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School Sport Concussions Draw National Attention as More States Draft Return-to-Play Laws


doi: 10.1097/01.NT.0000369542.29084.37
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A new organization has been launched to support the adoption of state laws to prevent high school athletes with concussions from returning to the field before they have been examined and cleared by a medical professional.

The need for state laws addressing concussions in high school athletes received prime-time exposure during the 2010 Super Bowl, with the launch of a new organization dedicated to speeding state legislation to prevent injured players from returning to the field before they have been examined and cleared by a medical professional.



The Zackery Lystedt Brain Project, the first nationwide initiative aimed at fostering such state legislation, was announced during the game in Miami.

The initiative, jointly sponsored by the Sarah Jane Brain Foundation and the American College of Sport Medicine, is named after Zackery Lystedt, a 13-year-old football player from Tahoma, WA, who suffered a catastrophic brain hemorrhage in 2006 after returning to a game after an earlier head injury. While the boy survived, he was in a coma for months.

Largely as a result of the incident, Washington state passed the nation's first return-to-play legislation in May 2009. Oregon and Texas quickly adopted similar measures, and Maine, California, Massachusetts, New Jersey, and New York are currently considering legislation.

Washington's law requires that any athlete injured in a head collision beremoved from play until they receive written clearance from a licensed medical provider. Certified athletic trainers who have been trained in the evaluation and management of concussion are included. The law also mandates educating coaches, young athletes, and their parents about concussion risks and symptoms.

While there has been no legislation at the national level, the House Judiciary Committee held a forum in Houston, TX, in early February, its third, to hear testimony on the issue and ways to reduce such injuries.

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Head injuries are relatively common in high-velocity contact sports, although their exact incidence in scholastic athletes is difficult to determine because many are not reported.

The Centers for Disease Control and Prevention estimates that there are 300,000 head injuries every year, while the National High School Sports-Related Injury Surveillance Study, the only major surveillance program for such injuries, reported that 68,000 concussions occurred during the 2008 high school football season. Of these, 16 percent of players who lost consciousness returned to the field the same day. Another study, by the Center for Injury Research and Policy at Nationwide Children's Hospital, found that 41 percent of 1,300 athletes with concussion symptoms returned to play the same day.

A study in the July 2009 issue of the American Journal of Sports Medicine by the National Center for Catastrophic Sports Injury Research, evaluated scholastic sport injuries over 13 football seasons between 1989 and 2002. In cases of a catastrophic brain injury, many students were playing with mild neurologic symptoms from an earlier head injury, the researchers found. In 35 of 59 cases where they were able to obtain information, players had experienced earlier head injuries and, of these, 71 percent occurred during the same season. Nearly 40 percent were playing with residual neurologic symptoms prior to the catastrophic injury.

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One of the study's authors, Robert C. Cantu, MD, told Neurology Today in a telephone interview that state legislation must include provisions for medical evaluation of any player with a head injury. Simply requiring coaches to be trained in recognizing concussion symptoms is not enough, he said.

“The coaches are not qualified to make return-to-play decisions before a player has been examined by a medical professional. ...These decisions need to be made by a doctor or certified athletic trainer,” said Dr. Cantu, a clinical professor of neurosurgery and co-director of the Neurologic Sports Injury Center at Brigham and Women's Hospital in Boston.

Dr. Cantu, who is also chairman of the department of neurosurgery at Emerson Hospital in Concord, MA, added: “I commend Washington for passing the first law, even if it took a $13 million lawsuit to make it happen. Sometimes good things do come from lawsuits.”

In 1986, Dr. Cantu developed guidelines that were adopted by the American College of Sports Medicine in 2006 and have become widely used. He also participated in development of practice guidelines published by the American Academy of Neurology in 1997. He is aware of only eight or nine states that have expressed interest in return-to-play legislation to date, while the Lystedt Brian Project hopes to have laws enacted in 24 states by the end of this year.

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Working with scholastic athletic head injuries can be difficult for neurologists, commented Tony L. Strickland, PhD, a clinical neuropsychologist and associate clinical professor of neurology at the David Geffen School of Medicine at the University of California-Los Angeles, who also directs the Concussion Management Clinic at the Sports Concussion Institute in Los Angeles.

“Unlike other patients, athletes tend to not report or underreport symptoms of concussion, while being at significantly higher risk of secondary injuries,” he told Neurology Today in a telephone interview. “It is critically important to be able to quickly determine the magnitude of any brain injury, through neurocognitive and other testing, in athletes under the age of 18 if we want to minimize risks of second-impact syndrome,” he said.

“Taking existing traumatic brain injury knowledge and simply applying it to youth and adolescent athletes is not enough, we need to continue development and application of evidence-based metrics to such injuries. That's why the concept of baselining is so important,” Dr. Strickland emphasized.



Such an approach would require that all scholastic athletes undergo standard neuropsychological and other testing, such as assessment of speed of mental processing, verbal and visual memory, and postural stability evaluations before each season. Their scores could then be used to more accurately identify changes after a suspected or observed head injury on the field. The technique has already been adopted in most major professional sports leagues in the United States, he noted.

“Baselining players is important because no two players are the same. It only takes about 25 minutes, and we can compare each player's scores before and after a concussion. This limits the Ouiji board approach to concussion management, and it's a quantitative and evidence-based approach that would also assist us in knowing when a concussion has resolved. We've adopted it in all of our professional contact sports – now we need it for the youth athletes.”

Another obstacle to improving management of scholastic sports injuries is that many players come from disadvantaged families who cannot afford health insurance, according to Dr. Strickland. He noted that Wells Fargo recently introduced the first insurance policy specifically for scholastic sports concussions.

“This removes the financial barrier for players to receive the specialty care they deserve, especially those from underprivileged communities who play high-velocity sports. The cost is very low – you can get $10,000 worth of coverage for about $4 per player per year, and it covers them across the entire season.”

If schools, communities, corporate organizations, individuals, or related stakeholders purchased such coverage it would protect players while giving neurologists the ability to provide quality care and be adequately remunerated for their time, he noted.

“Neurology is in a very unique position to help address this under-recognized public epidemic via helping to develop the standards for care in the emerging subspecialty of sports concussion management,” Dr. Strickland noted.



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• TORONTO, ON • APRIL 10-APRIL 17, 2010

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