PROFESSIONAL PRACTICE

Presence of Athletic Trainers in a Youth Football Organization: A Institution’s Experience

Jillian E. Urban, PhD; Erica K. Cheramie, LAT, ATC; Mary Kopacki, MS, LAT, ATC; Johna K. Register-Mihalik, PhD, LAT, ATC; Jason P. Mihalik, PhD, CAT(C), ATC; Joel D. Stitzel, PhD; Daryl A. Rosenbaum, MD

ABSTRACT serious.3 Incidence rates for con- Training and at least one person The experience presented in this report cussions in players ages 8 to 12 are carrying a Red Cross Card to be could inform other youth football or- similar to those of high school and present at all practices. Pop Warner ganizations about the challenges and players.4 However, requires at least one person at each benefits of implementing an athletic the consequences of concussion in practice who is certified in CPR/ trainer at the youth level. The authors younger athletes are of concern. First Aid or has completed the report their experience with having an A previous study suggests that re- National Center for Sports Safety athletic trainer present at practices and covery after a concussion may take PREPARE. Pop Warner requires game days for one youth football organi- longer in younger populations un- that a player safety coach be nomi- zation (ages 6 to 13) with more than 170 dergoing cognitive development.5 nated and trained through the USA players during two consecutive seasons. Additionally, the risk of heat illness Football Heads Up Football Pro- [Athletic Training & Sports Health Care. in youth football players is 10 times gram for each organization. 2017;9(2):53-57.] that of other youth sports.6 Many of the requirements are a Most youth sporting events do step toward improving the health not have medical personnel on the and safety of the athletes; however, here are approximately 3 . Instead, some coaches this basic medical training provides million participants in youth are often required to undergo ba- a minimum safety standard and is tackle football in the United sic medical training. The training not designed to train the coaching T1 States. Numbers have trended is intended to provide the basics staff to appropriately respond to an downward during the past 5 years, needed to respond appropriately injury. Additionally, several youth possibly due to parental concerns in the event of an injury or emer- football organizations that are about safety.2 The injury risk for gency.1,7 For example, American community-based and do not fall football is 5 to 7 times that of other Youth Football requires coaches to under the jurisdiction and guid- youth contact sports,3 with 13% of take the Centers for Disease Con- ance of the nationally recognized youth football injuries classified as trol Heads Up Online Concussion programs that require, or recom- mend, the safety resources men- From Wake Forest University School of Medicine, Winston-Salem, North Carolina (JEU, EKC, JDS, DAR); tioned above. Department of Biomedical Engineering, Winston-Salem, North Carolina (JEU, JDS); Department of Family and Previous studies have demon- Community Medicine, Winston-Salem, North Carolina (EKC, DAR); Innovative Athletic Training, LLC, Greensboro, North Carolina (MK); University of North Carolina at Chapel Hill, Chapel Hill, North Carolina (JKR-M, JPM); strated the benefits of the presence Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center, Chapel Hill, North Carolina (JKR-M, JPM); of a medical professional at youth Department of Exercise and Sport Science, Chapel Hill, North Carolina (JKR-M, JPM). Submitted: November 3, 2015; Accepted: October 19, 2016 and high school sporting events. The authors have no financial or proprietary interest in the materials presented herein. These studies have shown that the The authors thank the Matthew Gfeller Foundation, the Childress Institute for Pediatric Trauma at Wake Forest Baptist Medical Center, the Childress Institute’s Christopher Budd Fund for Pediatric Trauma Education, presence of a medical professional and the South Fork Panther Organization for providing support for the athletic trainer, and Karen Klein, MA, ELS, improves the identification of con- GPC, for assistance in manuscript preparation. cussion and may subsequently re- Correspondence: Jillian E. Urban, PhD, Department of Biomedical Engineering, Wake Forest School of Medicine, Medical Center Blvd., Winston-Salem, NC 27157. E-mail: [email protected] duce the number of concussions doi:10.3928/19425864-20170109-03 that are not reported or missed.8,9

