Having a Positive Impact as an Athletic Trainer

In an effort to keep things fresh a reach as many readers as possible A4IA will be having a guest blogger this week.  Mike Carroll, Head Athletic Trainer and Assistant Athletic Director at Stephenville High School (TX) has taken the time to write about his experiences and perspective as an athletic trainer at the secondary level.  Feel free to connect directly with Mike regarding your thoughts on his blog.  Thank you Mike for taking the time to contribute to A4IA's blog:

Regardless of their chosen profession a person wants to know that they are doing a good job and are appreciated.  When I got into athletic training over two decades ago I knew that I was not going to be told that I was doing a good job on a regular basis.  I also knew I wasn’t going to get rich (financially).  What I did know was that I would have to work hard.  Even if no one told me that I was doing a good job I would know I was from what I observed from my student athletes and colleagues.  Does that mean that I don’t want or need people to give me that affirmation?  Absolutely not.  It just means that I didn’t then and I don’t now crave public affirmation of how good I was or am at providing health care services. 

Fast forward from when I emerged from graduate school as a young idealistic, energetic, secondary school athletic trainer to today.  Today I am more businesslike in my approach to my job and in reality is a much better athletic trainer today than I was when I first started. Twenty plus years ago things that I could have never envisioned when I first started are now aspects of being a secondary school athletic trainer that I do not particularly enjoy (unbelievable increases in paperwork comes to mind initially).  At the end of the day, however, being a secondary school athletic trainer is about providing athletic training services to the student athletes at my high school so that they can participate in a safe fashion.  Yes, there are aspects of my job that are unappealing but I still do what I do because I love being an athletic trainer and I love working with this age group.  This brings me back to my original topic of appreciation.

Those of you who are reading this who are athletic trainers in the secondary school setting may nod your head or you may disagree completely, but there are times during the school year where the mentality feels like it is the athletic training room versus the world.  The kids don’t seem to understand the importance of what you are asking them to do.  The coaches are demanding and do not seem to want the star athlete to have the time to adequately recuperate from an injury.  The parents don’t understand that the injury that their child has, such as a concussion, could have negative long term consequences if not treated appropriately.  Some parents just want their kid to play in the big game.  This may go on for days or weeks at a time.  What can we as the athletic trainer do about this? The short answer is you keep on keeping on.  You do your job to the best of your ability and you keep the kids at your school safe.  Trust me.  There are times where it seems like no one appreciates what you are doing and why you are doing it.  The good thing is that couldn’t be further from the truth.

In the past couple of weeks I had two separate parents who renewed my love for this setting and why I work with this age group.  Without violating any privacy laws I will just say that I had one young person with a chronic injury that I helped get well and they returned to play the sport that they love.  With this kid I did it by realizing my limitations and referring them to a health care professional who could better treat the reason for their chronic injuries.  Both of the kid’s parents came up to me in separate conversations and thanked me for everything that I did for their child.  They both said in effect that it was refreshing that someone cared about their child as a person and not just as a good athlete and wanted them to have no lingering long term problems.  The second one was another student athlete that had a concussion that was not initially diagnosed by an ER doctor after an auto accident.  I did what I would have done had they suffered this injury in athletics, which is take them through our district approved concussion protocol.  This particular student is a senior and their team was about to enter the playoffs.  With some kids it wouldn’t be unexpected if the parents would want to overlook this injury just to give their kid one last chance at glory.  This wasn’t the case.  The mother of the child was completely supportive of what I was doing and thanked me for caring so much about her kid that I was willing to do what I thought was right even though others wanted to overlook the injury.  She also told her child this and they then relayed the information to me and the other kids on the team before a game.  This mother said that she completely supported what I was doing and appreciated my dedication to her child and the other kids that are in athletics at my school.

So what is the take away from all of this?  If you are an athletic trainer know that you are appreciated and even though at times it seems like the entire world is against you and what you stand for, that is not the case.  It may not happen often, but you will have a parent, coach, athlete, or someone else tell you that you are indeed appreciated for everything that you do even though at times it seems quite the opposite.  When that conversation happens it puts a little more wind in your sails and keeps you going strong during the seemingly endless seasons of high school sports.  If you are a parent or an athlete and you have read this far I challenge you to go to the athletic trainer at your school and tell them that they are appreciated and that nothing is more important that the health of their child or themselves.

Thanks to Beth Mallon and Heather Clemons for giving me the opportunity to write for the Advocates for Injured Athletes Blog.  I look forward to contributing more in the future.

