Blog Post

Applied Performance Science: Stress, Travel Fatigue and Recovery Techniques

Ryan Curtis MS, ATC, CSCS

Director of Athlete Safety and Performance

Stress and subsequent fatigue are a normal part of sport and life and often desired in order to augment adaption to training. The concept of periodization, being the organization of training stress and recovery, is usually on the forefront of performance and medical practitioner’s minds. When training and physical stress is balanced with adequate rest and recovery, acute fatigue is often diminished in a matter of hours or days. However, if the body is not allowed to return to a balanced state (homeostasis) before excess stresses are introduced, maladaptation occurs. In optimizing performance for sport or life, it’s important to note that not all stresses are desired or accounted for.In the midst of a hectic season or normal life demands, it’s easy to forget to acknowledge and appropriately prepare for things such as the stress of travel, sleep impairment, poor nutrition and/or hydration and injury. Implementing fatigue countermeasures begins first with recognition of outside stressors and then adherence to a few best-practice techniques.Below are a few visuals to help us become aware of undesired stress outside of training and techniques in combating travel fatigue and promotion of optimal recovery.

2018 Collaborative Solutions for Safety in Sport Florida Meeting



Last week, Dr. Casa and I were fortunate to attend the 2018 Collaborative Solutions for Safety in Sport (CSSS) meeting for the state of Florida. Stemming from the national CSSS meeting, the goal for this meeting was to implement the best practice policies at a state level for high school athletes. This same meeting occurred in 2017, and while the program was educational and facilitated some changes, the ultimate goal of the current meeting was to bring well thought-out policies to the sports medicine advisory committee and board of directors to pass. While this program was meant educational, it was not meant to be continuing education; rather a workshop with the goal to create and fully vet the wording of policy to be implemented by the Florida High School Athletics Association.




The program, designed and facilitated by Bob Sefcik, ATC, included dinner and a keynote address from Dr. Casa on Monday evening. Dr. Casa’s presentation provided context to the reasoning behind and the methodology utilized for the creation of the policy rubric and the rankings. Starting bright and early on Tuesday, the meeting was kicked off by Dr. George Canizares and Dr. Casa who discussed the current policies and stated that the current meeting was held based on the foundation that was laid in the 2017 meeting. They also noted that the goal of this meeting was to leave with written policy language.


Following the morning speakers, we heard from two families whose children suffered catastrophic injuries while playing high school sports in Florida. Courtney Sapp’s son, Payton, suffered a catastrophic head injury while participating in a junior varsity football. She described the pain and long-term consequences that not only Payton, but her entire family has ensued since his injury. Lori and Ed Giordano’s son, Zach Martin, suffered a fatal exertional heat stroke during a football practice in the summer of 2016. Unfortunately, in both cases, there was no athletic trainer present to care for the safety of the student athletes. Further, the families advocated for increased education of sport related injuries such as concussion, exertional heat stroke, and cardiac arrest. They charged the members in attendance to remember their stories and to do everything in their power to make sports safer.


For the purpose of this meeting, there were five specific areas to focus on creating policies for – cold-water immersion, environmental monitoring, concussion, coach education, and minimal expectations for high schools. Each topic area had its own break-out group with a variety of stakeholders (athletic trainers, physicians, administrators, coaches, and parents) represented in each meeting. Prior to the start of the meeting, a white paper document corresponding to the group you were assigned were disseminated, and thus a majority of the discussion surrounded the material provided on this white paper. I was fortunate to facilitate the Environmental Monitoring group with Dr. Seth Smith. Having tangible, realistic goals of creating specific wording for policies from the breakout sessions allowed for a focused message and resulting actionable items for the sports medicine advisory committee (SMAC) to discuss at their meeting that night.


I was honored to be invited to the SMAC meeting that evening to provide additional insight and expertise, if needed. The members of the FHSAA SMAC are a very professional, determined and organized with the common goal of wanting to improve the health and safety standards for student athletes. I was very grateful for the invitation, and thoroughly enjoyed listening to the discussions that occurred.