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It is standard to have a certified ath- Institute for Pediatric Trauma to position for a 6-month contract letic trainer at all collegiate and pro- expand upon this research and in- to attract a candidate with the fessional levels of football. Howev- clude advanced brain imaging pre- time availability and commitment er, a recent study reported that 70% season, post-concussion (if one throughout the season. It was es- of high schools have some access to should occur), and post-season. A timated that 50% of the position an athletic trainer, but only 37% local youth football organization would be devoted to on-field du- have a full-time athletic trainer and competing under the guidelines of ties and 50% to outreach (occa- there are few youth-level organiza- American Youth Football agreed to sional isolated high school event tions that have access to an athletic participate. The investigation team coverage) and assistance in the trainer.10 believed that the presence of an Sports Medicine Clinic (eg, room- During the 2013 and 2014 foot- athletic trainer at the practices and ing patients, demonstrating home seasons, our group worked games was necessary because the exercises, and applying braces). A with a youth football organization study protocol required recogni- position was created through the to hire an athletic trainer for prac- tion of potential concussion inju- Department of Sports Medicine at tices and games. In this article, we ries. This was chosen as a reliable Wake Forest Baptist Health and at report the feasibility and potential alternative to relying on reports of a hospital-defined 6-month salary benefits concerning emergency coaches, parents, or parental volun- of $16,328. The total cost to fund treatment, recognition of injury, teers with health care backgrounds the athletic trainer full-time for the and awareness of the importance of but inconsistent presence. length of the employment during safety procedures by way of an an- In the inaugural season, a posi- football season (with 50% effort ecdotal report of our experience for tion description was distributed to devoted to coverage of the youth the 2013 and 2014 seasons. The ob- the local North Carolina university organization) was $8,187. The jective of this report is to document athletic training programs, North funding for this position was made two seasons of experience with a Carolina Athletic Trainers’ Asso- possible through contributions full-time athletic trainer working ciation Facebook and Twitter pag- from the youth organization, grant with a single youth football orga- es, and to professional references funding, a charitable donation, and nization of more than 170 play- provided by colleagues. There was internal departmental funds. Dur- ers. This report may inform youth initial difficulty in finding inter- ing each of the seasons, a licensed sports leaders and sports safety ested candidates for the position, Sports Medicine physician signed advocates about the challenges and primarily because it would be a off on orders. There was no cost to benefits of having an athletic trainer part-time position given the num- the program for the physician and it in a youth football organization. ber of hours needed during the 3- was a necessary component to hav- or 4-month season (approximately ing an athletic trainer on field. CREATING AND FUNDING THE 18 to 20 hours per week); however, POSITION the position was eventually filled. THE ATHLETIC TRAINER’S A 2011 pilot study was conduct- At a rate of $35/hour, the resulting EXPERIENCE ed by the Virginia Tech–Wake For- cost was $7,500 for the season. This One athletic trainer was hired est School of Biomedical Engineer- cost included athletic trainer cov- for each of the fall football seasons ing evaluating head impact exposure erage, liability insurance coverage, during 2013 and 2014. In this youth in seven 7- to 8-year-old football and supplies because the person organization, players were aged 6 players in Blacksburg, Virginia. was employed by the youth orga- to 13 years old. Five teams, with 20 Athletes wore accelerometers in nization rather than through the to 30 players per team, practiced on their helmets for one season, which hospital. The youth organization separate areas of one football field showed that youth athletes received funded 40% of the position, with and two additional teams prac- head impacts that were similar in substantial financial support from a ticed 2 miles away at a local park. magnitude and frequency to those local charitable foundation. Each team practiced three nights occurring in high school and col- In the following season (2014), per week, with approximately two lege players.11 In 2012, our group our team believed that it was nec- full-contact practices per week. The received a grant from the Childress essary to make this a full-time athletic trainer operated primarily

