Concussion in High School Sports
Overall Estimate of Occurrence Is Not Available, but Key State Laws and Nationwide Guidelines Address Injury Management Gao ID: GAO-10-569T May 20, 2010Participation in school sports can benefit children but also carries a risk of injury, including concussion. Concussion is a brain injury that can affect memory, speech, and muscle coordination and can cause permanent disability or death. Concussion can be especially serious for children, who are more likely than adults both to sustain a concussion and to take longer to recover. These factors may affect return-to-play decisions, which determine when it is safe for an athlete to participate in sports again. GAO was asked to testify on concussion incurred in high school sports. This statement focuses on (1) what is known about the nationwide occurrence of concussion, (2) federal concussion prevention programs, (3) the components of key state laws related to the management of concussion, and (4) the recommendations of voluntary nationwide concussion management guidelines. To do this work, GAO conducted literature searches; reviewed injury databases, state laws, and documents from federal agencies and organizations that conduct work in high school athletics or sports medicine; and interviewed federal officials and experts who identified key state laws and nationwide guidelines and provided other information. GAO shared the information in this statement with the relevant federal agencies.
GAO identified three national databases that, as part of broader data collection efforts, collect information on the occurrence of concussion in high school sports, but they do not provide an overall national estimate of occurrence. Although the High School Reporting Information Online database provides national estimates of occurrence of concussion, it covers only 20 sports for high schools with certified athletic trainers. It may underestimate occurrence because some athletes may be reluctant to report symptoms of a possible concussion to avoid being removed from a game. The Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System provides national estimates only on concussions treated in an emergency room. The National Center for Catastrophic Sports Injury Research database provides information only on cases of concussion with serious complications and cannot provide national estimates of the occurrence of all concussions. The Centers for Disease Control and Prevention's program, Heads Up: Concussion in High School Sports, which began in September 2005, is the primary federal prevention program directed toward concussion. In addition, CPSC carries out prevention initiatives that include distributing educational materials, but these initiatives are directed more broadly at sports and recreation safety, such as appropriate helmets for football, baseball, and bicycling. The three key laws regarding the management of concussion in high school sports that were identified by federal officials and experts--those of Oregon, Texas, and Washington--all address concussion education and return to play, but their specific requirements vary. The education requirements vary with respect to who is to receive the education. For example, the Washington law targets coaches, athletes, and parents, while the Oregon law targets coaches only. There is also variation with respect to the content and frequency of education. The return-to-play requirements vary in the conditions under which athletes may return to play and in who may authorize it. For example, the Texas requirements apply specifically to athletes who lose consciousness, which excludes many concussions, and the Washington law requires return-to-play authorizations to be made by health professionals specifically trained in the evaluation and management of concussion. GAO found five sets of voluntary nationwide guidelines, which were developed by organizations that conduct work in high school athletics or sports medicine, that address the management of concussion in high school sports. All recommend monitoring an athlete with a concussion on the sidelines and assessing cognitive function regularly for signs of deterioration. All guidelines also recommend returning an athlete to play on a gradual basis, tailored to an individual's recovery and based on symptoms and the results of memory, cognition, and balance tests
GAO-10-569T, Concussion in High School Sports: Overall Estimate of Occurrence Is Not Available, but Key State Laws and Nationwide Guidelines Address Injury Management
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Testimony:
Before the Committee on Education and Labor, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 9:00 a.m. EDT:
Thursday, May 20, 2010:
Concussion In High School Sports:
Overall Estimate of Occurrence Is Not Available, but Key State Laws
and Nationwide Guidelines Address Injury Management:
Statement of Linda T. Kohn:
Director, Health Care:
GAO-10-569T:
GAO Highlights:
Highlights of GAO-10-569T, a testimony before the Committee on
Education and Labor, House of Representatives.
Why GAO Did This Study:
Participation in school sports can benefit children but also carries a
risk of injury, including concussion. Concussion is a brain injury
that can affect memory, speech, and muscle coordination and can cause
permanent disability or death. Concussion can be especially serious
for children, who are more likely than adults both to sustain a
concussion and to take longer to recover. These factors may affect
return-to-play decisions, which determine when it is safe for an
athlete to participate in sports again.
GAO was asked to testify on concussion incurred in high school sports.
