Doug Casa holds up a T-shirt showing progress made in protecting athletes against heat stroke. Since the shirt was printed, Arkansas and Arizona have joined the ranks of states that have implemented all seven guidelines recommended by the Korey Stringer Institute.
Athletic Training Students Learn From Leader in Battle Against Heat Stroke
Every year, high school football players begin fall practice in Arkansas in August, the hottest month of the year. Athletic training education students at the University of Arkansas are learning how to protect these student-athletes – as well as athletes in other sports, at all levels – from injury and illness during this potentially dangerous period.
Douglas Casa, one of the field’s foremost experts in hydration and exertional heat stress, spoke to the athletic training students and other students and athletic personnel at the university last spring at the invitation of Jeff Bonacci. Bonacci, a clinical assistant professor of kinesiology, directs the athletic training education program in the College of Education and Health Professions.
“Doug Casa is one of the leading authorities on heat-related illness and prevention,” Bonacci said. “He has been instrumental in helping states establish heat protocols for high school athletes, and we wanted to bring him to our campus so that he could share his expertise, particularly in light of heat-related deaths and injuries in Arkansas in recent years.”
Bringing in speakers of Casa’s caliber provides both information and networking opportunities for students, he said.
“The scholar lecture series promotes the growth of students, but it also shows people at high-level research institutions what we’re doing,” Bonacci continued. “In November, we will bring in Marjorie Albohm, who served as president of the National Athletic Trainers’ Association from 2008 until earlier this year.”
Albohm will speak on the changing job structure in athletic training and what other job opportunities exist outside the traditional setting.
Casa serves as chief operating officer of the Korey Stringer Institute based at the University of Connecticut, where he is a professor of kinesiology and director of the athletic training education program. The widow of Stringer, a Minnesota Viking who died from exertional heat illness during training camp in 2001, founded the research and advocacy institute.
The National Academy of Kinesiology ranked the University of Connecticut's kinesiology doctoral program No. 1 in the country, and the National Research Council ranked Connecticut No. 1 in research productivity by kinesiology faculty. Three alumni of the Connecticut program – Matthew Ganio, Stavros Kavouras and Brendon McDermott – are on the University of Arkansas kinesiology faculty.
Casa explained to the university students how dangerous working out in hot weather can be, especially for players who may have spent much of their summer in air conditioning. The key for football practice is easing gradually into the harder workouts in full gear, he said, a process called acclimation or acclimatization.
Casa travels the country working with individual states to persuade them to adopt these standards.
Heat stroke death due to exertion is one of the leading causes of sudden death in sport, according to the Korey Stringer Institute. Exertional heat stroke is characterized by a core body temperature of more than 104 degrees, central nervous system dysfunction and multiple organ system failure induced by strenuous exercise, often occurring in hot environments.
Casa, who suffered heat stroke himself as a teenager running a 10K race, recently edited a book titled Preventing Sudden Death in Sport and Physical Activity.
In 2010 in Arkansas, one football player died and another spent three weeks in the hospital after collapsing from heat stroke during football practice. In 2011, the state of Arkansas passed three pieces of athlete-safety legislation to try and prevent this type of tragedy in the future. They included coaching education regarding health issues, emergency action plans for schools, and access to automated external defibrillators, or AEDs, in athletic settings.
In June 2012, the Arkansas Activities Association, the governing board of high school athletic programs in Arkansas, adopted new heat acclimatization standards such as those recommended by the Korey Stringer Institute. Arkansas is one of seven states that meet all of the institute’s approved guidelines.
A water and cooling station at football practice
The sports medicine guidelines approved by the Arkansas Activities Association board for football practice:
- Football practice may begin on Monday of week No. 5 (of the fiscal year that begins July 1.)
- Schools cannot have consecutive days of “two-a-day” practices.
- Three days of conditioning with only football helmets and shorts are mandatory before full pads are worn.
- Thursday of week No. 5 is the first permissible practice with full equipment.
- Student-athletes shall not engage in more than three hours of practice activities on those days during which one practice is conducted.
- Student athletes shall not engage in more than five hours of practice activities on those days when more than one practice is conducted.
- The maximum length of any single practice session is three hours.
- On days when more than one practice is conducted, there shall be, at a minimum, one hour of rest/recovery time between the end of one practice and the beginning of the next practice.
Casa offered dramatic statistics to justify these acclimatization guidelines. He said 90 percent of heat illnesses occur during the first five days of practice and 80 percent of heat illnesses occur two hours after practice starts.
The good news is heat illness is 100 percent survivable when treated properly in a controlled sport situation, said Casa, who has testified as an expert witness for the plaintiff in 26 civil lawsuits brought after heat illnesses and deaths, all won by or settled for the plaintiff.
Master’s Degree Program
Certified athletic trainers are responsible for diagnosis, treatment, prevention, care and rehabilitation of injuries and illnesses affecting athletes, Bonacci explained. They serve as the medical liaison at schools for the athletes, parents, coaches, administrators and physicians.
