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States’ youth concussion laws vary in strength

PHOENIX – Criticized for its own handling of head injuries, the NFL launched an extensive lobbying campaign to pass laws protecting kids who get concussions while playing sports. The result: Within just five years, every state had a law on the books.

But are the laws strong enough?

An Associated Press analysis of the 51 youth concussion laws – one in each state and the District of Columbia – found that fewer than half contain all of the key principles in the initial bill passed in Washington state in 2009. That measure mandated education for coaches about concussion symptoms, removal from a game if a head injury is suspected, written clearance to return, and a concussion information form signed by parents and players.

About a third of the laws make no specific reference to which ages or grades are covered. Even fewer explicitly apply to both interscholastic sports and rec leagues such as Pop Warner or Little League. Certain laws make clear they cover public and private schools, others refer only to public schools, while some don’t say at all. Almost all lack consequences for schools or leagues that don’t comply.

New Mexico’s law, signed in 2010, covers high school and middle school athletes. It requires education for coaches, signed information forms by both the athlete and the parent or guardian, removal from a contest if a concussion is suspected and that he or she is held out for one week. It does not require a signature from a concussion specialist specifically for the athlete to return to play or practice. It does not cover rec leagues.

“We did make compromises … in some states where we wanted to get something. A ‘B’-level law, as opposed to an ‘A’-level law,” said NFL Senior Vice President of Health and Safety Policy Jeff Miller, who testified about concussions before Arizona’s Legislature on Tuesday while in town for the Super Bowl.

“Better to get something good, and get something in place,” Miller said, “as opposed to shoot for something fantastic in all places – and fail.”

The laws were passed with remarkable speed, but many were weakened because of concerns about cost. Jay Rodne, the Republican who sponsored Washington’s initial law, said putting expensive enforcement mechanisms in the bills would have caused many to fail.

Judy Pulice, in charge of state legislation for the National Athletic Trainers’ Association, helped guide the NFL as bills were written and was disappointed that the final products didn’t include penalties for noncompliance.

“What happens if you don’t pull the kid out of the game? What happens if you put them back in with no medical release?” Pulice said. “Nothing happens.”

The AP’s review of the laws passed after Washington found that only 21 have all four of the requirements in the model legislation.

All but two of the laws call for the immediate removal of an athlete from a game or practice if a concussion is suspected. All but four contain language about education for coaches.

Yet only 34 say that before returning to action, an athlete with a head injury must have written clearance from a licensed health care provider trained in the evaluation and management of concussions. Just 30 mandate that a concussion information form be signed both by the athlete and a parent or guardian.

“They don’t all have the (main) principles. Not every state has the same bite as Washington state,” said Dr. Richard Ellenbogen, chairman of neurological surgery at the University of Washington and co-chairman of the NFL head, neck and spine committee.

He treated Zackery Lystedt, the middle school football player who nearly died after getting two concussions in a game. Washington’s law was named for the teen.

After that landmark bill was passed, Ellenbogen recalled, he had a conversation with NFL Commissioner Roger Goodell about efforts to replicate the legislation.

“The commissioner asked me, ‘What do (you) want to get out of this?’ I said, ‘I want to see, in my lifetime, 10 more states pass a Zack Lystedt law,’ ” Ellenbogen said. “And he said, ‘No. We’re going to get all 50 states. And we’re going get them in under five years.’ ”

Goodell pushed for the laws at a time his league was facing almost daily reminders of concerns about the link between football and head injuries.

Researchers studying brain tissue of deceased former players such as Junior Seau and Dave Duerson, who both committed suicide, found signs of a degenerative disease also found in boxers and often connected to repeated blows to the head. Thousands of ex-players sued the league, saying it didn’t do enough to inform them about, and protect them from, concussions. President Barack Obama suggested fans might have a guilty conscience while watching football.

Against that backdrop, Ellenbogen said, the NFL held weekly conference calls with state legislators, doctors and other advocates. Miller, who led the lobbying, estimated the effort cost hundreds of thousands of dollars.

Their success was swift. By comparison, it took more than twice as long to get mandatory seat belt laws passed in 49 states; New Hampshire still doesn’t have one for adults.

“We wouldn’t have had 50 states pass these laws,” Ellenbogen said, “if it wasn’t for the financial backing and political gravitas of the NFL.”

Goodell wrote 44 governors whose states had not enacted laws. He spoke about the topic at Harvard’s School of Public Health and in an address to the Congress of Neurological Surgeons.

And when, a few days before last year’s Super Bowl, Mississippi became the last state to finalize its law – albeit a measure missing elements – the league patted itself on the back, saying it had “actively advocated” for the regulations.

In October, the NFL trumpeted that Goodell would accept the Brain Injury Alliance of Washington’s 2014 Leadership Award.

Now the question becomes how effective these laws might be in a country where, according to the Centers for Disease Control, nearly a quarter-million people under 19 were treated in emergency rooms for nonfatal, sports-related concussions in 2009.

For 10 years, Dr. Dawn Comstock has collected data from athletic trainers at hundreds of U.S. high schools, and she is comparing state-by-state concussion statistics from before and after each law was enacted to try to understand the practical effect the legislation is having.