Key Concussion Statements Released

Two prominent organizations have released statements regarding sports-related concussions in the last week or so.  The first statement released was the Consensus Statement on Concussion in Sport:  The 4^th International Conference on Concussion in Sport Held in Zurich, November 2012 and the second was the Summary of Evidence-Based Guideline Update:  Evaluation and Management of Concussion in Sport:  Report of the Guideline Development SubCommittee of the American Academy of Neurology.  This week’s blog post will attempt to highlight some of the key points and additional resources associated with these statements. Where possible I will discuss what it may mean for concussion management moving forward.  Since the publication of these documents, a variety of posts and/or stories including opinion and reaction have been published.  It is not the purpose of this blog post to provide my personal opinion on each statement, but to highlight the key information presented in each and allow informed readers to develop their opinions based on their understanding of this available information.

DEFINING CONCUSSION:

While each statement defines a concussion using different language, the key components are the same.  A concussion is a brain injury as the result of a direct or indirect force to the head resulting in functional changes to the brain.

4^th INTERNATIONAL CONFERENCE ON CONCUSSION STATEMENT (Zurich):

Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces.  Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of a concussive head injury include 1) direct blow to head or face, or indirect blow to the body; 2) results in rapid onset of short-lived impairment neurological function; 3) may result in meuropathological changes, but the acute clinical symptoms reflect a functional disturbance rather than structural injury; ad 4) results in a graded set of clinical symptoms that may or may not involve loss of consciousness.  Resolution of the symptoms typically follows a sequential course, but may be prolonged in some cases.

AMERICAN ACADEMY OF NEUROLOGY (AAN):

Concussion is recognized as a clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousnesss (LOC).

According to the 4^th International Conference Consensus Statement a majority (80 – 90%) of concussions resolve in 7 – 10 days, but can be longer in children and adolescents.  Very few concussions present with loss of consciousness.

CONCUSSION DIAGNOSIS: 

Diagnosis of concussion should be made by a licensed health care professional (LHCP), [athletic trainers fall into this category] according to both the AAN and Zurich statements.  The Zurich statement provides a much more detailed list of signs and symptoms that can lead to a diagnosis of concussion including: physical and/or emotional symptoms, physical signs, behavioral changes, cognitive impairment, sleep disturbance. 

CONCUSSION ASSESSMENT TOOLS:

The Zurich statement recommends the SCAT3 and Child SCAT3 when initially evaluating concussions.  The Sport Concussion Assessment Tool (SCAT) is a combination of injury history, Graded Symptom Checklist (GSC), cognitive function assessment, Standard Assessment of Concussion (SAC), and Balance Error Scoring System (BESS).  The AAN statement does not discuss the SCAT3 specifically, but does address some of the included assessments on an individual basis with moderate to high effectiveness with regards to recognizing concussion. AAN does recommend a combination of assessments work best, but does not recommend a specific combination of assessments.

Both Zurich and AAN reiterate that CTs cannot diagnose a concussion, but may be useful in ruling out more serious traumatic brain injuries (TBI).

NEUROPSYCHOLOGICAL TESTING:

Zurich recommends that neuropsychological assessment should not be the sole basis of management decisions, but should be seen as an aid to the clinical decision-making.  Formal NP testing is not required for all athletes, but when used should be utilized by trained neuropsychologists and should be one part of the return to play (RTP) decision-making process for the medical professional caring for the athlete.  Baseline testing was not considered a mandatory aspect of assessment, with insufficient evidence to mandate such testing according to Zurich.  Baseline may be appropriate in individual cases, but not as a standard of practice at this time.  AAN recommends that when NP is used that it be interpreted by a qualified neuropsychologists and should not be used in preadolescents as evidence to support such use is lacking.

CONCUSSION EVALUATION PROCESS:

According to Zurich when an athlete shows any features of a concussion a player should: 

1. Be evaluated onsite by a LHCP,
2. If no HLCP available player should be safely removed from play IMMEDIATELY,
3. Assessment of concussion should be made once first aid concerns have been addressed (rule out neck injury),
4. Do not leave the player alone following injury; should be consistently monitored for the first few hours after injury, it is possible that symptoms could worsen during this time,
5. Should not return to play on the day of injury.

AAN provides a very similar recommendation regarding concussion evaluation.  It provides additional emphasis on not returning athletes to play on the same day they have been suspected (not diagnosed) of having a concussion, particularly for adolescent athletes.  AAN also emphasizes that athletes must ultimately gain medical clearance for a LHCP in order to begin the return to play process.  Many states now also require these steps as part of their concussion management protocols as part of a legal mandate.