This statement focuses on (1) what is known about the nationwide
occurrence of concussion, (2) federal concussion prevention programs,
(3) the components of key state laws related to the management of
concussion, and (4) the recommendations of voluntary nationwide
concussion management guidelines. To do this work, GAO conducted
literature searches; reviewed injury databases, state laws, and
documents from federal agencies and organizations that conduct work in
high school athletics or sports medicine; and interviewed federal
officials and experts who identified key state laws and nationwide
guidelines and provided other information. GAO shared the information
in this statement with the relevant federal agencies.
What GAO Found:
GAO identified three national databases that, as part of broader data
collection efforts, collect information on the occurrence of
concussion in high school sports, but they do not provide an overall
national estimate of occurrence. Although the High School Reporting
Information Online database provides national estimates of occurrence
of concussion, it covers only 20 sports for high schools with
certified athletic trainers. It may underestimate occurrence because
some athletes may be reluctant to report symptoms of a possible
concussion to avoid being removed from a game. The Consumer Product
Safety Commission‘s (CPSC) National Electronic Injury Surveillance
System provides national estimates only on concussions treated in an
emergency room. The National Center for Catastrophic Sports Injury
Research database provides information only on cases of concussion
with serious complications and cannot provide national estimates of
the occurrence of all concussions.
The Centers for Disease Control and Prevention‘s program, Heads Up:
Concussion in High School Sports, which began in September 2005, is
the primary federal prevention program directed toward concussion. In
addition, CPSC carries out prevention initiatives that include
distributing educational materials, but these initiatives are directed
more broadly at sports and recreation safety, such as appropriate
helmets for football, baseball, and bicycling.
The three key laws regarding the management of concussion in high
school sports that were identified by federal officials and experts”
those of Oregon, Texas, and Washington”all address concussion
education and return to play, but their specific requirements vary.
The education requirements vary with respect to who is to receive the
education. For example, the Washington law targets coaches, athletes,
and parents, while the Oregon law targets coaches only. There is also
variation with respect to the content and frequency of education. The
return-to-play requirements vary in the conditions under which
athletes may return to play and in who may authorize it. For example,
the Texas requirements apply specifically to athletes who lose
consciousness, which excludes many concussions, and the Washington law
requires return-to-play authorizations to be made by health
professionals specifically trained in the evaluation and management of
concussion.
GAO found five sets of voluntary nationwide guidelines, which were
developed by organizations that conduct work in high school athletics
or sports medicine, that address the management of concussion in high
school sports. All recommend monitoring an athlete with a concussion
on the sidelines and assessing cognitive function regularly for signs
of deterioration. All guidelines also recommend returning an athlete
to play on a gradual basis, tailored to an individual‘s recovery and
based on symptoms and the results of memory, cognition, and balance
tests.
View [hyperlink, http://www.gao.gov/products/GAO-10-569T] or key
components. For more information, contact Linda T. Kohn at (202) 512-
7114 or kohnl@gao.gov.
[End of section]
Mr. Chairman and Members of the Committee:
I am pleased to be here today to discuss concussion incurred in
competitive high school sports. More than 7.5 million high school
students participated in high school sports in 2008-2009, according to
the National Federation of State High School Associations (NFHS).
[Footnote 1] Participation in school sports can benefit children, but
it also carries a risk of injury, including concussion. Concussion is
an injury to the brain that results in the temporary loss of normal
brain function and can have serious, long-term consequences.
Concussion among athletes has recently received increased attention,
and the long-term effects of concussion among professional football
players has been the focus of several congressional hearings.
Concussion is caused by a bump or blow to the head or by a jolt to the
body that causes the head to move rapidly back and forth. Even a mild
blow to the head could result in a concussion. Concussion can affect
memory, judgment, reflexes, speech, balance, and muscle coordination
and can result in serious complications, such as swelling, bruising,
or bleeding of the brain, which can cause permanent disability or
death. Most concussions, however, do not result in a loss of
consciousness, and some athletes may not experience symptoms until
hours or days after sustaining a concussion. Therefore, according to
the Centers for Disease Control and Prevention (CDC), all coaches,
parents, and athletes need to learn concussion signs and symptoms and
what to do if a concussion occurs.
