Behind the Line

January 29, 2015
Preventing heat illness in football players is a behind-the-scenes team effort. Getting coaches on board requires good communication and persistence.
By Patrick Bohn

Patrick Bohn is an Assistant Editor at Training & Conditioning. He can be reached at: [email protected].


When Joe Iezzi walked onto the field for his first preseason football practice as Head Athletic Trainer at Downingtown (Pa.) High School West in 1988, he was shocked at what he saw. It was a scorching hot day in August, and all the players were wearing full gear.

"I asked the head coach, 'What are they doing in pads and helmets in this heat?' and he responded, 'Joe, there are no rules governing what they can or cannot wear,'" says Iezzi, MS, ATC, LAT, PES, who retired in June. "That blew my mind. I spoke with him about how having all that gear on wasn't good for the players and got them out of the pads immediately."

Twenty-five years later, policies and attitudes regarding football practices in the heat have changed significantly thanks to ongoing research and educational efforts. But challenges remain, particularly at the high school level, where some coaches push back against acclimatization best practices and frequent water breaks, worried they will interfere with the team's practice regimen.

For an athletic trainer, working in conjunction with their football coach to keep football players safe in the heat can be difficult. In this article, we talk with experienced athletic trainers about how they've brought coaches up to speed on hydration, heat illness prevention, and acclimatization, and helped them adjust to new legislation recently put in place in several states.

TURNING THE TIDE
One of the biggest moves to prevent heat-related illnesses at football practices in the last decade has been the adoption of heat acclimatization guidelines at all levels of the game. In 2003, the NCAA implemented preseason acclimatization rules, and in 2009, the NATA released a consensus statement titled, "Preseason Heat-Acclimatization Guidelines for Secondary School Athletics," hoping every high school state association would adopt it. The guidelines cover everything from practice lengths, to time required between practices, to rules for introducing shoulder pads, full contact, and two-a-day practices.

But many have been slow enacting these policies. As of this writing, only 10 states have fully adopted the NATA's guidelines, with Missouri being the most recent to do so in May of 2013. While several other states have some rules in place to address acclimatization, they fall short of the NATA's recommendations.

What's preventing universal acceptance? "State associations are listening to the football coaches who cling to old ideas and not the medical professionals," says David Csillan, MS, ACT, LAT, Head Athletic Trainer at Ewing (N.J.) High School and co-chair of the task force that drafted the NATA guidelines. "The coaches say, 'The more hours players work and the harder they work, the tougher they'll be.' That gets the associations' ears, while our voices get drowned out."

When Csillan tried to get the NATA guidelines passed in New Jersey in 2009, the biggest road block was the addition of football coaches to a subcommittee of the state's Sports Medicine Advisory Committee that was charged with studying the idea. "Once that happened, the conversation shifted completely," he says. "Instead of the discussion focusing on player safety, it turned to coaches saying they would lose practice time and as a result, not be as prepared for games.

"To get any of the guidelines in place, we had to give and take," continues Csillan. "For example, rather than waiting five days before allowing full pads and hitting, we settled on three. It was tough for the medical professionals to accept, but in order to get some of the other guidelines passed, we had to compromise with the coaches."

Csillan's advice to others working on getting the NATA's recommendations in place is to come armed with a lot of information. "Make sure you have plenty of research to present to your state association," he says. "Then, go beyond the data. For example, you can find the number of student-athletes who were taken to a hospital after suffering from heat illness, but be sure to remind your audience that the actual total is higher and includes athletes whose parents took care of them at home."

If providing research doesn't work, explaining liability realities can be effective. "While our committee was discussing how to get the full guidelines passed, we had a meeting with area lawyers," Csillan says. "They told us, 'If a student-athlete goes to the hospital or dies because of heat-related illness, the first thing we're going to do is ask the state association why they're not using the guidelines suggested by the national association. Then, we'll ask the school district the same question.' Once administrators and coaches start worrying about being held liable, opinions can change quickly."

Finally, Csillan says, patience is critical. "Take things in small steps," he advises. "Our coaches went nuts in 2009 when we tried to pass all the guidelines at once. But we got several of them in place, and in 2011, we were able to say, 'Look, we already have most of them. All it takes now is a couple more changes.' They bought in quickly, and the full guidelines were adopted in May of that year."

A JOINT EFFORT
For athletic trainers in states that have embraced the NATA guidelines, the challenge can be getting your coach to understand and implement the new rules while still maintaining a positive relationship. When Georgia adopted the guidelines in March of 2012, William Utsey, ATC, Head Athletic Trainer at Wheeler High School in Marietta, Ga., sat down with his coach and made sure they understood each other.

"Before we even talked about the specific rules, I told him that we are all on the same team when it comes to both practices and player health," Utsey says. "I relayed that I knew what he wanted his team to accomplish on the field, and I didn't want to get in the way of that. But I did want to help him by keeping his players healthy.

