Month: January 2019

NCAA considering guidelines to help prevent offseason workout deaths (Sporting News)

The document outlines how schools should acclimate student-athletes into workouts following low-activity periods, which carry greater risk of injury or death because players have not yet adjusted to strenuous drills. It would also discourage the use of intensive workouts as a form of punishment, and establish how to properly diagnose and treat heatstroke.

Fourteen medical organizations, including the National Athletic Trainers’ Association and the Korey Stringer Institute — which strives to prevent sudden death among athletes at all levels — are reviewing the proposal and suggesting amendments. Brian Hainline, chief medical officer of the NCAA’s Sports Science Institute, said roughly half the organizations involved in the process have approved it, and the rest are expected to deliver formal reviews by Jan. 31. Hainline said he expects the document will be officially enacted and published by late spring.

“It’s a huge leap forward,” Hainline told SN, “because frankly, and we state this in the document, the vast majority of these non-traumatic catastrophic deaths and injuries are preventable.”

According to a 2017 study by University of Oklahoma head athletic trainer Scott Anderson published in the Journal of Athletic Training, 27 Division I athletes — all football players — have died from non-traumatic causes since 2000. That number does not include Maryland football player Jordan McNair, who died in June following a May 29 workout.

Still, it’s unclear how the best practices would be enforced, or whether the NCAA would eventually penalize institutions that don’t abide by the guidelines.

“Hopefully it’ll spur some dialogue and attention and cause some people to look at their programs,” Anderson said. “And you know I hear all the time, ‘The NCAA, all that is is a guideline. It has no teeth. There’s no punishment in there.’ And I understand that. But I also understand the power of a guideline.

“It’s not a law or a bylaw or legislation or anything else like that, but there’s a standard of care, and medically we violate that at our own peril. We’ve had to elevate our standard of care, our standard of how we train people. There needs to be absolutely some level of accountability and transparency.”

There was little public response from the NCAA when McNair died from heatstroke, eight months before initial review of the NCAA’s best practices guidelines. McNair’s medical treatment was marred by some of the same shortcomings that have contributed to the non-traumatic deaths of other student-athletes over the past two decades. The NCAA’s best practices proposal offers ways to avoid those mistakes.

The workout in which McNair suffered the heatstroke was the team’s first conditioning session of the summer, according to records obtained by Maryland student newspaper The Diamondback. Rather than being gradually acclimated to camp, McNair, a rising sophomore, was asked to complete a conditioning test of 10 110-yard sprints. He showed signs of exhaustion midway through the test and struggled to complete the drill, according to an independent reportcompleted by private investigative firm Walters Inc.

Maryland’s trainers then failed to meet basic protocol for diagnosing and treating heatstroke, not applying cold water immersion therapy to McNair, according to the same report. Cold water immersion is known to help patients recover from heatstroke when applied right away, according to Community Healthcare System athletic trainer John Doherty, who advises trainers in the Midwest how to respond to emergencies.

“It’s a very simple step that I work with my athletic trainers both at the collegiate and high school level constantly,” Doherty said. “I’m always reminding them that especially when there’s hot weather around, how valuable and necessary the cold water immersion stuff is because it is such a simple step and its success rate is to my knowledge 100 percent.”

After Maryland accepted “legal and moral responsibility” for McNair’s death during an August news conference, an NCAA spokeswoman told The Washington Post the university had “offered steps to ensure this does not happen again.”

At that point, however, DJ Durkin was still the Terrapins’ football coach, and assistant athletic director of athletic training Steve Nordwall and head football trainer Wes Robinson had not yet been dismissed. An independent investigationinto the football program’s culture, which found frequent instances of verbal abuse from coaches, would not conclude for another two-plus months.

When contacted for an update on Maryland’s plans to prevent future deaths, a school spokeswoman linked SN to a page listing corrective measures, saying 17 of 20 changes recommended by Walters Inc. had been completed. (Those recommendations can be found on page 67 of the below document).

The lack of action from the NCAA regarding McNair’s death consequently led critics to point out the organization’s refusal to weigh in on player safety issues while openly investigating and disciplining schools for competitive-balance violations, like paying college basketball players.

“Essentially the silence is deafening,” ESPN college basketball analyst Jay Bilas told SN. “It’s an odd feeling to see the NCAA sort of act in one fashion with regard to amateurism, and then with health and safety of athletes there’s not the same sense of urgency.”