Several factors may affect decisions about when it is safe for an
athlete to participate in sports again, which are referred to as
return-to-play decisions. For example, research has shown that
athletes who have sustained one concussion are at increased risk of
sustaining another concussion.[Footnote 2] An athlete who sustains a
repeat concussion before the brain recovers from the first--within
hours, days, or weeks--may recover more slowly or may have increased
likelihood of long-term consequences. Research has also shown that
children and adolescents are more likely than adults to sustain a
concussion and take longer to recover from one, although the reasons
for this difference remain unclear.[Footnote 3]
Several federal agencies have responsibility for working to promote
the health and wellness of children and youth, such as by developing
programs for the prevention or management of injuries. Within the
Department of Health and Human Services (HHS), CDC is responsible for
promoting the health and well-being of the U.S. population, including
creating policies to prevent unintentional injuries among children and
adolescents and to minimize the consequences of these injuries. These
responsibilities encompass conducting research and developing programs
and educational initiatives related to the prevention and management
of injuries, such as concussion. HHS's National Institutes of Health
(NIH) is responsible for conducting and supporting medical research to
improve health and save lives, including developing strategies to
prevent childhood illness and death and developing techniques and
technologies for the rehabilitation of individuals with physical
disabilities resulting from injuries, such as concussion. HHS's Health
Resources and Services Administration (HRSA) is responsible for
strengthening the maternal and child health infrastructure in concert
with states, communities, and private partners, including promoting
children's health and increasing access to comprehensive services for
patients with severe head injuries.
Other federal agencies that have responsibilities for promoting the
health and wellness of children and youth are the Department of
Education (Education) and the Consumer Product Safety Commission
(CPSC). Education has responsibility for administering programs that
promote the health and well-being of students, including a
discretionary grant program related to physical education. CPSC
regulates thousands of consumer products, including sports equipment,
with the goal of protecting the public from unreasonable risks of
serious injury or death.
In addition to these federal efforts, several private organizations
and states have either studied the occurrence of concussion in high
school sports or developed concussion prevention and management
guidelines. For example, research on sports injuries has been
conducted by the Center for Injury Research and Policy at Nationwide
Children's Hospital in Columbus, Ohio, through the National High
School Sports Related Injury Surveillance Study's High School
Reporting Information Online (High School RIO). In addition, the
National Center for Catastrophic Sports Injury Research (NCCSI) at the
University of North Carolina, Chapel Hill, studies catastrophic sports
injuries in high school and college athletes. Some states have passed
laws related to concussion incurred in school sports. In addition,
several organizations that conduct work in high school athletics or
sports medicine have developed voluntary guidelines for the management
of concussion.
You expressed interest in obtaining information on concussion incurred
by young athletes. My statement today focuses on concussions incurred
by students while playing or practicing competitive high school sports
[Footnote 4] and addresses the following questions: (1) What is known
about the nationwide occurrence of concussion incurred in high school
sports? (2) What federal programs are directed specifically at the
prevention of concussion incurred in high school sports? (3) What are
the components of key state laws regarding the management of
concussion incurred in high school sports? (4) What are the
recommendations of voluntary nationwide guidelines for the management
of concussion incurred in high school sports?
To determine what is known about the nationwide occurrence of
concussion incurred in high school sports, we conducted a literature
search of social science and medical databases to find articles
published from 1999 through 2009 that discuss or report national data
from public or private programs for tracking the occurrence of
concussion in high school sports. We reviewed documentation and
interviewed officials from CPSC, the Center for Injury Research and
Policy, and NCCSI. The interviews focused on information about data
collection methods and the generalizability, strengths, and
limitations of the data that these organizations collect. We also
conducted interviews with federal officials and experts from
organizations that conduct work in the area of high school athletics
or sports medicine to obtain assistance in identifying relevant data
sources and to obtain information about the strengths and limitations
of existing data sources.[Footnote 5] We identified these
organizations from interviews with federal officials, literature we
reviewed, and interviews with other experts. We then examined the
characteristics of the national databases we identified, including how
data are collected, the target population, and the sports studied. We
did not analyze the data to generate and report incidence statistics,
but rather to determine the manner in which the data are collected and
to analyze how this affects the availability of data on nationwide
occurrence. To determine what federal programs are directed
specifically at the prevention of concussion incurred in high school
sports, we searched federal Web sites to identify prevention programs
related to concussion in high school sports. We also interviewed
federal officials to identify federal prevention programs and to
obtain information and program materials, and we reviewed these
materials to determine when these programs were developed, how
educational materials are disseminated, and who the target audience is.
