TBI effects in school

Sometime during the last couple of days, I found an article from USA Today that addresses the issues that youth face in school after a mTBI.  This made me grateful that we took the time earlier this school year to meet with the local school nurses in their monthly meeting to explain to them the newest standards of care regarding mTBIs.  It was interesting that when I presented the nurses with the possibility that a young athlete may be restricted to a dark room with no stimulus for an extended period, that they didn't fully understand it.  (A well known neuropsychologist described this a "turning them into a mushroom." I like the analogy.)  The question was asked by the nurses "How much of their homework or tutoring should they be sending home to aid the injured student athlete in staying up to date?"  They were floored when I further explained that it was possible the doctor could say "None."  The entrenched ideals that came crashing down with my statement were visible in their expressions.  Further, they were shocked when I explained that  there have been recent, extreme cases where students have been forced to repeat grades because of a TBI that held them out of school for extended periods.  I found that they were certainly receptive of the information, despite the fact that the protocols seemed very contrary to what they have been practicing for many years.  I felt that the explanations of why the protocols are in place have aided greatly in their understanding.  Now the next step is to meet with school administrators to get them on board.

Another unfortunate incident

I understand that in Florida, where this occurred, there is a law that make the assault on a sports official more severe.  I hope they take every appropriate step against this young man to help him to understand how wrong he was.

No surprises with RTP delay increases after TBI

According to a recent article in the American Journal of Sports Medicine, kids who sustain a TBI are less likely to return to play within a week if they have neurocognitive testing performed as part of their treatment.  While this is probably a valid reason for using the testing, (and I doubt that the testing is that cause of any increase in impairments) I can think of several coaches who will have a very difficult time with understanding this issue.  I have already have heard several comments about how coaches will not refer to an ATC who will use the testing so that they can get their star athlete back in the game sooner.  Talk about a disgusting problem waiting to happen.  Fortunately, these coaches are in the overwhelming minority and I pray they are not in a head position that could result in an unfortunate situation.

Of course, the other disturbing finding in this study was that the vast majority of the TBIs were a result of a head to head hit.  The kind of hit that was called far too infrequently in high school football this past season as a penalty.

Finally, ESPN The Magazine also had an interesting, informal poll that asked various people who are involved in high school athletics and their attitudes towards TBIs.  The Concussion Blog as a short summary of it on their pages.

Irresponsible authors are also making it difficult to keep TBIs relevant

In a short commentary on a picture of  Cal’s Robin Rostratter playing volleyball with a helmet on, the author questions the necessity of wearing the helmet.  I am appalled by the complete lack of professional responsibility on the author's part to not investigate why the helmet was needed.  The author states that is has to do with a previous TBI, but does not say anything more than that.  I had a situation early in my career where a young basketball player consistently would end up with a TBI with even the slightest hit to the head.  My colleagues helped me look for answers to allow the young lady to continue to play and we wished we could have found a helmet like this for her to wear.  While it may not have prevented all of the TBIs that can occur from hitting her head repeatedly, she may have been able to avoid the symptoms returning from the common, mild knocks to the head.  I find this commentary on this article to be sickening in light of the current climate that athletic departments face concerning the issue of TBIs.  I would even be willing to bet that the author of this commentary had no direct contact with the student-athlete, the game, or the program at Cal and simply saw a picture that they felt they needed to comment on.

Irresponsible behavior by the few makes it harder for everyone

Today there are two stories that I have come across that describe the irresponsible behaviors that make the public so skeptical of everyone who tries to play by the rules.  In the first article, a physician in New Jersey passed away suddenly from a heart attack.  While tragic, this event is what caused the rest of the story to bubble to the surface.  It turns out that an exceptional number of law enforcement and fire fighting personnel were interested and dismayed at the news despite the fact the physician had no official ties to either department.  The public servants all knew this physician because he was writing illegal prescriptions for steroids for them.  He was their dealer.  If that isn't bad enough, most of the pharmaceuticals were being paid for by the public servants' insurance.  You guessed it, the insurance was paid for, at least in part, with municipal taxes.  The estimated cost to taxpayers was in the tens of millions.

The second article hits even closer to home since it is a story of negligence in the athletic world.  It seems that there are still coaches that will recommend a student-athlete not seek medical attention to rule out a possible TBI.  This is no surprise to me since I still hear these kinds of stories often enough to make them disturbing.  I still find it extremely foolish for a coach who has no medical background whatsoever to "make a diagnosis" on his or her own and give medical advice.  Yes, they are practicing medicine when they do this and it needs to addressed.  Otherwise, it is only a matter of time before the coach tells the wrong thing to the wrong athlete and they end up fighting litigation due to some tragedy.

TBI symptoms differ between genders

It is interesting to note that according to recent research cited here, that boys and girls will report different symptoms after sustaining a TBI.  According to this article and the research it cites, boys will more often complain of "amnesia and confusion/disorientation, whereas girls tend to report drowsiness and greater sensitivity to noise more often."

The fun part about this research is that I have been closely tied to it for about 4 or 5 years.  The research is called "High School Reporting Information Online."  It is run by Dr. Dawn Comstock of the Ohio State University medical center and tracks injury rates of children across the country in various high school sports.  I have been reporting our schools' injuries to the study for several years.  It is always fun to see that our school is contributing (even if it just a small percentage) to the kind of research that is being done here.  While this is not the first time I have seen this High School RIO study cited in an article, this is one of the more interesting results that have been found by the study.  It is certainly very practical and useful information in the hands of all high school ATCs.