“I’m sensitive to people getting a false sense of security,” said Comstock, of the Colorado School of Public Health at the University of Colorado Anschutz Medical Campus. “It’s great what (state lawmakers) did. But has it made a difference for any player playing any sport?”

Larry Cooper, athletic trainer at a school for grades 7-12 outside of Pittsburgh, charts concussions reported in all sports.

In the 2007-08 academic year, three years before Pennsylvania passed its law, there were 10 concussions reported at his school, he said. That rose to 15 in 2013-14, and 18 already in 2014-15.

“Parents and student-athletes are much more aware of signs and symptoms,” Cooper said.

State Education Signature Removal Signed All Rec. League Age Bill Signed Notes and Details
AL yes yes yes no no yes no reference 2012 A separate bill that would have kept an athlete with a concussion out a minimum of seven days did not make it out of committee.
AK yes yes yes yes yes no no reference 2011 Establishes a traumatic or acquired brain injury program and registry within the Department of Health and Social Services.
AZ yes yes yes yes yes no no reference 2011 Includes language that allows athletes to return to action the same day if initial suspicion of a concussion is not confirmed. Specifically notes that it does not apply to out-of-state athletes competing in Arizona. A bill introduced in January 2015 wants to “proclaim August 20, 2015, as Concussion Awareness Day in the State of Arizona.”
AR yes yes yes yes yes yes under 19 2013 Rare example of state legislation that includes all the basic tenets of the model legislation, applies to public and private schools, and to clubs, and to anyone participating if most are under 19 years old.
CA no yes yes yes no no MS, HS 2014 Latest amendment adds “a graduated return-to-play protocol of no less than seven days in duration under the supervision of a licensed health care provider.”
CO yes no yes yes no yes 11 thru 19 2011 Each volunteer coach for youth sports must complete an annual concussion recognition education course.
CT yes no yes yes no no no reference 2014 Does not require student signature on release form; does requires all parents and students to attend concussion awareness class.
DE yes yes yes no-x no no ES, MS, HS 2011 Preamble says “the National Football League and the National Athletic Trainers’ Association have announced a joint effort to promote legislation to raise awareness and protect youth athletes from the risk of concussions.”
DC yes yes yes no-x no yes 18 and under 2011 Applies to anyone 18 and under, covers public and private schools, and club sports, but includes no requirement that the health care provider who must provide written clearance has training in the evaluation and management of concussions
FL yes no yes yes no yes no reference 2012 Creates Sports Medicine Advisory Committee including eight physicians and three athletic trainers.
GA no no yes yes-y no yes 7 thru 19 2013 Specifies that it does not apply to college, church or synagogue activities, but says those are “strongly encouraged” to set up concussion policies.
HI yes yes yes yes yes no 14 thru 18 2012 Bill introduced in 2014 would’ve prohibited someone diagnosed with a concussion from engaging in contact sports for 30 days, but failed in committee.
ID yes no yes yes-y no no 18 and under 2012 An amendment that was introduced but not made law would have allowed return to play on same day in some cases and specifically prevented parents from acting as “qualified health professional.”
IL yes no no no no no no reference 2011 Puts all concussion management in the hands of the state high school sports association and individual school districts. A 2013 bill that would have made it state code did not pass
IN yes yes yes yes yes no HS only 2014 Original law passed in 2011; update in 2014 adds that athlete must be held out for at least 24 hours and adds concussion classes for coaches.
IA yes yes yes yes yes no HS only 2011 Applies to “any extracurricular interscholastic activity, contest, or practice, including sports, dance or cheerleading.”
KS yes yes yes no-x no no MS, HS 2011 A 2012 bill that died in committee would have added the specification that the athlete needs to be evaluated by a health care provider trained in the evaluation and management of concussion injuries.
KY yes no yes no-x no no all school ages 2012 Original version of bill limited reach to high schools, but that was amended to broaden its reach to “interscholastic” athletes.
LA yes yes yes yes yes yes 7 thru 19 2011 Does not apply to colleges or to “an activity which is entered into for instructional purposes only … or a lesson.”
ME yes yes yes yes-y yes no no reference 2012 Law does not establish a policy; instead directs the state’s Commissioner of Education to adopt a model policy that must include basic tenets. While the law mentions “written” clearance before an athlete can return to action, the eventual Department of Education guidelines do not.
MD yes yes yes yes yes yes under 19 2011 A bill introduced in 2014 that died in the House would have implemented a program to have players on one high school football team in each county wear concussion impact sensors.
MA yes no yes no-x no no no reference 2010 Covers marching band members. Legislation that was introduced in 2013 but died in chamber would have required baseline concussion testing for all high school athletes.
MI yes yes yes yes yes yes under 18 2012 Covers “participation in physical education classes that are part of a school curriculum.”
MN yes no yes yes no yes 18 and under 2011 After initial online training about youth sports concussions, coaches and officials need follow-up online training “at least once every three calendar years thereafter.”
MS no no yes yes-y no no grades 7-12 2014 Says an athlete removed from a practice or game because of a concussion can’t return that day “regardless of whether the athlete appears or states that he or she is normal.”
