It is impossible to bring up a discussion of school sports without mentioning the great bogeyman of sports-related injuries: concussions.
The number of concussions has been on the decline in recent years. But a recent estimate suggests that there are still about 4 concussions per 10,000 athletic exposures in high schools. An athletic exposure is a school-sanctioned practice or game.
In the same study, football was found to be the highest-risk sport (over 10 concussions per 10,000 exposures). And concussion rates in football games (but not football practices) rose in the past 5 years from about 33 to nearly 39 per 10,000 athletic exposures. Among sex-comparable sports, girls had higher rates of repeat concussions than boys.
Preventing and attending to injuries in schools
Because of these statistics and concerns about other sports injuries, school administrators nationally have taken great strides to ensure that schools have resources available to prevent this sports-related issue. In addition to things like mandated concussion training for school coaches and athletic staff, many states and school districts have expanded access to Athletic Trainers (ATs) during games and practices.
A national study from 2015 found that 70% of public high schools had contracts with ATs (up from 34% a decade earlier). ATs are involved in proactive injury prevention. This includes coaching education, pre-participation examinations for players, and implementing heat-acclimatization policies. ATs also help develop and implement emergency action plans, identify serious injuries like concussions, and implement return-to-play protocols. And they are trained in lifesaving skills and can provide care within minutes of symptoms.
The exception to this trend is California. According to data from the National Federation of State High School Associations, more than 800,000 high school students in California play an organized sport in school each year. Yet just 25% of public schools in California have a full-time athletic trainer on staff. And despite having state legislation mandating the health care staffing requirements for school sports, California does not include athletic trainers (ATs).
Interestingly, California is also the ONLY state that does NOT regulate the profession of ATs.
The value of athletic trainers in schools
There are some strong arguments for having ATs in schools. These include decreases in school absences and return-to-play time. Also, in a national sample of high schools, female students in schools without ATs (compared to those with) were 73% more likely to become injured and 3-6 times more likely to suffer a repeat injury. And schools with higher AT presence have better reporting and management of sports-related concussions.
But few arguments are as persuasive as the projected cost savings provided by the hiring of an on-site AT for a school healthcare team. The estimated annual cost savings if every high school in California were to employ a full-time AT is $14.7 million. In a single year, an estimate of 13,766 treatments valued at $2,753,200 can be provided by employing a single full-time athletic trainer. Even having a part-time AT can lower medical expenditures and decrease emergency department visits.
The American Medical Association, the American Academy of Pediatrics, the National Athletic Trainers Association (NATA), the California Interscholastic Federation, and the California Athletic Trainers Association (CATA, the NATA state branch) all endorse the inclusion of an athletic trainer as a mandatory part of school sports staff. So, what’s been holding athletic trainers back from being more deeply involved in California schools?
Pushback: scope of practice
In 2018, Assembly Bill 3110 was introduced to amend the California Business and Professions Code to include regulations for the certification of ATs. Currently, according to the California Business Code, ATs are authorized to provide services broadly as an “aide,” whether under a licensed physician/surgeon or physical therapist. The legalese here defines AT services as “performance enhancement” rather than healthcare, a fact which detractors build their arguments around. Despite reaching appropriations, this bill eventually died due primarily to budgetary concerns and questions about scope of practice.
This latter argument is important not only because it involves a hot topic in the health workforce, but because it also highlights competing interests working against ATs. The arguments against the re-introduced version of the bill this year (AB 1592) include remarks from many of the same trade groups which have been vocal against expanding and regulating AT participation as licensed healthcare providers. In particular, the California Physical Therapy Association and California Board of Occupational Therapy have been outspoken stating that “the ability to diagnose is well outside of the education and training of an athletic trainer.”
Compromise necessary and likely
It is important to note two things: 1) AB 1592 in its current form states that an AT may not diagnose a disease and 2) both CBOT and CATA support amending this bill to specifically limit the definition of “athletic activity” and scope of practice to those licensing schemes found in other states. NATA advocates for guidelines that limit an AT’s scope of practice to serving in conjunction with a licensed physician and providing services that can be performed on the field or in an outpatient setting (such as initial and secondary assessment/management of non-life-threatening injuries, CPR, AED, and splinting).
The California Assembly Committee on Arts, Entertainment, Sports, Tourism, and Internet Media comments that regardless of any disagreement, there should be regulation of ATs and a well-defined scope of practice, with AB 1592 providing the strongest licensing scheme to-date. Both CBOT and CATA have expressed willingness to work together towards proposing amendments to the bill that would ensure that the proposed scope of practice given to ATs neither exceeds their training, nor neglects the amount of oversight they will receive from a supervising physician.
It is difficult not to wonder if there may be vested interests in keeping ATs less autonomous. It is prohibitively costly to retain a licensed physician on a high school sports staff, much less a full-time physical therapist. So it’s hard to believe that ATs would substantially compete with others in the school health workforce. ATs can provide preventive services, including simple ankle wrappings, and urgent on-field care that can provide a smoother and safer transition to health care services outside of school. There are crucial safety decisions, including for concussions, on the field that can make the difference for a quick and safe recovery.
Funding remains a major challenge. NATA has released a series of funding strategies used in other states. These strategies include creating a tax credit for schools, a state fund, and/or applying for national grants, providing a pathway to alleviate budgetary concerns beyond simple licensing fees.
Looking forward
AB 1592 remains up for committee hearings until early 2020. CATA advocates that in addition to adopting NATA’s certification guidelines, it would like to work with CBOT to develop a licensing and regulatory structure that would maintain the respect and deference to existing scope of practice laws. With this impending opportunity, it is imperative now more than ever that California act to enhance the regulation and integrity of ATs and pave the way to making these providers available in more schools.
Editor’s Note: The third part in the school health series discusses school funding strategies to help support mental health services. The introduction to the school health series and Part 1 (Everything’s Coming up ACEs) are also available.
Fareed Dibazar