Key points

Introduction

Although public knowledge and awareness of concussions has increased over the years, it is estimated that before 2009, up to 40% of concussed youth athletes were prematurely returned to play after concussions. This premature return to play is widely thought to have led to tragic results, as one study found that 71% of football players that suffered a catastrophic head injury received a previous concussion in the same season, and 39% were playing with residual symptoms from a concussion. Despite multiple published guidelines and educational campaigns, tragedies still occur in youth sports after concussions.

The national push for concussion legislation began with the story of one child. Zackery Lystedt was 13 years old when, in 2006, he suffered a concussion while playing in a middle school football game. When Zack was holding his head and slow to get up after a tackle, an injury timeout was called and he was assessed by his coach. No medical personnel was on the sideline, as is typical in many middle school games. Zack sat out the next 2 plays until halftime and returned to play in the third quarter. He had increasing symptoms but continued to play, only to collapse in his father’s arms after the game was over. He was airlifted to a level 1 trauma center, where he received craniotomies for bilateral subdural hematomas. Zack’s road to recovery has been long and incomplete, as he continues to struggle daily with cognitive impairments and spastic hemiplegia.

As the Lystedt family labored to find meaning in this injury, they were assisted by their attorney, Richard Adler, president of the Brain Injury Alliance of Washington at the time. Efforts to initiate change in concussion management began first with a statewide education program. This program was accomplished with help from the local National Football League team (Seattle Seahawks), one of their physicians (Dr Stanley Herring), and the Centers for Disease Control and Prevention (CDC) Heads Up concussion education and awareness program. However, it became apparent that education alone was not enough. Adler describes an “inconsistency gap” that remains even after education; coaches continued to have different levels of understanding surrounding concussion, and many did not recognize the seriousness of a brain injury.

Another issue is the lack of institutional memory. One coach or one athletic director may be well educated in concussion management, but when that individual leaves a program or a school, strategies and policies fail to remain in place, as they have not become institutionalized into the culture of the school or school district. The result is that different schools or school districts may have different policies regarding concussions. In this respect, some athletes may therefore be safer than other athletes. Additionally, the conclusion was reached that education alone does not change behavior, and only legislation combined with the educational effort would help make concussion awareness and management more uniform.

With help from the Brain Injury Alliance of Washington, The University of Washington, the Washington State Athletic Trainers’ Association, the Washington Interscholastic Activities Association, and many others, Washington State’s Engrossed House Bill 1824 (Zackery Lystedt Law) was passed unanimously on May 14, 2009. By January 2014, less than 5 years later, all 50 states and the District of Columbia had also adopted youth sports concussion laws. To put this in perspective, only 21 states require bicycle helmets for all children, and only 34 have a primary seat belt law.

Sports concussion laws are not designed for primary prevention but instead aid in proper diagnosis and management after an injury has occurred, thereby preventing the tragedies that may occur from premature return to play. To effect this, the Lystedt Law has 3 basic tenets :

• 1.
  

  Education of athletes, parents, and coaches

  
  
• 2.
  

  Removal from practice or play for a suspected concussion at the time of the suspected injury

  
  
• 3.
  

  Medically supervised return to play

With the exception of Wyoming, the laws in all other states and the District of Columbia also stipulate these 3 tenets. Wyoming only requires establishing protocols for education of coaches and athletic trainers (without specifying requirements) and to address restrictions from school events after suffering a concussion. It does not require removal of athletes from games or practices if they are suspected to have suffered a concussion, nor does it require medical clearance before return to play. For the purposes of this article, the term sports concussion law will be used to indicate adherence to these 3 tenets.

Introduction

Although public knowledge and awareness of concussions has increased over the years, it is estimated that before 2009, up to 40% of concussed youth athletes were prematurely returned to play after concussions. This premature return to play is widely thought to have led to tragic results, as one study found that 71% of football players that suffered a catastrophic head injury received a previous concussion in the same season, and 39% were playing with residual symptoms from a concussion. Despite multiple published guidelines and educational campaigns, tragedies still occur in youth sports after concussions.

