shockingly high for a population of young, outstandingly fit individuals.

The risk factor is compounded when the athlete feels pressure to push beyond his ordinary limits.

“The vast majority of people who have sickle cell trait are asymptomatic,” according to Harmon, the University of Washington football team’s physician and a top sports medicine researcher.

“The only time it ever becomes an issue is with really hardcore physical activity. The two times people have problems with it are when they can’t stop or feel like they can’t stop.”

In other words, Powers’ belief that he needed to exercise even harder could have killed him.

Powers left Auburn after the 2008 season, before the NCAA initiated mandatory SCT testing and other precautions for all athletes in 2010. He was quick to assert that trainers didn’t know as much about the trait as they do now.

But Dr. Douglas Casa, sports medicine researcher at the Korey Stringer Institute, points out that many programs were independently testing long before the 2010 mandate, and that a position statement urging better precautions for athletes with SCT (co-authored by Casa, Harmon and others) was published in 2007. “It was certainly on the radar for a long time before the rule change in 2010,” he explained.

Dr. Douglas Casa, here testifying in the wrongful death suit of Central Florida's Ereck Plancher, believes that college athletic programs should have known about the dangers of sickle cell trait before the NCAA-mandated testing for the condition in 2010.

Dr. Douglas Casa, here testifying in the wrongful death suit of Central Florida’s Ereck Plancher, believes that college athletic programs should have known about the dangers of sickle cell trait before the NCAA-mandated testing for the condition in 2010.Gary W. Green/Associated Press/Associated Press

Still, the range of care and quality of SCT education was wide a decade ago. “No one was educated about the risks of sickle cell trait,” Casa explained. “That’s something you educated yourself about as a medical professional.”

Powers relied on common sense to keep from overexerting himself in high school and college, even when his peers were outperforming him in workouts. “I was always a guy who knew my limits. If I felt like I was getting tired, I would take myself out.”

But college football is a culture of pushing past limits, whether to win a championship, preserve a scholarship or please a powerful coach. And too many athletes have pushed themselves past SCT’s point of no return in the last decade.

The workhorse

Like most identical twins, Devaughn and Devard Darling were nearly inseparable. But their paths diverged on the gridiron: Devard became a wide receiver in high school, while Devaughn was a two-way player heading toward a college career at linebacker.

Devaughn and Devard Darling on the Florida State sideline, circa 2000.

Devaughn and Devard Darling on the Florida State sideline, circa 2000.Photo courtesy of the As One Foundation

“In our last year of high school, Devaughn was the workhorse,” his brother recalls. “He played offense and defense. And he would always cramp in the fourth quarter.”

There’s nothing unusual about a two-way player cramping up in the Texas heat late in the game. But the Darlings possessed the sickle cell trait. The Bahama-born twins were never tested for the condition, so no one knew they had it. And because this was the late 1990s, few understood the associated risks.

“We just thought he was getting overworked,” Devard said. “Obviously, he was. But those were the telltale signs. Looking back, we should have paid more attention to that.”

The Darling twins found out they possessed SCT during their freshman physicals at Florida State. No accommodations were made for them. At dawn on a February morning in 2001, the twins lined up for then-head coach Bobby Bowden’s legendary “mat drill,” an hour-plus of high-speed tumbling, running, rolling and crawling, a regimen that would give a Marine drill sergeant pause.

 “There was an unwritten rule that we couldn’t get water,” Devard remembers. “And the No. 1 rule was: You can’t quit. They used to say, ‘before you die, you will pass out. And if you pass out, the trainers will take care of you.’

“That was our mentality. That was drilled into our heads.”

Devaughn, who had passed out during the previous Thursday’s workouts, fell to his knee after an exhausting series of tumbles on the morning of February 26. He complained of chest pains and blurred vision, according to a report by Michael Krause for SB Nation. Coaches ordered him to finish the drill.

“It got to the point where they were just sending Devaughn back by himself over and over again,” Devard said.

He finished the drill and collapsed. He was pronounced dead less than two hours later. Bowden called Devaughn “the first player I’ve ever coached in 47 years who actually worked himself to death.”

It was a tragic death, as well as an almost certainly preventable one. The Darling family sued for damages. The university agreed to a $2 million settlement in 2004, though the bulk of the money was held up by legal red tape for more than a decade.

