Hot Zones with Doug Casa

Hot Zones: Dr. Doug Casa And Return To Play

As summer begins in earnest, nothing would feel quite so normal as the sounds of whistles chirping from across America’s football fields, the pop of the pads as young men collide with blocking sleds, and the voices of coaches directing and instructing student-athletes.

Depending upon the spread of the coronavirus in the U.S. and the location of a given high school or university — as well as a variety of other factors — those scenarios may not be that far off.

Still, every coach and every student-athlete out there faces a once-in-a-lifetime challenge to return to play and remain safe amid the risk for infection, and they must do so as the summer sun blazes down upon them. The risk for Exertional Heat Illness (EHI) will be higher because:

  • Student-athletes didn’t play spring sports and could be significantly deconditioned heading into summer.
  • The level of intensity with which student-athletes completed at-home workouts is a major unknown.
  • Student-athletes will arrive at practice with widely varying levels of preparedness.
  • Student-athletes who are mentally tough will try to push themselves harder when they ought not, trying to fight through a level of adversity they are not physically capable of pushing through.

These variables alone — combined with many other unknowns — have created a situation that puts student- athletes in danger, and so coaches must be willing to change how they do their jobs.

“We have to think differently this year than in the past,” says Douglas Casa, Ph.D., ATC, FNAK, FACSM, FNATA. Casa is a professor of kinesiology, director of athletic training education and research associate for the Human Performance Laboratory at the University of Connecticut. He is also CEO of the Korey Stringer Institute. “Whatever their normal tradition is, coaches need to have a one-year hiatus on what they think is normal. These people have not been active all these months, officially. So the people who are going to be arriving in July to athletic performance training or practice are going to have the greatest variability that any coach has ever seen.”

Tolerance And Variety

Student-athletes who return to football practice in the summer are always coming back from 6-8 weeks off at the high school level. Some are going to be in exceptionally good shape this year. They took advantage of the time they had at home, having had more time to condition themselves than they’ve ever had before. The largest group of student- athletes by far will have performed some moderate amount of work under their “safer at home” orders. Maybe they had some weights or improvised workouts to keep themselves reasonably fit. There are going to be some student-athletes who did nothing for three or four months in a row. Their level of deconditioning is going to be alarming.


Now, coaches will be putting all those student-athletes into a position where they must compete and prove themselves under what will be a brutal summer sun. Bad things can happen in that environment under normal circumstances. Just think what could happen under the bizarre circumstances in which we currently live.

“You’ve got to remember that the most important factor to enhance your exercise tolerance — by far — is not heat acclimatization; your fitness is by far the most important factor,” says Casa. “So we always tell people to get fit first and get heat acclimatized second. You have to be thinking about the absolute basics, about a two-week window of just trying to get basic fitness up to speed and get people somewhat near each other before you even think about stressing them in the heat. Because we’re really starting from nothing. This really has to be a one-month window before I would even consider doing something really hard in gear and equipment.”

One key to success is making sure you aren’t making a student-athlete feel bad if they’re in the group that’s not doing particularly well or struggling. Not everyone needs to be at the same level of conditioning to be on the same team. Coaches might have three different groups out there: prepared, moderate and unprepared. Never belittle a student-athlete for the group he’s in. There are so many unknowns that if we put everyone in the same group and force average athletes to try to keep up with elite athletes, you could have a disaster on your hands.

“The deconditioning for athletes who haven’t done much athletic work over the past couple of months could result
in something catastrophic,” he says. “Their heat tolerance could be gone, and they might have put on more weight. So, their obesity or percentage of body fat might be higher than it typically would be. Those people are at the greatest risk. Coaches must feel comfortable partitioning people out based on their abilities when they come back. Then, slowly ramp them up and be super flexible. If someone’s struggling and not doing well, don’t go after them. Just think about why they might be struggling. Because another thing might be — let’s face the reality —almost every team in America or at least every high school in America is going to have one or two people who have COVID-19 or who have just recovered from it.”