To conclude, it was remarkable to see the amount that can be accomplished when key stakeholders within a state, with a common goal, collaborate to improve the current standards. It is truly a team effort and the comradery between the members in attendance was aspiring to be a part of. The policy ranking project was meant to be a project to help states identify areas of strengths and areas of improvement. We are excited to see states such as Florida take the findings of the project and use it as ignition to help improve the safety for our athletes. We fully believe that through policy change at the state level, and thus influencing the local implementation, that we can significantly reduce the amount of catastrophic injuries.


I would like to reiterate our deepest gratitude to Bob Sefcick for his generosity, helpfulness and invitation for Dr. Casa and I to participate in this event. We would also like to thank George Tomyn and the FHSAA for hosting the meeting.

98th American Meteorological Society Meeting

Korey Stringer Institute Medical and Science Advisory Board Member

Yuri Hosokawa PhD, ATC


As one of my last tasks as the Vice President of Education and Communication, I attended the 98th American Meteorological Society (AMS) Meeting in Austin to present at the joint session, Informing Heat-Health Practitioners to Reduce Risk through Impact-Based Decision Support. The first half of the session was comprised of case study presentations that showcased the use of weather data, such as the wet bulb globe temperature (WBGT), to conduct health risk assessment in public health, occupational health, and athletics. While there still remain limitations in deducing the association between WBGT and health outcomes, use of weather data to make informed decisions for future heat events to minimize its adverse effects on health, economy, and productivity are being investigated across the U.S.A continued effort in observational and intervention-based studies are warranted to identify successful models.

Presentations included in the latter half of the session, including my presentation from the KSI, were reports from current initiatives supported by the National Integrated Heat Health Information System (NIHHIS). The NIHHIS is being developed by the Centers for Disease Control and Prevention (CDC), the National Oceanic and Atmospheric Administration, and domestic and international partners to understand this problem, develop a robust and science-informed response, and build capacity and communication networks to improve resilience. My presentation at the session featured KSI’s on-going inter-agency collaboration in drafting a round table document among athletics, military, and occupational settings to use WBGT for activity modifications in the heat. Other NIHHIS projects featured in the session included a project lead by the National Oceanic and Atmospheric Administration in North Carolina that investigated the use of web-based forecasting tool (Heat Health Vulnerability Tool) by community stakeholders and the Hot Spots project, which aimed to increase the heat resilience in Mexico border region through education and evidence-driven public health interventions.


As depicted by presentations in the session, a successful environmental heat risk assessment requires an inter-agency and interdisciplinary network. Projects led by NIHHIS provide great examples for others to follow, and it is no doubt that exercise physiologist and athletic trainers play integral roles in examining the impact of heat.

EATA Meeting 2017

Kelsey Rynkiewicz, ATC, NREMT

Assistant Director of Education

The winter weather did not stop the 70th Annual Eastern Athletic Trainers’ Association (EATA) Meeting and Clinical Symposium from being held in Boston, MA on January 5th-January 8th.


The 4-day conference started off with an Educators Conference in which numerous professionals presented information on competency based learning, fostering clinical capabilities, incorporating research components, and integrating evidence based practice within Athletic Training Education. The Educator’s Conference also included a Profession Development & Peer to Peer Session.  Jessica Barrett and Dr. Stephanie Mazerolle, both members of the UConn Department of Kinesiology, facilitated the Young Educators Peer to Peer Session.


The EATA Student Program provided additional opportunities for student learning and involvement. The annual District 1 and District 2 Quiz Bowls were hosted Friday night. Patrick Coley, a senior in UConn’s undergraduate Athletic Training Program and the President of UConn’s Athletic Training Society, represented UConn during the District 1 Quiz Bowl. Presentations as part of the Student Program included topics such as Blood Flow Restriction Therapy, Current Topics of Concussion Evaluation and Management, and Prosthetics. There was a panel presentation known as “Stories from The Sidelines” in which panelists discussed their involvement in caring for victims of the Boston Marathon bombing and introduced the ATs Care peer support group.