To describe the components of key state laws regarding the management
of concussion incurred in high school sports, we interviewed federal
officials and experts who provided assistance in identifying relevant
state laws. We then reviewed the laws and identified their key
components, similarities, and differences. The state laws we reviewed
were those identified to us by federal officials and experts and do
not necessarily constitute a complete list of all state laws that
might address, specifically or in a broader context, the management of
concussion incurred in high school sports. To describe the
recommendations of voluntary nationwide guidelines for the management
of concussion incurred in high school sports, we interviewed federal
officials and experts to obtain assistance in identifying nationwide
guidelines and to obtain information about the development of the
guidelines. We excluded those guidelines that focused on one sport
only or were developed prior to 1995. We then reviewed the guidelines
and relevant documents and identified the guidelines' key
recommendations and the similarities and differences across
guidelines. The guidelines we reviewed were those identified to us by
federal officials and experts and do not necessarily constitute a
complete list of all nationwide guidelines that might address the
management of concussion incurred in high school sports.
We shared the information in this report with CDC, CPSC, Education,
HRSA, and NIH. The agencies provided technical comments, which we
incorporated as appropriate.
We conducted our work from October 2009 through May 2010 in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence
to meet our stated objectives and to discuss any limitations in our
work. We believe that the information and data obtained, and the
analysis conducted, provide a reasonable basis for any findings and
conclusions in this product.
Available Information about the Occurrence of Concussion in High
School Sports Cannot Provide an Overall National Estimate:
We identified three national databases that, as part of broader data
collection efforts, collect information on the occurrence of
concussion in high school sports, but they do not provide an overall
national estimate of occurrence. These databases are the NCCSI
database, the CPSC's National Electronic Injury Surveillance System
(NEISS), and the Center for Injury Research and Policy's High School
RIO. (See table 1 for descriptions of the databases.)
Table 1: Characteristics of Concussion Occurrence Databases:
Database: National Center for Catastrophic Sports Injury Research
(NCCSI) database;
Managing organization: University of North Carolina at Chapel Hill;
Information characteristic: Data gathered: Injury information about
cases of catastrophic injuries in high school and college athletes,
including concussions with serious complications;
Information characteristic: Sources used to identify injuries: Media
reports obtained through Internet searches and questionnaires sent to
state high school associations to identify catastrophic injuries;
Information characteristic: Methods used to collect data: Researchers
review published accounts and contact the school, coach, doctor, and
family of the injured athlete.
Database: National Electronic Injury Surveillance System (NEISS);
Managing organization: Consumer Product Safety Commission (CPSC);
Information characteristic: Data gathered: Information on injuries
related to a consumer product for all patients--including those
diagnosed with a concussion--treated in emergency departments[A];
Information characteristic: Sources used to identify injuries: Random
national sample of approximately 100 hospitals with 24-hour emergency
services, stratified by size;
Information characteristic: Methods used to collect data: Hospital
staff conduct chart reviews and assign a code for the type of injury
the patient sustained and a code based on the product or activity
associated with the injury, if applicable.
Database: National High School Sports Related Injury Surveillance
Study (High School RIO);
Managing organization: Center for Injury Research and Policy,
Nationwide Children's Hospital, Columbus, Ohio;
Information characteristic: Data gathered: Participation and injury
information, including concussion, for 20 high school sports;
Information characteristic: Sources used to identify injuries: Random
national sample of 100 high schools with certified athletic
trainers[B] who have volunteered to participate, stratified by
geographic location and size;
Information characteristic: Methods used to collect data: Athletic
trainers report information online weekly.
Source: GAO analysis of NCCSI, CPSC, and Center for Injury and
Research Policy database operations documents.
[A] In addition, since 2000 CDC has provided funding through an
interagency agreement with CPSC to expand NEISS to collect information
from about two-thirds of the hospitals in the sample on all types and
causes of nonfatal injuries, including those not related to consumer
products, for all patients treated in their emergency rooms.
[B] Certified athletic trainers are health care professionals who have
a bachelor's or master's degree in and are board certified in athletic
training.
