Protecting student athletes
Training a student athlete, such as a football player, in the old days, consisted of heading to the school's weight room and pumping iron to the coach's specifications. But not anymore. Today, athletic training is a specialized field, the result of a four-year college degree, national certification and state licensing. As both a move to prevent injuries and an effort to rehabilitate athletes, many local public and private schools have added certified athletic trainers to their athletic departments. Like rare prized orchids, student athletes are treated very carefully, with many schools' fears of concussions, ACL tears, and other injuries now front and center. Athletic trainers are different from both coaches and physical therapists, educated and trained in injury and illness prevention and strategies which focus on optimizing a student athlete's quality of life, not only while they are in high school, but over the long term. Today, they are considered both health care professionals and part of the athletic department, a bridge that ties the two together to maximize a student's athleticism while protecting their minds and bodies. Hiring athletic trainers can also provide protection for a district against liability if the student is injured. “About 37 percent of high schools have athletic trainers available to athletes for practices and competitions, and about 60 percent don't have anyone available if a student has an injury or problem,” said Steve Broglio, professor of athletic training in the School of Kinesiology at University of Michigan, who has been certified as an athletic trainer for the last 15 years. “Some coaches, if we're lucky, are CPR-trained. But it's not their job. Their job is to coach their teams. Trainers work to prevent injuries, like to the ACL, heat stroke, lacerations, cervical spine injuries and concussions. It's a frontline defense against these injuries, especially in contact sports like football, ice hockey, lacrosse, and cheerleading.” In Oakland County, many schools either have an athletic trainer on staff, or have contracted with a health care system which provides a trainer directly to the school. The National Federation of High School Athletics (NFHS) chooses not to take a position on the matter. “We leave that in all of our 51 member state agencies,” said Bob Colgate of NFHS. “Some schools may not have the money for a certified athletic trainer, but we ask if they have an emergency action plan. Most use a combination of certified athletic trainers and health professionals. We recommend that all schools have an emergency action plan that is going to get coaches, the administration and athletes involved.” He said they have e-mailed a copy of their recommendations, which include the athletic director's responsibility, what the in-person coach should do, what the online coach advisor and trainer should do, what an event coach and trainer should do, and set up protocols for events, to every high school in the country. “It's very general, but it's very well done,” Colgate said. Your student athlete, if they attend West Bloomfield High School, Bloomfield Hills High School, or Groves High School in Birmingham, and they have a sports injury, or suffer heat stroke during two-a-days in football practice, the first person taking care of them will likely be the athletic trainer hired by the school's athletic director. But, if your child attends Seaholm High School in Birmingham, and he or she suffers a sprained ankle or torn ACL, there isn't an employed or contracted athletic trainer, but rather, a personal first responder, a man who has been with the school since 1982, “with many similar duties,” said athletic director Aaron Frank, yet lacks the skills and accreditation. A certified medical first responder is a person who has completed a course and received certification in providing pre-hospital care for medical emergencies beyond basic first aid and CPR, but is not trained for more advanced medical care. “The first thing we always do if anything is questionable is dial 911,” said Frank. “We're fortunate that we rarely don't have a physician in the stands because of our parents.” “What happens in the time between calling 911 and their arrival? What do you do when a kid is in serious pain?” asked a Birmingham resident who had a child who used to attend Seaholm. “There can be long-term ratifications. What happens when they travel? Are these coaches supposed to be trained in being first responders when kids get hurt? This man is certified at the lowest level. Kids are faster and bigger than ever. Girls play just as much, and just as hard as boys.” Bill Watson, Seaholm's first responder, graduated from Seaholm in 1977, and Western Michigan University with a physical education degree in 1983, according to his LinkedIn profile. Frank asserts that Watson predates athletic training certification. However, the Michigan legislature passed a law, Public Act 368 of the Public Health Code, determining licensing requirements and creating the continuing education rules in 1978, when Watson was still in college. “There is a specific scope of work that is appropriate for his limitations as a state medical first responder by state licensure,” Frank said. “He doesn't do any medical procedures, or any evaluations within the scope of a medical trainer.” Frank said Watson works in consultation with a sports medicine practice that works with the school, immediately sending them students when there are any concerns. “Ultimately, it's the coach's decision,” on when to put a student back in, other than with concussion protocol, which Watson is trained in, along with all athletic department staff, which is now a requirement codified in state law. “We're not going to override what a physician says,” Frank said. “Whatever we have in writing is the gold standard.” A Bloomfield Township parent with two children at Seaholm, including a senior daughter who plays varsity volleyball, and will play college volleyball, was appalled to learn Watson is not a certified trainer. “We're