The EATA General Session included a wide variety of presentations including injury response behaviors, eating disorders, athletic insurance, concussions, healthcare communication, and the rehabilitation and treatment of athletic-related injuries.  Attendees also had an opportunity to earn evidence based practice continuing education units which are part of the Athletic Training Board of Certification continuing education requirements.


Members of KSI had the opportunity to not only attend the conference, but also share recent research with the Athletic Training community.


Dr. Douglas Casa presented a lecture titled “The KSI State Rankings of Health and Safety Policies for High School Athletes: What it Means for the EATA Member States.” Dr. Casa discussed the rankings of the 51 State High School Athletics Associations which were released on August 8, 2017.  The states were ranked based on a 100-point rubric that assessed compliance with the current best practices for health and safety in high school athletics. Dr. Casa focused on the EATA member states and provided suggestions and strategies for improving health and safety standards.

Kelly Coleman presented original research in the form of a poster presentation titled “Junior Faculty Knowledge of Institutional Expectations for Tenure and Promotion.” Justin Rush also presented a poster titled “Spatting Increases Ankle Stability in Collegiate Field Sport Athletes: A Critically Appraised Topic” from his undergraduate work.


As always, the EATA provided a great weekend of education, sharing important research, and networking. Next year’s conference will be held in Valley Forge, PA.  We hope to share more research from KSI in the future to continue to educate others and promote the Athletic Training profession.


Paving the Way for Heat Safety in Athletes, Warfighters, and Laborers

Yuri Hosokawa, PhD, ATC

Vice President of Communication and Vice President of Education


Every October, members of KSI travel to Washington D.C. to volunteer at the Marine Corps Marathon medical tent. This year’s trip was also a special one because we were able to continue our efforts from last year in building relationships and exchange ideas with the National Oceanic and Atmospheric Administration (NOAA), Uniformed Services University of the Health Sciences (USUHS), the Occupational Safety and Health Administration (OSHA), and the National Institute for Occupational Safety and Health (NIOSH).


On Thursday, October 19th, KSI had the honor of gathering representatives from federal sectors that regulate heat activity modification guidelines or study implications of heat in the welfare of warfighters and laborers. The meeting was sponsored by the National Integrated Heat Health Information System (NIHHIS:, whose mission is to understand global health threat from extreme heat, develop a robust and science-informed response, and build capacity and communication networks to improve resilience. Participating agencies of NIHHIS include: Office of the Assistant Secretary for Preparedness and Response (ASP), Centers for Disease Control and Prevention (CDC), United States Environmental Protection Agency (EPA), the Federal Emergency Management Agency (FEMA), NIOSH, NOAA, OSHA, and the Substance Abuse and Mental Health Services Administration (SAMHSA).


KSI has a good history in working collaboratively with the occupational and military sectors, however, it was not until last year that we were able to gather representatives from all three sectors– athletic, occupational, and military­– to convene at single location and exchange ideas for future collaborations. Integration of climate and weather data from NOAA is also critical in making data driven decision to enhance the policies and guidelines for the people in these settings who are often exposed to extreme heat. Participants of this year’s meeting are currently working on a manuscript that gathers current consensus regarding heat activity modification guidelines for the physically active population (athletes, warfighters, and laborers), which we hope to release next year.



On the following day, we attended the IIRM Sports Medicine Conference hosted by the International Institute for Race Medicine, MedStar Sports Medicine, and MedStar National Rehabilitation Network. The meeting was attended by many medical providers and students who were also volunteering at the Marine Corps Marathon. At the meeting, Dr. Douglas Casa gave a presentation regarding wearable technologies in sport. Despite the recent advancement in wearable technology, his presentation warned that there is yet to be reliable, real-time, noninvasive hydration and internal body temperature assessment devices on the market. As the field of wearable technology continues to grow, researchers and clinicians must stay up-to-date with the technology advancement while also acknowledging the technological limitations to make the best-informed decisions about using data from these devices.