Athletic training student Scott
Williams works in the Razorback
The duties of athletic trainers are basically the same, regardless of the level of play – high school, college, professional or Olympic, he said. Diagnosing and assessing injuries are basically the same at all levels.
The University of Arkansas offers one of only 27 entry level master’s programs in athletic training education in the United States and the only one in the Southeastern Conference, although newcomer Texas A&M has started a program that is not yet accredited. A bachelor’s degree or master’s degree is necessary for a student to take the professional certification exam offered by the National Athletic Trainers’ Association Board of Certification.
Students in Arkansas’ program complete clinical rotations in Division I and high school athletic programs, physical therapy clinics, and medical rotations with doctors.
“We give our students a good variety of clinical experience to allow them to see the work from different perspectives,” Bonacci said. “A student may come in with a strong desire to work in Division I sports and then decide they like the high school level better. The direction they take depends on what they like.”
Bonacci described the program’s focus as student-centered and said it draws students from all over the world. Several students from Japan have completed the program and two are currently enrolled.
“One advantage of this diversity is that these students bring information and techniques that are not familiar here,” he said. “We have an open-door policy. Some programs are so structured they won’t allow new techniques.”
One of the challenges faced by Casa and the Korey Stringer Institute in lowering the chance of serious injuries and illnesses is that not all high schools employ athletic trainers. Many schools in Arkansas do not have athletic trainers on the sidelines during practice, Bonacci said, and rely on emergency medical services provided by municipalities for assistance with injuries that may occur during games.
Medical clinics have helped some school districts tremendously by providing athletic trainers for their schools, he said. The marketing practice allows the clinics to build a reputation among athletes who may need their services.
“The schools get a break financially and they get high-quality help,” Bonacci said. “It helps the sports program, too. Having an athletic trainer on staff makes a team more competitive. Injuries are detected earlier and athletes return to play quicker.”
Athletic trainers who go to work for schools may have to educate administrators and coaches about the proper way to treat heat stroke, both Bonacci and Casa said. They described the preferred treatment as immediate immersion of the athlete’s body in a tub of cold water while monitoring the athlete’s temperature with a rectal thermometer.
“You cool first and transport second,” Casa said. “The goal is to get the body temperature under 104 within 30 minutes. Cold water is the fastest way to cool the human body, according to research, but the water in a tub must be stirred aggressively to prevent a boundary layer of warm water from forming next to skin.”
Bonacci explained that waiting until the athlete arrives at hospital to start cooling the body dramatically decreases the chances for a good outcome. The use of a rectal thermometer is also important for accuracy, he said.
“The rectal thermometer provides the gold standard for heat stress assessment,” Bonacci said. “Temperatures taken orally or on the forehead are statistically and clinically inaccurate, sometimes by as much as 4 to 5 degrees. That can make a huge difference in someone’s life expectancy.”
Casa told the audience at his spring visit that the Korey Stringer Institute’s goal is to prevent needless tragedy in sports and other physical activities, but many states beef up their regulation of sports only after tragedy occurs.
Doug Casa speaks to students.
In addition to preventing sudden death in sports, the institute works to promote the athletic training profession.
“We won’t get away from preventable athlete deaths until we have an athletic trainer at every high school,” Casa said.
In the United States, 42 percent of high schools employ athletic trainers, he said.
Casa talked about other medical conditions such as head injuries and cardiac ailments. More and more, high school athletes are being asked to mimic college athletes in their level of performance and training, raising the risk of injury in an environment that often does not have the same level of professional athletic trainers and coaching staff that can be found in college football, he said.
“You can play a role when working with schools by advocating for heat acclimatization rules,” Casa told the university students. "We (athletic trainers) have to own this area. We are medical professionals capable of preventing sudden death in sport.”
Alumni Come Back
Also last spring, Bonacci arranged a discussion for college faculty and staff with three local athletic trainers and BJ Maack, the past president of the Arkansas Athletic Trainers’ Association. Chad Fink, Mark Haynes and Kolani Hollemen, University of Arkansas alumni, talked about their jobs as athletic trainers at Northwest Arkansas high schools.
The state association supports the use of certified athletic trainers at all high schools with sports programs, Maack said, and he described instances where having an athletic trainer on the sideline during a heat-related illness made a difference in the affected player’s survival.
“If a school can afford to play sports, field a team, hire eight assistant coaches and have a nice facility, it can afford this one person,” Maack said.
The association offers professional development for coaches including a demonstration on how to set up practice during hot weather for optimal player safety.
The athletic trainers stressed that, not only do they need to have the medical skills to take care of athletes, they need to communicate effectively with all the groups involved: students, parents, coaches, school nurses and outside physicians.
It’s important to have someone on site who can talk with everyone to ensure the students’ needs are met, they said. Athletic trainers can be vital middlemen, talking with physicians and then turning around and talking with parents who might not have a high school education. When it comes to health issues such as physical activity, nutrition and getting adequate rest, kids motivated by sports may be more likely to listen to an athletic trainer than their parents.