all under the assumption he's the trainer. They've introduced him as the trainer, and the kids all call him the trainer. The coaches refer to him as the trainer,” the woman said, who asked to not have her name used as she has a younger student playing contact sports at the school. “We've never been told he's a first responder. My daughter sees (Watson) before every game and every practice to have her hand wrapped. My daughter feels the trainers at other schools during tournaments at other schools are much better. Often, the girls are hoping he's not at a game, and that another trainer will be there. “As a parent, it makes me concerned,” she continued. “I would think most people think he's a trainer. He's dealing with football players.” Groves, under athletic director Tom Flynn, has a full-time athletic trainer, Kelly Salter, working with their students. Flynn did not return repeated calls for comment. “Kelly is wonderful, and Tom is a former trainer,” said John Johnson of the Michigan High School Athletic Association. “It's one of our best testing schools for us.” “Groves has gone through three or four trainers. Kelly Salter is very, very good,” Frank said. “The person we have here is respected by our physicians, and he also helps out with lots of other jobs, like filling the water jugs, repairing equipment. There's so many other issues to the jobs. And kids love him. They follow him on Twitter. I'm sure when Bill retires, we'll post for a full time athletic trainer or go through a health care system.” But Frank is not ready to do that now, and it's not a requirement for the Michigan High School Athletic Association. “We don't mandate, because we don't force funding,” Johnson said. “We can have requirements, but schools that don’t adopt the requirements can participate in our tournaments. In a perfect world, we'd like every school to have a trainer, but it's not going to happen because of financial realities. It's a staff person. You're talking about a personnel issue.” Rochester Community Schools contracts three athletic trainers through Crittenton Hospital, one for each of their three high schools, who each work full-time at the school, providing 1,400 hours for the entire school year. Chelsey Bonney arrives at Rochester Adams High School each school day between 1 and 2 p.m., and works until 7 to 10 p.m., depending upon games and practices. Saturdays she is also on as well. She works on hundreds of athletes each day, depending upon the season. “After school, I know I will tape for athletes who have practices or games. After that I will do evaluations for injuries that are not emergency,” she said. “Then, after that, if anyone has rehab, I will go over that, unless there's a game to go to. After that, there's a lot of parent phone calls to return.” Bonney is a licensed athletic trainer in Michigan, having received her bachelor's degree from Aquinas College in Grand Rapids in athletic training and pre-physical therapy. Rochester High School and Stoney Creek High School each have a dedicated athletic trainer also employed by Crittenton. Farmington Schools contracts through University of Michigan MedSport, employing four athletic trainers. “We have one trainer at each school and one float,” along with occasional students from universities doing their internships, said Jamie Franklin, one of the trainers, who said they average about 25 hours a week at the high school. All of the trainers are college educated and BOC certified and licensed. “We cover all home athletic events, away varsity football, and then practices as hours allow.” “We are always at games that are considered contact sports, but also at games that are not considered contact,” added Kristi Lewis-Keatts, another Farmington trainer. “Many days, especially in the spring and fall, there are multiple games going on, we are onsite, but have to determine which sport has the highest risk of injury. That is typically what takes priority.” Lewis-Keatts said the scope of their daily responsibilities “range from lacerations and other wounds that may or may not need stitches, to fractures of many different types, to ligaments sprains, muscle strains, tendonitis, concussions, heat illness, unknown heart conditions, the list goes on. We're typically involved in rehabbing athletes. Sometimes they go to physical therapy first, and sometimes we are instructed by an MD on what they want us to work with the athlete. Sometimes they just need strengthening in order to stay injury-free.” Most schools have trainers working on both male and female athletes. “With only one athletic trainer at a school, it's impossible to separate. In school, we were taught that we would have to evaluate an injury on a male or female,” said Lewis-Keatts. “I will speak with the parents first, and then assess as need be. If the athlete or parent is not comfortable, I will refer to a doctor. I always make sure there is another person with me. For example, an athlete with a groin injury may benefit from a hip spica by an ace wrap. I always make sure I am not alone wrapping them since it can be considered a sensitive area.” According to the 2010 Overview of Skills and Services of the National Athletic Trainers' Association, a professional membership association serving and advocating for certified athletic trainers, “Athletic trainers are the only health care professionals whose expertise in prevention ranges from minor sprains to catastrophic head and neck injuries, and from minor illnesses to exertional heat syndrome. Nutritional and wellness also play an integral role in the athletic trainers' work in preventing injury and illness. Athletic trainers recognize when consultation with other health care providers is necessary and refer accordingly.” Among the description of athletic trainers' services include their ability to assess for potential injuries and illnesses through pre-participation physical exams; to design and implement conditioning programs; design and implement emergency action plans to ensure medical personnel are prepared in an emergency situation; educate