Starting Slow

So, now it’s time to switch it into high gear, right? We must get ready for a long season, so it’s time to ramp up the intensity, right? At this point, most data-driven coaches would say, let’s gather the data and establish some baselines. Let’s get measurement going so we can really figure out how to push these kids, but Casa says that it’s still too early for that. Remember, the “new normal” is going to be far more new than normal. As a sports scientist, Casa says collecting data is the perfect thing to be thinking about. At the same time, as an athletic trainer, that concept scares him a little bit.

“Sometimes, you have coaches come back and say, okay, we’re going to do a 2 mile run to see where everyone’s at, just so we have an idea of fitness,” says Casa. “But the problem is, is that if you come back and have everyone doing that 2 mile run, as a group, you’re going to have that peer pressure there, you’re going to have varied fitness, and you might have some people who are just not ready to do a 2 mile run. And then if you do sprints, if anyone has sickle cell trait and hasn’t been training, they might be at the greatest risk at that moment.”

Instead, Casa says it would best to perform individual fitness assessments. Tell an athlete to run 1 mile. Don’t max out on your mile. Go hard, but don’t go all out. Find out what you’re capable of, and don’t push beyond your limits. Individual assessment will likely keep athletes far safer than if they are in a group of 30 guys and just trying to keep up, when it’s literally not possible — based on their level of fitness — without incurring some sort of injury.

“There is going to be so much variability,” he says. “I agree with the concept of knowing where someone’s fitness is, because then you can help them move forward. But, I would be careful. Don’t go and do 20 200 meter sprints just to see their recovery pace, because people are going to struggle.”

Besides, many high schools don’t even have the technology to collect that baseline data to begin with. Without that level of technology, coaches must go slow to go fast.

“For the first 7-10 days, I would consider not testing, just so we don’t go into this asking a completely deconditioned person to push himself maximally,” says Casa. “I don’t think there’s much to be gained by having to test on the first day, but I would consider just doing some good old fashioned conditioning and fitness work on the first 7-10 days, and then consider testing them. I just have a great fear of people testing all out when we haven’t seen them. These athletes are so mentally tough, some of them will push themselves into some dangerous situations.”

Observe And Act

Still, unless we are all willing to stay home and avoid others for the next year, we are going to need to be mentally disciplined enough to get back out there in a responsible way and come to terms with living under the threat of coronavirus. For coaches and athletic trainers, this means taking care to watch student-athletes closely and acting quickly if you see them in trouble.

It will be important to collect wet bulb globe temperature in your area in conjunction with using the heat acclimatization guidelines from NATA. Collecting actual data will certainly keep athletes safer.

At the same time, there are practical measures coaches and athletic trainers can take, common sense approaches to managing the safety of student-athletes.

“Modifying equipment usage, having more rest breaks rather than longer rest breaks, having shade available during those rest breaks, those are all things that should be done,” says Casa. “The biggest thing is the ‘red herring.’ You’re going to have certain people who are susceptible to risk on given days. For example, here’s a person who’s gone all out the last 850 days you’ve practiced with him, never has backed off, never has been a wimp, ever. This day, he’s struggling. Do you push him through that. No, you don’t push them through that day because he might be getting the flu or he might have started with a 103 degree fever that day. He might’ve just started a new medication you’re not aware of. Or maybe, he missed the last three nights of sleep because his mother is going through chemotherapy. If that person has always been amazing, we need to be really responsive to his struggles and not push him.”

Instead, coaches and athletic trainers need to pull that athlete to the side and ask what’s going on. If something’s up, you stop pushing. Coaches and athletes are never going to make gains on a day when the athlete is sick.

“That’s the message that’s even more amplified this summer,” says Casa. “We have to take safety precautions right now. Trust me, I’m not telling you to not push people through pain. I know people need to suffer to become a better athlete. I’m talking about the person who’s always tough and always fights and who is struggling at the moment.”

