Christopher Giza, MD, Gerard A. Gioia, PhD
Sarah Jane Brain Foundation Steering Committee

Introduction

Concussions are one of the most commonly reported injuries in children and adolescents who participate in sports and recreational activities. A concussion is caused by a blow or motion to the head or body that causes the brain to move rapidly inside the skull, resulting in neurobiological dysfunction.  This dysfunction commonly includes altered mental status, physical symptoms (such as headache, fatigue and dizziness), cognitive problems (such as memory disturbance and slowed thinking), emotional changes (such as irritability or sadness) and difficulties with sleep. Concussions can occur in any organized or unorganized sport or recreational activity and can result from a fall or from players colliding with each other, the ground, or with obstacles. Concussions occur with or without loss of consciousness, but the vast majority occur without loss of consciousness. The risk of catastrophic injuries or death increases when a concussion is not properly evaluated and managed. Continuing to play with a concussion leaves the young athlete potentially vulnerable to greater injury, longer recovery times, long-term functional deficits, or even death.

In an effort to improve the safety measures for student-athletes, a host of states in the US have introduced legislation to address the problem of concussions in youth sports. The states of Oregon (Max’s Law) and Washington (Zackery Lystedt Law) passed legislation mid-year in 2009. Since that time, a growing number of states have written legislation related to aspects of improving sports concussion management. As an organization of clinicians, researchers, educators and public health advocates, the Sarah Jane Brain Foundation (SJBF) would like to promote efforts to improve the existing needs in youth sports concussion management. These efforts fall within the purview of the Mild TBI Category of Care, which has identified concussion in youth sports as one important area of emphasis. Therefore, we have reviewed the available bills and developed three Core Principles that these bills collectively address. While the role of SJBF is not to develop or implement legislation per se, its unique collection of brain injury professionals and families across the entire country serves as a key network to assist and provide guidance to each state and jurisdiction in their efforts. Furthermore, the SJBF shares similar goals with other national organizations involved in the sports concussion field such as the American College of Sports Medicine, Centers for Disease Control, and National Federation of State High School Associations (NFHS) as well as other national and international bodies such as the Concussion in Sport Group, American Academy of Neurology, American Academy of Pediatrics and others – all of whom are making important efforts to improve the safety measures for student-athletes. The Zackery Lystedt Brain Project of the SJBF will use four main methods to advance these three Core Principles: a) public awareness, b) education and training, c) legislation and d) encouraging further research. Working collaboratively with each of these organizations is viewed as centrally important in our common goal of improving concussion safety for the youth student-athlete.

Three Core Principles

In examining the current legislation, and in considering the current state of the research and clinical guidance with respect to the evaluation and management of sport related concussions in youth, three Core Principles are proposed: 1) Education, 2) Identification/Protection and 3) Medical Evaluation.

Core Principle 1. Education of Key Stakeholders

The first Core Principle – education – is fundamental and clear in all of the legislative efforts. There is strong acknowledgement that a gap in knowledge and awareness exists amongst the key stakeholders with formal education as a solution. These stakeholders include the coach, parent and student-athlete. Education focuses on developing a working understanding of what a concussion is, recognizing its signs and symptoms, understanding the risks of not taking action, and knowing the appropriate steps to take when a concussion is suspected. A number of established training materials and programs currently exist for this specific purpose. An additional feature to the legislation is an education/ training verification process. For example, a post-test and certificate would be provided to the coach for completion of the training program. For the parent and student-athlete, a signed statement of completion and acknowledge of the concussion management program has also been proposed.

Core Principle 2. Identification and Protection of the Student-athlete

Equipped with the necessary knowledge of concussion signs, symptoms, and risks, Core Principle 2 gives rise to an action step - the coach, parent, and/or student-athlete must recognize the suspected concussion, and protect him/her from further harm by removal from the athletic event.

Core Principle 3. Appropriate Medical Evaluation and Return to Play

Once the student-athlete is removed from play, Core Principle 3 requires an appropriate medical evaluation of the concussion to be undertaken by a licensed heath care provider (LHCP) trained in the evaluation and management of concussion. The student-athlete is not allowed to return to practice or game play until receipt of a written evaluation and ‘clearance’ (i.e., full recovery criteria have been met).

Terminology:

While the specific definition of the following terms is subject to some debate, for the purposes of the Core Principles, the terms concussion, head injury, brain injury and mild TBI should be considered interchangeably.

Optional Points: Potentially beneficial points for consideration (good ideas but not ‘mandated key points’):

• Regular recertification of concussion education may be a valuable component of Core Principle 1.
• Education of school officials, nurses, counselors, and teachers may also be beneficial to identify concussed students and to facilitate recovery.  This point is thus related to all 3 Core Principles.

Caveats and exceptions (details to be considered in discussions about sports concussion legislation):

• Situations may arise when a suspected concussion evaluated immediately by a Licensed Health Care Provider turns out not to be a concussion.
• Although seemingly self-evident, LHCP that provides written clearance must be the one who actually evaluated the athlete.
• The precise definition of a LHCP may include different clinical specialties, but as a minimum should include only licensed clinical professionals with appropriate training/ experience in sports concussions/mild TBI.