The Problem: Increasing Incidence of Concussions in Youth-Sports
Youth-Sports provide unique and invaluable opportunities for the emotional, physical and psychological development of children and adolescents. In addition to the myriad health benefits of physical exercise, youth-sports help children to build self-esteem and learn conflict resolution as well as leadership and peer interaction skills. Unfortunately, increasing levels of participation, mean increased incidence of injury. In Canada and the U.S., popular sports like Hockey, Soccer and Football, expose participants to a high risk of concussive injuries. In Canada alone there has been a 58% increase in the number of emergency room visits for concussions since the period 2003-2004. While in the period from 2010-2011, children accounted for some 38% of all Ontario residents visiting emergency rooms for concussions. [1]
Concussions are especially dangerous in young athletes. Medical literature has revealed increased risks of short and long-term health repercussions, specific to youth and adolescent athletes who have suffered from concussions. [2], [3], [4] In fact, there are reports of cases where concussions in young athletes have resulted in permanent brain injuries and even death. [5], [6] This may be partly because concussions in young athletes go undiagnosed or may be unreported by the athlete. [7] Concussions in young athletes can be more difficult to diagnose because younger athletes may not be able to accurately describe their symptoms. This can lead to injured athletes receiving insufficient time to recover. This problem is exacerbated when an athlete suffering from an undiagnosed concussion is returned to physical activity or to the classroom prematurely.
One possible solution is a concussion management plan. Such a plan would require the establishment of concussion treatment protocols and the appropriate ongoing training in concussion identification and treatment, for all parties involved in youth-athletic decisions. This includes parents, coaches, trainers, assistants, athletic organizations and school boards. Legislation can be used to ensure that all stakeholders involved in youth athletics are employing evidenced based best-practices in the diagnosis and treatment of concussions.
This article discusses the use of concussion-safety legislation to better protect young athletes from the immediate and long-term risks of concussions. A legislative model is proposed and the advantages and limitations of existing concussion safety laws in the U.S. and Canada are compared to the model.
The Proposed Solution: Concussion Safety Laws
Concussion-safety laws can bridge the gap between treatments suggested in the most recent brain injury research and the safety standards implemented on the field of play. Medical research is constantly developing new and better ways to identify, diagnose and treat concussions. However, it can take a long time before research findings are routinized and adopted as safety standards on the field. The development of concussion-safety laws presents an opportunity for legislatures in Canada and the U.S. to be proactive in protecting their young athletes from brain injuries. Such laws could establish uniform standards and best-practices of care as well as mandating continuous improvement based on the most current medical knowledge. For example, literature suggests that cognitive baseline testing allows for more accurate measurement of the subtle cognitive deficits that can occur post concussion. [8] Rhode Island, which passed its concussion safety Act in 2010 [9], is already considering amendments to implement cognitive baseline testing as part of its concussion safety legislation. [10]
Concussion-Safety Law: A Legislative Model
For athletes under the age of 19, current medical literature suggests a standard of care for concussive injuries that includes the following minimum requirements:
The removal from play of a youth-athlete who is suspected of having suffered a concussion. (“If in doubt, sit them out.”)
Requiring that a youth-athlete who has suffered a concussion be cleared by a licensed medical professional trained in the evaluation and management of concussions, before returning to play or to the classroom.
In addition to these minimum requirements, effective concussion safety legislation needs to be enforceable. Legislation should also be capable of raising awareness on the issue(s) it seeks to address.
Attaching liability and/or civil or criminal penalties for non-compliance would make concussion safety legislation enforceable. While this would increase the administrative costs of enforcing and ‘policing’ the legislation, attaching penalties would encourage greater compliance and correspondingly reduce the risk of brain injury in young-athletes.
To increase the visibility of the issue of concussions in youth-sports, an effective concussion safety law should at least require that the parents or guardians of student athletes be regularly educated on the risks of concussive injuries and made to sign a release form stating the same. This will increase the shared sense of responsibility; parents who are aware of the associated risks are less likely to tolerate unsportsmanlike behavior or attitudes from their children or their children’s coaches. In the long-term, an increased level of awareness and shared responsibility should have a transformative effect by directly reducing the instances of concussions as well as facilitating better treatment in those instances when concussions do occur.
Concussion Safety Laws: The State-of-Play in the U.S.
With rare exception, U.S. State and federal legislatures have been particularly responsive to the need for concussion-safety laws. As of May 2012, 38 U.S. states along with the District of Columbia, had enacted some form of concussion safety law. Several of the remaining states have similar laws pending. At the Federal level, a concussion safety bill was introduced in the U.S. House of Representatives in 2011.
These laws are intended to better protect children and adolescents who are engaging in organized physical activity and to increase awareness of concussions as a serious injury. As such, federal and state concussion legislation has largely followed the legislative model of the Zackery Lystedt Law (Lystedt Law). Mr. Lystedt was a high school football player who suffered a permanent and debilitating brain injury after being returned to the field of play prematurely. Mr. Lystedt and his supporters successfully lobbied the Washington state legislature to pass a law, which would better protect student athletes from concussions. On May 14th 2009, the Zackery Lystedt Law (EHB 1824) was passed into law in the state of Washington. [11]
The Lystedt Law contains the two essential provisions suggested in our legislative model and an additional provision addressing the dissemination of information on concussion:
If a young athlete is suspected of having a concussion, he/she must be removed from a game or practice and not be permitted to return to play. When in doubt, sit them out.