I will also be looking forward to the January Journal of Athletic Training to see the article that is mentioned in this publication.

US News and World Report Article

Athletic Training was ranked as one of the top 50 careers for 2011.  The projections for the 8 years has athletic training job creation outpacing nearly every other healthcare field at a staggering 34%.  Most of those jobs are expected at the high school level.

From what I have seen transpire over the last few months in the media, I find this very easy to believe.  However, budgets still need to improve at schools in order to see this kind of growth, even with the amount of attention that is being placed on this shortage.  I do hope that this will happen at least as well as is forecasted.  The shortage may even push salaries higher for all of us and help attract more young people to the profession.

That didn't take very long.

Just over 1 week after the start of the winter season and we already have our first postponement due to poor weather.  This usually doesn't occur until after Christmas in our area, so I truly hope that this is not a sign of what is to come this winter season.

A seminar on ImPACT

A couple of weeks ago, a few of my colleagues and I travelled to Pittsburgh to attend a seminar on the use of the ImPACT software for TBI testing.  (Never mind that Pittsburgh is a really tough place to navigate for someone who has never been in the city.)  The course was an excellent presentation that offered a full explanation on how to interpret the scores that student-athletes will receive after taking the exam.  It also was highly productive in understanding some of the errors that may occur in the test because the student athlete did not follow directions on the exam.  While I have had some previous experience with the software, hearing about some of the subtleties of the scoring will certainly help in the interpretation of the scores.  I am looking forward to implementing the program in full after the first of the year.

The CDC offers a lot of resources free

Another website that has a lot of lockerroom material to hang on posterboards for coaches.  The CDC offers many of them free of charge.

Addendum 11/18/2010:
Also, the Defense Centers of Excellence has some resources that are more applicable to military personnel, but the concepts are very similar.

I hope the NATA sends the AAN a big fruit basket for Christmas this year.

The American Academy of Neurology (AAN) released a statement that gave athletic trainers a huge endorsement for what we do every day.  "The AAN issued five specific guidelines in the statement, which recommends that any athlete suspected of having a concussion should be removed from participation until he or she is seen by a physician trained in the evaluation and management of sports concussions, and that an athletic trainer should be present at all practices and games where a concussion might occur."  Needless to say, this can offer athletic trainers some additional job security in this very tight economy.  That is something that everybody is looking for today.

Another part of their statement states that a neurologist or a physician with proper training should be referred to when return to play decisions are being made for any athlete who has been diagnosed with a TBI.  Once again, I feel they are reinforcing a point that all athletic trainers would agree with.  In particular, I would hate to see a physician allow a kid to RTP when their field of practice doesn't require them to be well versed in TBIs, such as a urologist or an obstetrician.  While they may be very good at what they do, most specialists who have not been trained to work with TBIs have not been exposed to it since medical school.

The next big issue for athletic departments to deal with

I have quickly seen more attention being turned to energy drinks being consumed before athletic participation, especially before competition.  The health risk that this poses is often being overlooked by the kids that are consuming the beverages despite the not so ominous warnings on the side of the cans.  The biggest problem is that a lot of these beverages contain ridiculously high levels of caffeine and /or caffeine-like stimulants (such as guarana).  The caffeine introduced into the body artificially increases heart rate before activity.  Once the athlete begins exercise, the HR continues to increase as a normal function of exercise.  This combination can result in some dangerous arrhythmia's due to the increased stress on the cardiac tissue. Caffeine is also a well known diuretic.  It increases urine volume.  This can lead to faster dehydration and heat illness during exercise.

Furthermore, the other substance commonly found in this drink is taurine, a naturally occurring amino acid that the body uses during exercise.  Dietary intake is usually sufficient to supply what the body needs in order to function.  However, because of some perceived benefits from taurine during exercise, it didn't take long for enterprising individuals to create a way of synthesizing it and adding it to other products in large doses to products.  The theory was once again, "If a little helps me, a lot should help me more."  Currently, research is looking into how taurine helps in the development of the central nervous system and its effects in large doses.  There is some controversy as to whether it works as a stimulant or a depressant. "In a recent article from MedicalNewsToday.com, researchers at Weill Cornell Medical College in New York say they were “surprised” to find taurine “extraordinarily active” on brain receptors. Even though taurine is known to be a key amino acid, the researchers say they’re curious and puzzled still about the function of taurine in the brain, and have more questions than answers."

I realize I may be pushing limits of tolerance with everything that has changed with respect to TBIs and some upcoming issues on heat illnesses, but I will be pushing to get these drinks banned from the school because of their use before competition in athletics.  I also understand that I have my work cut out for me since the marketing of these drinks has been so heavy towards sporting events, especially the "extreme sports."  The marketing has allowed people to believe that these drinks are actually meant for people who exercise, and therefore; are completely safe.

