issue brief YOUTH SPORTS-RELATED CONCUSSION PUBLISHED DECEMBER 2019 The prevalence and negative consequences of sports-related concussions (SRCs) have led the Centers for Disease Control and Prevention (CDC) to consider SRC a major public health problem among children and young adults. KEY POINTS Studies have shown that state-level helmet and concussion laws result in a higher diagnosis rate for concussions and increased helmet use in children. Research indicates that the highest risk of concussion is among the youngest athletes, but Mississippi law only applies to school athletic events in grades 7-12 and does not cover recreational sports. Mississippi law does not address return to learn (RTL) protocols that make accommodation to help return children to the classroom after suffering a concussion. Research indicates sports-related concussions SRCs are under-reported, and Mississippi law does not require reporting for SRCs. Sports-related injuries are one of the most common causes of concussion in children and young adults. Outcomes associated with concussion are cognitive and behavioral issues that can be disruptive to a child’s life and ability to learn. Long-term impacts of WHAT IS A CONCUSSION? A concussion is an injury caused by direct concussions have been linked with slower recovery, persistent cognitive impairment, or indirect force to the brain precipitating a chronic traumatic encephalopathy (CTE), and chronic neuropsychiatric symptoms disruption of brain function accompanied such as depression. Concussion symptoms typically resolve within seven to ten by a range of symptoms and signs of altered cognitive function. Though the symptoms of days post-injury, with full recovery in most cases occurring within three months. In concussion can vary, typical symptoms are some cases recovery can last over three months up to several years. However, prior headache, imbalance, dizziness, memory concussions have been linked with subsequent concussions indicating susceptibility loss, cognitive slowing, photosensitivity, fatigue, and concentration difficulties. to repeat injury, especially during recovery. If not identified and managed, concussion can lead to brain swelling, permanent brain damage, and even death. Impact on Children and Young Adults Research indicates that the impact of concussions on children is severe given that their brains are still developing, making them more susceptible than adults to repeat WHAT IS SECOND IMPACT SYNDROME? Second Impact Syndrome occurs when a injuries. The symptoms and long-term impacts of concussions have been shown to second concussion happens before a first impair children academically. According to the CDC, concussion rates among children concussion has properly healed causing rapid ages 10-19 increased by nearly 100,000 in 2009 compared with 2001. According and severe brain swelling. This can occur days or weeks after the first concussion. to the Youth Risk Behavior Survey, SRCs affected about 2.25 million high school students in 2017. These numbers are likely underestimated given that reported data frequently does not capture injuries that would have qualified as a concussion if medical attention had been received. As of 2015, 113,136 children and young adults were participating in high school athletics in Mississippi. In the state, between 2015 and 2018 4,900 concussions were diagnosed in a clinical setting for children ages four to 19. The highest risk sports for concussion are basketball, soccer, lacrosse, baseball and softball, football, cheerleading, ice hockey, and horseback riding. Interventions such as helmets have been found to have a significant impact on mitigating severe 1 of 4 Center for Mississippi Health Policy � Brief: Youth Sports-Related Concussion � December 2019 traumatic brain injury (TBI) in sports like horseback riding, demonstrating a 96% A recent survey among Mississippi 4-H horse show participants found that when risk reduction for intercranial bleeding associated with wearing a helmet. Currently, asked whether minors should have to wear Mississippi’s concussion law does not address horseback riding and Mississippi a riding helmet in Mississippi anytime does not have a law specifically requiring the use of a helmet when riding on public they are mounted on a horse on public property respondents indicated an average property or at public events. favorability of 2.67 out of 5. FIGURE 1: CONCUSSION RATES BY SPORT AMONG HIGH SCHOOL AGED PARTICIPANTS Baseball, Softball 5-13% Basketball 10-13% Horseback Riding 10-15% Soccer 11-15% Football 17% Concussions comprise 91% of reported head injuries related to horseback riding. Cheerleading 20% Lacrosse 17-21% Ice Hockey 22% 0% 5% 10% 15% 20% 25% *Note: Rates indicate percentage of total injuries for each sport. Marar M., McIlvain N.M., et al. (2012). Epidemiology of Concussions Among United States High School Athletes in 20 Sports. The American Journal of Sports Medicine, 40(4): 747-755; Zuckerman S., Morgan C., et al. (2015). Functional and Structural Traumatic Brain Injury in Equestrian Sports: A Review of the Literature. World Neurosurgery 86 (6):1098-1113. Legislation and Policy Covering Sports-Related Concussion Legislation has been a long-standing effective way to institute protections for children from sports-related TBI since the 1990’s when states began to implement bicycle helmet laws. A study conducted in San Diego an average 84% rate WHAT IS “RETURN TO PLAY?” increase in helmet use among children after passage of a helmet law. After Return to play (RTP) guidelines are a Wisconsin’s sports-related concussion law was passed in 2012 a study found preventative measure focus on the standardization of regulations for sports that over half of the students who were aware of the law said the law would make organizations. Many require coaches, them more likely to report a concussion. States with sports concussion laws parents, and athletes to be educated on concussions. demonstrate a 10% higher health care utilization rate for diagnosed concussions than states without concussion laws. The American Academy of Pediatrics cites concussion laws as having a positive impact by increasing the reporting of symptoms and decreasing instances in which athletes are allowed to return to play after exhibiting symptoms of concussion. Overview of State-Based Approaches to Sports Concussion Laws Since 2007, all 50 states have enacted legislation to address youth sports-related concussions. As of 2017, over half of states require educational training for coaches, parents, and students on concussion recognition and awareness. Most states require a medical professional to examine and clear a player before they WHAT IS “RETURN TO LEARN?” Return to Learn (RTL) guidelines are measures can return to play. Over half of states have specific return to play (RTP) guidelines. that focus on total cognitive and physical rest Most state laws have RTP restrictions which set a minimum length of time for to ensure the concussed athlete is symptom how long an athlete must wait before returning to activity based on testing by a free before returning to full coursework. healthcare professional and require the athlete to be free of all symptoms. As a part of RTP guidelines, the CDC recommends baseline testing of all athletes to Identifying concussions quickly is important assess balance, brain function, and presence of concussion symptoms prior to because the risk of repeat concussions is the start of an athletic season. Currently, four states have baseline testing as a greatest in the first 24 hours post-injury. component of their RTP guidelines. 