The Darling family was awarded $2 million from Florida State after Devaughn Darling died after an exhaustive series of workouts at the school in February 2001.

The Darling family was awarded $2 million from Florida State after Devaughn Darling died after an exhaustive series of workouts at the school in February 2001.Mark Wallheiser/Associated Press/Associated Press/Associated Press

It was not the first SCT-related football death, and it would be far from the last.

Gone forever

Deaths from complications associated with sickle cell trait have been common enough over the last 20 years to fall into a predictable pattern.

Ereck Plancher of the University of Central Florida died in March 2008 after an extended series of conditioning drills in which, according to testimony by one of Plancher’s teammates, players were denied water and training staff was excluded from the sessions. The teammate also testified that then-Central Florida head coach George O’Leary yelled obscenities at Plancher, whose SCT condition was documented, as he struggled to his feet during an intense workout in a field house nicknamed “The Oven.” A jury awarded the Plancher family $10 million in a wrongful death suit against the university; later, that figure was capped at $200,000, due to Florida’s complicated immunity laws.

Cal’s Ted Agu died in February 2014 after a drill that required him to sprint up and down a hill while connected to his teammates by loops of rope. Agu, a linebacker entering his senior season, began stumbling and struggling midway through the workout and collapsed halfway up the hill, according to his teammates, far from trainers and emergency equipment.

The Agu family was awarded $4.75 million in wrongful death damages. The University of California acknowledged liability in the case.

Dr. Casa served as an expert witness in the Agu and Plancher cases, among others, and found many common factors among SCT-related deaths.

“There’s lack of proper preparation,” he explained. “The athletic programs had the knowledge of the sickle cell trait, but they didn’t implement best practices to prevent the condition. Once it happened, they didn’t take care of the person properly.”

Ereck Plancher's parents, Gisele and Enock, leave the courtroom during the wrongful death trial of their son, who died in 2008 while a member of the University of Central Florida football team.

Ereck Plancher’s parents, Gisele and Enock, leave the courtroom during the wrongful death trial of their son, who died in 2008 while a member of the University of Central Florida football team.Gary W. Green/Associated Press

Casa’s research into individual cases reveals bumbling that would almost be comical if it weren’t so tragic. Plancher was tested for SCT twice by Central Florida. The university lost track of the first result, according to Casa. Even after Plancher had tested positive for SCT in two separate screenings, the program “didn’t appear to employ precautions that had been recommended by a national athletic trainers’ organization nine months before Plancher died,” wrote ESPN’s Mark Fainaru-Wada regarding an investigation of the case by the network’s Outside the Lines program.

Casa himself jogged up the hill where Agu died. It’s L-shape and steep slope made it impossible for trainers stationed at the bottom of the hill to supervise athletes near the top. An automated external defibrillator and other medical equipment were stored far from the field; Casa said that Cal’s trainer neglected to bring the potentially life-saving equipment (smaller than a laptop bag) with him for the remote training session.

“We can look at every case and find flaws,” Casa said. “But the bottom line is that the kid ends up being gone forever…just because other people couldn’t implement simple policies or didn’t have support from the athletic department.”

The culture of college football is also a factor: Bowden-like tough-guy coaches, the never-quit attitude, the fear athletes face when confronting a coach or even standing up for a struggling teammate (starting jobs and scholarships can hinge on absolute obedience), a disconnect between coaches, trainers and the medical staff about where rigorous conditioning ends and reckless endangerment begins.

“The football strength-and-conditioning sessions at the college level, unfortunately, have been so unregulated for a long time that it was like the Wild West,” Casa said. “They could do anything they want.”

The NCAA has made efforts to address the issues in recent years, but those efforts come with their own set of controversies.

The NFL, meanwhile, has gone a decade without a serious SCT-related incident.

Nothing out of the ordinary

When most football fans hear the words “sickle cell trait,” they think of former Steelers safety Ryan Clark, who nearly died from a flare-up of the condition after a game against the Broncos in 2007.

Steelers safety Ryan Clark had his spleen and gallbladder removed when his SCT flared up after a game played in the Denver altitude.

