From the Legislature to the Field: "Return-to-Play" Laws and Youth Concussions

This post was written by Debra Gordon, MS. Debra is a seasoned health care communications professional who specializes in speaking, teaching and communicating about the U.S. health care system, health care reform and health policy. She has been a consultant since 1999. Previously, she was a newspaper reporter for The Virginian Pilot in Norfolk, Virginia, and the Orange Country Register in southern California, where she covered health and medicine. She is also the author, co-author or ghostwriter on more than a dozen health-related books.

Scientific research over the past decade has concluded that sports-related concussions, also known as traumatic brain injuries (TBIs), are hardly benign. These injuries can have lasting cognitive and behavioral effects — particularly in children and adolescents — that are even more devastating when players suffer a second blow, especially if they have not fully recovered from the first. However, many coaches and even parents often underestimate the amount of time that is necessary to recover after a suspected concussion, or the players themselves ask to return. [i],[ii]

Between 2001 and 2009, an estimated 173,285 children and adolescents 19 and younger were treated for a TBI in U.S. emergency departments, with the number increasing 62 percent during that time. Of the top five activities in which these injuries occurred, three — football, basketball and soccer — are sports-related. [iii] Indeed, a 2010 study estimated that 9 percent of all sports-related injuries in high school athletes were related to concussions. [i] The actual rate of sports-related TBIs, however, is likely far higher given that most concussions go unreported or are treated on an outpatient basis.

 

Mary J. Barron, Ph.D., assistant professor in the Exercise and Nutrition Sciences Department at the Milken Institute School of Public Health, is a certified athletic trainer. She says that one of the reasons concussions are so dangerous is that they are particularly difficult to identify, prevent and treat.

"You can't wear a brace for your head like you wear a brace for your ankle to prevent ankle sprains," Barron says. Further, the causes of a concussion have a lot to do with other forces beyond a simple impact; acceleration, deceleration and torsion all play a role, too. This means that treatment is equally complicated: "Just a doctor's note is not the golden ticket," she continues. "Just because you don't have symptoms [of a concussion] on Monday doesn't mean you're practicing Monday. You're probably not practicing until Thursday."

"Just a doctor's note is not the golden ticket. Just because you don't have symptoms [of a concussion] on Monday doesn't mean you're practicing Monday. You're probably not practicing until Thursday."

To address the significant public health threat posed by sports-related concussions in children, all 50 states and the District of Columbia passed so-called "return-to-play" legislation between 2009 and 2014. The laws vary, but nearly all states require education or training on concussion recognition and appropriate responses (although just 20 require that coaches receive such training). Most also require that athletes immediately stop playing if a concussion is suspected. Players may return to practice or competition only after a health care provider has evaluated and cleared them after a minimum of 24 hours. However, only slightly more than half of the states require that the health professional be trained in TBI identification or management. [iv][v]

The rapid implementation of public policy to address concussions is "unprecedented in the medical field," wrote the authors of a study evaluating the effects of the legislation. [vi] Unfortunately, the laws are too often based on shaky science and do not go far enough to prevent TBIs from occurring in the first place. [v]

The impetus for return to play laws

Washington State passed the first return-to-play law in 2009. Known as the Zackery Lystedt law, the legislation is named after the 13-year-old middle school football player who returned to play 15 minutes after suffering a concussion, resulting in a TBI that left him in a coma for nine months. He still remains in a wheelchair.

Washington's legislation is considered the "gold standard" for return-to-play laws, one that, an Associated Press investigation reported in 2014, just 21 states matched. The analysis also found that about a third of state laws don't reference which ages or grades are covered; few apply to recreational sports; some do not cover private schools; and nearly all lack any consequences for schools or teams that don't comply with the law. [vii]

Nonetheless, the laws appear to be having an effect. A study from researchers at the University of Michigan and the University of Washington compared concussion-related health care use before and after several states implemented the legislation, finding a significant increase in the rate of youth seeking medical attention for concussions, even in states that had not passed such legislation. The rate increase was significantly higher in states with return-to-play legislation compared to those without (92 percent versus 75 percent).

The authors concluded that increased attention to and awareness of the concussion issue led to greater use of concussion-related health care. Particularly important, they wrote, is that there was no corresponding increase in inpatient or emergency department visits, while office-based visits did increase. This suggests greater attention to potential concussions soon after the injury, reducing the risk that athletes will continue to play.

Lessons Learned

In 2013, the National Center for Injury Prevention and Control (NCIPC) conducted a case study evaluation on return-to-play implementation efforts in Washington and Massachusetts, interviewing stakeholders about what worked and what didn't. [viii] Among the key findings and recommendations:

  • Obtain stakeholder input (parents, health care professionals, athletic directors and trainers, coaches).
  • Build in time for planning and implementation. One suggestion: Provide a checklist for schools to ensure they are fully implementing all components of a state's specific law.
  • Consider a comprehensive approach to preventing injury, including athlete education to prevent concussions, such as blocking techniques. Require that athletes use protective gear and warm up appropriately before play.
  • Incorporate or recommend strategies for preventing concussions and other injuries among student athletes while developing implementation guidance or regulations.
  • Work to increase awareness of the law among coaches, parents and athletes, which can reduce resistance to implementation.
  • Provide access to return-to-play policies to recreational sports teams.
  • Increase student and parent awareness of the severe consequences of subsequent injury to reduce resistance to reporting symptoms.
  • Ensure that implementation and guidelines are based on the most recent science.
  • Identify local professionals with adequate training in concussion management.
  • Consider the importance of "return to academics." Medical organizations recommend a rest from cognitive activities as well as physical activities. "If you have a muscle strain, you try to limit working that muscle," Barron says. "If you do academic work [too soon after suffering a concussion], you're making the brain work harder, so it can delay the recovery."
  • Identify and provide the necessary resources to implement, monitor and evaluate the laws.