CONCUSSION MANAGEMENT AND RETURN TO PLAY:

Zurich emphasizes BOTH physical and cognitive rest until acute symptoms resolve. This seems particularly important for adolescent athletes and modification of activities such as texting and watching television should be considered as part of the cognitive rest component.

Both Zurich and AAN recommend a graded RTP program prior to full medical clearance and return to sport.  Zurich recommends a minimum of 24 – 48 hours of rest (symptom free) prior to beginning return to play protocol.  Also, child and adolescent athletes should not return to sport until they have returned to schools successfully.  A specific graded RTP protocol is provided in the Zurich statement, but it should be individualized and progressed only when the athlete is symptom free following completion of the current stage.  Children and adolescents recover more slowly and the RTP should take a more conservative approach.

OTHER INFORMATION:

When it comes to other factors likely to affect the likelihood of concussion or prolonged symptoms from a concussion both Zurich and AAN agree that a previous history of concussion makes an athlete more susceptible to future concussions.  The AAN statement goes on to list other factors that may increase risk including being a male in collision sports such as football or rugby.  Some evidence demonstrates that female athletes are at greater risk for concussion in soccer and basketball as compared to their male counterparts.  Body checking in hockey is also likely to increase risk.  Zurich lists several factors as “modifying factors” and conveniently lists them in a table as part of their statement. 

Understanding the role of protective equipment in the prevention of concussions has come into further focus and according to both Zurich and AAN there is currently no evidence that shows mouth guards or helmets prevent the occurrence of concussions.  Mouth guards do prevent dental and orofacial injuries, while helmets can reduce forces placed on the brain, but this does not translate to preventing concussions.

The ability to predict whether an athlete is at increased risk for prolonged or chronic impairment following diagnosis of a concussion is difficult at best.  According to the AAN statement there is some evidence that shows that elevated post concussion symptoms, lower SAC scores, and BESS deficits could be associated with more severe or prolonged postconcussive impairments.

The AAN goes on to recommend that education of school-based professionals (coaches, teachers, administrators, etc.) by LHCP trained in understanding concussion and their prevention is critical.  The LHCP should also be involved in the education of athletes and parents regarding the risks, recognition and management of concussions.

SUMMARY:

After reviewing both statements it seems there is much that Zurich and AAN can agree on when it comes to diagnosing and managing concussions.  The Zurich statement seems to be focusing on sports-related concussions as a whole and does include some additional information about CTE and other topics not addressed by AAN.  The AAN statement clearly focuses on concussions as it relates to children and adolescent athletes whereas Zurich includes information about this population as part of a greater athlete population.   In the end I think the AAN has it right when it recommends education of school-based professionals who will be dealing with concussed athletes in some way.  I would argue that education is the one biggest tool we have to improve prevention, diagnosis and management of sports-related concussion whether they happen to a child or a professional athlete.

ADDITIONAL RESOURCES:

SCAT3

Child SCAT3

AAN Sports Concussion Took Kit

(this includes some fact sheets and the new app)

HERE is Beth at a recent ASA event talking about the AAN Guidelines.

Submitted by Heather L. Clemons, MS, MBA, ATC

Casinelli Survives Neck Injury to Return to Sports

This past week I had the privilege of sitting down with Samantha Villa to talk about October 14, 2011.  For those of you who do not know, Samantha was working a high school football game versus Carlsbad High School as the athletic trainer for La Costa Canyon High School that night.  The game was a typical high school football game when Sam Casinelli went to make a tackle on an opposing player and ended up face down on the field. 

One… Two… Three… and Sam has not tried to get up.  At this point Samantha ran out onto the field along with her team physicians to assess the situation.  Sam was conscious and complaining of neck pain, but was able to wiggle his fingers and toes.  He did admit to having numbness and tingling in both arms at the time of the hit.  Given this information, Samantha made the decision to spineboard Sam.  An ambulance was called during this time, since there wasn’t one on site and he was transported to the nearest trauma center.

At the hospital Sam’s x-ray revealed two fractured vertebrae in his neck.  Shortly, thereafter more testing showed damage to ligaments that stabilize the vertebrae as well, leading to surgery to repair this damage.  Sam was in the hospital for about a week and out of school for about 11 weeks.  Sam went through a rigorous rehabilitation process, but did not require a halo brace during his recovery. 

During this time, Sam and the family expressed their thanks to Samantha Villa as the athletic trainer and all the other health professionals involved in Sam’s treatment and recovery.  Neurosurgeon Sanjay Ghosh, M.D. wrote the following in a letter to La Costa High School and those involved in Sam’s care with the permission of the family:

“It is my opinion that if Sam had suffered at most 10lbs more of force during his injury, this would have rendered him permanently partially quadriplegic.  Furthermore, if it were not for the great attention to detail of the first responders in the field, I am quite certain that we would have had the same catastrophic result.  You and your staff are to be commended for attending to him in such a manner and recognizing the serious nature of his injury, as your care and attention clearly had a profound impact on this young man’s life.”