Steelers safety Ryan Clark had his spleen and gallbladder removed when his SCT flared up after a game played in the Denver altitude.Gene J. Puskar/Associated Press/Associated Press

Doctors knew Clark possessed SCT, but they did not associate his intense postgame pain with the condition despite the obvious exertion-at-altitude red flags, according to an SB Nation interview by Sarah Kogod. Clark suffered through high fevers and constant pain for weeks before doctors realized that sickled blood cells caused tissue death in his spleen. He eventually had both his spleen and gallbladder removed. And though Clark ultimately returned to the NFL, he never again played a game in Denver.

Clark’s story is well-known and harrowing. It is also atypical of the NFL experience for an SCT carrier, especially now that the risks associated with the trait are better understood.

Once Powers understood the risks of playing through SCT, he reached out to Clark (as well as doctors and trainers) for advice before facing the Broncos in Denver. He decided to play what turned out to be a grueling game against Peyton Manning‘s high-powered offense in 2014.

“Even though I was fatigued like everybody else, it wasn’t anything out of the ordinary,” Powers said of his appearances at Mile High Stadium. “I knew if I got to a certain point where I needed a break, I wasn’t going to hesitate to take myself out of the game.”

Other SCT carriers in the NFL have made similar decisions. Geno Atkins played in Denver both in 2011 and 2015. Atlanta Falcons running back Tevin Coleman chose to play there last year.

Atkins described the experience of playing at high altitude to Fox Sports in 2013 (h/t the Cincinnati Enquirer).

“I remember just running to the bench to get a tank of oxygen because I was just dead tired,” he said in the feature. “That was the first time I felt fatigued, tired and couldn’t really catch my breath as [I could] if we were in Cincinnati. You are still able to as long as you are aware of it and take the proper steps.”

Not all NFL players with SCT have enjoyed near-symptom-free careers. Cardinals receiver John Brown slipped through the cracks of the NCAA’s screening policy. He attended Pittsburg State, which as a Division II program was not required to screen incoming athletes until 2012. Brown was not diagnosed with SCT until last year when doctors investigated the chronic leg pains that slowed him in the first half of the season.

Once doctors identified the pain as sickle cell-related, a regimen of carefully monitoring his hydration and exertion got Brown back to full speed.

Football games themselves are not high-risk events for SCT episodes: frequent substitutions and breaks between plays give players plenty of ways to regulate their exertion levels. Once in the NFL, players are protected by collective bargaining (conditioning activities are tightly structured and regulated) and a (generally) enlightened attitude about conditioning from exercises like the mat drill.

As a result, NFL players have a matter-of-fact attitude toward a manageable health condition. “Knowing what I know now,” Powers said, “I can tell whether it’s a flare-up or if it’s because I ate some pizza last night that I shouldn’t have before I ran.”

At the college level, however, SCT remains a controversial matter, starting with the NCAA’s screening policy.

A test fraught with peril?

The gene that causes sickle cell trait, a mutant strain of one of the genes that tell the body how to form hemoglobin (the oxygen-carrying molecules in our bloodstream), carries a surprising hidden evolutionary advantage. When a person with the mutation is stricken with malaria, their red blood cells are more likely to be quickly processed and eliminated by the spleen, taking the sometimes-deadly infection with them.

That means the sickle cell trait was naturally selected among populations in regions where malaria outbreaks were common throughout human history, particularly Africa. Which is why an estimated eight to 10 percent of African-Americans carry SCT, according to the American Society of Hematology. The condition is relatively rare among the rest of the American population.

That makes an otherwise simple health screening a matter fraught with racial overtones and perils.

Cardinals receiver John Brown did not find out until last year that he carried the sickle cell trait, which doctors identified as the cause for leg pains he suffered early last season.

Cardinals receiver John Brown did not find out until last year that he carried the sickle cell trait, which doctors identified as the cause for leg pains he suffered early last season.Hannah Foslien/Getty Images

After the NCAA began screening all athletes for SCT in 2010, several medical and healthcare advocacy groups denounced the policy. An article titled “Screening Student Athletes for Sickle Cell Trait—A Social and Clinical Experiment” appeared in the New England Journal of Medicine. That article outlined a long list of questions and concerns, ranging from medical privacy concerns to issues of stigmatization, self-image and future employability. Even now there are questions as to whether the trait causes exertion-based deaths at all or is simply a genetic marker for another problem.

