Sports-related concussion among school-aged athletes in the United States is an issue of increased visibility in the media, in clinical settings, and in legislative capitols across the country (Duff, 2009; Salvatore & Sirmon Fjordbak, 2011). Estimates of concussion incidence range as high as 3.8 million per year (CDC, 2007), translating into an average rate of about 10% of athletes sustaining a concussion during any season, either during practice or play.
When is it safe for a student-athlete who has sustained a concussion to return to play? There is no consensus on the best course of action (Duff, 2009). Physicians, coaches, and trainers often use individualized, graduated return-to-play protocols based on neuropsychological testing and other factors.
Some states have laws that mandate these protocols, while other states have rejected or never introduced such legislation. A careful review of federal and state legislation governing concussion management plans, based on information gathered from texts of bills and laws from each state's governmental website (see sidebar for state websites), reveals the variability.
At this point in the year, most states have concluded their regular legislative sessions. Bills that passed through the legislative branch of government have either been signed into law or await a governor's signature (see chart [PDF]). As of July 29, 2011:
- 31 states and the District of Columbia have passed bills related to concussion management into law or have bills awaiting the governor's signature.
- Seven other states have legislation pending.
- Six states have introduced no legislation relative to this issue.
- Five states had bills introduced into the legislature that were unsuccessful.
Many states have followed the lead of the National Collegiate Athletic Association (NCAA). In April 2010, the NCAA adopted policies that require a concussion management plan specifying that collegiate athletes who sustain a concussion should be removed from the current contest and may not return to practice or play until receiving clearance by a team physician or designee. Further, student-athletes should be presented with information on concussion and must sign a statement accepting responsibility for reporting injuries and illnesses, including concussion symptoms, to medical staff (NCAA, 2010).
The wording of legislation introduced across the country includes some recurrent themes. Most of the bills embrace some form of the following language:
- Coaches and trainers must receive training in concussion management, including recognizing the signs and symptoms of concussion. They must follow return-to-play protocols that involve graduated levels of activity.
- Concussion-management training for coaches and trainers must be reviewed annually, with periodic recertification of skills.
- Athletes and parents must receive information on concussion signs and symptoms prior to the start of each season, and must sign informed consent allowing the student to play.
- Athletes who sustain a concussion may not return to play in the same game.
- Athletes must receive written clearance from a physician or other licensed health care professional before returning to play or practice.
"Protecting Student Athletes from Concussions Act of 2011" (H.R. 469) was introduced into the House of Representatives in January 2011 by Sen. Timothy Bishop (D-N.Y.) and has been referred to the Subcommittee on Early Childhood, Elementary, and Secondary Education. The bill, which has garnered 24 co-sponsors, would require school districts receiving Elementary and Secondary Education Act funding to establish regulations for the prevention and treatment of concussions.
The bill institutes minimum state requirements, including the establishment of a concussion safety and management plan. It would mandate education for athletes, parents, and school personnel about the nature of concussion; support for students recovering from concussion, including academic accommodations; and best practices to ensure uniform safety standards, treatment, and management.
Consistent with most state laws and the NCAA regulations, the bill requires parent notification of injury and also requires that a student who sustains a concussion be removed from play and prohibited from returning to athletic or academic activities until he or she receives written release from a health care professional. The release may also require the student to follow a graduated return to normal activities based on the student's symptoms.
One critical component missing from most of the bills is the requirement for a pre-participation baseline assessment of cognitive-linguistic function. A number of instruments are appropriate for this type of data collection (including traditional pencil-and-paper tests and batteries). In addition, technology-based applications measure response speed and accuracy and a range of cognitive functions such as verbal memory, attention to task, sequencing, and visuospatial
processing. The availability of this kind of baseline data allows more accurate measurement of some of the subtle—yet significant—deficits that can occur post-concussion but that are not readily observable on traditional imaging studies (e.g., CT, MRI).
Bills with a baseline assessment requirement (e.g., H.B. 677 in Texas) have faced opposition for a number of reasons, related primarily to the cost of the baseline assessment. In the current budget climate, both at the state and federal level, limited resources are available for new programs, and unfunded mandates carry little weight. However, states willing to shoulder the burden of the expense would be recognizing the benefit of prevention, rather than paying the associated costs in cases of catastrophic injuries for which local schools could be found liable. Of the state laws reviewed, only Rhode Island has passed a law mandating baseline cognitive assessment. In New York, A.B. 5188, which mandates baseline testing, is pending. Similar measures failed in Texas and Hawaii.
Other states are approaching the issue from the perspective of non-binding resolutions, rather than statutes. New Jersey, for example, has resolutions pending in committee in both the General Assembly (A.R. 85) and in the Senate (identical companion bill S.R. 74). This measure urges schools to implement baseline cognitive assessment of school-aged athletes for the purpose of objective measurement, appropriate management, and safe return to play. This resolution does not have the force of law, nor does it address the fiscal implications of this type of assessment, but it does serve to increase legislators' and educators' awareness of the potential impact of concussion in the school-aged population.
A further limitation is that speech-language pathologists are not typically included in the definition of licensed health care providers. Some states, as well as the federal bill, define "health care professional" as individuals licensed, certified, or otherwise recognized by states who are experienced in identification and management of concussive injuries. Although return-to-play decisions should not rely solely on one opinion (SLP or otherwise), the collection and analysis of cognitive-linguistic data, both at baseline and post-concussion, is within the scope of practice of speech-language pathology. The addition of such information gathered by SLPs can contribute to the formulation of appropriate return-to-play protocols and management decisions.
The increased awareness of concussion incidence, prevalence, and recovery sequelae is being addressed at state and federal levels. Importantly, SLPs need to be aware of the effects of concussion on communicative and academic function. In the past three years, 29 states (plus two more pending approval by their respective executive branches) have enacted legislation that specifically addresses the prevention and management of sports-related concussion in school-aged athletes. None of the bills specifies SLPs as members of the concussion management team. However, as legislation is enacted and policies change, SLPs can be recognized as licensed health care providers, well-positioned and well-prepared to be a part of the nationwide efforts to prevent and manage concussion.