[End of table]
According to experts and federal officials, while none of the
databases can provide a national estimate of the occurrence of
concussion in high school sports, two of them provide national
estimates of the occurrence of concussion for the populations they
study. High School RIO provides national estimates of the occurrence
of concussion in 20 sports for high schools with certified athletic
trainers,[Footnote 6] based on its sample of 100 high schools with
certified athletic trainers.[Footnote 7] Because it collects data on
participation in the sports it studies, High School RIO also
calculates injury rates by sport and by sex. NEISS provides national
estimates of the occurrence of concussion treated in hospital
emergency departments, based on its random national sample of
approximately 100 hospitals with 24-hour emergency services.[Footnote
8] The third database, NCCSI, provides information on cases of
concussion with serious complications, but it cannot provide national
estimates of occurrence of all concussions.
According to experts and federal officials, High School RIO and NEISS
have certain strengths. The information collected by High School RIO
is timely, as athletic trainers in the sample schools report data on a
weekly basis. According to CPSC officials, the information collected
by NEISS is also timely, in that hospitals in the sample report
information on a daily basis and NEISS receives approximately half of
the data within 4 days of the patient's being seen in the emergency
department. In addition, both High School RIO and NEISS collect
information in ways--such as through certified athletic trainers and
through review of medical charts, respectively--that experts report to
produce more reliable information than other methods.
Experts and federal officials have noted that notwithstanding these
strengths, the national estimates provided by High School RIO and
NEISS may be underestimates of the overall national occurrence of
concussion in high school sports. For example, High School RIO gathers
information only on concussions that are reported to or observed by a
certified athletic trainer, but, according to officials from an
athletic trainers' association, athletes may be reluctant to report
symptoms of possible concussions to athletic trainers to avoid being
removed from play. In addition, the athletic trainers cannot be
present at all practices and games and the coaches and parents who are
present may not recognize the signs or symptoms of a concussion,
resulting in an underestimate of the actual number of concussions in
the schools studied. Further, some athletes may consult their family
physician about signs and symptoms of a possible concussion without
reporting it to the athletic trainer. These concussions would not be
included in the database. In addition, because High School RIO
collects information on only 20 sports, its data cannot be used to
estimate the occurrence of concussion in all sports. Similarly, NEISS
gathers information only on concussions in patients who are treated in
emergency departments, but not all athletes with a concussion go to an
emergency department for treatment. Furthermore, the medical charts
that are reviewed by hospital staff for NEISS may not always indicate
detailed circumstances of the concussion, and therefore the staff may
miss some concussions that were sustained during athletic
participation.
Experts and federal officials identified additional features of the
databases that may lead to further uncertainty and thus preclude the
use of the data to provide comprehensive national estimates of
concussion in high school sports. For example, High School RIO does
not collect data from schools that do not have certified athletic
trainers, and researchers do not know how the occurrence and reporting
of concussion in schools with athletic trainers differ from schools
without athletic trainers or what effect any difference would have on
estimates of occurrence. In addition, according to CPSC officials,
NEISS cannot always indicate whether a concussion was sustained during
participation in a sport or simply involved sports equipment. For
example, NEISS would count a concussion sustained by a person who was
hit on the head with a baseball bat as a sports-related concussion,
regardless of whether or not the injury was incurred during a baseball
game or practice.
The Primary Federal Program Directed Specifically at Preventing
Concussion in High School Sports Is CDC's Heads Up: Concussion:
CDC's Heads Up: Concussion in High School Sports is the primary
federal program directed specifically at preventing concussion in high
school sports. The program, which is one of CDC's educational
initiatives, is intended to provide educational materials for coaches,
athletic trainers, athletic directors, parents, and athletes to
prevent concussion.[Footnote 9] The Heads Up: Concussion in High
School Sports tool kit includes a concussion guide for coaches with
information on signs and symptoms and strategies for preventing
concussions, a coach's quick-reference wallet card, a coach's
clipboard sticker with concussion facts and space for emergency
medical contacts, two fact sheets--one for parents and one for
athletes--in English and Spanish, an educational DVD, posters for
school gymnasiums, and a disc that contains additional resources.
According to CDC officials, the Heads Up: Concussion in High School
Sports materials were developed by a panel of experts from CDC and
outside the federal government.
CDC rolled out the Heads Up: Concussion in High School Sports program
in September 2005 to coincide with the beginning of the school year.