Seven years later, those concerns remain valid, according to Dr. Biree Andemariam of the Sickle Cell Disease Association of America, one of the institutions opposed to the NCAA’s screening policy.

Athletes who test positive for SCT “could get passed over for scholarships,” Dr. Andemariam said. “They could get passed over for playing time. They could be seen as a liability.”

And the athletes passed over for scholarships or starting opportunities would be overwhelmingly, though not exclusively, African-American.

“Yes, it would proportionally affect those of African heritage, no doubt about it,” Dr. Andemariam agreed. “But we’re concerned about everyone who could potentially be stigmatized at a pivotal point in their careers.”

That may seem like a misplaced fear at first; after all, several prominent NFL players possess SCT, offering both evidence that the NCAA is not denying opportunities to carriers of the trait and examples to programs of how successful SCT-carrying athletes can be.

“It’s not going to deter a coach from offering a kid a scholarship,” Devard Darling said. “You know how coaches are. I haven’t heard of anyone getting discriminated against or anything.”

Darling, ironically, is one of the high-profile examples of a player whose college football career was disrupted by SCT. After Devaughn died, Florida State refused to let him back on the field.

“I learned the business of college football really quick when that happened. They saw me as a liability. I had a Florida State doctor look me in the eye and tell me I was never going to play football again after asking me three questions.”

Yet Darling quickly got another opportunity at Washington State. “Someone still picked me back up,” he said. “If you can play, you can play.”

Devard Darling was forced to transfer to Washington State when Florida State officials refuse to let him play again in the wake of his brother's death due to sickle cell trait.

Devard Darling was forced to transfer to Washington State when Florida State officials refuse to let him play again in the wake of his brother’s death due to sickle cell trait.Otto Greule Jr/Getty Images

But not everyone can play college football at Devard Darling’s level. What happens to a fringe player in line for one of a small program’s final scholarships, or a freshman who must be held out of his coach’s favorite drag-ropes-up-hill conditioning drill?

“We know about the ones who have successfully made it,” Dr. Andemariam said. “We don’t know about the ones who didn’t. We don’t have that data.”

Dr. Brian Hainline, chief medical officer of the NCAA, points out that the screening-and-education program has not just gotten results—just one SCT-related death since 2010, large numbers of SCT-carrying athletes competing across collegiate sports and levels—but changed attitudes.

“I think we’ve eliminated the stigma at the NCAA level,” Dr. Hainline said. “It’s just considered routine. You may have a sickle cell trait-carrying athlete, and that athlete is ultimately going to compete at the same level as everyone else. You just have to put safeguards in place.”

Organizations like the SCDAA believe the safeguards and education would work just fine without the screening. The U.S. Army does not screen recruits. It has used the “universal precautions” approach to prevent exertion-related deaths since 1996, a protocol endorsed by the SCDAA. Even in boot camp, there’s no good reason to push any individual to the point where they collapse from exhaustion.

Yet even in a well-regulated, well-designed conditioning drill, emergencies happen. For team physicians, knowing that a player has SCT can make the difference when a medical crisis occurs.

“For my athletes, I want to know if somebody has asthma, if someone has diabetes, so I can watch them closely and take special precautions,” Dr. Harmon said. “If somebody’s struggling, your differential diagnosis changes how quickly you need to act and what you need to do if you know they have an underlying medical condition.”

Falcons running back Tevin Coleman and a handful of NFL players with SCT have found playing in Denver can exacerbate the potential effects of physical exertion.

Falcons running back Tevin Coleman and a handful of NFL players with SCT have found playing in Denver can exacerbate the potential effects of physical exertion.Dustin Bradford/Getty Images

While all infants in the United States are screened at birth for the disease, parents often forget about a condition unlikely to affect their child for many years, and medical record keeping in the United States can be haphazard. Many athletes reach college age not knowing their status, so the choice becomes screening (and potentially discriminating against) an at-risk population or placing members of that population at an increased health risk.

“We don’t screen men for breast cancer,” Dr. Harmon said. “Nobody seems to get upset about that. But when you overlay this filter of race, it becomes political.”

“If I had a black athlete in high school in any sport where they would be training intensely, I’d test them. To me, that’s just pragmatic.”

Prevention versus exploitation

More than anything else, Devard Darling misses the quiet times with his late twin brother.