For the parents that could "use a little help"

The NFHS has created a course for parents to help them to understand what a proper behavior is and what is expected of them during sporting events.  While it would be nice to see this as required of all parents before they take their seat on the sidelines, I certainly don't see this happening.  The course allows parents to reflect on what kind of sporting parent they are and allows them to improve their skills.  However, I am sure that even if it is required, there are those that would simply click through it as fast as possible and never really take the time for self reflection.  The best part of this course is the certificate that is given at the end of the course upon siccessful completion.  I think that the better use of this course would be to require this of any chronically problem parents before they are allowed to return to the stands.

Another resource for proper tackling techniques

Information for avoiding TBI through proper tackling technique can be found on this webiste from USA football.

Tim Tebow 2009

Eric Legrand 2010

It is time to return to more judicial use of tapings

Lately, a lot of kids have been dropping into the training room and demanding to get their ankles taped.  Many are doing it because they have recently "tweaked" their ankle or "rolled" it and they are afraid it will get worse.  Fair enough, but the statement is getting abused by those who want "game day tape jobs" or just like "the way it feels", the "tightness of it" or think that it somehow makes them run faster.  Unfortunately, this abuse has taken a toll on the limited supplies that I have each year.  (Yes boys and girls, I did say limited supplies and they have to last the whole year.)

While I am sure this will create some arguements, the first thing that needs to change is that nobody will be taped indefinitely after an injury.  I have some athletes who had a mild ankle sprain as a freshman and still claim to need it as a senior.  That will end with the start of winter season.

Also, the practice of coaches "sending kids in to get taped" and getting back out on the field will end.  I will not be taping kids just to satisfy a coach, who with no medical training, thinks they have the authority to dictate the treatment.  While this has not been a very big issue at our school, this can be an issue with visiting teams.  I will be requiring some form of documentation from visiting schools' ATC or physician that they need to be treated with tape before I do it.

My prayers are for this young man and his family

ESPN is reporting that Eric LeGrand is paralyzed from the neck down after a hit he delivered during a kickoff coverage in a game this past weekend.  In the video included on the site, you can clearly see that he hit the ball carrier with his head in a lowered position making contact with the crown of his helmet.  This is spearing.  This is why the rule was written more than 30 years ago.  This needed to be flagged and penalized. 

I understand that the most important part of this situation is the young man and his health.  I wish him nothing but the best for a full and speedy recovery.

However, the one thing missing on the video is the flag.  Being an ATC and a high school football official, this incompetence by the officials gives me cause for great concern.  The problem is one of the perception by the spectators that this is a legal hit and should never be penalized.  This creates the ignorance that leads to the comments that were so disturbing to me in the youth video I referenced in a previous post.

Comments on a Webinar Today

First, for those of you who don't know what it is, think of a seminar performed over the web.  That is how it gets its name.  The topic of a webinar can be anything you can think of.  The nice part is that you can attend a webinar in your pajamas from home.  You are not expected to arrive at some venue and sit in a lecture hall for a seminar.  It is an outstanding way to bring content over long distances too, since you don't have to travel.

This webinar was presented my Dr. Mickey Collins, a leader in the United States on sports related TBIs.  He is one of the founders of ImPACT software that many schools, colleges, and professional teams use to baseline and test their athletes to judge the severity of a TBI and when it is safe to RTP.  It was very encouraging to hear Dr. Collins assert that often times, EDs will give advice as to when it is safe to RTP when they really should not be doing it.  There are far too many variables that go into treating a TBI that can create a large difference in the rate of recovery between athletes.  He states that there is no way any ED physician could know when it is truly safe to RTP unless they are able to follow up with the athlete consistently.  This, of course, is not within the scope of ED physicians.  Dr. Collins even went so far as to say ATCs should disregard those recommendations completely.  Since I recently had an ED physician try and offer RTP guidelines recently that I ignored, I was very pleased to hear this.  However, I foresee a parent who will not be as agreeable when I hold a child out longer than the ED physician stated was necessary in the future and it can create a serious amount of tension.  I would hope that some education to the ED physicians about referring mild TBI cases to those trained in follow up care would be shortly forthcoming.

The other fascinating part of the webinar was the description of what is going on physiologically in the brain to create the energy deficit that the brain experiences after sustaining a TBI.  Now I admit, I was never one to find the physiology of anything else all that exciting and trying to explain the Kreb's cycle now would be fruitless without some serious review.  The concept of how long the brain remains in an energy deficit state is the part that is really scary.  With athletes that report lingering symptoms, the deficit can last up to a week in 90% of cases and even longer in the other 10%.  A few cases never really recover and need to be removed from participation in contact sports.  Certainly after watching the number of videos that can be found on secondary impact syndrome, it is enough to scare anyone into doing the right thing.

Finally,  the last point that I found interesting was that the research stated that children who sustain TBIs heal much slower than adults do.  Children, whose brains are still developing up until the age of 22, simply take longer to heal from TBIs.  That is not the point that was new to me, as I have heard that many times before.  However, Dr. Collins points out that just because an NFL player (who are all adults and most are older than 22) can return from a TBI in a week, doesn't mean that a high school player or their parents should think that it is safe for the high school athlete to do the same.  Again, this point can become a strong point of contention with a parent who thinks that their son or daughter really needs to be out on the field playing in order to earn the scholarship.

One thing is for sure, I will be sharing this webinar with colleagues so that they can all benefit from the same information.

Another helpful video on TBIs released by the NATA

The National Athletic Trainers' Association has released another video online regard TBIs in football.  This one is hosted by Steve Young and is another superb resource for coaches and parents.  This video helps to explain the risks of injury and why there has been such a large spotlight turned on this subject for the past year.