Get Cold Fast

If coaches and athletic trainers do run into a situation where a player is clearly struggling, preventing EHI is critical. Coaches must observe, act and treat it like the serious situation it is. EHI can be a life or death situation, and cold-water immersion immediately following collapse from heat stroke has been 100 percent survivable in every single heat stroke Casa has ever tracked.

“If someone gets in a cold water immersion tub within 10 minutes of collapse, no one has ever died from it in recorded history,” says Casa. “This is amazing when you think it’s one of the top three killers in basic training, laborers and for athletes of all the medical conditions. So it’s really as simple as a 150 gallon Rubbermaid tub. It’s $150 at a Tractor Supply, Home Depot or ACE Hardware. You need a water source, some kind of hose, some kind of spigot at your school.

“Then you need three coolers or four coolers full of ice. Almost every high school in America has an ice machine and you don’t have to dump the ice in until you need the tub. If you don’t use the tub for heat shock, you can still use that ice for treatment after practice for general therapy. It doesn’t have to go to waste. You fill the tub half full with water and then you put the coolers of ice in when you need it and it gets cold within two minutes.”

Almost all medical conditions that can kill high school athletes, whether they live or die will be decided within the first 10 minutes. Cardiac conditions, brain bleeds, heat stroke, sickle cell trait, anaphylactic shock, those things will be decided the first 10 minutes. That is generally before an ambulance can arrive.

“Unfortunately, I’ve been an expert witness on over 40 high school heat stroke death cases,” says Casa. “High schools lost every single case. The reason I’m mentioning this to prove a point is that the juries always feel that a tub, ice, and water is not too much to ask for. You’re paying a few hundred thousand dollars for coaches, equipment, field maintenance, custodians, landscapers, owning the property, all this stuff. The jury just can never rationalize that a couple hundred dollars wasn’t worth saving a kid’s life.”


National Athletic Trainers’ Association Inter-Association Task Force Preseason Heat-Acclimatization Categories and Guidelines

For the following heat-acclimatization categories and guidelines, a practice is defined as the period of time a participant engages in a coach-supervised, school-approved, sport- or conditioning-related physical activity. Warmup, stretching, and cool-down activities are included as part of the 3-hour practice time. All conditioning and weight-room activities should be considered part of practice. A walk-through is defined as a teaching opportunity with the athletes not wearing protective equipment (for example, helmets, shoulder pads) or using other sport-related equipment (for example, footballs, blocking sleds, marker cones).

First 5 Days

  • During the first five (5) days of formal football practices, walkthroughs were no more than one (1) hour in length
  • Double-practice days did not occur during the first five (5) days of formal football practices

Length Of Practice

  • Single-practice days consisted of practices no more than three (3) hours in length
  • Double-practice days consisted of practices no more than five (5) hours in length in total
  • No more than two (2) practices per day

Length Of Rest Breaks

  • A three-hour (3) recovery period occurred between the practice and walk-through (or vice versa)
  • Two (2) practices were separated by a break of at least three (3) continuous hours that was in a cool environment
  • Double-practicedayswerenotfollowedbyanother double-practice day
  • One day of complete rest after six (6) consecutive days of practice

Athletic Trainer Presence

  • Athletic trainer must be on-site before, during, and after all practices
  • Athletic trainer has ability to cancel/delay practice because of inclement weather/heat restrictions

Equipment Alterations

  • Helmet was the only equipment worn on first two (2) days of practice
  • During days 3–5, only helmets and shoulder pads were worn
  • All protective equipment was not worn until day six (6)

Contact Drills

  • Contact with blocking sleds was not initiated until day three (3)
  • Contact with tackling dummies was not initiated until day three (3)
  • One-hundred percent full-contact drills were not initiated until day six (6)

This article was written by Paul Markgraff, managing editor of AFCA Magazine.


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