“The times it was just us two, together in our room, chillin’. The things that only I shared with him and he shared with me. I look back and I laugh at times, but no one else can relate because it was just me and Devaughn there. Those special times we had as twins, always having someone there for you, that bond that we had.”

Devaughn Darling was buried in a Florida State Seminoles uniform. The university awards a scholarship in Devaughn’s name. But Devard and his family are not involved in the scholarship program in any way. “They have been so standoffish to me and my family,” he said.

The Darlings were awarded $2 million in damages from Florida State in 2004. Due to the vagaries of Florida state law, the family just earned legal rights to the bulk of that money only two months ago.

What’s most frustrating about SCT-related deaths is how preventable they are. Experts constantly compare SCT to asthma or bee-sting allergies: Know your condition, inform your trainer, carry an EpiPen or inhaler (or hydrate and know the warning signs for overexertion) and the risks can be trivialized.

“It doesn’t take a high IQ to manage this,” Casa said.

Devard Darling now speaks to young athletes and students about the importance of finding out if they carry the sickle cell trait and how to navigate the condition.

Devard Darling now speaks to young athletes and students about the importance of finding out if they carry the sickle cell trait and how to navigate the condition.Photo courtesy of the As One Foundation

But unlike asthma or other conditions, SCT touches on many of our national anxieties and political hot buttons, from racial inequality to inequities in health care and education to the outdated macho-guy attitudes about conditioning that some coaches still cling to.

The trait-carrying college football player navigates a minefield between a test that could jeopardize his career and workouts that could jeopardize his life. The NCAA sets standards, but experts like Casa worry about whether all member programs will rise to them once the field house doors close.

“We’re willing to exploit their ability to perform at their best,” he said. “But we’re not willing to back it up with the proper health and safety standards.”

At lower levels, high school and youth athletes who immigrated to the United States or had a non-traditional upbringing (adoption, foster care, custody issues, blended families, etc.) may not know their status. And youth coaches and high school trainers may lack the training or resources to deal with an SCT episode.

Indeed, there have been many changes for the better in recent years on the SCT front. But there are too many ways a young athlete can be placed at unnecessary risk. And all the positives steps arrived too late for the football players who died as the result of misinformation, indecision or the outright stubbornness of a coach or program.

“It’s unfortunate that Devaughn had to die for so many things to change,” Darling said.


Source: Bleacher Report

NATA Clinical Symposia & Expo

Alexandra Finn

Assistant Director of Education

Athletic trainers from around the country gathered in Houston, Texas for the 2017 Annual NATA Clinical Symposia & AT Expo. The four day Clinical Symposia provided athletic trainers with the ability to explore new areas and benefit from the latest research. KSI was well represented by fifteen presenters who continued the mission of educating athletic trainers about our latest research. The warm weather of Texas was a constant reminder of the significance of heat in our southern states, but the strong interest showed by attendees from across the country demonstrated that athletic trainers are gaining an understanding that exertional heat illnesses are an issue of national concern. The selection of so many KSI members provided a unique opportunity for KSI to further its educational mission to maximize performance, optimize safety and prevent sudden death in sport.

Presentations kicked off early Tuesday morning when Andres Almeraya presented in the Master’s Oral Student Finalist session. His research about “Implementation of Automated Defibrillator Policies in Secondary School Athletics” demonstrated the strong need for additional state legislation to mandate that all secondary schools follow best practices. Andres entered the day as a finalist and was selected overall the best oral presentation in this section. Congratulations and well done, Andres! Dr. William Adams presented his work on the “Implementation of Heat Acclimatization Policies in Secondary School Athletics” during the Treat the Heat Session.

This year four KSI staff members: Luke Belval, Alexandra Finn, Rachel Katch and Brad Endres were selected to present a Free Communication Poster Presentation on Tuesday morning. Luke Belval presented on “Sex-based Comparison of Exertional Heat Stroke Incidence in a Warm-Weather Road Race.” Alexandra Finn presented on the “Implementation of Wet Bulb Globe Temperature Policies in Secondary School Athletics.” This research revealed that currently there are only three states that meet all the best practice recommendations in this area. Rachel Katch presented data titled “Cold Water Immersion in the Treatment of Exertional Heat Stroke Remains the Gold Standard at the Falmouth Road Race,” which demonstrated the significance of a road race having immediate cold water immersion available to treat exertional heat stroke. Finally, Brad Endres presented on the “Epidemiology of Sudden Cardiac Death in American Youth Sports.” Congratulations to both Alexandra Finn and Brad Endres who were selected as Master’s Poster Presentation Finalists. Brad’s poster proved to be the judges’ favorite taking home top honors for KSI in this category. Well done Brad and his research team!