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TABLE 1 Injuries Assessed by the Certified Athletic Trainer in Two Seasons of Youth Footballa Home Organization Other Teams Injuries 2013 2014 2013 2014 Concussions (out of play) 4 4 6 7 Fractures 2 3 5 1 Neck/spine (required boarding) 3 0 11 4 Medical (EMS activated) 1 0 2 5 Dislocations 2 0 0 0 Contusions 10 0 0 0 Sprains 3 3 2 2 Heat-related illness 0 4 0 0 Totals 25 14 26 19 EMS = emergency medical services aInjuries were only counted if presented to the athletic trainer. from the main practice field and was 2013 Season and information cards describing on-call for the teams practicing at Prior to the 2013 season, refer- her role. As the season progressed, the remote field. The athletic trainer ees, coaches, parents, and league the athletic trainer found it criti- split time on-field between prac- representatives managed injuries. cal to create relationships with the tices (6 to 8 hours/week) and games For the first time in the history of coaches of both teams and the game (8 to 9 hours/week) throughout the American Youth Football in North officials. On game day, she intro- season. The athletic trainer sat at Carolina, a paid and trained medi- duced herself, gave coaches and of- the same location on the sidelines cal professional was assigned to ficials an information card describ- of the practice field with a view of the management of youth football ing her role, and advised that she be the teams during each practice and injuries. Over the 15-week sea- waved onto the field for significant would stand along the sidelines son, the athletic trainer attended injuries. However, when a serious with the team that was playing dur- 45 practices and 10 game days (ap- injury occurred, family members ing each game. Game days in this proximately 6 to 7 games per game and fellow parents often came onto league consisted of six to seven day, 1 to 1.5 hours each game). the field as well. There was no in- games running back-to-back, with While on duty, the athletic trainer jury action plan in place to outline the youngest teams playing in the assessed roughly equal numbers of crowd management responsibili- morning and the oldest teams play- injuries in the home and opposing ties, which complicated the athletic ing in the afternoon. The athletic teams (Table 1). The injuries as- trainer’s ability to assess the injured trainer suggested steps to make the sessed ranged from minor contu- athlete. There was also confusion playing environment safer, such sions and sprains to fractures and regarding her role when an oppos- as creating an emergency action concussions. One concussion re- ing player was injured. The athletic plan and assisting individual play- sulted in the athletic trainer and trainer felt professionally obligated ers with conditioning, stretching, physician recommending that the to assist in these situations, but hydration tips, and other topics, in athlete sit out for the remainder of coaches and parents occasionally addition to assessing injuries. The the season. resisted. This confusion was likely athletic trainer served as an injury The athletic trainer started on due to the novelty of actually hav- prevention and safety resource to the first day of regular season ing a medical provider on site at this the organization, including the par- practice. The first 2 weeks were level of play, and improved over the ents, athletes, and coaches, and was an adaptation period for the ath- course of the season as the coaches, available for one-on-one advise- letic trainer to get to know coaches parents, and players gained a better ment, demonstration, and educa- and educate them about her train- understanding of the athletic train- tion when deemed appropriate. ing and skills through business er’s role on field.

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TABLE 2 board felt that formally introduc- Recommendations for Successa ing the athletic trainer to the league Seek funding through the youth organization and/or local supporting stakeholders (ie, chari- would help define working rela- table organizations, raised registration fees, or local business sponsors). tionships with other associations Hire the athletic trainer through an organization (ie, hospital system), which might provide and league officials. This work- support for liability coverage and supplies. ing relationship could lead to the Identify a local sports medicine physician(s) partner to support the athletic trainer and sign development of on-field injury off on orders. assessment protocols, in conjunc- Establish a working relationship between the youth organization and athletic trainer prior to tion with local emergency medical the start of the season and engage in group development of the emergency action plan and services. The board identified cost additional safety policies (eg, injury follow-up). as a major challenge and suggested Introduce the athletic trainer and clearly communicate his/her role to the home organiza- paying the athletic trainer by the tion (coaches, parents, and players) and the league (referees and opposing team coaches, day rather than hourly to more parents, and players). easily plan a budget. After the first Integrate the athletic trainer into the organization’s culture. season, the board president stated, aData adapted from Urban JE. Athletic trainers key for youth sports. Childress Institute for Pediatric Trauma website. https://saveinjuredkids.org/blog/athletic-trainers-key-for-youth-sports-safety/. 2015. “Ask the [charitable foundation] to again contribute. We certainly could not fund this on our own.” 2014 Season injury incidence compared to other During the 14-week season in teams (Table 1). However, on more CHALLENGES 2014, a new athletic trainer was than one occasion, the athletic train- There were challenges to imple- hired 3 weeks into the start of pre- er was compelled to cite the Gfeller- menting this program. Prior to the season practice and 1 week prior to Waller Concussion Law to explain first season, it was difficult to find the first game. This was partially to parents why their son was not an athletic trainer interested in a due to delays in identification of allowed to return-to-play. Although seasonal part-time position. To candidates and completion of new this law does not specifically include make this position more attractive employee orientation. The athletic youth athletes, it does provide a best in the second season, it was made trainer attended 36 practices and practice standard for concussion a full-time 6-month position with 12 game days. In this season, some management. the associated medical center iden- teams were split between multiple tifying and compensating for ad- fields on game days due to low YOUTH FOOTBALL ditional clinical duties. Six candi- enrollment at opposing organiza- ORGANIZATION’S PERSPECTIVE dates subsequently applied within tions. Thus, the athletic trainer The youth organization board 2 weeks. needed to prioritize which games members believed that provid- Controlling the activity of play- to attend; this often resulted in the ing an athletic trainer made a clear ers restricted from participation due older team having athletic trainer statement about their organiza- to injury, especially those recover- coverage rather than the younger tion’s commitment to player health ing from concussions, was difficult team. In this season, fewer injuries and safety. Overall, the organiza- because the athletic trainer was were noted than in 2013 for both tion enthusiastically supported responsible for monitoring teams home and opposing teams (Table continuing their association with practicing simultaneously on mul- 1). the athletic trainer and had several tiple fields. Players rarely followed Overall, the second season with suggestions. The board suggested up with the athletic trainer after an a full-time athletic trainer at the that the athletic trainer hold a pre- injury, so the athletic trainer relied youth level was positive. The orga- season educational clinic for par- heavily on coaches to update her nization placed increased emphasis ents. It was recommended that the on the status of players at the be- on practicing tackling and block- athletic trainer assume responsibil- ginning of each practice. Resistance ing techniques and cardiovascular ity for the emergency action plan to return-to-play management was conditioning, which may have been and coordinate a required safety observed, particularly in the case of partially responsible for the lower training session for coaches. The concussion management. Although