An NCAA spokesman said the best practices currently being reviewed are the result of an NCAA-hosted information-gathering summit in 2016. That said, the document uses recommendations from a 2012 inter-association task force — composed of leading organizations in the sports medicine industry — that met independent of the NCAA and presented its findings in hopes of being formally adopted by the organization.

Hainline — who wasn’t affiliated with the NCAA at the time the 2012 task force presented its findings — said he felt the organization has moved at an appropriate pace in putting the document together. He cited required input from people throughout the college landscape, including athletic departments and school presidents who make up the board of governors.

Korey Stringer Institute head Dr. Douglas Casa, though, said better cooperation at all levels of the NCAA, particularly from football coaches, could have facilitated change sooner.

“If (the NCAA) had endorsed that back in 2012, there’s a really good chance the deaths that have happened since 2012 would have never happened,” Casa said. “Some of the things we had written were simple things that would have required modifications to prevent these deaths for happening. You know, Jordan McNair is the perfect example because it was extremely simple solutions to save Jordan’s life.”

Hainline hopes by publishing these guidelines, the NCAA can begin taking a more active stance on student-athlete health and safety. And while he and Casa both feel the best practices now being weighed are a sign of progress for improving student-athlete safety, the impact of that document will likely hinge on the receptiveness of the college sports community.

A high-ranking conference official with direct knowledge of how institutions view the NCAA’s place on this issue told SN it could prove difficult for the NCAA or conference leadership to regulate workouts. The official said schools are fiercely independent and bristle at attempts to manage their practices. Most do follow proper protocol already, the official added.

“(The NCAA and conferences) are not in the trenches, we’re not there on a daily basis,” the official said. “Now could we or should we be? That’s a philosophical question, one we’re not built for today.

“Historically, institutions have a strong desire to have their autonomy when it comes to how they spend their money, their academic integrity … and their medical training.”

To that end, Hainline emphasized his belief in a “philosophical shift” from the traditional model of self-regulating institutions to one where the NCAA provides oversight on health and safety matters — potentially even punishing schools unwilling or incapable of following along.

“I believe there should be consequences. I believe the membership and board of governors are moving in that direction,” Hainline said. “The needle is shifting. … I would say for an organization like (the NCAA), the needle is shifting rather rapidly. Others can say it’s 100 years too slow.”

Source: Sporting News

National Winter Sports Traumatic Brain Injury (TBI) Awareness Month

Brad Endres, MS, ATC, CSCS

Assistant Director of Sport Safety, Korey Stringer Institute

The new year is upon us, and with the changing of the calendar comes the increased participation in our beloved winter sports. Fittingly, January is National Winter Sports Traumatic Brain Injury (TBI) Awareness Month, so before you dust off the skates or head up the ski-lift, here is a breakdown of what you need to know to stay safe out on the slopes or in the rink.

What is a traumatic brain injury (TBI)?

The types of traumatic brain injuries include sport-related concussion (SRC), diffuse brain injury, second impact syndrome, subdural hematoma, and epidural hematoma.  Although cerebral concussions rarely cause death, they can be the starting point for other deadly brain injuries.


How often does TBI occur?

Between 1.6 million-3.8 million TBIs are seen in sports each year in the United States. Athletes under the age of 15 represent the majority of TBIs. Also, in every age group males show a higher rate of TBIs than females.


What is a sport-related concussion?

According to the 5th International Conference on Concussion in Sport held in Berlin, October 2016, a SRC is defined as a TBI induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.
  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.
  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.


What are the signs and symptoms of a SRC?

The suspected diagnosis of SRC can include one or more of the following:

  1. Mechanism of Injury (eg, direct blow to the head)
  2. Physical signs (eg, loss of consciousness, memory loss, neurological deficit)
  3. Balance impairment (eg, unsteady gait)
  4. Behavioral changes (eg, irritability)
  5. Cognitive impairment (eg, slowed reaction times)
  6. Sleep/wake disturbance (eg, sleepiness, drowsiness)
  7. Signs and Symptoms including the following:
Signs Symptoms
  • Disorientation, confusion
  • Retrograde/anterograde amnesia
  • Loss of consciousness
  • Automatism
  • Unequal pupil size
  • Combativeness
  • Slowness to answer questions
  • Loss of balance
  • Atypical behavior/personality changes
  • Vacant stare
  • Nystagmus
  • Headache
  • Nausea
  • Balance issues/dizziness
  • Tinnitus (ringing in the ears)
  • Diplopia (double vision)
  • Blurred vision
  • Trouble sleeping
  • Trouble concentrating
  • Memory issues
  • Irritability, sadness,
  • Sensitivity to light or noise


What to do if a TBI / SRC is suspected?

