With research mounting on the dangers of student-athlete concussions, a majority of states have ramped up their legislative efforts to get concussion-management laws on the books.
By the time high school football practice kicked off toward summer’s end, 31 states and the District of Columbia had passed a student-athlete concussion law. Eleven more have similar legislation pending. In late February, only 11 states had such laws.
“It is only a matter of time until there are data showing how these state concussion laws are preventing catastrophic injuries, saving lives, and preventing chronic outcomes from repeated concussion,” said Dr. Kevin Guskiewicz, the director of the Matthew Gfeller Sport-Related Traumatic Brain Injury Research Center at the University of North Carolina at Chapel Hill.
A concussion occurs when the head jostles back and forth rapidly, causing the brain to shift in the skull. Unlike broken bones, concussions leave no visible marks on people, which may cause some student-athletes to downplay the severity of their injuries.
In every concussion law passed so far, except for those of Idaho, Vermont, and Wyoming, some version of this idea appears: If a student-athlete is suspected of sustaining a concussion, he or she must immediately be removed from competition and obtain medical clearance before returning to play. That, in theory, would help counteract student-athletes’ trying to hide their symptoms to continue playing.
States like New Mexico, New York, and Oregon go further, requiring student-athletes to remain symptom-free. Some experts argue that the provision doesn’t pack much punch, though, as doctors are unlikely to clear a student-athlete who still exhibits signs of a concussion.
“Having persisting somatic, cognitive, and/or emotional symptoms is one sign of acute concussion,” said Christine Baugh, the research coordinator at the Boston University Center for the Study of Traumatic Encephalopathy. “What this means is that the symptoms are a sign that the athlete’s brain is still healing. Therefore, no doctor should clear a student-athlete to return to play if any symptoms are apparent.”
Symptoms include memory impairment, inability to concentrate, irregular sleep patterns, headaches, nausea, dizziness, and sensitivity to light or noise, according to the federal Centers for Disease Control and Prevention.
Roughly half the states with concussion laws require coaches—the ones responsible for recognizing the symptoms and removing players from practice or games—to undergo regular concussion-recognition training. A few extend the requirement to school nurses, athletic trainers, volunteers, and officials involved in interscholastic athletics.
All but six states—Colorado, Connecticut, Idaho, Nebraska, Oregon, and Wyoming—with concussion laws also require schools to issue concussion-awareness information to parents to sign and return before their children can take part in school athletics.
With the momentum for student-athlete concussion laws continuing to build nationwide, some experts believe there’s plenty of room for future concussion laws to develop further.
“All states’ laws have not been able to cover the spectrum, and I hope this is ultimately where we end up,” Dr. Guskiewicz said.
A Model Law?
An estimated 146,000 high school student-athletes sustained concussions in the 2008-09 school year, according to research from the Center for Injury Research and Policy, in Columbus, Ohio. That number jumped to about 187,000 in the 2009-10 school year, which can be partially attributed to higher concussion awareness and thus better reporting.
A recent study in the online journal Brain Pathology revealed that one traumatic brain injury, such as a concussion, suffered even in childhood, can cause permanent damage to the brain. Another study, recently published in the journal Pediatrics, found that a number of student-athletes’ deaths caused by head injuries would have been preventable with better equipment and more defined return-to-play guidelines.
The National Football League, which has encouraged all 50 states to adopt student-athlete concussion laws, calls Washington state’s 2009 Lystedt Law “model legislation.” It was named after Zack Lystedt, a former high school football player who nearly died on the field after he suffered a concussion and continued playing.
Specifically, the NFL points to three characteristics of that law that should appear in all states’ versions: requiring parents or guardians to sign a concussion-information form; removing student-athletes suspected of concussions from play; and making concussed student-athletes obtain medical clearance before returning.
Of the 31 states that already have laws, along with the District of Columbia, 25 meet the NFL’s criteria, as does D.C. (Colorado, Connecticut, Idaho, Oregon, Vermont, and Wyoming fall short.) Of the 11 states with pending legislation, only Michigan and New Hampshire don’t have bills that satisfy all three criteria.