At the time of his injury, Sam was a junior at La Costa High School. He is now a thriving senior there who no longer plays football, but continues to be a key member of the school’s baseball team.  In fact, Sam was able to play baseball last spring (2012), just several months after his injury.  Sam was also a student-coach as a member of the football team this past fall, giving him the opportunity to continue to support his teammates.  For her part, the California Athletic Trainers’ Association (CATA) recognized athletic trainer Samantha Villa for her actions that evening with the Save A Life Award.  Her colleague Christina Scherr, who is also an athletic trainer in the San Dieguito UHSD nominated her.

If you would like to see more regarding Sam’s injury check THIS out. 

If you know Samantha take the time this March to thank her for being an athletic trainer, after all it is National Athletic Training Month.  If Samantha isn’t your athletic trainer, but you have one at your high school, be sure to take the time to thank him or her, you never know when he or she may be the one to save your life.

Submitted by Heather L. Clemons, MS, MBA, ATC

National Athletic Training Month Helps Kick Start Fundraising for A4IA

As National Athletic Training Month (NATM) is now officially here I thought it would be interesting to find out what people are doing to raise awareness about athletic trainers and their important role in athletic health and safety.  I did not have to go far.  Stephenville High School in Stephenville, Texas and the Athletic Training Club at The Ohio State University has taken it upon themselves to help raise funds for A4IA.  Given A4IA’s mission of promoting the profession of athletic training and this year’s motto of “Everybody Needs and Athletic Trainer” it seems a natural fit.

I had the opportunity to speak with Kendall Goldberg, one of two athletic trainers, along with Mike Carroll at Stephenville High School who put together a t-shirt sale as part of their promotion of NATM.  Both Mike and Kendall are not only advocates for A4IA, but are very active within the NATA and Southwest Athletic Trainers’ Association (SWATA).  Their idea is to sell t-shirts that include on the front, “I 'HEART' My Athletic Trainer” in an effort to promote the need for athletic trainers in high schools.  If you are interested in a t-shirt, you can download an order form and contact Mike or Kendall (their information is available via the Stephenville HS link above).

While speaking with Kendall I learned that there is a small athletic training student program at Stephenville which includes a basic sports medicine class as well as first aid and CPR.  Additionally, Mike and Kendall work with all the athletes on campus.  It is commonplace for older students to advocate for the athletic training staff to the younger students who are hesitant to seek help or are unsure of what Mike and Kendall do.  There is another type of advocacy happening at Stephenville because of this t-shirt sale; Stephenville students are realizing how fortunate they really are to have Mike and Kendall.  They often return from away trips where there is no athletic trainer surprised and disappointed that athletic trainers are not available to them or their opponent.  These high school athletes are beginning to understand at a very young age the importance of athletic trainers.  I would argue that this awareness and understanding could lead to future parent advocates for athletic trainers at more high schools.

At The Ohio State University Alexis Heimert, Vice President and the rest of The Ohio State University Athletic Training Club are planning and participating in the 4^th annual Running with the Buckeyes, a 5K race coordinated by the group.  Each year the event promotes NATM and happens on March 24, 2013.  You can register in advance or race day.

Alex and the rest of the group found out about A4IA through the Facebook page and Tommy’s video.  They did more research to learn about the organization and its goals.  The club, impressed by A4IA’s desire to promote the profession of athletic training, a primary purpose of the club, decided to help.  They felt it was their responsibility as future professionals to advocate for organization that promotes their profession through public education, pushing for increased access to athletic trainers, and the important role athletic trainers play in athletic health care.

These are only two examples of athletic training advocacy happening this month that could use your support.  These two groups decided to help A4IA by raising money on its behalf.  If after reading this, you want to get involved it can be as simple as saying thank you to your athletic trainer for all their hard work, supporting one of the events above or checking with your local, state or regional athletic training organization to see what events they have planned.  Other events to consider:  1) write your state representative in California to support passage of AB864, state licensure for ATs, 2) check out the Far West Athletic Trainers’ Association (FWATA) site for a variety of events, or 3) come up with an event of your own! 

Grassroots advocacy can make a difference as the students at Stephenville High School and The Ohio State University have shown us.  Every little bit helps, so what will you do? 

Happy National Athletic Training Month!

Submitted by Heather L. Clemons, MS, MBA, ATC