State Experiences Implementing Youth Sports Concussion Laws: Challenges, Successes, and Lessons for Evaluating Impact

Abstract

While provisions of youth sports concussion laws are very similar, little is known as to how they are being implemented, factors that promote or impede implementation, or the level of compliance in each jurisdiction. We aimed to describe state experiences with implementation in order to inform ongoing efforts to reduce the harm of sports-related traumatic brain injury and to guide future evaluations of the laws' impacts and the development of future public health laws. We conducted key-informant interviews in 35 states with recently enacted concussion legislation. States varied considerably in their readiness and capacity for implementation. Factors facilitating implementation included existing partnerships, procedures, and resources; centralized implementation authority; prior related efforts; and involvement in the policymaking process by those now charged with implementation. Inhibitors included ambiguous statutory language, unclear delegation of authority, and compliance difficulties. Ongoing challenges persist, including primary prevention; determining which providers are qualified to make return-to-play assessments and contents of those assessments; compliance difficulties in rural and under-served areas; and unclear responsibility for enforcement. Despite the similarity of youth sports concussion laws, early evidence suggests there is considerable variation in their implementation. These findings are critical for ongoing empirical investigations to accurately evaluate the laws' provisions and to identify successful legal approaches to protecting young athletes.

A Multifactorial Approach to Sport-Related Concussion Prevention and Education: Application of the Socioecological Framework

“…26 Several groups have evaluated the implementation and effectiveness of state concussion laws. Lowrey and Morain 27 found more successful implementation in states where policymakers worked with stakeholders (eg, individuals in the state's department of public health) whose involvement in implementation aided in accounting for contextual barriers and facilitators. Two groups 28,29 found that implementation of the laws, including educational provisions for coaches, was associated with increased SRC knowledge among coaches.…”

The Legal Landscape of Concussion

“…Generally this is designated in 1 of 3 ways: (1) to a “licensed physician” (Alabama, North Dakota, South Carolina, and Texas), (2) to a “health care provider” (Arizona, Colorado, Delaware, Georgia, Kansas, Mississippi, Missouri, New Hampshire, Nevada, Oregon, Tennessee, Utah, Vermont, and Wisconsin), or (3) to a “licensed health care provider trained in the evaluation and management of concussion” (Alaska, Arkansas, California, District of Columbia, Florida, Hawaii, Indiana, Iowa, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, New Jersey, New Mexico, Ohio, Oklahoma, South Dakota, Virginia, and Washington). 11 …”

“…12 If a concussion is diagnosed but symptoms resolve, the athlete is not permitted to return to play that day. 7,11 In states with relevant concussion laws, only if the licensed healthcare provider determines by his or her full evaluation that there was no concussion can the athlete return to play on the same day as a suspected concussion. 5 The licensed health care provider should document his or her evaluation, clearance decision, and ongoing observation of the athlete (whether the athlete is cleared or not) throughout the rest of the contest.…”

The Four Stages of Youth Sports TBI Policymaking: Engagement, Enactment, Research, and Reform

“…Some of this research focused on evaluating the direct impact of such laws, 12 while other research focused on evaluating the engagement of key stakeholders prior to enactment 13 and the experiences of those charged with implementation at the state level. 14 Most recently, this journal devoted an entire symposium issue to evaluating multiple dimensions of such laws, and pointing to future uncertainties. 15 At the same time, advances in medical research, 16 and even the acknowledgment of sports associations, 17 suggested that, at a minimum, the initial interventions were a good place to start -with opportunity for reform to follow.…”