Drug Prevention and Testing

Our school district is re-examining our policies on drugs and alcohol use and looking into the community's reactions to the possibility if testing for drug use.  Needless to say, this is a hot topic in our district just as it has been in many others.  Ohio law states that we can test any kid that participates in any extra-curricular event they don't receive a grade for.  This includes athletics, drama club, chess club, and even parking sticker privileges.  I don't know how this final revision of our policy will take shape, but if the following meetings are to be anywhere near as entertaining as the open forum last week, the notion of testing will be hotly contested.  Tonight's second public forum meeting will be, I'm sure more of the same issues being raised.  There are a great number of people who, despite its legality, think that the schools are overstepping their charge and becoming more of a parent if they do test.  I have to admit, I find it very hard to argue with this assertion.

Another resource I just located

USA Football has four videos on their website about safety precautions including:

1. Concussion (TBI) awareness
2. Heat Illness Prevention
3. Helmet Fitting
4. Shoulder Pad Fitting

These are a must see for any first time youth football coaches to obtain a better understanding of the risks associated with playing football.

This is VERY scary for many reasons.

In an article by Richard C. Senelick, M.D., on his blog in the Huffington Post, he tackles the issue of inappropriate comments made by parents, spectators, and coaches of youth sports during games.  He even points to a very disturbing video on Youtube that shows a couple of kids colliding during a practice with very poor tackling technique that results in the one kid crying after the play.  Quite frankly, he was lucky to be moving after the hit.  The most disturbing part of the video is not in the short 8 seconds that is played, but rather the number of comments from viewers who think the video is some how funny or encouraging.  Some parents even go so far as to say that they hope that their kid hits in the same way.  This is vile, disgusting, and reprehensible.  Quite frankly, I feel that this kind of behavior needs to be treated with zero tolerance and have those parents banned from participation.

Facemask Removal Cheat Sheet

Published by the College of Health and Rehabilitation Sciences at Sargent College, this is a cheat sheet for proper facemask removal to access a victim's airway.

TBI cheat sheet for coaches

The National Athletic Trainers' Association just published this article in their NATA News for September 2010.  It is a cheat sheet for your coaches to help identify TBIs when they occur.

Congressional Hearings on TBIs

In this article, Lindy Washburn describes the testimony of a seventeen year old basketball player who appeared before a congressional committee to talk about her long term symptoms related to her repetitive TBIs.  She stated she had as many as seven TBIs from playing basketball over her short career and has since had five more due to other incidents after she quit basketball.  While I realize the severity and the consequences of second impact syndrome and the effect that multiple TBIs can have on a young brain, I have a big problem with congressional hearings on the subject and the potential for federal guidelines as a result.  At one point in the article, the writer makes a very dubious remark about the reliance on athletic trainers and physicians for determining the RTP standards for each athlete.  While the TBI testing software is a very useful tool for helping doctors and ATs to determine how much progress an athlete has made, it is still not the final answer.  There is much to be said about the clinical experience and expertise of physicians and ATs using the tools.  Even the developers of the software suites are quick to point this out.  This article makes it sound as if the software is the only determining factor in the RTP decision.  This seems to be a little irresponsible to overstate the value of the software.

Wow, this could be really big.

Last week, the Columbus Dispatch published a week-long series of articles that looked at the culture of youth sports in America, and specifically, in Ohio.  This series was referenced in by previous post dated August 29th, 2010.  It now appears that in response to this series of articles, that the OHSAA is willing to reach out and provide leadership and oversight to the many recreational programs in Ohio that offer youth sports.  This would be a large undertaking that would require a vast expansion of staff and finances for the OHSAA.  I find this to be very interesting since the article indicates that Governor Strickland would be in favor of looking at this and possibly pushing the state legislature to provide funding for it.  This could be a huge market increase for athletic trainers as well since it only makes sense that we will be called on to assist in the development of programs.  This would not only create a much larger market of jobs for LATs in Ohio, but would also create a big shortage of LATs.  Things could get interesting VERY quickly if this goes well.

Affects of youth sports on children and parents

This should be an interesting series of articles by the Columbus Dispatch this upcoming week. I do plan to follow this report and see what they found in their research. I anticipate that this report will try and gain a perspective on the drive to have kids participate on travel teams that cross the country to play in the most competitive tournaments at great financial costs and, occasionally, with significant injury.

Why ATCs are an important part of any school's athletic program

Over the last few months, there have been a staggering amount of publications that argue very strongly for the need to place Certified Athletic Trainers at every high school. The argument has even been made that if you can't afford an athletic trainer, then you can't afford sports like football, wrestling, hockey, and lacrosse. I have never thought about this problem too much since the majority of the schools that I have consistent contact with have an athletic trainer on site. However, after having started out as a part time ATC for a local school, I do appreciate how difficult that can be. I have only recently begun to think more about why it is so important for the schools to have full time athletic trainers as most of the current articles call for. I have to admit, they are right. With the attention being focused so heavily on TBIs and heat illnesses today, there is no good excuse for a school system to not have a full time ATC for their program. It is simply a demonstration of fiscal responsibility to make sure that your school has a full time athletic trainer. The athletic trainer does so much in prevention and treatment that they usually end up paying for themselves.