Later in the afternoon of the conference, we also participated in a workshop that was designed to review various treatment algorithms for medical conditions commonly seen at race medical tents in the form of problem-based-learning scenarios.  Exercise-associated collapse, cardiovascular arrest, exertional heat stroke, exertional hyponatremia, exercise associated muscle cramping and bleeding-control were covered in the workshop, all lead by the content experts. The hands-on workshop provided opportunities for young professionals to practice the skills for the first time and stimulated the exchange of various experiences from the veteran providers.



KSI was stationed at the Aid Station 9 on the day of the race, which was located between mile-21 and 22. The wet bulb globe temperature reading one-hour past the start of the race was in the mid-60’s, but quickly reached the high 70’s by noon, placing this year’s race as one of the warmer race in the history of the Marine Corps Marathon. The coordination of work among the corpsmen, athletic trainers, nurses, physical therapists, and physicians at the aid station was great. We also treated several exertional heat stroke patients on-site, where we made sure to cool the patients below 39°C before transport.


Our trip to Washington D.C. is a true demonstration of our mission statement– to provide research, education, advocacy and consultation to maximize performance, optimize safety and prevent sudden death for the athlete, warfighter and laborer. Whether we are treating marathon runners from exertional heat stroke or optimizing the regulations for worker safety in the heat, the physiological premise and impact of exertional heat stress is the “same” across athletes, warfighters, and laborers. Integration of minds across disciplines, such as the NIHHIS meeting, and continued advocacy to provide evidence based exertional heat stroke care are some of the core missions we will continue to carry forward from KSI.  #Strive2Protect

CamelBak Elite Athlete Testing

Gabe Giersch, MS

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

KSI had the awesome, unique opportunity to test two CamelBak sponsored pro-athletes over

the course of two days! The athletes were Lea Davison, a two-time Olympian Mountain Biker (2012 & 2016), and Gediminas Grinius a decorated Lithuanian trail runner. Some very fit, athletically decorated media personnel underwent testing as well. The athletes were able to undergo heat and sweat testing, where they exercised for 60-minutes total. Because it was a hot environment, the athletes were asked to collect their sweat in a specially prepared towel,and atthe end of their hour, we didwhole-body wash downs to collect samples to assess their sweat electrolyte concentrations. Whole-body wash downs are the gold standard for assessing whole-body sweat electrolyte concentration and very few labs across the country still use this technique. Many have moved over to local collection in sweat pouches, which is a great method of assessing local sweat, but not necessarily valid for whole-body calculations.

The athletes were also able to complete an anaerobic threshold test or a VO2max test where we tested their ability to ward-off an accumulation of lactate (a by-product of anaerobic metabolism) where we could extrapolate their anaerobic threshold based on continual readings, or their maximal oxygen uptake by exercising until volitional fatigue, respectively. This was a great opportunity for KSI and allowed us to use our expertise to interact with some incredible athletes.

Back in Falmouth– 2017

Yuri Hosokawa, PhD, ATC

Vice President of Communication, Vice President of Education

Ryan Curtis, MS, ATC, CSCS

Associate Director of Athlete Performance and Safety


Our summer is not complete without going to Falmouth, MA, to work at the New Balance Falmouth Road Race medical tent and continue our research and educational initiatives. We have been very fortunate to have the support from the race board members to have KSI presence at the pre-race medical symposium, health & fitness expo, and at the race as medical volunteers and research staff.


NB Falmouth Road Race Medical Symposium

With a host of medical volunteers and invited guests in attendance, this year’s NB Falmouth Road Race Medical Symposium featured presentations on a range of relevant topics including recognition and treatment of running-related orthopedic injuries, physiological concerns when developing strategies to optimize performance in the heat, and wearable technologies that can assist in optimizing performance.