Return to Play Laws: Washington, Texas & Mississippi

The table below compares three return-to-play laws: Washington State, the first passed; Texas, considered one of the most stringent; and Mississippi, the most recent such legislation.

  Washington State (2009) Texas (2010) Mississippi (2014)
Concussion Oversight Team None Each school district or charter school participating in sports must have a team that develops a return-to-play protocol based on peer-reviewed scientific evidence. None
Guidelines and Education Requires that all school districts’ boards of directors and state interscholastic activities associations develop concussion guidelines and educational programs. Requires that the concussion oversight team complete continuing education courses at least once every two years. Requires the department of health to recommend a concussion recognition education course that is available online to provide information on the nature and risk of concussions in youth athletics.
Signed Concussion and Head Injury Information Sheet Required annually from parents and players. Required annually from parents and players. Required annually from parents.
Removal From Play Immediate removal if concussion suspected. Immediate removal if the coach, physician or other licensed health care professional, or the student's parent or guardian, suspects a concussion.* Immediate removal of any athlete who reports or displays any signs or symptoms of a concussion, followed by referral to a licensed physician, preferably one with experience in managing sports concussion injuries.
Return to Play Only after written clearance from a health care provider with specific training in the evaluation and management of concussions. Only after physician evaluation and written consent and completion of the return-to-play protocol. Student and parent must also sign a consent form confirming they are aware of the risks. Only after full recovery and clearance by a health care provider.
Legal Immunity Compliant school districts are immune from liability for injury or death of athletes participating in private, nonprofit sports events that occur on school property if the sports league provides proof of insurance and a statement of compliance with concussion management policies. School districts and charter schools are not immune from liability, but the members of the concussion oversight committee are. Schools, health care providers, school-related organizations and other entities are immune from liability if they have complied with the provisions of the act.

*Note: Texas joins Arizona as one of only two states that gives an athlete’s parent the right to remove him or her from a game if they suspect a concussion.

Conclusion

While return-to-play laws are certainly a step in the right direction in addressing the dangers of concussions among youth athletes, public health experts agree that they cannot be the only response to the problem. For instance, none of the laws ban certain movements or strategies that contribute to concussions, and none require data collection of traumatic brain injury. Barron cites the Mississippi law as one in particular that could use improvement; concussion education for parents and athletes as well as for coaches, should be required, and not simply recommended. Furthermore, Mississippi requires removal of a player who exhibits symptoms of a concussion, but Barron says the Texas law is much stronger in this regard because it mandates removal from play if a parent, guardian or health care professional so much as suspects a concussion, even in the absence of obvious symptoms.

There is no medical consensus on how long kids should stay off the field. [v] However, Barron recommends that communities and legislative policy err on the side of caution: “When in doubt, sit them out.”

The other important thing for communities to remember is that not all concussions are created equal — “We all react to injury differently,” Barron says — which means that treatment and recovery time must be tailored to the individual and the circumstances under which the concussion occurred.

Ultimately, Barron says, successful treatment and prevention of concussions is contingent upon policy that facilitates greater community awareness and support. “When someone is diagnosed with a concussion, it needs to be a team approach of how to deal with that concussion,” she says. “The doctor, athletic trainer, school nurse, administration, teachers [all need to] be on the same page.”

[i] Halstead ME, Walter KD. American Academy of Pediatrics. "Sport-Related Concussion in Children and Adolescents." Pediatrics. 2010; 126: 597-615.

[ii] Baugh CM, Shapiro ZE. "Concussions and Youth Football: Using a Public Health Law Framework to Head Off a Potential Public Health Crisis." Journal of Law and Biosciences. 2015; 2 (2): 449-458.

[iii] Gilchrist J, Thomas KE, Xu L, McGuire LC, Coronado VG. "Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Among Persons Aged Less Than or Equal to 19 — United States, 2001–2009." Morbidity and Mortality Weekly Report. CDC, 2011; 60 (39): 1337–1342.

[iv] National Conference of State Legislatures. "Traumatic Brain Injuries Among Youth Athletes." Available here.

[v] Harvey HH. "Reducing Traumatic Brain Injuries in Youth Sports: Youth Sports Traumatic Brain Injury State Laws, January 2009-December 2012." American Journal of Public Health. 2013 July; 103 (7): 1249-54.

[vi] Gibson TB, Herring SA, Kutcher JS, Broglio SP. "Analyzing the Effect of State Legislation on Health Care Utilization for Children With Concussion." JAMA Pediatrics. 2015; 169 (2): 163-168.

[vii] Fendrich H, Pells E. “AP Analysis: Youth Concussion Laws Pushed by NFL Lack Bite.” The Associated Press. January 28, 2015. Available here.

[viii] Centers for Disease Control and Prevention. “Implementing Return to Play: Learning from the Experiences of Early Implementers.” 2014. Available here.