Call to Order and Roll Call
The1st meeting of the Task Force on Middle School Interscholastic Athletics was held on Monday, July 16, 2012, at 1:00 PM, in Room 129 of the Capitol Annex. Representative Carl Rollins II, Chair, called the meeting to order, and the secretary called the roll.
Members:Senator Mike Wilson, Co-Chair; Representative Carl Rollins II, Co-Chair; Senator Joe Bowen, Representative Joni L. Jenkins; Kevin Brown, Adam Lantman, Barry Lee, Elizabeth Miles, Greg E. Mitchell, Rita Muratalla, Dan Seum, Jr., and Julian Tackett.
Legislative Guest: Senator Dan Seum.
Guests: Dr. Trevor Wilkes, Orthopedic Surgeon, Lexington Clinic; Myron Thompson, Director of Risk Management, Kentucky School Boards Association; and John Roberts, Vice-President, R. J. Roberts, Inc.
Welcome and Introduction of Task Force Members
Representative Rollins said the Task Force on Middle School Interscholastic Athletics was created as a result of HCR 155, enacted in the 2012 Regular Session of the General Assembly. It was established to study the current oversight of middle school athletics and to produce a final report by December 7, 2012, including findings and recommendations to improve middle school athletics.
Representative Rollins welcomed and thanked the members for serving on the task force. Senator Wilson expressed his pleasure of serving on the task force. The members introduced themselves.
Presentation: The Middle School Athlete: Unique Health Concerns
Dr. Trevor Wilkes, orthopedic surgeon with the Lexington Clinic and fellowship trained in sports medicine, said evidence-based medicine aims to apply the best available evidence gained from the scientific method to guide clinical decision making. The recommendations cited in his presentation are categorized based on the levels of supporting evidence. Category A evidence is consistent, high quality studies; Category B evidence is supported but limited-quality studies; Category C evidence is based on consensus and expert opinion; and Category D evidence is conflicting and not routine.
Almost no high level evidence supports having distinctly different management of middle school versus high school athletes. Ages 11 to 14 is the onset of puberty and is a period of rapid change. Physically, these children go through growth spurts, their growth plates grow, and tendons and ligaments expand. Cognitively, they develop the ability to determine long-term consequences and to see other sides of issues, go through an important neuro-motor development, and may experience a sensory/motor – disconnect. Graphs showed growth to be at its steepest rate for this age group and bones to grow the most during this time.
The Pre-Participation Physical Exam (PPE), although only an Evidence Category Level C, is a vital part to screening athletes. The PPE should be used to screen each middle school athlete for potential risk factors related to the heart, cognitive function, and bones and joints. Athletes with deficits, about 5 percent according to a study in the 2010 British Journal of Sports Medicine, need to be referred to specialists. Screening providers should be knowledgeable in pediatrics and demands of the sport. What the PPE should include is controversial, such as an EKG and baseline neuro-cognitive tests in case of concussion; more research is needed.
Overuse or repetitive trauma injuries (Evidence Category B) represent approximately 50 percent of all pediatric sport-related injuries. Emerging evidence indicates that the sheer volume of sport activity, whether measured as number of throwing repetitions or quantity of time participating, is the most consistent predictor of overuse injury. Efforts should be made to limit the total amount of repetitive sport activity engaged in by pediatric athletes to prevent or reduce overuse injuries. The general consensus is that alterations or modifications need to be made but there is no evidence at this time of what those changes should be.
Athletes in middle school are susceptible to overuse injuries. Open growth plates are susceptible to repeated micro-trauma, as is the case with gymnasts, causing pain and disability. Causes of growth plate injuries include improper technique, early specialization, excessive training with inadequate rest, and muscle weakness and imbalances. Coaches and trainers can address these issues. Some data suggest that pediatric athletes should do no more than 16 to 20 hours per week of vigorous physical activity (Evidence Category B). Athletes should be given one to two days off per week and never have more than five days of the same sport per week (Evidence Category C). Trainers should only see a 10 percent increase in training intensity per week.
Prevention programs for the general conditioning of youth carry over into athletics. Multiple high quality studies confirm the value of preventive pre-season conditioning programs that focus on areas such as the knee with regard to ACL tears, overhead athlete’s shoulder, and jumper’s knee (Evidence Category A).