MO yes no yes yes no no no reference 2011 Requires statewide athletic organizations with a public school district as a member to publish an annual report on student-athletes’ concussions.
MT yes yes yes yes yes no no reference 2013 Law called “The Dylan Steigers Protection of Youth Athletes Act,” in memory of a football player from the state who died after a brain injury during a spring scrimmage at Eastern Oregon University.
NE yes no yes yes no yes 19 and under 2011 Law makes clear it does not require schools or other youth sports organizations to “provide for the presence of a licensed health care professional at any practice or game.”
NV no yes yes no-x no yes 18 and under 2011 Specifies that it does not prohibit counties or cities from adopting a similar ordinance governing skiers or snowboarders
NH yes no yes yes no no grades 4-12 2014 Original law passed in 2012, updated in 2013 to change from grades 9-12 to 4-12, updated in 2014 to add distribution of concussion information sheets but no signature required.
NJ yes yes yes yes yes no grades K-12 2010 Resolution in 2011 urged school districts to implement baseline cognitive testing.
NM yes yes yes no-x no no MS, HS 2010 Athletes held out for a minimum of one week after brain injury.
NY yes no yes no-x no no no reference 2011 Law proposed in 2015 in New York City would require doctor to be present at all games and doctor or athletic trainer at all full-contact practices.
NC yes yes yes yes yes no MS, HS 2011 Requires every school to keep records of its compliance with head injury regulations
ND yes yes yes yes yes no no reference 2013 Amends law passed in 2011 to specify that written authorization clearing an athlete to return to practice or competition must be kept by the school district or school for seven years after the student is no longer enrolled.
OH yes no yes no-x no no no reference 2014 Updates original 2012 law to require physicians who conduct assessments to meet minimal educational requirements, but makes no specific mention of a head-injury expert.
OK yes yes yes yes yes no MS, HS 2010 A bill that was introduced in 2014 but expired would have introduced penalties for athletic trainers, coaches or referees who allow an athlete to return to action the same day as a concussion, including suspensions of one month for a first violation, of the rest of the season for a second, and permanent suspension for a third.
OR yes no yes no-x no yes 18 and under 2013 Original law passed in 2009 applied only to schools and was missing some basic elements; the later version is more comprehensive but applies to non-school youth sports leagues.
PA yes yes yes yes yes no no reference 2011 Penalizes coaches for violating rules, including suspension for rest of the season for a first violation, for the rest of the season plus the following season for a second, and permanent suspension for a third. Another bill introduced in 2011 that died in committee would have required baseline testing.
RI yes yes yes yes yes no 19 and under 2014 Original law passed in 2011 “encouraged” baseline testing. Updated law adds language requiring school nurses to get concussion education and encouraging teachers to.
SC yes no yes no-x no no MS, HS 2013 Athlete can return to action on same day if on-site evaluation does not confirm suspicions of concussion.
SD yes yes yes yes yes no HS only 2011 Applies only to high school athletes. Coaches should complete a concussion training program each academic year.
TN yes no yes yes no yes ES, MS, HS 2013 Athlete required to sign consent form only if 18 or older.
TX yes yes yes no-x no no no reference 2011 Calls for concussion oversight teams with at least one physician and, “to the greatest extent practicable,” at least one athletic trainer, advanced practice nurse, neuropsychologist or physician assistant with training in concussion evaluation and treatment.
UT yes no yes yes no yes under 18 2013 Notes that “sporting event” does not cover the use of lift tickets or passes at a ski resort or a ski or snowboarding class or school at a ski resort, “unless the skiing or snowboarding is part of a camp, team, or competition that is organized, managed, or sponsored by the ski resort.”
VT yes yes yes yes yes no ES, MS, HS 2013 Schools should notify a parent or guardian within 24 hours if an athlete on one of its teams gets a concussion. For a high school “collision sport,” the home team should have a health care provider, who should notify the visiting team’s athletic director within 48 hours if a visiting athlete gets a concussion.
VA yes yes yes no-x no yes no reference 2014 Athletes evaluated by appropriate licensed health care professional as determined by Board of Education; does not specifically mention training in evaluation and management of concussions
WA yes yes yes yes yes yes no reference 2009 The original youth concussion state law, signed by the governor on May 14, 2009, known as the Zackery Lystedt law. The opening section of the legislation pertains to limiting liability of a school district for the injury or death of someone in a recreational league on school property.
WV yes yes yes yes yes no MS, HS 2013 Requires schools to submit a report within 30 days of an interscholastic athlete getting, or suspected of getting, a concussion in a practice or game.
WI yes yes yes yes yes yes under 19 2012 Bill that was introduced and failed in 2014 would have eliminated requirement for student and parent to sign consent form.
WY yes no no no no no no reference 2011 The weakest and least-specific of the 51 laws, it says each school district should “adopt protocols to address risks associated with concussions,” including “restrictions concerning participation in school athletic events.” A bill introduced in 2012 but not passed would have strengthened the state’s guidelines. Legislation was introduced Jan. 21, 2015, seeking to limit liability of governmental entities or public employees “for any claimed failure to implement or inadequacy of concussion related protocols.”

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