Dr. Rebecca Stearns presented research during the session “When Exercise Gets Hot.” Her study focused on “Repeated Exertional Heat Stroke Incidence in a Warm-Weather Road Race.” Following Dr. Stearns presentation, two KSI members; Kelly Coleman and Alicia Pike spoke during the Diversity and Inclusion Considerations in Athletic Training session. Kelly Coleman presented data about the “Perceptions of Race and Ethnic Diversity on Athletic Training Clinical Practice” while Alicia Pike spoke about “Providing Medical Care to Male Sports Teams: Attractors to Employment for Female Athletic Trainers.

To finish the day, Dr. Robert Huggins provided an update on “An Overview of Secondary Schools ATLAS Project: Where Are We Now?” demonstrating the progress in mapping secondary schools across the nation.

The second day started off strong with three KSI members presenting. First, Sarah Attanasio provided insightful information about the ATLAS project. In a well-attended session, Dr. Douglas Casa discussed “Catastrophic Heat and Exertional-Related Condition Among Athletes.” Lastly, Samantha Scarneo presented data about “Implementation of Emergency Action Plan Policies in Secondary School Athletics.” Her study focused on the importance of every high school having an athletic trainer prepare an emergency care plan.

On the final day of presentations KSI members Kelsey Rynkiewicz, Dr. Robert Huggins, Dr. Yuri Hosokawa, Dr. William Adams and Alicia Pike all had an opportunity to present their data. Kelsey Rynkiewicz presented data on the “Implementation of Concussion Policies in Secondary School Athletics.” Dr. Robert Huggins presented on three different topics on Thursday. The first presentation looked at the “Presence of Athletic Trainers, Emergency Action Plans, and Emergency Training at the Time of Sudden Death in Secondary Athletics.” His second presentation provided data to support why all athletic trainers should be staffed and the importance of an athletic trainer in the ability to reduce risk and save lives. His last presentation was titled “State High School Athletic Policy Change Successes and Barriers: Results from Collaborative Solutions for Safety in Sports Meeting.” Dr. Yuri Hosokawa presented information on “Optimizing the Direction of Care: A Secondary Insurance Claim Analysis.” Dr. William Adams presented information on the “Current Status of Evidence-Based Best Practice Recommendations in Secondary School Athletics.”  Lastly, Alicia Pike looked at “Examining Sport Safety Policies in Secondary Schools: An Analysis of States’ Progress Toward and Barriers to Policy Implementation.”

It was a privilege for so many KSI members to have the opportunity to provide much needed information about subject matters such as the prevention and care of exertional heat illnesses to athletic trainers who are heading to summer sport training camps or planning for preseason training for fall sports. When not presenting, KSI staff members took advantage of the tremendous opportunity to learn from colleagues from other institutions. The annual conference, which will be moving to New Orleans, LA next year, is well worth the investment to attend!

University of Wisconsin Medical School Seminar

Rachel Katch, MS, ATC

Associate Director of Military and Occupational Safety

One of the dedicated missions of the Korey Stringer Institute (KSI) is to provide the most evidence-based information and education on preventing sudden death in sport and physical activity, and on June 24th, 2017, KSI had the opportunity to work on that mission. After traveling to Wisconsin, Dr. William Adams and I disseminated an eight-hour seminar with the specific focus of preventing sudden death in sport and physical activity. Our hosts were affiliates of the University of Wisconsin Medical School, and many individuals attending the seminar were local high school and collegiate athletic trainers. There were four individual presentations followed by a lab portion, in which participants received hands-on training and practice regarding the gold standard method of recognizing and treating exertional heat stroke (i.e., rectal temperature, cold water immersion). For many individuals, this was the first time practicing the skills needed to save a life from exertional heat stroke. The presentations given, including one evidence based practice session, included the following:

  • Preventing Sudden Death in Sport: Overview of Current Epidemiology and Prevention Strategies
  • Development and Implementation of Health and Safety Policies in Youth Student Athletes
  •  Optimizing Safety and Performance During Exercise: The Role of Hydration and Fluid Regulation
  •  Evidence Medicine in the Realm of Heat Stroke and Sudden Death: The Long Journey from Evidence to Policy

One of the more interactive portions of the seminar was the exertional heat stroke lab. After receiving a presentation on the best-practice recommendations, the participants were able to translate their knowledge into practice; some, if not all, for the first time. With the gold standard recognition and care of exertional heat stroke being well documented for decades, being able to practice these skills and break down the negative stigma around rectal thermometry and cold-water immersion is imperative to positive patient outcomes.

KSI is humbled to be able to not only provide the evidence-based research and literature, but also the means of translating that research into practice, and we are grateful to our hosts for providing us the opportunity to get our message out to fellow medical professionals.

American Society for Safety Engineers Heat Stress Panel Discussion

Gabrielle Giersch, MS

Associate Director of Education & Assistant Director of Athlete Performance and Safety

On Tuesday June 20th, I had the pleasure of representing KSI and sitting on a panel for the American Society of Safety Engineers entitled “An athletic approach to heat stress – beyond water, rest, and shade.” On this panel, we discussed the importance of keeping laborers safe, and using the knowledge we’ve garnered on athletes to do so. We discussed the causes of heat related illnesses, contributing factors, and how to best prevent heat illnesses from occurring in a working population. This panel could definitely be considered a conversation with a very active audience who was very interested in the topic and asked a lot of great questions! While the panel was only an hour long, some great information was put forth and hopefully with collaborations and putting the knowledge that we all have together, we can reduce the amount of heat related illnesses and deaths among laborers!

Preventing Sudden Death in Sport– CoxHealth Sports Safety Conference

Brad Endres, ATC, CSCS

Assistant Director of Sports Safety Policies

The prevention of sudden death in sports begins well before a catastrophic injury occurs.

It may be true that heroes are made in how they respond when they are needed most. Many stories throughout the country give testament to the life-saving nature of an appropriate and timely response to medical emergencies in sport. While these stories are indeed uplifting, they are often the result of a great amount of effort dedicated to being prepared in the event of an emergency. During their 2017 Sports Medicine Conference, the Sports Medicine team at CoxHealth exemplified the old adage that “practice makes perfect”, and it was truly a sight to behold. This team, led by Dr. Shannon Woods, was a shining example of how to collaborate with multiple health care providers in order to create, implement, and practice “best-practice” policies and procedures intended to promote athlete safety. KSI was invited to travel to Springfield, MO to take part in the Conference, and it was inspiring to witness the rubber meet the road in regards to the practical application of research.

Throughout the two days of the conference, KSI staff led evidence-based educational sessions on exertional heat illnesses. KSI Vice-President of Communication and Education Dr. Yuri Hosokawa started off the conference on Friday morning with an evidence-based presentation about the prevention, recognition, and treatment of exertional heat illnesses. After the presentation, she led the participants through a practical lab session on the “best-practices” of responding to an individual suffering from exertional heat stroke (EHS).  The participants attending the Friday session of the conference included athletic trainers, coaches, sports medicine physicians, EMS personnel, and school administrators from local area high schools, given that these practical skills would be vital for treating one of their athletes in the event they developed EHS while participating in sports. On Friday afternoon, CoxHealth staff led mock emergency scenarios where participants  were able to gain hands-on practice of what they had learned in the morning. The participants took the scenarios seriously, which led to great discussions during the scenario debriefings. Additionally, the local Springfield news station recorded a news segment about the Conference in order to spread the word about emergency preparedness and athlete safety.

On the final day of the conference, the participants included physical therapists, physicians from other specialties, parents of young athletes, and other interested members of the community. Yuri and I geared our presentations to a slightly different audience, but the message was largely the same: evidence-based policies and procedures can indeed save lives.

Yuri and I were thankful to be invited to the 2017 CoxHealth Sports Medicine Conference, and proud to represent KSI at such an impressive collaborative event. Being in compliance with “best practice” emergency response policies is not always the easiest thing to do, but networks like CoxHealth Sports Medicine are proving that it can be done. Because of their efforts, the athletes they serve will undoubtedly be safe and well cared for.