Results of new research indicate that, contrary to previous thinking, youth do not have less effective thermoregulatory ability compared to adults during exercise in the heat when adequate hydration is maintained. Middle school athletes should follow heat guidelines (Evidence Category A) and target modifiable risk factors such as frequent breaks, daily weigh-ins, gear, and rest between efforts.
Little research is available on patients under 14 regarding the influence of concussions and there is no established baseline data to guide return to play. There is concern for the role that the cognitive damage of concussion plays on the rapid brain development of athletes in the middle school age group. Some data indicate that from 1997 to 2007, sport-related concussions doubled. A British study found a minimum of three months of symptoms after a confirmed concussion; an Australian study showed two or more concussions statistically lowered the athlete’s GPA; and children under the age of 20 have a higher risk of the potentially fatal Second Impact Syndrome.
Volume of pitches per game and season is the most important factor in baseball pitchers’ injuries (Evidence Category A). Technique is also important; according to a Los Angeles study, the risk of injury increases eight fold if two out of five parameters defined are incorrect. USA Baseball has published evidence-based guidelines for middle school baseball: 75 pitches per game; 600 pitches per season; 2,000 pitches per year; no throwing for three months per year; only one overhead sport per season; no breaking pitches until age of 14; and never play the positions of pitcher and catcher on consecutive days.
In response to a question from Senator Bowen, Dr. Wilkes defined overhead sport as football quarterback, baseball, volleyball, swimming, and any weighted activity with hands above the head. In response to a question from Representative Rollins, Dr. Wilkes said that basketball does not qualify as an overhead sport. He can provide a list of overhead sports.
Strength training is recommended as part of the conditioning program for middle school athletes since it has no harmful effect on growth plates. Body weight exercises, core stability, and low weight – high repetition should be emphasized. Middle schools with strength and conditioning programs need to implement lower standards per body weight compared to high schools.
In response to a question from Representative Rollins, Dr. Wilkes said that instruction for coaches on strength training varies. Mr. Tackett said that it is not required for middle or high school coaches. It has been suggested that, when the course on sport safety that coaches have to take is revised again, a module on strength training be added.
In response to a question from Senator Bowen, Mr. Tackett said that traditionally teachers would also be coaches, but now schools rely more on hiring outsiders to be coaches who may not necessarily have an education background. Mr. Mitchell said that the majority of middle school coaches are paraprofessionals. Dr. Wilkes stressed the importance of educating coaches by offering coaching clinics.
Dr. Wilkes said all athletic trainers and athletic health care providers should participate in injury-surveillance efforts, including Web-based and other registries that are a powerful tool for injury prevention (Evidence Category C).
There have been some recent developments for 9 to 14 year-old athletes. USA Baseball has published evidence-based pitch count guidelines; USA Cycling has published a gear ratio limit; USA Swimming is developing guidelines for training and racing; and running mileage limits have been published in Australia for middle school athletes.
Dr. Wilkes summarized that the ages of 9 to 14 represent a rapid period of physical and cognitive growth; little high level evidence exists to guide recommendations on rules and training; and distinct differences from high school ages, with regard to athletic participation, are poorly defined. He said that despite the lack of evidence, some trends emerge with consensus in the 9 to 14 age group: the importance of the PPE; attempt to minimize overuse injuries; tread carefully with concussions; follow published heat guidelines; observe current pitch count limits; and permit and encourage modified strength training. Over the next 5 to 10 years, more Level A and B research and evidence will emerge for guidelines.
In response to a question from Representative Rollins, Dr. Wilkes said that weight loss to stay within a wrestling classification is harmful.
In response to questions from Senator Wilson, Dr. Wilkes said that it is not typical for young athletes to develop Osgood-Schlatter syndrome; about 5 to 7 percent of young athletes experience it. Most overuse injuries are a complex interplay between genetics, previous injuries, and athletic training program, and it is difficult to pinpoint the real cause of such injuries. Level C evidence is that it is increasing due to longer training hours, single sport focus, and the lack of education of some of the coaches to incorporate strength and flexibility into the training program. There is little evidence that stretching prevents injury.
In response to a question from Senator Wilson, Dr. Wilkes said that the recommended 16 to 20 hours per week of vigorous physical activity include game time.