students, coaches and parents; to inspect facilities to ensure they are free of hazards, are sanitary, and that the equipment is maintained properly; and refer the students to appropriate medical professionals when necessary. Unlike a coach or a medical first responder, athletic trainers are educated and trained to examine patients and determine injuries and illnesses and diagnose them. Part of their job is to perform assessments and to do the appropriate care for concussions; open and closed wounds; seizures; asthma; shock; bone breaks; diabetic reactions; allergies; and drug overdoses. They are also trained to provide certain rehabilitation protocols, from exercises and agility training to manual therapy, like massaging certain muscles and helping restore range of motion to joints. “High school athletics can be hazardous, and high school athletes have evolved – they're big, they're strong, and they're fast,” said Dr. Jeff Kline, director of sports medicine at Beaumont Sports Medicine. “Athletic trainers are the most trained individual to make qualified medical decisions on the field – more than a doctor or nurse. The experience they have on programmatic completion is based on their education.” Today, athletic trainers must hold a bachelor's degree, with many universities offering specialized programs in athletic training. Once an individual has that bachelor's degree, they can then sit for the national certification, called BOC, and then obtain licensing in the state of Michigan as a health care professional. “There is only one certification, the BOC,” Dr. Kline said. “You cannot sit for it without having been to an undergrad program from start to finish. Then you pass your board exams, and can be licensed in the state of Michigan.” According to the “BOC Standards of Professional Practice,” the mission of the Board of Certification (BOC), which has been responsible for certification since 1969, is to “certify athletic trainers and to identify, for the public, quality healthcare professionals through a system of certification, adjudication, standards of practice and continuing competency programs...and is the only accredited certification program for athletic trainers in the United States.” It also indicates a compliance with a code of professional responsibility. All licensed Michigan athletic trainers must participate in continuing education, which Dr. Kline said now follows the BOC requirements, which is 50 credit hours every two years. “Ten of those credits have to be evidence-based credits, which means the content has to be based on current practical research. For example, using the best current research on how to treat a sprained ankle,” he said. University of Michigan's Broglio said today, there are no poor quality athletic trainers. “It's all certified and regulated in Michigan. It's standardized across the United States, and Michigan has state licensure, which insures standard of care,” he said, which should alleviate concerns on the part of parents and schools. Broglio, Tom McAllister of Indiana University, and Mike McCirea of Medical College of Wisconsin, in conjunction with the NCAA and Department of Defense, are doing a 30 to 50-year study of of 17,000 athletes at 21 universities, male and female, in sports from football and hockey to cross country to golf, to study the long term effects of concussion on current 18-22 year olds. John Ciecko, athletic trainer for Bloomfield Hills High School, became interested in the field of athletic training when he was playing football at Albion College. “I got hurt my freshman year, and spent so much time in the athletic training room, I took an intro class,” he said. “I really excelled in it and was interested in it.” He received his bachelors in athletic training from Albion, and has a master's degree in the field from California University of Pennsylvania, along with his BOC. Along with concussions, he said he sees a lot of overuse injuries, especially in shoulders, knees, elbows and wrists, from students specializing early in one sport. He said high school athletes think they can immediately bounce back, but often he has to hold the student back to protect them from re-injuring themselves. “It's about applying the right amount of rest and conditioning, and getting the student back as a part of their team,” Ciecko said. “That's what it's all about being a high school athlete. We always want them to be a part of the team, especially in practices, as much as possible. Then our goal is to get the student back in play.” Ciecko is a full-time employee of the Bloomfield Hills School district, and when possible, he is aided by one or two interns in their final semester from Central Michigan University, who work as his assistants. “They get 12 credit hours. It's a full semester, a full course load,” he said. “They spend 40 hours a week. We have 17 teams right now in 11 sports, from freshman sports to varsity, male and female, so it helps us give the athletes here at BH the best possible care.” Ciecko said they have a trainer at every single home game, and try to have someone at every away boys' and girls' basketball game. In the fall, when there are more sports, “It's dictated by the schedule. We always travel with football. I cover varsity, and I always send an intern with the JV team. It's a nice thing to give the intern an independent work environment to get ready for when they graduate.” West Bloomfield High School has one trainer, Aimee Neubecker, who handles all of the school's athletes, which can include about 300 students during the fall, 200 in winter, and another 200 or so in the spring. A Central Michigan University graduate in athletic training with a master's from Eastern Michigan University in exercise physiology and her BOC, she said she covers all of the school's home games. “If there are multiple home games, I'm at the highest risk sport, or the highest level – for example, if there is a varsity and junior varsity game, I'll go to a varsity boy's baseball game over a junior varsity girls' soccer game, even though the soccer game has a higher