"With that mutual agreement in place, addressing his concerns was easier, because he knew I respected what he was trying to do," he continues. "We took a look at the rules, and he wanted to know exactly what was allowed during the walkthroughs on days one through five. I told him the players should be in shorts, T-shirts, and tennis shoes, and the practice should entail discussing schemes and plays. Because we'd established a good relationship, he knew I wasn't trying to take away from what he could do."

Mary Cardarelli, MS, ATC, LAT, Head Athletic Trainer at Manchester (Conn.) High School, talked with her football coach not long after her state adopted the guidelines in March of 2013 and has been revisiting that conversation ever since. "Don't just talk about the rules one time and then leave the coach on his own," she says. "Coaches have a lot to keep track of, and they may forget what's allowed on certain days. You wind up taking him by surprise if you tell him that the players can't wear full pads just as they are getting ready for practice.

"Instead, talk to the coach ahead of time about what he's got planned for the next few days," Cardarelli continues. "That way, if there's an issue, you can discuss modifying the plan--maybe having a chalk talk instead. If you're direct about these issues, most coaches will be receptive to you."

When it comes to implementing the guidelines, Utsey stresses one critical point: documentation. "Write down exactly what time practices start and end," he says. "That allows you to go up to a coach and tell him, 'We've only got a few more minutes.' Also, if the coach has the players stay in pads for too long, and you need to talk to your athletic director about it, you're able to show exactly what happened."

Some of the rules might force coaches to change the way they normally do business, so a little advice may be helpful. "One of the things coaches don't like about the guidelines is the three-hour rest period between practices," Csillan says. "They feel like they have to baby-sit the players during that time. Discuss ways they can fill that time productively, such as going over film with the team."

Finally, remember to not just focus on the varsity head coach. "When I spoke to our football coaches about the new guidelines, I made sure every one of them was present," Csillan says. "This information isn't just pertinent to the varsity team, and it's crucial to make sure the message stays consistent from the head coach to the assistants."

ON THE BALL
Whether or not your state has the NATA guidelines in place or your institution follows NCAA rules, every athletic trainer still needs to educate their football coach about the importance of preventing heat illness and heat acclimatization. Jeff Pounds, MS, ATC, NASM-PES, Director of Athletic Training at Coastal Carolina University, starts by explaining what players' bodies go through in the heat. "You have to point out that heat illness is not instantaneous, but a cascade, and is therefore 100 percent preventable," he says. "It starts with dehydration, then heat exhaustion, then heat stroke. If coaches understand the entire process, they can keep problems from developing.

"Sometimes, coaches are skeptical of health and safety rules because they feel it's impossible to prevent every injury," Pounds continues. "But that's not the case with heat-related issues, so we stress that."

Iezzi points out how heat illness can affect a player long-term. "I talk to my coaches in terms they understand, and that's usually performance," he says. "For example, I'll tell them, 'If we push our guys too hard in August and one of them gets heat exhaustion, he's going to get worn out by that and be more at risk for an injury later in the season."

"Let's say a player's been pushed too hard in the heat, and he's got a deer-in-headlights sort of look," Utsey says. "I'll point him out to the coach so he can see how much it affects that student-athlete's play."

Another of Utsey's strategies is to remind coaches about heat illness constantly. "I post information on the dangers and symptoms of heat illness on the bulletin boards of the field house," he says. "That way, our coach sees it each day as he walks to and from his office. I also post articles on players who get heat illness so he understands what exactly it is we're trying to avoid."

Jack Marucci, MS, ATC, Director of Athletic Training at Louisiana State University, says high school athletic trainers can also point to the next level for backup. "If you've got a coach who talks about wanting to run his program the same way a top college does, make sure he knows that we're already doing all of these things," he says. "At LSU, our top concern is trying to prevent heat illness. You can tell your coach, 'The elite schools make this a priority, and you should too.'

"You can even go a step further and talk about how the military takes things like WBGT [Wet Bulb Globe Temperatures] into account when training soldiers," Marucci continues. "If a coach understands guidelines are in place at other institutions, especially ones that he and his players respect, he won't hesitate to implement them at his school."

Equipment can be another critical component to stress. "We've taken temperature readings of players' shirts, and the difference between a black shirt and a white shirt can be as much as 17 degrees," Marucci says. "Coaches don't often know how much effect dark colors can have, so point it out to them and request that the players wear light colors when possible."

Coaches may also not be aware of how certain playing surfaces react to heat. "Lots of schools are using synthetic turf," Marucci says. "We've taken readings and found that the on-field temperature can be 40 degrees higher on a synthetic turf field compared to a grass one. Show a coach that, and it really makes an impact. Then, they're more likely to move practice to a grass field if they have the option."

If all else fails, you can discuss worst-case scenarios. "I tell coaches that we don't ever want to be on the front page of the newspaper because a football player died as a result of the heat," Utsey says. "If such a tragedy happens, every one of us is going to be out of a job, and it's possible that we're going to have to defend our actions to a jury."