The national push for concussion legislation began with the story of one child. Zackery Lystedt was 13 years old when, in 2006, he suffered a concussion while playing in a middle school football game. When Zack was holding his head and slow to get up after a tackle, an injury timeout was called and he was assessed by his coach. No medical personnel was on the sideline, as is typical in many middle school games. Zack sat out the next 2 plays until halftime and returned to play in the third quarter. He had increasing symptoms but continued to play, only to collapse in his father’s arms after the game was over. He was airlifted to a level 1 trauma center, where he received craniotomies for bilateral subdural hematomas. Zack’s road to recovery has been long and incomplete, as he continues to struggle daily with cognitive impairments and spastic hemiplegia.

As the Lystedt family labored to find meaning in this injury, they were assisted by their attorney, Richard Adler, president of the Brain Injury Alliance of Washington at the time. Efforts to initiate change in concussion management began first with a statewide education program. This program was accomplished with help from the local National Football League team (Seattle Seahawks), one of their physicians (Dr Stanley Herring), and the Centers for Disease Control and Prevention (CDC) Heads Up concussion education and awareness program. However, it became apparent that education alone was not enough. Adler describes an “inconsistency gap” that remains even after education; coaches continued to have different levels of understanding surrounding concussion, and many did not recognize the seriousness of a brain injury.

Another issue is the lack of institutional memory. One coach or one athletic director may be well educated in concussion management, but when that individual leaves a program or a school, strategies and policies fail to remain in place, as they have not become institutionalized into the culture of the school or school district. The result is that different schools or school districts may have different policies regarding concussions. In this respect, some athletes may therefore be safer than other athletes. Additionally, the conclusion was reached that education alone does not change behavior, and only legislation combined with the educational effort would help make concussion awareness and management more uniform.

With help from the Brain Injury Alliance of Washington, The University of Washington, the Washington State Athletic Trainers’ Association, the Washington Interscholastic Activities Association, and many others, Washington State’s Engrossed House Bill 1824 (Zackery Lystedt Law) was passed unanimously on May 14, 2009. By January 2014, less than 5 years later, all 50 states and the District of Columbia had also adopted youth sports concussion laws. To put this in perspective, only 21 states require bicycle helmets for all children, and only 34 have a primary seat belt law.

Sports concussion laws are not designed for primary prevention but instead aid in proper diagnosis and management after an injury has occurred, thereby preventing the tragedies that may occur from premature return to play. To effect this, the Lystedt Law has 3 basic tenets :

• 1.
  

  Education of athletes, parents, and coaches

  
  
• 2.
  

  Removal from practice or play for a suspected concussion at the time of the suspected injury

  
  
• 3.
  

  Medically supervised return to play

With the exception of Wyoming, the laws in all other states and the District of Columbia also stipulate these 3 tenets. Wyoming only requires establishing protocols for education of coaches and athletic trainers (without specifying requirements) and to address restrictions from school events after suffering a concussion. It does not require removal of athletes from games or practices if they are suspected to have suffered a concussion, nor does it require medical clearance before return to play. For the purposes of this article, the term sports concussion law will be used to indicate adherence to these 3 tenets.

Education

The first tenet of sports concussion laws is education of athletes, parents, and coaches. However, it is generally not specified how this education should occur. Implementation of educational programs for families and coaches is, therefore, somewhat variable. The Lystedt Law requires that, at a minimum, “on a yearly basis, a concussion and head injury information sheet shall be signed and returned by the youth athlete and the athlete’s parent and/or guardian prior to the youth athlete’s initiating practice or competition.”

Additionally, “each school district’s board of directors shall work in concert with the Washington interscholastic activities association (WIAA) to develop the guidelines and other pertinent information and forms to inform and educate coaches, youth athletes, and their parents and/or guardians of the nature and risk of concussion and head injury including continuing to play after concussion or head injury.” Many other states have taken a similar route by requiring education of coaches but without stipulating the specifics of how it should occur. This task is often given over to a statewide sports governing body. As will be discussed later, the Lystedt Law, as written, does not directly mandate education of coaches. This is true in many other states as well, whereas some have explicitly mandated annual education of coaches.