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there have been recent efforts to ed- CONCLUSIONS Topline Participation Report. Jupiter, FL: Sports Marketing Surveys USA; 2013. ucate parents and coaches on con- The objective of this report was 3. Radelet MA, Lephart SM, Rubinstein EN, cussion awareness, this observation to document two seasons of experi- Myers JB. Survey of the injury rate for highlights that parents and coaches ence with a full-time athletic trainer children in community sports. Pediatrics. may not fully understand the im- working with a single youth foot- 2002;110:e28. portance of proper injury manage- ball organization of more than 170 4. Kontos AP, Elbin RJ, Fazio-Sumrock VC, et al. Incidence of sports-related concus- ment, which can be provided by an players. Recommendations for suc- sion among youth football players aged athletic trainer. cessfully implementing an athletic 8-12 years. J Pediatr. 2013;163:717-720. Game days were long, making trainer at the youth level are provid- 5. Guskiewicz KM, Valovich McLeod TC. Pe- fatigue a factor for the single ath- ed in Table 2. Overall, proper intro- diatric sports-related concussion. PM R. 2011;3:353-364. letic trainer. Initially, the lack of a duction of the athletic trainer to all 6. Yard EE, Gilchrist J, Haileyesus T, et al. cohesive emergency action plan parents, coaches, and game officials Heat illness among high school athletes: sometimes complicated the ath- was vital to successful integration of , 2005-2009. J Safety Res. letic trainer’s ability to work with the athletic trainer into this environ- 2010;41:471-474. injured players because there was ment. Most of the injuries observed 7. Echlin PS. Concussion education, identification,and treatment within no plan in place when the athletic were minor; however, the emergency a prospective study of physician-ob- trainer began the position. How- action plan was activated eight times served junior ice hockey concussions: ever, this improved in the second over the two seasons. In our experi- social context of this scientific interven- tion. Neurosurg Focus. 2010;29:E7. season because the athletic trainer ence over the two football seasons, 8. Echlin PS, Johnson AM, Riverin S, et al. A was actively involved in the devel- a youth football organization found prospective study of concussion educa- opment and execution of the plan. significant value in having an athletic tion in 2 junior ice hockey teams: impli- A potential barrier to imple- trainer present at most practices and cations for sports concussion education. Neurosurg Focus. 2010;29:E6. menting a full-time or part-time games. Cost was a major obstacle 9. LaBella C, Henke N, Collins C, Comstock athletic trainer in a youth football and required assistance from chari- RD. A comparative analysis of injury rates league is expense. A less costly al- table foundations, although funding and patterns among girls’ soccer and ternative would be to hire an ath- from raised registration fees or local basketball players at school with and without athletic trainers from 2006/07- letic trainer only for game days. business sponsors was not explored. 2008/09. Paper presented at: American However, in addition to loss of Otherwise, this plan for youth foot- Academy of Pediatrics Council on Sports practice coverage and resulting ball organizations is feasible, appre- Medicine & Fitness; 2010; New Orleans, LA. fragmented care, there would be ciated by parents, and may enhance 10. Pryor RR, Casa DJ, Vandermark LW, et al. less opportunity for the athletic player safety through improved in- Athletic training services in public sec- trainer to educate coaches, players, jury awareness, prevention, and as- ondary schools: a benchmark study. J and parents on specific health and sessment. Athl Train. 2015;50:156-162. safety issues. It also would be more 11. Daniel RW, Rowson S, Duma SM. Head impact exposure in youth football. Ann difficult for the athletic trainer to REFERENCES Biomed Eng. 2012;40:976-981. integrate into the organizational 1. Rizzone K, Diamond A, Gregory A. Side- 12. Urban JE. Athletic trainers key for youth culture as a member with a respect- line coverage of youth football. Curr sports. Childress Institute for Pediatric Sports Med Rep. 2013;12:143-149. ed role who is able to affect system Trauma website. https://saveinjured- 2. Sports & Fitness Industry Association. kids.org/blog/athletic-trainers-key-for- improvements. 2013 Sports, Fitness, and Leisure Activities youth-sports-safety/. 2015.

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