In all states’ laws, a designated group—typically involving the state board of education, the health department, and the governing board for athletics—must design either a training course for coaches or a concussion-information system for parents, coaches, and student-athletes. Not all states require their schools to follow the model concussion-response protocols designed by those bodies.
While Colorado’s law doesn’t meet the NFL standard, it does include a feature that only a handful of states share: The rules extend past school sports, into private youth-sports organizations such as Little League and Pop Warner. Most of those states require private organizations to follow similar rules, if not carbon copies, of what all schools must do.
What’s Next?
Experts on concussions have come up with a number of suggestions to minimize the risks to student-athletes. The most prominent potential improvements on the horizon are:
• Baseline concussion tests. Administered before the start of a sports season, these tests are meant to measure the normal levels of brain activity in a healthy student-athlete. When a concussion is suspected, the athlete retakes the test, and a medical professional compares the results. The larger the difference in the responses, the higher the likelihood of a concussion. Recent research suggests baseline concussion tests are critical for accurate diagnosis, yet no state currently requires schools to use them.
“Athletes vary tremendously on these tests,” said Dr. Mark Lovell, the chief executive officer of ImPACT, a Pittsburgh-based company that issues baseline tests, “and if you don’t have a baseline, it is difficult to detect change in the case of mild or subtle injury.” Dr. Lovell stopped short of saying that states should require baseline testing, as he believes there hasn’t been enough time for schools, particularly in rural areas, to establish concussion programs.
• Return-to-play guidelines. A growing number of neuroscientists believe that once a student-athlete obtains medical clearance to return after a concussion, he or she should do so gradually. The 2008 Zurich Consensus Statement on Concussion in Sport recommended a five-step return-to-play process, in which athletes would have to remain symptom-free for 24 hours to advance through a protocol of light aerobic exercise, sport-specific activity, noncontact training drills, full-contact practice, and finally, return to play. No state currently mandates a specific return-to-play model.
Ms. Baugh of BU supports the same return-to-play model as outlined in the Zurich consensus statement. “If symptoms reappear at any time during this gradual reintroduction, the stepwise return-to-play system will allow for intervention and reduction of activity,” she said. “As all brain injuries are different, doctors should be sure to treat on a case-by-case basis rather than imposing an arbitrary time frame.”
• Mandatory training for adults. Ideally, experts say, coaches, school nurses, athletic trainers, and other adults involved in youth sports should undergo concussion training annually. Training should include information about concussion symptoms, recognition hints, and the dangers of returning to play before being fully healed.
Dr. Guskiewicz of UNC’s Gfeller center says that future concussion laws need a clearer description for “training in concussion management for clinicians.”
“This has been too vaguely written in some of the states’ laws,” he said, “and while difficult to police or regulate, it would eliminate the confusion and would improve care.”
• Extending coverage. Roughly a half-dozen states already extend their concussion laws beyond school sports, including to private youth organizations. Those states largely make the private sports leagues follow the same rules.
• Limiting contact. Ms. Baugh said that current laws fail to “limit the overall number of impacts incurred by these student-athletes, at least in any meaningful way.”
“With current research suggesting that the total number of impacts incurred (both concussive and subconcussive hits) can lead to degenerative brain disease down the road, it is imperative that we limit the total number of hits to the head taken by these youth athletes,” she said. “Because these athletes take more than half the hits in practice, limiting the number of ‘hitting practices’ is the easiest answer.”
Idling in Congress
Rhode Island has legislation pending that would define the exact kind of medical professionals who can clear student-athletes, require coaches to undergo training, suggest training for nurses, and make baseline testing mandatory.
And earlier this year, federal lawmakers reintroduced a bill in Congress that would require school districts to educate parents, coaches, and student-athletes about the risk of concussions, along with a “when in doubt, sit out” policy for those with symptoms. The bill has idled in a House subcommittee since late February.