WATER, WATER EVERYWHERE
No plan to protect student-athletes from heat illness would be complete without a component focusing on hydration. It's crucial that athletic trainers work with football coaches to keep players hydrated both before and during practice.

"When I see situations where football players aren't adequately hydrated, it's usually not an intentional move by the coach," Iezzi says. "I think coaches can completely lose track of time during practice. I've told my football coach the players need to take a water break, and he's responded, 'Really? I thought we just had one.' Because I write down the time of each break, it's easy to show him one is needed again."

If your coach constantly takes too long between hydration periods, you have to assert yourself. "This can be difficult, especially if the coach is a respected veteran and you're inexperienced," Cardarelli says. "But you have to have the confidence to go out on the field and confront the coach if necessary. Ask yourself: do you want to prevent or treat?

"If you get resistance, there are a couple of strategies you can try," she continues. "The first is asking them what they are hoping to accomplish in practice and point out that denying the players water won't help. If that doesn't work, turn it around and ask if they would be okay with their son or daughter practicing in the heat with no water. I've found that to be effective."

It's also important to have coolers and hydration stations set up all around the practice field, so players can drink and cool off even if the team isn't taking a break. "It's all about providing resources," Pounds says. "We have water anywhere players group together on the field, so if they're watching teammates do a drill, they can get a quick drink."

Hydration can be accomplished through food as well, something Marucci says LSU has done for years. "Water is critical, and we have coolers everywhere," he says. "But inside our cooling tents, we also have plates of fruit, like grapes, which players can eat to effectively re-hydrate."

While keeping athletes hydrated on the field gets most of the attention, Pounds reminds his players and coaches to drink water all day long. "We give each person a water bottle and point out the places to get water in our facility," he says. "With the football and strength and conditioning coaches on board, we're able to ensure that players have their water bottles with them in team meetings and when lifting. We challenge the players to be hydrated all the time."

As many other athletic trainers do, Csillan uses weight charts to make sure players are drinking enough. "If a player has lost too much weight, he is held out of practice," he says. "And because the coaches know we've talked to the kids about hydrating, the coaching staff will get mad at them for not doing what they need to do, not at us for holding a kid out."

Whenever you talk to coaches and players about hydration, it's important to speak on their terms. "When a player doesn't adequately hydrate and says he feels sick, I walk him and the coach though it like it's an injury evaluation and point out what he could have done to prevent it," Pounds says. "Rather than getting too heavy into numbers, I say 'With what you weigh, you need to drink a bottle and a half of a sports drink before practice.' That's something they can grasp.

"Another thing our strength and conditioning coach does, which works really well, is show players a picture of a juicy steak next to beef jerky," Pounds continues. "He asks them which one looks better and more pliable. Everyone points to the steak. Well, that's the piece that's hydrated."

Getting your coaching staff on board with hydration, ultimately, means a better functioning team. "It's my job as athletic trainer to make sure everything is set up properly," Utsey says. "Do we have enough coolers? Are they in shaded areas? Are there cold towels soaking? If I make sure I have these things in place, my coach can concentrate on the X's and O's during practice."


Sidebar: School Rules
While heat guidelines developed by governing bodies are important to put in place, some athletic departments also construct their own school-specific policies. Jeff Pounds, MS, ATC, NASM-PES, Director of Athletic Training at Coastal Carolina University, helped put protocols in place for the athletic program when the school started a football team in 2002.

"At that time, there wasn't as much information out there, but we based a lot of our guidelines on the research done by Douglas Casa on heat illness," Pounds says. "Any policy you create needs to have a foundation in existing research because that will give it legitimacy."

Pounds adds that a policy shouldn't simply be a list of restrictions. It should also educate those who read it. "The first half of our protocol consists of the definition, prevention and treatment of, and recovery from heat illness," he says. "We wanted to make sure that was explained in enough detail that the coaches understood its importance."

Another component is a chart detailing Wet Bulb Globe Temperatures (WBGT) and the activities permitted when each threshold is reached. "For a long time, we used the same guidelines the Marine Corps did because they had done the most research on working in heat while wearing gear," Pounds says. "But we're constantly evaluating the policy and looking for ways to improve it. We recently switched to the guidelines used by the Georgia High School Association, because we felt they were more relevant to athletics, especially football."

The final piece of the policy covers fluid replacement and hydration guidelines. Overall, Pounds says it has been accepted by the coaching staff, but there are things you can do to make it go over easier.

"We didn't give coaches a lot of input into the creation of our guidelines, largely because they trusted us," Pounds says. "But we kept their concerns in mind. For example, we make sure to take the WBGT readings early enough in the day so the coaches can put a backup plan in place if the temperature is too high to practice. They appreciate that."

To view Coastal Carolina's heat illness guidelines, which is in its Sports Performance Policy and Procedures manual, click on the "Policy and Procedures" link at:
www.coastal.edu/sportsperformance/training.
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