Sickle Cell Trait In Athletes “REAL LIFE” “A Common Sense Approach”

1. Sickle Cell Trait In Athletes“REAL LIFE”“A Common Sense Approach” Chris A. Gillespie, MEd, ATC, LAT

2. THE FACTS • Since 2000 exertional sickling is the leading cause of non-traumatic death in NCAA Football … All Divisions. • In FBS --- if you add heat, heart, and asthma --- Combined, match the total dead from sickling. • In the last 12 years there have been NO traumatic deaths in FBS; no catastrophic head injury; no catastrophic neck injury; no comotio cordis.  (although three deaths in non FBS schools – One cardiac non-trauma related AND two head injury related) • Not one single FBS football player in the last 12 years has died playing football. • Not one single FBS football player in the last 12 years has died practicing football. • They have ALL died PREPARING to play football … 4 in winter workouts, 4 in summer workouts, and 2 in September conditioning drills … ALL in STRENGTH/CONDITIONING SESSIONS!

3. NOT JUST COLLEGE or FOOTBALL • 2000 - 12 y/o male football, conditioning, Ohio • 2002 - 14 y/o female basketball, conditioning, Texas • 2004 - 15 y/o male football, pre-season practice, Texas • 2006 - 12 y/o male football, conditioning, Florida • 2009 - 16 y/o male football, conditioning, Maryland • 2010 - 15 y/o male football, pre-season practice, Florida • 2011 - 14 y/o male football, conditioning, South Carolina • 15 y/o male football, conditioning, Texas • 16 y/o male football, conditioning, Florida

4. HIGH SCHOOL FOOTBALL 2011 • 7 non-traumatic practice deaths • 5 were African-American • 3 deaths attributed to exertional sickling • 4th is suspected exertional sickling • 60-80% of African-American high school football players who collapsed and died in summer practices had SCT/sickling as a COD

5. Case Study • 1990 football season • 19 year old black male football player • Collapsed after running one and one half mile distance run • Complained of leg pain and mid & low back ache • Sickle cell crisis with acute exercise related rhabdomyolysis • Increased Creatine Kinase level (CK)

6. Rhabdomyolysis Definition: A disorder involving injury to the kidney caused by toxic effects of the contents of muscle cells.

7. Rhabdomyolysis Causes & Incidence Myoglobin is an oxygen binding protein pigment found in skeletal muscle. When skeletal muscle is damaged, myoglobin is released into the bloodstream. It is filtered out of the bloodstream by the kidneys. Myoglobin may occlude the structures of the kidney, causing damage such as acute tubular necrosis or kidney failure. Myoglobin breaks down into potentially toxic compounds, which will also cause kidney failure. Necrotic (dead tissue) skeletal muscle may cause massive fluid shifts from the bloodstream into the muscle, reducing the relative fluid volume of the body and leading to shock and reduced blood flow to the kidneys.

8. Creatine Kinase (CK)orCreatine Photokinase (CPK) An enzyme found predominantly in the heart, brain, and skeletal muscle. When the total CPK level is substantially elevated, it usually indicates injury or stress to one or more of these areas.

9. Normal Creatine Kinase (CK) Values Male: 38 - 174 units/L Female: 96 – 140 units/L

10. CK Levels A high CK, or one that goes up from the first to the second or later samples, generally indicates that there has been some damage to the heart or othermuscle. It can also indicate that your muscles have experienced heavy use.

11. CK Levels People who have greater muscle mass have higher CK levels than those who don’t, and African-Americans may have higher CK levels than other ethnic groups. Very heavy exercise (such as in weight lifting, contact sports, or long exercise sessions) can also increase CK.

12. What is Sickle Cell Trait? • Not itself a disease • Hereditary condition • One abnormal gene for hemoglobin (S) • Genetic type AS • Sickle Cell Anemia Disease is SS

13. Who has Sickle Cell Trait? • About 8-10% of the U.S. black population has sickle cell trait • Only about 1% have the disease • SCT is also found in non-blacks as well, but less frequently

14. For Many YearsAthletic Organizations… • Characterized SCT as a benign condition that does not affect the longevity of the individual

15. Genetics Education is the Key

17. Testing for Sickle Cell Trait? • Simple blood test • Mandatory vs. voluntary (changes) • What do we do if the test is positive? • Genetic Counseling • Health care issues • Work-out adaptation

18. Sickle Cell Trait – Medical Problems • Inability to concentrate urine normally • Blood in the urine • Spleen problems especially at high altitudes • Exercise related rhabdomyolysis • Exercise associated sudden death

19. Warning Signs • Leg pain • Back pain • Hematuria • Dehydration • Fatigue • A positive SCT test • When in doubt…..

20. Crisis – Time is of the Essence! • Must seek timely and appropriate medical care for the athlete who is potentially suffering from sickle cell crisis….This is a TRUEmedical emergency !

21. Proper Hydration & Hot Weather • Avoid dehydration • Acclimatization is key • Condition before athletic bouts begin • Do not exercise in a dehydrated state or during acute illness • Drink fluids “all day” • Know your athletes

22. Exercise and Work-Out Routine • CONTROVERSIAL • No running over 100 yards at any time! • Increased rest periods between bouts of exercise • Unlimited hydration before, during, and after exercise • Performance levels increase with these changes

23. Precautions per the Inter-Association Consensus Statement • Exclude from Day-1 conditioning tests • Slow, paced progressions of training • Allowing longer periods of rest and recovery between repetitions • Heat stress, dehydration, asthma, illness, and altitude create additional risk • Stop activity with onset of symptoms • Set a tone that encourages consideration for the athlete with sickle cell trait

24. Selectively Opting Out of Sports • All SCT positive athletes at Samford University since 1990 have been football players • In interviews with these athletes, we have hypothesized that athletes choose sports where they will excel • Athletes with SCT most likely cannot excel in sports with high aerobic demand so they opt out of these sports at an early age

25. Medical History Questions • Do any of your close relatives suffer from SCD or SCT? • Have you ever been tested for SCT? • If yes, was the test positive? • If yes, what have you done differently? • Do you fatigue more than your peers in aerobic related activities? • If yes, explain? • Have you ever selectively opted out of a sport or activity because of fatigue? • If yes, explain why and list the types of symptoms that you have had during these situations.

26. CONCLUSION • Most of the studies in this area have been done in the military setting • Most of the knowledge that we have gained in athletics is gained from anecdotal information • More studies regarding the risk involved in athletics must be done • An Inter-Associational SCT Task Force met in February 2007 to discuss ways to prevent the senseless deaths of athletes with Sickle Cell Trait. As a result the NCAA took some corrective action – but it’s not enough!

27. THE FACTS • Since 2000 exertional sickling is the leading cause of non-traumatic death in NCAA Football … All Divisions. • In FBS --- if you add heat, heart, and asthma --- Combined, match the total dead from sickling. • In the last 12 years there have been NO traumatic deaths in FBS; no catastrophic head injury; no catastrophic neck injury; no comotio cordis.  (although three deaths in non FBS schools – One cardiac non-trauma related AND two head injury related) • Not one single FBS football player in the last 12 years has died playing football. • Not one single FBS football player in the last 12 years has died practicing football. • They have ALL died PREPARING to play football … 4 in winter workouts, 4 in summer workouts, and 2 in September conditioning drills … ALL in STRENGTH/CONDITIONING SESSIONS!

28. Thank Youfor yourtime & attention!