Protecting youth sport participants by regulating treatment

During the past few years, orthopaedic surgeons around the country who cover scholastic and club athletic teams have learned that their state legislatures have passed laws mandating that every child who sustains a concussion must be cleared by a qualified health professional before returning to sports. These regulations are one component of a nationwide effort supported by multiple stakeholders, including the National Football League (NFL), to protect youth athletes from the sequelae of traumatic brain injuries.

As of October 2012, 40 states, the District of Columbia, and the city of Chicago have enacted legislation to address traumatic brain injuries in youth athletes, according to the NFL. Eight other states have bills that have been introduced or are pending. The model legislation for this movement is the Lystedt Law, which was passed unanimously in Washington state in May 2009. Named for Zackery Lystedt, a middle-school football player who was permanently disabled after returning to a game with a concussion, the legislation has the following three principal tenets:

• Immediate removal of any player suspected of having a concussion and the requirement that athletes be cleared by a healthcare professional trained in the evaluation and management of concussions before returning to play
• Mandated educational outreach to coaches, parents, and athletes
• A requirement that parents sign a form acknowledging receipt of information about concussions and the risks of concussion involved with sport

As codirector of The Boston University Center for the Study of Traumatic Encephalopathy and cofounder of the Sports Legacy Institute, an organization dedicated to the study, treatment, and prevention of the effects of brain trauma in athletes and other at-risk groups, Chris Nowinski is a researcher and advocate for bringing concussion injuries to national attention. He discussed the rationale behind concussion legislation with AAOS Now Editorial Board Member Howard R. Epps, MD.

Dr. Epps: Your personal story is very interesting. You played football at Harvard and wrestled professionally before head injuries forced you to retire and got you interested in understanding postconcussion syndrome and leading the effort to raise awareness on concussion injuries. Looking back, do you think things could have been different for you as you were coming through sports in high school and college?

Mr. Nowinski: No question about it; my sports experience would have been different with the protections we have today. I would have had less brain trauma. I would have had fewer concussions. It may have changed the way I played or the sports I played.

Dr. Epps: What is the history of the “three-tenet” legislative approach to concussions?

Mr. Nowinski: The first state to develop that legislative protocol was Washington, with the Lystedt Law. The folks in Washington put together a structure that was very successful and was adopted by various other states. The education aspect of it is different in each state. Some states have none and some states have comprehensive education programs for a lot of constituencies.

Dr. Epps: I understand there is also interest in moving toward implementing a hit count or something similar to try to limit the amount of exposure to head trauma.

Mr. Nowinski: Right. That is something the Sports Legacy Institute supports. The Lystedt Law and similar legislation are great for handling concussions when they are diagnosed and for education, but they are not really focused on prevention.

Prevention is always better than treating a concussion. So that’s the idea behind the hit count and the other programs we have. If we count pitches in baseball to protect the elbow, why aren’t we counting hits to protect the brain?

Dr. Epps: If we really want to prevent concussions, why don’t we just have kids switch to flag football or something where there is no contact?

Mr. Nowinski: True, but that is almost impossible with football and other contact sports. With children and with their parents’ consent, however, we can work to make them safer. We also hope that this information will guide people to safer sports or to creating safer sports in their communities. We shouldn’t allow sports to derail a child’s promising future, and right now we aren’t doing enough to protect them. This is life and death for some children, and for others it is a choice between two different futures.

Dr. Epps: When you say ‘we aren’t doing enough,’ are you referring to the quality of equipment or just overall exposure to injury?

Mr. Nowinski: I mean everybody—parents, medical professionals, coaches, administrators—isn’t doing enough to protect young athletes.

Dr. Epps: Today’s professional football players are so fast and strong, it seems almost inevitable that they will get badly injured. Is enough being done at the collegiate and professional levels to protect players?

Mr. Nowinski: The NFL is actually doing a pretty good job now. They are continuing to close the obvious gaps to make players safer. The problem is that safety measures require resources and infrastructure that aren’t available the further you go down. The people who need the least protection get the most, and the people who need the most protection get none. I mean the youngest kids in the poorest areas.

College sports is its own world, and generally has a poor educational program on concussion. Although football is a big money-maker for some schools, there appears to be little attention on the long-term health of the players.

Dr. Epps: When you say infrastructure in the NFL, what do you mean?

Mr. Nowinski: The NFL has a team of doctors, athletic trainers, a neuroscientist expert with every team. They have athletic trainers in the skybox watching the television feed just in case they miss concussions. They will call down to the medical staff who may have not seen it.

Dr. Epps: There is always that tension between wanting to win and protecting the players. Do you think the balance has shifted toward player protection now?

Mr. Nowinski: Player protection is vastly better than it was but it is certainly not perfect. Guys are still being pressured to play through the pain.

Dr. Epps: And guys want to play through, too, I assume?

Mr. Nowinski: They want to play through. Some do it knowingly and others don’t realize what risk they are taking.

Dr. Epps: What sports other than football and hockey are the most concerning?

Mr. Nowinski: All contact sports have risk; sports like soccer and lacrosse also have a higher risk of concussion that needs to be managed.

Dr. Epps: Do you think the wave of legislation has made a positive difference?

Mr. Nowinski: Legislation is clearly one of the most powerful tools we have for making children safer very quickly but it can only take us to a rational safety level. What’s necessary next is reform of individual sports.

Reaching Consensus on Concussion
The Fourth International Consensus Conference on Concussion in Sport met Nov. 1–2, 2012, in Zurich, Switzerland. Representatives from national and international sport organizations, including the NFL and the International Olympic Committee, discussed sideline assessment of concussion, diagnosis and return to play, difficult case management, management of pediatric concussion, long-term problems, and knowledge transfer and education. Organizers expect to develop practical, simple, easy-to-use tools for coaches, paramedic personnel on the sidelines, and others.

Additional information
Sports concussion
Ringing the Bell on Concussion Management
The 2008 Zurich Consensus Statement