Removal from play

In keeping with the provisions of the Lystedt Law, “a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time.” Diagnosis and management of concussions is a medical issue, and only a health care provider is expected to evaluate an athlete to determine if a concussion has occurred. Coaches do not have the medical training to diagnose concussions and are not expected to do so. By stipulating that any athlete suspected of a concussion is removed from play, coaches need only to recognize when a concussion may have occurred and are not expected to rule in or rule out a concussion. Education of coaches often directly highlights the signs and symptoms that indicate a possible concussion and that require removal from play. Immediate removal of an athlete from play helps avoid devastating injuries such as second impact syndrome and subdural hematomas.

Return to play

In Washington, “a youth athlete who has been removed from play may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion and receives written clearance to return to play from that health care provider.” In Washington, the WIAA, as the governing body for most interscholastic activities, determined which medical providers it would accept as qualified to make return-to-play decisions. This action helped avoid debates about scope of practice during the legislative process, which may have slowed down passage of the law. In states that have specified which providers may provide clearance, contentious battles among provider types have been encountered during the legislative process. In rural areas, access to physicians may be limited. Therefore, it is important to identify other providers that can appropriately manage athletes in a timely fashion, allowing greater access to care and limiting potentially unnecessary restrictions to athletes. Although specific return-to-play guidelines are not specified in the law, the standard of care is a stepwise process that has been thoroughly discussed elsewhere, with at least 24 hours between each step.

Challenges in education

Educational initiatives do work to increase concussion knowledge and awareness, but the optimal method of delivery has not yet been elucidated. The CDC launched the Heads Up: Concussion in Youth Sports initiative in 2007. This program is an online toolkit with information for athletes, parents, coaches, and school administrators. There is also a section designed for physicians. This content is freely available on the CDC web site.

After reviewing the CDC Heads Up materials, 82% of high school coaches found the material helpful, and 50% said it changed their views on concussions. A similar study of coaches of youth sports showed that 77% of coaches reported that they were better able to identify athletes that may have suffered a concussion, and 63% reported increased recognition of the seriousness of concussions. However, these findings indicate that 23% of coaches still did not perceive youth concussions as serious, even after reviewing the material.

To be truly effective, any educational initiative must also change athlete and coach behavior. A study in Washington found that for 58% of parents and 30% of athletes, their only concussion education is signing the required information form before the start of the season. It is not yet clear how well this passive form of education assists in transfer of knowledge and, perhaps more importantly, how well this leads to actual changes in behavior. In fact, 1 year after the Lystedt Law, a survey of parents and coaches involved with youth soccer found that more than 90% knew that concussions were serious and could identify neurologic symptoms associated with concussions, but only 85% knew of the Lystedt Law and only 73% knew that written medical clearance was required before return to play.

Nearly all coaches receive multimodal information, and it may be that this method is more beneficial for learning information and for helping change behavior. Multiple other educational initiatives exist to help increase knowledge and awareness in student athletes, from web-based initiatives, to community outreach educators, to personal stories. The goal of these initiatives is to change behavior and encourage reporting of symptoms by alerting athletes to the dangers of concussions.

Challenges in athlete reporting

Several studies found that athletes still do not always report concussion symptoms, even after the passage of legislation. A concussion that is not reported cannot be treated effectively. In a study done in Washington state 1 year after implementation of the Lystedt Law, many athletes still stated they would not always report symptoms. Even athletes that can recognize the signs and symptoms of a concussion may be reluctant to report these symptoms to coaches for fear of being removed from play. Three years after passage of the Lystedt Law, 69% of athletes reported playing with symptoms (most commonly headache), and 40% of these athletes reported their coaches were not aware of their symptoms. A prospective study of female youth soccer players in Washington state from 2008 to 2012 found that 59% reported playing with symptoms both before and after the law was passed.