A licensed health care professional must clear the young athlete to return to play.
Athletes, parents and coaches must be educated about the dangers of concussions each year.
Concussion Safety Laws: The State-of-Play in Canada
In stark contrast to the U.S., Canada’s first concussion safety law was only proposed in 2011. [12] Since that time, Ontario has become the first and only province in the country to pass concussion safety legislation with the amendments to its Education Act. Generally, Ontario’s amended Education Act includes the main provisions of the Lystedt Law, however the amendments go a step further and broaden the powers of the Minister of Education in the following ways:
Building awareness beyond schools about the dangers of concussions and how they should be managed.
Establishing a committee to provide advice on concussion prevention, identification and management in schools and to study how evidence-based resources can be best used.
Limitations of Current Concussion-Safety Laws/Additional Considerations
The existing concussion-safety laws in Canada and the U.S. represent an important first step in the use of legislation to protect young athletes from concussions. However the current legislation has three major limitations:
1. Uniform Implementation
Establishing uniform standards between U.S. states and between the U.S. and Canada would ensure that athletes competing across state or national lines would receive uniform care for concussive injuries. Presently, the wording of each concussion safety law differs between Ontario and the U.S. and between U.S. states.
2. Absence of Specialist Medical Personnel
In smaller towns and rural areas, access to medical specialists is limited. Current concussion safety laws do not mandate that medical personnel attending at the field-of-play or the hospital have any specialized training in the treatment of concussions. While such a requirement would better standardize care, it may also prove to be prohibitively expensive. In order to control costs, perhaps existing front-line medical personnel (paramedics and nurses) could be suitably trained to diagnose and manage student-athlete concusisons. This would give concussed athletes access to the specialist care that is needed post-concussion while managing the cost of such care.
3. Lack of Cognitive Baseline Testing
An important component of a concussion management policy is establishing a pre-participation baseline assessment of cognitive function. [13] The availability of such baseline data would allow for more accurate measurement of the subtle cognitive deficits that can occur post concussion. With the exception of proposed amendments to Rhode Island’s safety laws [14], most current concussion safety legislation in Canada and the U.S. stops short of requiring cognitive baseline testing.
Conclusion
Given the seriousness of concussions in young athletes and the increasing incidence of injuries in the under 19-age group, there is a need for standardized concussion safety laws in Canada and the U.S.
Ideally, such concussion-safety legislation would require the use of cognitive baseline testing and the presence of medical personnel specializing in the diagnosis and treatment of concussions at youth sporting events. However, the cost of implementing and enforcing such safety legislation uniformly across Canada and throughout the U.S. may be prohibitive.
At the most basic level, an effective concussion safety law intended to protect young athletes, should require that injured athletes be removed from the field of play and allowed to rest from cognitive and physical activity until cleared by a medical practitioner who is qualified to treat concussive injuries.
Perhaps a modified approach could be taken to control costs while still protecting young athletes. All organized youth sports could be required to meet the minimum concussion safety standards. Those sports in which the highest incidence of concussive injuries occur, could be subject to higher safety standards including the presence of appropriately trained medical personnel during games and the use of cognitive baseline testing for all athletes participating in those sports.
Layth is the Principal of Lucentem Sports & Entertainment Law in Toronto. He has extensive experience in the combative sports world. He has been the General Counsel for Kickboxing Canada since 2007. He can be reached at layth@lucentem.com
Paul is a recent graduate from the University of Toronto where is received is JD and MBA degrees. Paul interests in law school included international trade and human rights. Paul can be reached at paul@lucentem.com
[1] Ontario Ministry of Education, ” McGuinty Government Launches New Concussion Strategy” News Release (March 6, 2012) at subheading: Quick Facts < http://news.ontario.ca/edu/en/2012/03/protecting-student-athletes.html>
[2] Laura K. Purcell, “Evaluation and Management of Children and Adolescents with Sports-Related Concussion” Canadian Paediatric Society (January 1 2012) at para. 4.
[3] B. Patoine, “Sports Concussions & The Immature Brain;
Young Athletes May Be More Vulnerable to Mild Brain Injury” (accessed August 25th 2012) at paras 3-5
[4] T. Maugans, M. Grady, “Recovery From Concussions in Young Athletes May Take Longer Than Thought” (accessed August 25th 2012)
[5] P. Strom, ” Can Concussion Lead to High School Suicide?” (August 4th 2012)
[6] J. Frollo, “Three Years Later Lystedt Law protects Young Athletes in 34 States and D.C.” (May 2012), ,http://usafootball.com/news/featured-articles/three-years-later-lystedt-law-protects-young-athletes-34-states-and-dc.
[7] Supra note 3. At Subheading “Misconceptions and Under-Recognition”
[8] Dr. B. Fjordbak, “Protecting Student Athletes: Growing Number of States Pass Concussion-Related Legislation” (August 2011), at subheading: “Limitations”
[9] School and Youth Programs Concussion Act, S 2034.
[10] Amendments to the School and Youth Programs Concussion Act, H5440.
[11] Engrossed House Bill 1824 < http://apps.leg.wa.gov/documents/billdocs/2009-10/Pdf/Bills/House%20Passed%20Legislature/1824.PL.pdf>
[12] BILL M 206 — 2011 Concussions in Youth Sport Safety Act
[13] Supra at note 8
[14] Amendments to Rhode Island’s Laws would mandate the use of cognitive baseline testing.