Addendum 8/28/10: Scripps News has a series of articles that discusses this problem in depth.

The correct kind of sports bra?

OK, so aside from all the jokes that can be made (and probably already have,) this is an aspect to sports medicine that has often been swept under the rug and ignored. The people who are conducting the research are often laughed at and given over to ridicule for looking at this subject. However, as this article points out, this is a much more serious subject than previously thought. Having the right kind of sports bra can make a big difference in the rate of injury in other areas of the body if the findings from this research turn out to be reliable and valid.

The obvious question is does size matter in this case? The research and article suggest that it does matter, a lot. Individuals with larger cup sizes tend to distribute weight differently during exercise than those with smaller cup sizes. Because of the increased stress on the inside of the legs during running, this can possibly lead to a greater incidence of shin splints and stress fractures. This then discourages women from exercising regularly and creates a whole litany of issues. Yes, this topic does matter and needs to be treated seriously and researched more. I, however, will gladly let others do the research so that I can't be accused of having other motives for wanting to conduct the research.

Repeated TBI and Lou Gehrig's Disease?

Researchers will publish an article tomorrow in the Journal of Neuropathology and Experimental Neurology that links repeated head injuries to Lou Gehrig's disease, according to Alan Schwarz of the New York Times. In Mr. Schwarz's article he describes that Lou Gehrig's disease may not be the same as A.L.S. as it has been thought for the last 70 years. In fact, the researchers hypothesize that it is an entirely new condition that presents like A.L.S. The researchers site different protein strains are at work in the brain for Lou Gehrig's disease that aren't found with A.L.S.

Mr. Schwarz also does an exceptional job recounting the number of reported injuries that Lou Gehrig suffered during his career in his article. With the details that he gives, it makes me shudder to think that he was allowed to RTP. Of course, that was a different era of sports medicine that didn't recognize the risks involved with letting him RTP. I will look forward to reading the research tomorrow and see what their findings are.

A look at gender and rate of injuries in high school

At Ohio State, there has been an injury tracking system in place for a few years now that assembles information about the rates of high school injury in various contexts. In this article, it compares the rate of injury between genders. Of no surprise is that more boys are injured, but that is greatly influenced by football and wrestling. (Two sports with minimal participation by girls.) However, girls are getting injured at higher rates in basketball, soccer, and softball when compared to the boys' comparable sports. As of yet, there is minimal explanation as to why, only hypotheses.

Looks like metal bats will stay, for now.

It looks like a deal has been struck in California to avoid a state legislature writing a new law banning metal bats from youth baseball. The agreement looks like the fielders will be required to wear a piece of protective headgear. I am unsure from this article as to which fielders will be required to wear the headgear, or even if this will affect any athletes outside of California. It is natural to assume that the pitcher would be required to wear them. The debate would rage over the infielders, particularly the shortstop and the second baseman. I don't see the need for any of the outfielders to wear the head gear.

Weigh-in Charts for Football Using a Simple Spreadsheet

For a number of years, I have had a problem with the weigh-in and weigh-out procedure with football. The problem I have had is that the scale and charts are often set up in a locker room where the coaches often don't go to look at the charts, much less do the tedious calculations that are needed. Without doing the calculations, the weight chart are simply ineffective and a waste of time for the team to perform.

Therefore, in October of 2002, I had an article published in the NATA News that offered a simple additional step that created an easier method for making the calculations. In this article I offered a chart that displayed the greater than 97%, 97%, 96%, and 95% values for every possible weight from 100 lbs up to 330 lbs. This was color coded green, yellow, orange, and red for each level of weight loss. The athlete was to then use either a matching highlighter on his weigh out value or use an appropriate colored pencil to record it. This system worked as long as you could keep the pencil tips sharp or the highlighters from drying out. (The kids frequently lost the caps for the highlighters.)

Eventually, I got tired of replacing highlighters and pencils and decided to relocate the scale into the athletic training room. This was one of the best ideas I ever had. I continued using the paper and pencil method for another year, but I still found that I was looking for the caps far too often. So I decided that i needed to design a simple spreadsheet on Microsoft Excel and add the file to an outdated laptop computer that I can left in my office for the kids to record their weights on.

In this file, I was able to let the program do the calculations for me and appropriately color the cells using the conditional formatting function. The cells are either white, yellow, orange, or red depending on the amount of weight lost from time of weigh in to weigh out. Furthermore, I was also able to set a conditional format that allowed me to compare weigh in values between each day. Currently, the cell will remain pink in color (to differentiate it from the red) if the athlete weighs in at less than 99% of his weight from the previous day. This is an added feature and was a function that would have been far too confusing to add to the paper and pencil route. The best part is that it is done automatically for me in the spreadsheet. The spreadsheet is currently designed so for a Monday start to two-a-days and assumes practices Monday through Saturday with a day off on Sunday. Changing this is not difficult to anyone who knows how to operate the formulas in the cells. If needed, this document can also be printed out. The only maintenance that I have had to perform with this file was to weights to the correct columns since they were entered incorrectly and making sure I save the file to the hard drive each day. I can even go so far as to copy it to a flash drive or network the computer wirelessly to backup the file automatically.