risk.” Actually, many of the trainers, athletic directors, and experts noted that many female athletes are having higher incidents of injuries, whether from concussions or other injuries. “Women's soccer, basketball, softball, all have higher injury rates for concussion than their male counterparts,” University of Michigan's Broglio noted, with statistics pointing women have incident rates up to five and eight times higher than males. “There are a number of theories as to why women are more likely to have more, from that women have weaker neck musculature, and are not able to stabilize their heads; to women are more likely to report injuries to a parent or medical professional. There's less stigma for girls having an athletic injury. That's a theory I personally agree with. On the back end, women have a longer reporting period. A guy will say after seven days, 'Put me back in.' A girl will say 'I still have a raging headache.' Both will still have the headache, but the guy will try to play.” One of the top rates of injuries, Broglio said, is from cheerleading, both in terms of cervical spine injuries, fractures, sprains, lacerations and concussions. “You take a 90-pound female athlete practicing on concrete, doing gymnastics in the air, and then being caught, or not, and falling,” he noted. Private schools have also made the investment into athletic trainers. “I'm hired for a reason – it's to preserve students' health and minimize the school's risk. Part of the role is to educate those around you,” noted Ross Cooper, Detroit Country Day Schools’ associate director of athletics and head athletic trainer, who has been a trainer for 18 or 19 years at “five or six secondary schools in the metro area, and my tenth here,” and is in his third year as head trainer at the school. While hired by the school, Cooper has two assistants hired through Henry Ford Health System, as well as a team physician. “We're also a popular intern site, with usually one a semester from Grand Valley University.” Detroit Country Day has had trainers for the last 20 years or so, he said. “We're on the middle school campus as well, so many students grow up seeing us for a whole lot of things. We get a little pushback from some intense parents who want to see their kid play, but we explain why it's important to protect the athlete, and often defer to our judgements. We're in a position of communicating with our parents. We have our own sports medicine notes and information. Parents can view what we've done. We also strive to put someone on the phone and put the parents online. Kids see us as much as they see the coach. And our coaching staff defers to us implicitly. If anything is ever questionable, we refer out, maybe something more that a doctor should see and be referred to.” Over the years, Cooper said he has seen lots of changes in the industry, notably with more standardized assessments based on knowledge. “More knowledge is better,” he said. “We've been at the forefront of concussions and the handling of neurocognitive testing for the last 10 years, doing baseline testing and post-injury comparisons. We have it coordinated by the students' physicians or our team physician, so that way the senior athletic trainer is not the only one making that assessment.” He said that creates a safer environment for the student athlete. “That way he or she is competing when they're ready, and all the medical professionals agree they're ready.” Steve Carter, the full-time athletic trainer at Cranbrook Schools for the last two-and-a-half years, came to the school after he retired as the trainer for the Detroit Tigers, a position he had for 25 years. A part-time assistant is contracted through Henry Ford Health Systems. “I have quite a line here after school. I have about 45 minutes. In that time, fall and spring, I see about 20 to 35 kids in that 45 minutes,” he said, setting up stretching routines, taping them up, or giving them modalities to do. “I've been doing this for 30 years, so I can talk to an athlete for five minutes and get a good idea of the injury before even putting my hands on them.” During a season, he said he typically sees one to two knee injuries, at least one knee surgery a season, an ACL tear, a ligament tear, and concussions. “I do a lot of strengthening and conditioning with students. Besides concussions, my time is spent on knees, ankles and backs,” Carter said. “We also spend a lot of time with JV athletes, teaching them conditioning, and young female athletes, who often don't have the neck strength large males do.” He noted that their volleyball team this fall had the same number – three – of concussions that their varsity football team had. “Science has progressed that we can diagnose it sooner than just saying 'You had your bell rung.'” They use a variety of diagnostic tests, including the SCAT3 test, which measures balance, cognitive, memory and verbal cues, as well as subjective items, like the degree of a headache, dizziness, and nausea. Carter said he has also added the Sway balance phone app. “It uses the GPS on a phone to see their balance, measuring it and gives a base score,” he said. He has also added the King-Devick test to his arsenal, which is an objective memory test that can be administered by trainers, coaches and parents on the sideline when a concussion is suspected. “They're two more objective tests of a head injury that makes my job easier. It makes parents feel better, too. It's a more scientific approach if their child is concussed. They cost about $1,200, but it's worth it.” Once kids are ready to play, “I'm very aggressive about getting our athletes up and moving,” Carter said. “You're making memories. If they're playing, they're making memories. I push them a little, because some are just growing pains. There's a big difference between soreness and pain. A big part of my job is educating them, and teaching them the difference between soreness and pain.” “I would encourage everyone to have someone there. I get weekly e-mails that an athletic trainer saved a life,” noted Michigan's Broglio.