2 of 4 Center for Mississippi Health Policy � Brief: Youth Sports-Related Concussion � December 2019 Another common policy instituted among states focuses on athletes returning to school, often referred to as return to learn (RTL) guidelines. The accommodations offered by schools vary, but typically include reduced class time, modification of curriculum, and monitoring by academic staff. Presently, 12 states have laws that require a return to learn policy. The National Football League (NFL) and The CDC and American Medical Society for Sports Medicine recommend laws that National Collegiate Athletic Association include all sports and children of all ages. To date, 26 states have expanded their (NCAA) have adopted concussion protocols based on scientific research concussion laws to cover recreational sports, broadening the protective effect of published by medical professionals as their laws beyond school-based sports. Research indicates that the highest risk of part of the recommendations from the International Conference on Concussion concussion is among the youngest athletes, but only half of state concussion laws in Sports (ICCS). Several other medical applies to all grades (K-12). professional associations such as Society of Sports Medicine, National Trainers Most state laws do not have specific enforcement mechanisms, but do have Athletic Association, American Academy of Neurology, and American Academy of provisions that specifically grant immunity for medical professionals treating injured Pediatrics have adopted similar positions to athletes and others responsible for making decisions about whether an athlete can the ICCS. return to play. However, Oklahoma recently passed legislation under which game officials and team officials could face incremental penalties ranging from extra training to suspension for not removing an athlete from a game if suspected of a UTILITY OF ATHLETIC TRAINERS concussion in accordance with the current law. Only 53% of athletes who sustained a sports- related concussion at schools with low trainer availability underwent return to play A recent study found that athletes at high schools with high athletic trainer protocols, compared to 100% at schools with availability were more likely to be diagnosed with a sports-related concussion high athletic trainer availability. than athletes at schools with low athletic trainer availability. Several states have explored having athletic trainers present at all high school sporting events to increase concussion identification. Arkansas and North Carolina recently developed a task force to look into how to increase the number of trainers available to provide services in the state and Oklahoma’s State Board of Health supported a resolution to make athletic trainers available to all high schools in the state. Mississippi’s Sports-Related Concussion Law Mississippi sports-related concussion law does the following: EDUCATION FOR COACHES According to the Mississippi High School Requires each local school board, administration of private schools, and Activities Association (MHSAA) School Safety Protocols all head coaches are required to governing bodies of charter schools to adopt a policy on concussion take a concussion course under the National management and return to play policy. Federation of State High School Associations (NFHS) curriculum. Requires removal of an athlete from play for one day if they display any symptoms or signs of concussion, and prevents the athlete from returning to play or practice until symptoms have fully resolved and they have been cleared by a health care provider. Requires parents to receive and sign a copy of the school’s concussion policy. Applies to school athletic events for grades 7-12. Provides immunity regarding concussion protocol enforcement for private and public schools, school employees, health care providers, school and school district membership organizations and associations, private clubs, public recreational facilities, and athletic leagues. 3 of 4 Center for Mississippi Health Policy � Brief: Youth Sports-Related Concussion � December 2019 Discussion Legislation has a significant impact on the likelihood of athletes disclosing a A SIGNIFICANT PUBLIC HEALTH ISSUE Medical professional organizations such possible concussion, getting patients to go to concussion clinics earlier, and as the National Academy of Medicine, speed of recovery. Mississippi’s concussion law does not currently address or American Medical Society of Sports apply to: children not between 7th and 12th grades; concussion education for Medicine, National Trainers’ Athletic Association, American College of athletes; recreational sports, baseline testing; appropriate equipment for all Sports Medicine, American Academy sports where concussion is a risk; implementation of return to learn guidelines of Neurology, and American Academy that prioritize returning to the classroom before returning to play; require of Pediatrics support the Center for Disease Control and Prevention’s reporting of incidences of concussions; safe play rules; or athletic trainer assessment that youth SRC is a availability. significant public health issue. Most of the gaps in Mississippi’s policy approach to concussions could be filled with minimal financial expenditure or resource allocation. For example, changing the law to apply to children of all ages and recreational sports would cover the most at-risk population, regardless of whether they are participating in scholastic-based sports or recreational leagues, at minimal cost to the state. Other policy changes, such as mandated reporting could be accomplished with current resources. Making athletic trainers available for all high school athletic events would likely require state expenditure and should be weighed against the research showing trainers are a valuable resource to help identify concussions. An important question is how to enforce the state’s concussion law. States like Oklahoma and Arkansas have provisions in their laws requiring enforcement, but these states are the minority. All states provide immunity for those responsible for carrying out the law but states struggle to decide how to mandated adherence. 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(2016) Interassociation Consensus: Diagnosis and Management of Sports-Related Concussion Best Practices. Available at https://www.ncaa.org/sites/default/files/SSI_ConcussionBestPractices_20170616.pdf Center for Mississippi Health Policy 1 of 2 � Appendix: Youth Sports Related Concussion � November 2019 @mshealthpolicy Center for Mississippi Health Policy � Brief: Youth Sports-Related Concussion � December 2019