To access the files directly, the links are:

Old Weight Chart - http://bit.ly/bstKYj

Spreadsheet - http://bit.ly/dadJSB

Respecting an Athletic Trainer's Decision Regarding RTP

This article reminded me of a coach that I have worked with in the past. At the time, I was working as a part-time athletic trianer for a local high school. This meant that often, I would tell an athlete that I was going to hold him or her from practice until I had a chance to see them again in a day or two (depending on what day of the week it was.) Most of the coaches I worked with in this school had no problems with this since I also gave them a phone number to contact me if anything changed in the meantime (for better or for worse.) Unfortunately, I had one coach who would accept my opinion if I was telling the student athlete that he or she could continue to practice or play. However, if I chose to hold a kid out of participation, (or even allow them to participate with restrictions,) this coach would flatly tell me that the athlete needed to get a second opinion. This coach even so far as to tell one athlete that they needed a second doctor's opinion even when the first doctor agreed with my findings to the letter. Eventually, the parents became wise to this coach's games and were able to remove him from his position using this complaint along with several complaints.

The part that really stuns me about this as I look back now is that it should have been more obvious to me what the coach was doing and trying to take advantage of the fact that I was recently graduated from college and working in my first two years out of school. When I look back on that situation now, I find that I would have a much stronger reaction to a coach who consistently questioned my decisions when it went against his wishes.

Threats to High School Athletics

Do you ever wonder why high school coaches are being required to have more and more training? This radio interview of a representative of the National Federation of High School Associations explains why there are so many new programs being developed to teach coaches "how to coach."

PYFL fundraiser

For all those that attended the PYFL fundraiser last night, thank you. I trust you had as much fun as I did. I hope that more people would turn out for next year's fundraiser and help suuport our children.

And now for something almost completely irrelevant.

This was posted by sportsmd on twitter covering a New York Times article about about the validity of using lucky charms as an aid to athletic performance. Superstitions aside, the article reports that a study found a significant difference in the success rate of people who were wish good luck or believed that they were using a lucky piece of equipment to aid them. The article does not attempt to exlpain the psychological effects of why or how this works, but it was amusing to see this kind of quirky study showing some intriguing results.

"Preseason Heat Acclimatization Guidelines for Secondary School Athletics"

A series of videos produced by the National Athletic Trainer's Association that discuss interventions to prevent heat illness in secondary schools.

NFHS Coach's Education on TBIs

I was suprised to see that I haven't previously covered this in my blog because I have seen this course available for the last couple of weeks. This course covers a coach's responsibility in the event of a TBI. It was produced by the National Federation of High Schools (NFHS). This is a free course and I highly recommend that every coach and official takes a look at this presentation.

This presentation can also be used to educate administrators and teachers who may not be aware of how TBIs affect the student athlete. I recommend this course for them to view as well.

Outside the Lines: Second Impact Syndrome

This is an ESPN video that takes a look at second impact syndrome.

Does Post Exercise Massage Improve Blood Flow and Reduce Lactic Acid?

Here is an interesting blog post that reviews a study in the Medicine and Science in Sports Exercise. The study only found that the blood flow was decreased every time pressure was applied to the area during a massage regardless of the technique. Blood flow only returned to normal after each stroke. It does not look promising that massage reduces lactic acid post-exercise.

Cheerleading "Athletic, but is it a sport?"

Here is an article covering the recent decision from a federal judge that declares that cheerleading is not a sport, albiet very athletic.

Whether you agree with the decision or not, I think that something has been left out of the discussion. The fact that the rules governing cheerleading vary tremendously from middle and high school to division II and III in college and to division I in college should be considered much closer. In the smaller school divisions and in MS and HS, the rules restrict a lot of the stunts that the division I cheerleaders often perform. I think that this needs to be accounted for in the this ruling, and it was not. It makes this decision unfortunate since the cheerleaders who do this extra stunts that require the skills of a gymnast are not accounted for.

TBI informational PowerPoint presentation

Here is the PowerPoint presentation that is given to all parents of high school and middle school athletes. This presentation discusses the risks of TBIs and treatment once a TBI is suspected.

I almost missed this.

I just received my rule books for football yesterday (I have also been an official for high school footbal for 20 years,) and in the Ohio supplemental booklet I saw that the officials will require written authorization to RTP from the LAT as well as the MD or DO. I guess I will be creating a form soon.

Addendum 8/8/2010
Ok, so now I find out that the reference the rule makes to written authorization has nothing to with giving the official a note of any kind, but rather it means that the LAT, MD, or DO write their normal, legally required documentation for the injury. This has nothing to do with showing or giving the officials any kind of documentation for their future reference. I think that this was a completely unnecassary clause in the rule that simply increases confusion for everybody.

Another Video Explaining the Dangers of TBIs

What is a Concussion? by the NATA, and the NHL.

Video on Proper Tackling Technique in Football

Heads Up Video by the NATA and the Riddell Corporation.

A Bunch of Resources on Various Sports Medicine Topics

A new feature to this blog is that I have added a feed on the left side that follows my Delicious.com bookmarks. I frequently add bookmarks to this site with topics related sports medicine for adolescents and youth. There are many articles on a variety of topics and the list is added to frequently.

Hibiclens MRSA handout

This is a handout that can be printed and passed out to students that discusses the danger of MRSA.

Weigh Out Sheets

There is a description of how to use these sheets at the end of the file. Print them out in landscape mode on a color printer and you should get four pages. Here is the link to the weigh out sheets.