Other studies found that the most common reasons athletes do not report symptoms are not thinking it was serious enough, not wanting to be removed from play, and not wanting to let down teammates and coaches. Athletes also report thinking that they are expected to play through injuries and that because symptoms are sometimes nonspecific, they do not always want to report them to coaches. Studies find conflicting evidence about whether greater knowledge of concussions is associated with improved athlete reporting. One study of athletes ages 13 to 18 showed that younger athletes were actually more likely to report symptoms, raising the question of whether nonreporting is a learned behavior as athletes feel more pressure to perform. Legislation is one piece of the puzzle, but changing the culture of athlete reporting will likely take ongoing work.

Challenges in implementation

Schools and school districts that are regulated by interscholastic athletic associations already have procedures in place for policy implementation and education. For community and recreational leagues, however, their decentralized nature may make educational initiatives and compliance monitoring more challenging. Getting the word out to health care providers also takes time and effort. Three months after passage of the law in Illinois, almost one-third of pediatricians did not know the law existed, although 77% did provide written documentation about return to play guidelines as part of their usual concussion management. Presumably, awareness of the law has increased substantially in the intervening years, although this has not been studied.

Costs of implementation

The Lystedt Law was specifically crafted to be revenue neutral, indicating that there should be no extra cost to any state or local agency or to the school districts to implement the law. This was a key phrase to help the legislative process but is also a key concept for ongoing success of the law. Much of the educational component of the law has already been discussed above. Coaches’ education in multiple other subject areas was already required by the WIAA, so concussion education was able to be distributed with delivery systems already in place. Additionally, the informational sheet for athletes and parents/guardians and an educational video for coaches were developed by physicians at the University of Washington, with the help of an educational grant, which allowed both of these materials to be available for free on the WIAA web site. Physicians also volunteer to give in-person talks about concussion at least yearly at the WIAA Coaches School, again tapping into an educational program that was already in place.

Additional educational materials are available for free at multiple sites, most commonly through the CDC Heads Up program. This program now has specific educational materials for coaches, parents, athletes, game officials, school officials, and health care providers, with online training courses for high school coaches, youth coaches, and clinicians. The National Federation of State High School Associations also has free training for coaches.

One possible indirect cost of concussion legislation is that some schools or school districts may choose to have athletic trainers at practices and games of particularly high-risk sports as a response to legislation, but this is generally not mandated by the law. The presence of an athletic trainer helps ensure the health and safety of the athletes for any medical emergency that may occur, not just concussions, and is therefore a likely worthwhile cost.

Health care utilization

The law stipulates that athletes must receive clearance from a medical provider before return to play. It is presumed that this would lead to increased health care costs as well. With passage of the Lystedt Law in Washington State, a partnership was formed with the children’s hospital and the only level 1 trauma center in the state to ensure that even children without health care insurance could be seen and evaluated for concussions. With the interim passage of the Affordable Health Care Act, many more children now have health care insurance, thereby enhancing access to providers.

A study by Gibson and colleagues looked at health care utilization from 2006 to June 2012. Not all states had passed concussion legislation by this point, so comparisons between states could be made. They found that concussion-related health care utilization increased in all states after 2009 and increased by only 10% more in those states with legislation as opposed to those without. Even before institution of the Lystedt Law in Washington State, there was a nationwide upward trend in concussion-related health care utilization, and up to 60% of the increase seen after 2009 in those states without legislation is a continuation of that trend. The remainder is thought to be owing to elevated awareness after passage of the law. Interestingly, the rate of concussions seen in Emergency Departments and use of computed tomography scans did not increase, which would appear to indicate that athletes were seeking care through the appropriate channels in outpatient clinics.

Athletes seen for concussions may also incur increased orders for blood work, brain MRI, physical therapy, referrals to specialists, and neuropsychological testing. All of these lead to increased costs for families and insurers. Although many would argue that the increase in health care utilization is appropriate, as it indicates that athletes are now receiving reasonable and necessary medical care for their brain injuries, the financial effects that occur cannot be denied. Additionally, athletes that were merely suspected of suffering a concussion will also require a visit with a health care provider, and some of these athletes may not even have a concussion diagnosed after evaluation, again adding to the cost to the family.