Veteran NB FRR orthopedic medical provider, Dr. Don O’Malley, drew upon his experneces to give a thorough review of his top 10 running related orthopedic injuries. Dr. William Adams, a member of KSI’s medical and science advisory board and current assistant professor at the University of North Carolina at Greensboro, presented on physiological concerns and strategies when optimizing performance in the heat. The third invited speaker was Ryan Curtis, MS, ATC, CSCS, Associate Director of Athlete Performance and Safety, who discussed integration of wearable technology to optimize performance in the heat.  The symposium was concluded with our Chief Medical Officer, Dr. John Jardine, who also serves as the Co-Medical Director of the NB Falmouth Road Race. He briefed attendees on the logistics and chain of command that will be followed on the day of the race. Overall, the 2017 NB FRR Medical Symposium featured not only relevant topics in medicine but additionally offered a glance into the future of health and performance optimization.


Health & Fitness Expo

This year was our first time to participate in the Health & Fitness Expo as an exhibitor. The increased recognition of the KSI among the Falmouth runners was evident. We had many runners come stop by, and it was such a rewarding experience to have some of them share their personal stories about how they or their family members and friends were saved from exertional heat stroke by the NB Falmouth Road Race medical volunteers.



At the expo, we also met with this year’s study participants who already participated in a series of laboratory tests at the University of Connecticut in mid-July to early August. These runners were provided with an ingestible thermistor pill, which allow researchers to readily measure their internal body temperature on the day of the race.



Race Day

Race day for both medical and research volunteers started before dawn on Falmouth Sunday. The research crew set up the morning data collection booth at Lawrence School, which was where all runners met to get on shuttle buses to the starting line in Woods Hole. The research data collection included measurements such as participants’ gastrointestinal temperature, sweat rate, and pre- and post-race blood and urine collection.



At the medical tent, medical volunteers gathered to review the triage protocol and proper methods for treating exertional heat stroke. Chris Troyanos, Medical Coordinator of the NB Falmouth Road Race, Dr. Jardine and Dr. Robert Davis, the co-medical directors, and Dr. Douglas Casa from KSI lead the group of veteran and novice medical volunteers so that the medical tent was ready for runners who would be finishing the 7.1-mile course in the forecasted warm and humid conditions.



Findings from the NB Falmouth Road Race study will be analyzed over the course of the next several months and will be prepared for scientific presentations at the National Athletic Trainers’ Association and American College of Sports Medicine annual meetings in 2018.



 #RunFalmouth #Strive2Protect #RaceMedicine

2017 Summer Intern KSI Fellowship Experience

Miwako Suzuki, KSI Intern Fellow

My name is Miwako Suzuki, and I am an Athletic Training student at Indiana State University. Gratefully, I was chosen to receive the opportunity to intern at the Korey Stringer Institute in the Summer Fellowship Program. I am originally from Japan, and I studied Athletic Training there as well. While receiving my education in Japan, I found it necessary to learn more about prevention and management of emergency conditions, and this sense of mission brought me to the United States. I became aware of the KSI four years ago when I was still in Japan through Dr. Yuri Hosokawa, Vice President of Education and Communication at the KSI, and I have been attracted to the KSI since then. The past two months and ten days that I spent with the KSI members were full of great experiences and learning.

Among the several projects that I worked on during the summer, the main focus was placed on the Athletic Training Locations and Services (ATLAS) Project. The aim of the ATLAS Project is to determine the extent of current athletic training services provided in the secondary school setting, and it was launched in January 2016 with these goals:

  • Create a real-time database of athletic training services in secondary schools
  • Create a directory for each state’s athletic training association and high school athletics association
  • Assist states in moving toward full-time athletic training services
  • Provide useful data to each state’s athletic training association and high school athletic association
  • Identify common factors associated with increased athletic training services across the country
  • Provide data to assist with legislative efforts to improve healthcare for high school athletes


At the beginning of the summer, the ATLAS Project was at the stage of figuring out the extent of athletic training services in the last 10% of high schools that we had been unable to reach. To reach those schools, I have tried multiple methods such as making phone calls, writing emails to athletic directors, and searching their website for athletic trainer’s information. Even though I made some progress with these strategies, the most effective method was reaching out to athletic trainers of the neighboring high schools of the unknown schools for help. From this experience, I have learned firsthand that ATLAS is not only a great database but also a very useful communication tool. While interacting with high school athletic trainers throughout the nation, many of them showed their appreciation and support for this study. I am very grateful to be one of the members to propel this important project forward. I would like to thank Dr. Robert Huggins for including me in this project and always guiding me. I also would like to thank Sarah Attanasio, ATC, for teaching me and providing help whenever I asked.