As part of the agency's promotional activities for its national roll-
out, CDC developed press kits and other promotional materials, and to
promote the program, it partnered with 14 public and private
organizations, including Education, physician associations, and other
organizations that conduct work in high school athletics or sports
medicine. CDC also conducted a targeted media campaign consisting of e-
mails and telephone calls to local, regional, and national media
outlets, regional and national newspapers, and general and specialty
magazines. In addition, the Surgeon General served as a key
spokesperson and participated in radio interviews with program
officials.[Footnote 10] CDC estimates that it distributed 20,000 tool
kits within the first 3 months of the program and reached 6 million
listeners and readers through the targeted media campaign.[Footnote
11] Agency officials estimate that CDC distributed more than 300,000
Heads Up: Concussion in High School Sports materials overall by the
end of December 2009.[Footnote 12]
CDC has continued to update and expand its Heads Up: Concussion in
High School Sports materials. CDC plans to release updated Heads Up:
Concussion in High School Sports materials in spring 2010 to coincide
with the release of free online training for high school coaches
developed by CDC and NFHS, which will include downloadable Heads Up:
Concussion materials and an educational video. CDC has also continued
to expand its Heads Up programs to target broader audiences.[Footnote
13] In addition, CDC officials told us that the agency created sports-
specific materials in conjunction with the national governing bodies
for youth and high school football, lacrosse, and ice hockey[Footnote
14] based on the Heads Up: Concussion in High School Sports and other
materials. The sports-specific materials include prevention and safety
information related to each sport and its equipment. The agency plans
to continue developing specific materials for additional sports.
Other federal agencies administer programs related to concussion, but
most of these programs are not directed specifically at the prevention
of concussion in high school sports. CPSC carries out initiatives that
include developing educational materials such as brochures and fact
sheets. These initiatives are not targeted exclusively at high school
sports, but are directed more broadly at sports and recreation safety
for youth and adults. For example, CPSC developed a brochure on which
helmets to wear for a variety of activities, such as football,
baseball, and bicycling, to prevent head injuries, including
concussion. HRSA and NIH administer grant programs related to
concussion and brain injury from all causes and for all age groups.
HRSA grants focus on high-risk groups including youth ages 15-19, and
NIH grants have supported some research on concussion in high school
sports. However, neither agency administers programs specifically for
the prevention of concussion in high school sports. According to
department officials, Education does not administer any programs
related to the prevention of concussion.
Concussion Education and Return-to-Play Requirements Are the Focus of
Key State Laws, but Exact Requirements Differ:
The three key state laws regarding the management of concussion that
were identified by federal officials and experts all include
requirements related to concussion education and athletes' return to
play. (See table 2.) The education components of the key state laws--
those of Oregon, Texas, and Washington[Footnote 15]--vary in terms of
targeted group and frequency of training. The return-to-play
requirements of the key state laws vary with respect to the conditions
under which the requirements apply and the personnel who may authorize
return to play.
Table 2: Components of Key State Laws Regarding the Management of
Concussion Incurred in High School Sports:
Education requirements:
Components: Schools covered;
State (Year enacted): Oregon (2009)[A]: School districts[D];
State (Year enacted): Texas (2007)[B]: Public schools and any other
schools subject to University Interscholastic League (UIL) rules[E];
State (Year enacted): Washington (2009)[C]: School districts[F].
Components: Targeted group(s);
State (Year enacted): Oregon (2009)[A]: Coaches;
State (Year enacted): Texas (2007)[B]: Coaches, trainers, physicians
who assist with activities, sponsors of extracurricular activities,
and athletes[G];
State (Year enacted): Washington (2009)[C]: Coaches, athletes, and
parents.
Components: Content;
State (Year enacted): Oregon (2009)[A]: Recognizing symptoms of
concussion and knowing how to seek medical treatment;
State (Year enacted): Texas (2007)[B]: Recognizing symptoms of
potentially catastrophic sports injuries, including concussion[H];
State (Year enacted): Washington (2009)[C]: Understanding the nature
and risk of concussion and head injury, including the risk of
continuing to play after a concussion or head injury.
Components: Frequency;
State (Year enacted): Oregon (2009)[A]: Annual;
State (Year enacted): Texas (2007)[B]: Not specified, but an annual
safety drill is required. A UIL official reported that UIL requires
education for coaches and students annually;
State (Year enacted): Washington (2009)[C]: Not specified for coaches;
athletes and parents must sign an information sheet annually.
Components: Return-to-play requirements:
Components: Conditions under which return-to-play requirements apply
following injuries;
State (Year enacted): Oregon (2009)[A]: Presence of signs, symptoms,
and behaviors consistent with concussion following an observed or
suspected blow to the head or body or diagnosis of concussion;
State (Year enacted): Texas (2007)[B]: Loss of consciousness for any
reason;
State (Year enacted): Washington (2009)[C]: Suspicion of concussion.