Vacation

It was almost possible to completely avoid my job for four full weeks. ALMOST. I have to admit it will be nice to get back.


PirateATC

PPE's - an important, tedious task

We have finally reached the most relaxing time of year. The school year is over and the kids are enjoying their summer break. I am also on a long vacation and am trying to enjoy the break. The only drawback is having to work through the monotonous pre-participation examinations that are also seem to occur with great frequency at this time. While I fully understand the importance of the screenings and agree that they are a vital tool to the sports medicine process, performing them can be quite tedious.

Ohio High School Athletic Association Adopts New TBI Rules

The OHSAA adopted new rules regarding the treatment of Traumatic brain injuries in high school athletes of all sports in its May 13th meeting of the board of directors. The rules appear to have been adopted as expected by the Ohio Athletic Trainers' Association, but the full wording of the precise rule has yet to be published on the website's meeting minutes. The above link gives nothing more than a synopsis of these meetings.

Big Ten adopts a waiver for Traumatic Brain Injuries

The Big Ten Conference has adopted a waiver after an educational program for all its athletes. I wonder if this idea could be applicable to the high school athletes and their parents as well.

New High School Concussion Rule

So I understand from our state convention that the new rule applies to every high school sport, not just football. I am very glad to hear that. Furthermore, it looks like the rule in Ohio will state that only AT and MD/DO (with experience with traumatic brain injuries) will be able to make a return to play decision. This is another big step in the right direction. I see a few issues cropping up and each school system will need to have a policy in place when an MD/DO other than the team physician gives a student-athlete a clearance to play that the team physician does not agree with. Needless to say, that will be sticky. Other than that, there will need to be a significiant amount of parent, coach, school administrator, and student-athlete education regarding the new rule. I applaud the OHSAA for their efforts and willingness to work with other groups to define the rule for Ohio.

Youth football leagues and concussions

With the new rule that is going into effect at the high school level, I now question what many youth football leagues will do to try to comply with the rule. It will be a significant liability to simply volunteer as an Athletic Trainer to clear a kid to return to play. I imagine that if any ATC does volunteer to do it, they would certainly maintain a very conservative stance on allowing a kid to return, even more so than for the high school student athlete. (If being more conservative is even possible.) Our local youth league is already looking into various options and I plan on consulting to offer them insights as this develops.

Youth Sports Injuries

I am glad to see that there are some positive role models stepping up and starting to state that youths specializing in one sport all year long is not going to guarantee future success. The fact that these high profile athletes are stepping forward and telling eveyone that it is okay to participate in more than one sport while growing up.

NY Times article from March 30, 2010

This is an interesting article posted in the NY Times. I would like to say that I found this one on my own, but I will call it a "reblog" (I guess that is the blogging equivalent of retweeting) from Joe Przytula's blog.

I am not entirely sure what to think of this since I have my own opinions of the national debates, but I am not ready to apply them to such a specific case here.

Another article to underscore the current attention given to concussions

Concussions policy fuzzy for student athletes

On the lighter side of things..

Today I was talking to a few parents about people that I have encountered during my career and how potentially serious problems became fairly humorous situations once the truth was known. I guess the best way to explain this situation is to give a couple of examples.

The first one realtes to an individual who was up in arms about how the school district is trying to cut budgets, but I was somehow able to order "personalized coolers" at some unknown high cost tothe district. The Athletic Director, who was at the center of a long list of questions about how the district was spending money, was able to respond very quickly top this accusation. The A.D. simply explained that we found a stash of older football helmet stickers that we weren't using anymore since we had changed the emblem on the sides of our helmets. He also stated that he would pass on the information to me the following day about this conversation. When it was toild to me, I wasn't sure whether I was supposed to be feel complimented that it looked so professionally done or if I should feel like I was reprimanded. The best part was that the A.D. wasn't sure either.

The second instance occurred during a track meet and softball game. The parent of the injured girl was upset that I was not immediately on scene and had to be called in to attend to their daughter. They even went so far as to accuse me of being sexist. Nevermind I left a girls' softball game for that. The A.D. also thought that the accusation was extremely unfounded and in poor taste.

CDC - Recognizing Concussions

CDC on recognizing concussions.

Heads Up: Concussion in Youth Sports

New drug K2 stirs concern - NCAA.org

New drug K2 stirs concern - NCAA.org

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Timing is everything

It seemed unusual that no sooner had I read an article about the young pitcher in California who was hit in the head with a baseball, that I had a near miss at one of our first games of the year. The pitcher in our game was hit in the left shin with a line drive and, despite being able to remain standing, was in obvious pain. He tried to minimize the injury and continue to play, but his coach (they were the visiting team) decided he didn't want him to continue. (Fortunately, I would have recommended the same.) The young man spent the rest of the game on the bench with ice on his leg.

What I found most interesting was the conversation that ensued. An older gentleman who was watching the was horrified "to see this happen again" and wondered why the metal bats were still permitted in the game. To say that this person was a traditionalist would be an understatement. He continued to complain until a couple of younger fans accused him of being "outdated, out of touch and being an alarmist." I found it disconcerting to see the younger fans with such a lack of concern for the potential severity an injury. I assume that it was primarily because I have been around the game long enough to see some terrible injuries from line drives. It also demonstrated for me the "invincible attitude" that adolescents possess and use in their decision making process.