Testing for the Falmouth Road Race study began in mid July. We conducted a modified heat tolerance test on recreational runners of a wide range of ages who are participating in the New Balance Falmouth Road Race on August 20th, 2017. Although the study will not be completed until the race day, collecting data on individuals’ physiological responses to exercise in the heat was a great learning opportunity for me. I believe that the wide distribution of demographics of this study allowed me to encounter various responses among the subjects. With regard to conducting a laboratory test, I observed the effort of the KSI members to make the study robust. I was very fortunate to learn from such experienced and passionate colleagues. I would like to express my deepest gratitude to Dr. Yuri Hosokawa and Kelsey Rynkiewicz, ATC, for their effort to involve me in this study.


On August 20th, which will be my last day as a KSI fellow, I will be at the New BalanceFalmouth Road Race and will serve as a medical volunteer with the KSI staff. The Falmouth Road Race has been recognized for its high incidence rate of exertional heat illnesses because of the environmental conditions and its short duration (7.1 miles), which allows runners to maintain relatively high intensity throughout the entire duration of the course. According to a previous study from the KSI, this race has saved multiple exertional heat stroke patients each year. Since I have never encountered a real exertional heat stroke case, I would like to take this opportunity as a great hands-on learning experience.


I appreciate every aspect of the activities that I had the opportunity to take part in at the KSI. The KSI was an even greater place than I expected. All the members are making a great effort for their projects with the strong passion and commitment for the KSI’s mission. I believe that this is the reason why the KSI has been successfully leading our profession. Lastly, I would like to thank Dr. Douglas Casa for providing such a great opportunity. I fully enjoyed summer 2017 with such great colleagues.

Health and Safety Policy Ranking for High School Athletics

Samantha Scarneo, MS, ATC

Director of Sport Safety

On Tuesday, August 8th, the Korey Stringer Institute held a press conference for the release of the Health and Safety Policy Ranking for High School Athletics. The goal of this project was to review publically available information from high school associations and state legislation to determine how states are mandating safety standards for their athletes. A positive finding from this study is every state, including the District of Columbia, has some type of health and safety policy requirement for their high schools to follow. However, not a single state meets all of the minimum best practice requirements for the areas focused on in this project; which happen to be the top causes of sudden death in sport, accounting for over 90% of sport-related deaths.


North Carolina is leading the way scoring a 79%, followed by Kentucky (71.13%) and Massachusetts (67.4%). KSI was honored to have Mr. Bob Gfeller, Mr. David Csillan, and Dr. Morgan Anderson as well as Dr. Douglas Casa and Dr. William Adams, speak at the press conference. Dr. Adams began the press conference stating the methods used for this project, which included accessing publically available information from state high school associations and legislation. Dr. Casa followed up with information pertaining to the results of the study. Csillan, athletic trainer from New Jersey, provided comments about his continued advocacy for New Jersey to implement best practice standards statewide. Mr. Gfeller spoke on the importance of implementing policies to ensure that no parents need to go through the tragic loss of a child. Dr. Morgan Anderson echoed these comments by stating “We have tragic examples from the past that motivates us daily to make a change.”

The Orthopedic Journal of Sports Medicine will publish the study with these findings in the September issue. The accepted version of the PDF can be found here.

Change is difficult. There may be states who are not thrilled with these published findings, too. However, these data are the reality of current health and safety policies in high school athletics. This report is dedicated to the parents who have lost, or those parents who have their sons and daughters participating in sport, and it can be the conduit in making sure that your children’s safety are accounted for by the governing organizations. I urge you all to contact your state high school association leaders and legislators to find out if they are 1) aware of where they stand in the ranking and 2) their plans forward for improvement.