Components: Removal from play;
State (Year enacted): Oregon (2009)[A]: Athlete removed from any event
or training on day of injury;
State (Year enacted): Texas (2007)[B]: Athlete removed from play on
day of injury. According to a UIL official, these decisions are made
by personnel designated by the school, typically a coach or athletic
trainer;
State (Year enacted): Washington (2009)[C]: Athlete removed from play
at the time of injury. According to the Washington Interscholastic
Athletic Association (WIAA), removal is the responsibility of the
coach.
Components: Return-to-play requirements;
State (Year enacted): Oregon (2009)[A]: Athlete may return to play no
sooner than the day after the athlete sustained the blow to the head
or body and only after the athlete (1) no longer exhibits signs,
symptoms, or behaviors that are consistent with concussion;
and (2) receives a medical release from a health care professional;
State (Year enacted): Texas (2007)[B]: Athlete may not (1) return to
the practice or competition during which the athlete became
unconscious, or (2) participate in any extracurricular athletic
activity until the athlete receives written authorization from a
physician;
State (Year enacted): Washington (2009)[C]: Athlete may not return to
play until the athlete is evaluated by and receives written clearance
to return to play from a licensed health care provider trained in the
evaluation and management of concussion.
Sanctions:
Components: Possible sanctions for failure to comply with law;
State (Year enacted): Oregon (2009)[A]: The law does not provide
sanctions;
State (Year enacted): Texas (2007)[B]: The law provides that schools
shall be subject to a range of penalties determined by UIL. According
to UIL, penalties range from reprimand to disqualification and can
affect individuals, such as a coach, or the school;
State (Year enacted): Washington (2009)[C]: The law does not provide
sanctions. WIAA rules state that students cannot participate in
competitive district athletics without having a signed concussion
information sheet on file with the school district.
Source: GAO analysis of key state laws and relevant implementation
guidelines.
[A] 2009 Or. Laws, ch. 661. The law does not specify a particular
association or other entity to assist in implementation. The law first
applies to the 2010-2011 school year.
[B] 2007 Tex. Sess. Law. Serv., ch. 1296 (West). The Texas
Commissioner of Education adopted the Extracurricular Activity Safety
Training Program of UIL as the safety training program to be provided
under this law. Implementation guidelines for this program are
provided by UIL.
[C] 2009 Wash. Sess. Laws, ch. 475. Implementation guidelines are
developed by school districts in concert with the Washington
Interscholastic Activities Association (WIAA).
[D] According to an official from the Oregon Department of Education,
this term does not apply to private schools.
[E] UIL is a voluntary-membership, nonprofit organization created by
the University of Texas at Austin to provide leadership and guidance
to public school debate and athletic teachers. According to a UIL
official, the league has 1,300 member schools, all but 2 of which are
public schools.
[F] The Washington State Superintendent of Public Instruction has
issued a memo indicating that, while the law does not mention private
schools directly, WIAA directs all member schools to follow the new
requirements. WIAA has 800 public and private member high schools and
junior high or middle schools, approximately 10 percent of which are
private schools, according to a WIAA official.
[G] The Texas law also requires directors of school marching bands to
complete the education program.
[H] Among other potentially catastrophic sports injuries that the law
mentions are heatstroke and cardiac arrest.
[End of table]
All three state laws include requirements for education on concussion,
but they vary in the groups targeted and the content and frequency of
the education. The educational requirements of the Oregon law are
targeted at coaches. In addition to coaches, the Texas law specifies
that additional persons--such as athletic trainers, sponsors of
extracurricular athletic activities, physicians who assist with
activities, and athletes--also must complete an education program.
[Footnote 16] The Washington law is the only one that requires that
parents, in addition to coaches and athletes, receive education. The
Oregon law is unique in that it requires that coaches receive
education on concussion symptoms annually. The Texas and Washington
laws are silent on how often coaches should complete such an education
program.[Footnote 17]
The Washington law is the only state law we examined that requires
school districts to work with a state athletic organization to develop
guidelines, forms, and educational materials. School districts in
Washington worked with the Washington Interscholastic Activities
Association (WIAA) to develop a document, which athletes and parents
must sign annually, that contains information on the risks of
concussion and on how to recognize the signs and symptoms of
concussion.[Footnote 18] By signing the document, parents and athletes
are acknowledging their understanding that the athlete will be removed
from play or practice by the coach if he or she is suspected of having
a concussion. WIAA also developed fact sheets and an educational video
for coaches that describe the signs and symptoms of concussion and
propose a management strategy for coaches to follow. Much of the
information distributed by WIAA is modeled after CDC's Heads Up:
Concussion materials.