While I am not convinced that the metal bats have increased the number of injuries that have occurred from the line drives, I do feel that the severity of the injuries are certainly greater. I also understand that the home run makes the game much more exciting, but I question if it is worth the risk of injury.

Opening Day is Here!

You have to love opening day for softball and baseball in our little corner of the world. The ponds behind 3B and SS were each about 3-4 inches deep.

A Little More on Concussions

A colleague of mine reminded me of a story that she told me recently after reading my blog and thought it might be worth adding to this story.

This colleage asked me a couple of months ago about return to play standards after a concussion. The story told to me second hand a few months ago, so some of the details I may be a little fuzzy on. Her nephew was playing hockey when he sustained a very significant concussion. If I recall correctly, this was actually the second concussion he had suffered this season. The treating physician, a neurosurgeon, gave the athlete strict instructions to remain at home for a period of about 5-7 days. During this time he was to minimize stimulation as much as possible. This included no TV, video gaming, reading, and to minimize interactions with others. (This is being prescribed more often by physcians as a means to give the brain time to heal after the injury.) While a lot of research is continuing into this practice, on the surface, it makes sense that the brain would need time to heal.

Now for the disturbing part of the story. The teachers at his school, while reluctant to accept this plan of care, went along with it since they didn't want to cross a doctor's orders. However, the hockey coach was beside himself and was ready to throw this young man off the team when he didn't show up to support his teammates later in the week at another hockey game. Somehow, I guess he didn't think that being a spectator in a game that the young man cared greatly about was any kind of siginificant stimulation. It required parental intervention with the coach's supervisors to get the coach to back away from his threats.

This situation, I think, just reinforces the need for Athletic Trainers to be present and helping to inform coaches of just what is going on in with their althetes. I think that a lot of the headache in this case (no pun intended,) could have been averted with the right amount of education to all of the parties involved.

Cold Weather Softball/Baseball

Oh how much I am looking forward to being outside again for these two sports. I am not ready to freeze while doing it though.

Concussion Management in High School

With all of the attention that the NFL has finally given to the issue of concussions, it is not a suprise that the NFHS has begun to reexamine their rules as they relate to concussions as well. The first place to start is obvious, in football. The reasons to start here is first, the timing of the season, since rules changes for football for the succeeding season are usually approved in February. It is also one of the sports with the highest risk. However, I have not heard if the same rule was instituted in soccer. I would hope so, since now is the time to make changes there as well.

I also understand that since the official is the one person that is closest to the athletes that are at risk of injury during the course of the game, that they are given more authority to remove a student athlete from the game than they previously had. (Previously, they could only send an athlete out of the game if they suspected that the athlete was rendered unconcious.) The new rule allows the official to send an athlete out of the game for any suspected concussion symptom.

Now this is where it gets complicated. The previous rule allowed for an athlete to return to the game only with a written clearance from a physician. This was not a bad way to do it. However, now the official, who more than likely has no medical background whatsoever, can send an athlete out for any symptom including a headache. The problem here is that an athlete may complain to a teammate of a headache caused by skipping lunch or having a small, relatively benign, muscle pull in their neck during the game. If an official overhears this, he should send the athlete out of the game to be looked at. The problem is that there is not always a physician on the sidelines of a game. This is especially true at the sub-varsity levels. Under the old rule, there was no way to return an athlete if this was the scenario.

Fortunately, the rules comittee was willing to expand their interpretation of who could allow the athlete to return. However, this still poses yet another problem. The NFHS is a national boady and cannot make the rules too specific to govern who is qualified for all 50 states. Therefore, they chose to use vague language in the rule and settled for "appropriate medical personnel." I believe that it was understood to be left to each state athletic governing body to define this rule more specifically for each state. This is necessary because of differing state practice laws for many the diverse medical professionals that may be present at games. I can assume that the rules committee wanted to include Certified Athletic Trainers (that can also be licensed or registered depending upon the state.) I am also fairly certain that the intent was not to expand the list too greatly so as to prevent any individual from simply walking out of the stands and saying "I can do this." This can place far too many people and organizations at risk of litigations.

I am also aware of that the Ohio High School Athletic Association (OHSAA) is looking into defining this terminology as we speak. They have contacted other professional organizations in the state of Ohio asking for their input into this matter. This includes the Ohio Athletic Trainer's Association (OATA.) It is my hope that every ATC that received the invitation to the survey participates. The OATA has brought up some interesting arguements about whom to exclude from the list for various reasons.

The survey also asks about the possible use of neurological baseline testing requirements for all athletes at a local hospital or clinic. While I think this would be ideal, I question some of the logistics of getting this done. The locally popular software program has been advertised widely as a premier program for this assessment. I have had some experience using it in the past, and I agree that it is a high quality product. However, when it became cost prohibitive to the high school I work for, we had to discontinue the annual subscription. The hospital system that I am employed by has looked into becoming a provider of this program as well. However, this has run into a serious roadblock since larger, globally recognized hospital system that is in our market area already has a contract with the software program. The software company will not even return our phone calls due to their contractual commitments to this other system.

Video Links:
ESPN commentary on YouTube
Time Magazine article on long term effects of concussions

If anyone else has thoughts on this topic, please feel free to comment.