Any person suspected of a SRC should be removed from the mountain or event area immediately and evaluated by a licensed healthcare professional who is trained in the evaluation and management of concussions. The injured person suspected of a SRC should not return to activity on the same day as injury. Finally, continued monitoring of an athlete evaluated of having a SRC is necessary in order to observe any deterioration of physical or mental status (which warrants transport to local healthcare facility).


How do you treat an individual with a TBI / SRC?

After being evaluated by a health professional, treatment and management of a TBI/SRC includes:

  • Physical and Cognitive Rest: Physical and Cognitive activities that result in an increase in symptoms should be avoided during the acute phase of concussion treatment
  • Medications that mask the symptoms of a concussion (NSAIDS, Aspirin, stimulants, and antidepressant) should be avoided, especially in the acute phase of the injury.
  • The use of acetaminophen (Tylenol) may be considered in treating symptoms such as headache but should be used after the acute phase of the injury
  • Athletes sustaining a concussion should have a follow-up appointment with their general practitioner to evaluate the mechanism of injury, the course of symptoms, and any previous history of concussive injuries.
  • Return-to-play following a concussion should follow a graded return-to-play protocol. This protocol should consist of 5-7 stages and take 5-7 days to complete (if there is no recurrence of symptoms). The graded return to play protocol should begin once the athlete has a cessation of symptoms for at least 24 hours. An athlete must be prohibited from returning to activity if they are still experiencing symptoms.
  • The goal of the return to play protocol is to progressively increase the duration and intensity of exercise to ensure that there is no return of symptoms with physical exertion. See the table below to see an example of a 6-stage return-to-play protocol.
Rehabilitation Stage Functional Exercise at each Stage of Rehabilitation
1.  No activity Complete physical and cognitive rest
2.  Light aerobic exercise Walking, swimming, or stationary cycling keeping intensity <70%
No resistance training
3.  Sport specific exercise Skating skills in ice hockey, slide board for skiing, general agility drills
No head impact activity
4.  Non-contact training drills Progression to more complex training drills (eg: passing drills in ice hockey, bunny slopes for skiing/snowboarding)
May begin progressive resistance training
5.  Full-contact practice Participate in normal training activities
6.  Return to play Normal game play or event competition


How do I prevent a TBI / SRC?

Based on the most updated consensus statement created by a committee of sports medicine professionals at the 5th International Conference on Concussion in Sport, the following steps were recommended for TBI prevention:

  • Protective Equipment: There is sufficient evidence in terms of reduction of overall head injury in skiing/snowboarding to support strong recommendations and policy to mandate helmet use in skiing/snowboarding. The evidence for mouthguard use in preventing SRC is mixed, but suggests a positive trend towards a protective effect in collision sports (such as hockey).
  • Rule Change/Risk Compensation: The strongest and most consistent evidence evaluating policy is related to body checking in youth ice hockey (ie, disallowing body checking under age 13), which demonstrates a consistent protective effect in reducing the risk of SRC.
  • Aggression/Violence: Appropriate competition and the aggressive nature of some sports is not discouraged, however unnecessary violence or other aspects should be evaluated based on the merit they provide in the sport.
  • Education: The ability to detect and deal with a TBI is enhanced when everyone on the slope or ice is looking out for the safety of the athletes.  Education should include the athletes themselves, coaches, administrators, and parents.  It should cover basic tools for recognition, what to do if they suspect a concussion, and the process of treatment and returning to participation.

What are the risk factors for SRC?