Mr. Seum mentioned a football player and two basketball players dying from enlarged hearts. In response to his questions, Dr. Wilkes said enlarged hearts in young athletes are common and cardiac death is the single most common cause of sudden traumatic death from sports. The PPE includes a stethoscope examination and a student is referred to a specialist when a problem is detected. On a practical level, PPEs are done on many students in a short period of time. Performing EKGs on all students has been proposed but this is not an evidence-based recommendation; it is a controversial topic and the cost effectiveness would have to be taken into account. The best that coaches can do is to observe students who do not look well.
Mr. Tackett said that over-usage is a big problem. He gave an example of a basketball team playing 51 ball games in a season. Some kind of limitation needs to be implemented.
In response to a question from Mr. Tackett, Dr. Wilkes said he would like to see the same standards set for contact sports to be applied to all middle school sports because he sees concussions also in cheerleaders.
In response to a question from Representative Jenkins, Dr. Wilkes said that there is consensus that those providing PPEs be knowledgeable and have sports-related expertise, and do PPEs to stay competent.
In response to a question from Representative Jenkins, Dr. Wilkes said that cardiologists recommend that automatic external defibrillators (AEDs) be present at every feasible event. Having AEDs available at all school facilities is the minimum recommendation.
In response to a question from Mr. Lee, Dr. Wilkes said that the guidelines for high school athletics should be the minimum for middle schools. Some guidelines should be different, such as pitch counts and strength training.
In response to a question from Mr. Lee, Dr. Wilkes said that recognition is the main factor for the numbers of concussions almost doubling. Other reasons for the increase are more participation and the emphasis on being bigger and stronger in a shorter period of time.
Mr. Mitchell said that based on his experience as a coach, middle school sports are different. Minimum standards are needed but middle school sports should not be overregulated.
Presentation: Athletic Risk Management
Mr. Myron Thompson, Director of Risk Management with the Kentucky School Boards Association (KSBA), said that there are no members of KSBA on the Task Force and they could contribute valuable input.
He said KSBA insures about half the school districts in Kentucky. Sport is very important in our society and the worst thing that can happen is when a situation results in an athlete’s death and criminal charges are made against the coach or a fellow athlete. The course for coaches focuses on safety training and at least one trained person has to be present at every high school athletics practice and competition. Adequate supervision is of the utmost importance as claims can be very expensive. Mr. Thompson cited examples of athletes suffering injuries and death, resulting in expensive settlements. Coaches need to be adequately trained to adhere to the regulations. Regular drills are needed to prepare for possible situations in which an athlete gets injured or collapses. In 2007, there were two high school football deaths nationwide; in 1968 there were 36. Better education and equipment have contributed to the decrease in deaths over the years.
Athletic programs have risks and good guidance is needed when dealing with middle school athletes. Coaches need to be well prepared in student injury management, and proper supervision is needed. Sex abuse, hazing, and bullying are other situations that need to be guarded against. Any of these situations can lead to a lawsuit. The reputation of a school board also needs to be protected. Risk management is about maximizing safety and minimizing liability. Coaches need to guard against situations that could get them fired or even going to jail. When something goes wrong, lawsuits are usually filed against the school board. Most school districts have athletics policies, and the KSBA Policy Service has an athletics handbook that can be made available to committee members.
Other factors that need to be considered regarding risks involved with athletics are parent involvement at athletic events and the possibility of brawls; the handling of money with regard to booster clubs, concession stands, and gate entrance fees; transportation of athletes; coaches adhering to regulations to prevent heat injuries; athletic trainers being trained for emergency response regarding concussions; having AEDs available; sports facilities being compliant with regulations; stands being safe and in good condition with sturdy railings; bleacher inspections; equipment safety; and having contracts and insurance when leasing facilities.
Mr. Thompson said that KSBA recommends that school board members at the high school level receive an annual report from their athletics director, covering what has happened in the sports program, good and bad.
In response to questions from Mr. Tackett, Mr. Thompson said that the KSBA boundary and coach training is typically for KSBA insurance members but is also offered for free to school board members. KSBA does not have a recommended model or disclosure for financial accountability; that is something that needs to be addressed.
In response to questions from Mr. Mitchell, Mr. Thompson said that if the school district has jurisdiction over a middle school athletic event or activity, authorized volunteers under the direction of a school employee are covered by the Kentucky School Boards Insurance Trust (KSBIT) general liability policy. KSBIT does not cover participants. The insurance policy does not contain any requirements for a PPE or release forms. KSBA does not have any specific middle school insurance coverage requirements.
In response to questions from Senator Bowen, Mr. Thompson said that practices may start too early in the season and contribute to injuries and deaths. Practices need to build up gradually to get student athletes acclimated to the weather. Overlapping of different sports may also be a contributing factor and may warrant an evaluation.
In response to a question from Mr. Lee, Mr. Thompson said that district policies and procedures must be followed in order to be covered by the KSBIT policy.
In response to a question from Mr. Seum, Mr. Thompson said that coaches need to use caution when providing transportation to a student athlete and not to engage in a pattern that could be perceived negatively.
In response to a question from Mr. Tackett, Mr. Thompson said that non-public schools participating in athletics are not insured by KSBIT. Non-public schools would need individual insurance policies and would need to adhere to those policy provisions.
Presentation: Student Accident Insurance & Industry Changes
Mr. John Roberts, Vice President of R. J. Roberts, Inc. insurance agency, said that his agency provides accident insurance to over 130 school districts and colleges, and is also the agent for the Kentucky High School Athletic Association (KHSAA) Catastrophic Program. This coverage pays the medical bills when athletes are injured. Any middle school athlete playing up to the high school level is covered by the KHSAA Catastrophic Program. Districts may have a separate student accident program to cover their athletes. Middle school athletes may also be covered by their parents’ personal insurance or by a voluntary plan purchased through the school district. All student accident insurance rates are increasing because of the increase in the numbers of claims. As a result, fewer schools are purchasing coverage, creating a huge coverage gap. Districts may require individual insurance, but monitoring is weak.
The current KHSAA Catastrophic Program is a $5 million maximum benefit for 10 years with a $25,000 deductible. It is a medical benefits policy; it pays 100 percent of usual and customary charges in excess of other insurance in force and includes a $20,000 death benefit. This coverage is for students participating in interscholastic competitions governed by KHSAA, including school-supervised practice, tryouts, game-related activities, and related travel. KHSAA adopts the best practices for heat-related injuries and concussions. A catastrophic accident policy for middle school athletes would be good to consider. It helps to have best practices in place when an agent is negotiating rates with companies for coverage.
Monitoring insurance is difficult; not all school districts in Kentucky purchase student accident insurance. Regulation for middle school students would help with rates. The best solution would be to create a Middle School Catastrophic Program for all districts, similar to the KHSAA Catastrophic Program.
In response to questions from Representative Rollins, Mr. Roberts said that middle school athletes are not covered under the KHSAA Catastrophic Program unless they participate on a high school team. The cost for the KHSAA Catastrophic Policy is $180,000 to $200,000 for the entire state.
In response to questions from Mr. Mitchell, Mr. Roberts said he is not familiar with any middle school risk management standards. He is vaguely familiar with the KHSAA physical examination form. The KHSAA release consent form is not considered when underwriting at the catastrophic level or with respect to the student accident programs. Roberts Insurance & Investments does not provide coverage to middle schools. There is no need for extra coverage if schools have a student accident plan because that plan provides coverage for all school sponsored and school supervised activities.
In response to a question from Mr. Mitchell, Mr. Roberts said that heat-related injuries are a concern. He will provide information regarding standards and by-laws underwriters look for when writing school athletics policies.
In response to questions from Mr. Mitchell, Mr. Roberts said that two levels of insurance for middle school student athletes would be feasible: the Athletic Only Policy covering $0 to $25,000 and the catastrophic policy. Coaches at the middle school level are covered for injuries, but not for accidents.
In response to a question from Mr. Lantman, Mr. Roberts said that wrestling club teams can obtain the same student accident coverage as middle schools. Boone County provides student accident coverage for all club teams.
Representative Rollins announced that future meetings will take place on the third Monday of each month. The next meeting will be on August 20. Meeting dates thereafter are September 17, October 15, and November 19.
The meeting was adjourned at 3:20 PM.