  • Previous concussions: A previous history of a concussion increases the risk of sustaining another concussion on the order of 2-5.8 times greater risk
  • Number, severity and duration of symptoms: Evidence has shown that those who report a greater number of symptoms, or report a greater severity of symptoms or duration, may experience a longer recovery than those who experience less severe symptoms.
  • Sex: Research has shown that females experience a higher incidence of concussion in addition to reporting a increased number/severity/duration of symptoms, and prolonged recovery.
  • Age: Young athletes may experience a prolonged recovery from a concussion and may be due to the differences in the developing brain of a child/adolescent compared to that of an adult brain
  • Sport, position, and style of play: Depending on the sport, position, and the athlete’s style of play increases the risk of concussion. In sports where there is player-to-player contact, the risk of concussion increases. The table below outlines the incidence the risk of concussion for various sport.
  • Mood Disorders: Mood disorders such as depression, anxiety, and irritability may complicate both the diagnosis and management of a concussion
  • Learning disabilities and attention disorders: Learning disabilities such as ADD/ADHD or others that result in some form of cognitive dysfunction can complicate the management of a concussion and may lead to a longer recovery time post-concussion

So bundle up, have fun, and most importantly stay safe this Winter! For further information, check out the TBI page at the Korey Stringer Institute’s website at The 5th International Conference on Concussion in Sport publication can be found at

30 NCAA Football Players Have Died During Workouts Since 2000, HBO Reveals (American Council on Science and Health)

When writing about this topic three weeks ago, our focus was mostly on the failure of high schools to protect student-athletes from potentially-fatal heat stroke.

Little did we know what the big boys – for a much longer time – were failing to do as well.

With a key preventive measure being so simple – the availability of a tub full of ice water – it defies all logic that this simple step isn’t being taken everywhere strenuous workouts are being held.

But now comes the revelation that NCAA football players are being worked so hard during practice that they’ve been regularly dying of heat stroke since the beginning of this century.

This week, the HBO newsmagazine show “Real Sports with Bryant Gumbel” reported that “since the year 2000, 30 players have died as a result of college football workouts.” The cause: heat stroke, which is completely preventable if college officials overseeing grueling practices – usually athletic trainers – can identify a stricken player’s physical distress while it’s happening and immediately have him immersed in a nearby ice bath.

Yes. Thirty dead players in 18 years, or nearly two every year.

And inevitably, when grieving parents ask what could have been done to prevent such a senseless tragedy, they are always – always, 100 percent of the time – presented with this overlooked remedy. A solution so simple, in fact, that is must make their loss even more painful.

“A tub, ice and water would have saved their child’s life. That simple,” states Dr. Douglas Casa, who is “among the leading experts of sudden death in sports,” according to correspondent Jon Frankel. “It will save their life, every time.”

And yet, having icing tubs available during practice is not mandated by the NCAA.

Even more frustrating, HBO‘s Frankel revealed that Dr. Casa, who leads the Korey Stringer Institute, a leading organization on heat stroke and its link to player fatalities, has collaborated with colleagues in drafting a list of specific recommendations that detail how these type of fatalities can be prevented.

The document, “The Inter-Association Task Force for Preventing Sudden Death in Collegiate Conditioning Sessions: Best Practices Recommendations,” was sent in 2012 to the NCAA, which has failed to enact the practices, in their entirety or even partially. The organization said the changes would be too difficult for member colleges and universities to implement. (photo of Dr. Casa courtesy: Korey Stringer Institute)

In the meantime, college football players continue to die from heat stroke. Most recently it was Jordan McNair, a 19-year-old at the University of Maryland, whose core body temperature soared to 106 degrees during a May 29 workout while undergoing intensive conditioning that included repeated 100-yard sprints. The freshman was not placed in an ice bath while awaiting EMTs and died 15 days later.

In addition, there’s this: “The rise in the deaths during workouts has corresponded with another sharp rise,” Frankel noted, “the rise in the prominence and pay of strength and conditioning coaches.” Men in these positions have been given ever-greater influence to push football players to their physical limits, and they’ve been doing just that.

But Frankel tells us that there’s one substantial shortcoming with their professional education in this field: strength and conditioning coaches can get certified without learning anything about player health. All they have to do is pass a 13-hour course – one that includes no safety training at all.

“The deaths, at this point in time, absolutely it’s predictable. They’re going to occur. It’s disturbing. It’s really inexcusable,” said Scott Anderson, the longtime athletic trainer for the University of Oklahoma. “Without question, the role of the strength and conditioning coaches has grown over time. There should be some accountability that comes with that.”

In the wake of these 30 deaths, the NCAA has yet to mandate any safety or medical training for strength and conditioning coaches, HBO reports. And not one has ever been disciplined as a result of a player fatality during their watch.

Source: American Council on Science and Health