The Texas law requires the Commissioner of Education to develop and
adopt a safety training program, and the Texas Commissioner of
Education adopted the extracurricular athletic activity safety
training program provided by the University Interscholastic League
(UIL).[Footnote 19] The UIL training manual includes a section on
recognizing the signs of concussion and one on reducing head and neck
injuries. The latter section states that an athlete with signs of head
or neck trauma should receive immediate medical attention and not be
allowed to return to play or practice without permission from proper
medical authorities. UIL has also developed a parent information
manual that includes a section on concussion signs and management. In
addition, UIL has contracted with the Brain Injury Association of
America to provide to schools and coaches 25,000 palm cards for the
management of sports-related concussion, which outline the protocol
that every school must follow when dealing with possible head injuries
that occur in practice or play of all UIL activities.[Footnote 20]
The Oregon law requires that the State Board of Education establish
rules regarding the required concussion education for coaches. An
official from the Oregon Department of Education told us that these
rules have not yet been established, as the law first applies to the
2010-2011 school year.
The return-to-play requirements of the key state laws vary with
respect to the conditions under which the requirements apply. The
return-to-play requirements of the Texas law apply only to athletes
with injuries that result in a loss of consciousness and therefore
exclude many concussions. In contrast, the return-to-play requirements
of the Oregon and Washington laws apply to athletes with symptoms of
or suspicion of concussion.
While each state law requires that an athlete removed from play
receive written permission from a health care professional before
returning to play, the laws vary in the types of health professionals
who can provide such permission. The Texas law requires clearance from
a physician, and the Oregon law requires clearance from a health care
professional. The Washington law requires that an athlete suspected of
having a concussion be evaluated and cleared to return to play by a
health professional specifically trained in the evaluation and
management of concussion. WIAA's Web site indicates that such
professionals include medical doctors, doctors of osteopathy, advanced
registered nurse practitioners, physicians' assistants, and licensed
certified athletic trainers. According to the WIAA Web site, the
organization is considering whether other licensed health care
providers have sufficient training to qualify them to authorize return
to play. The Oregon law is the only one of the three we reviewed that
specifically prohibits an athlete removed from play or practice from
returning to play or practice on the same day.
Voluntary Nationwide Guidelines for Managing Concussion Incurred in
High School Sports All Recommend Assessing Concussion on an Individual
Basis, with Gradual Return to Play:
Federal officials and experts we spoke with identified five sets of
voluntary nationwide guidelines that address the management of
concussion in sports.[Footnote 21] (See table 3.) One set specifically
targets high school sports, while the other four contain broad
recommendations for the management of concussion in athletes of all
ages.[Footnote 22] All five sets of guidelines contain similar
recommendations for assessing concussion and managing the athlete,
including making return-to-play decisions. For example, all sets of
guidelines recommend that an athlete suspected of sustaining a
concussion should be monitored closely on the sidelines following the
injury and his or her cognitive function assessed at regular intervals
for signs and symptoms of deterioration--such as fluctuating levels of
consciousness, balance problems, headaches, or nausea. All sets of
guidelines also recommend returning an athlete to play on a gradual
basis, tailored to the individual athlete's recovery and based on the
athlete's signs and symptoms and the results of various concussion
assessment tools, such as tests of memory, cognition, balance, and
physical exertion. The set of guidelines that specifically targets
high school sports, which was developed by NFHS, recommends a gradual
increase in mental activity appropriate to high school students, such
as attending an abbreviated school day and engaging in short periods
of reading. If the athlete remains symptom-free, this is to be
followed by a gradual increase in low-impact physical activity once
the athlete has returned to a full school day. In addition, this set
of guidelines recommends that high school athletes playing high-risk
or collision sports or having a history of previous concussions should
undergo tests of cognition, memory, and balance prior to the start of
season to serve as a baseline in case an injury occurs.
Table 3: Concussion Management Guidelines:
Title: Concussions (Mild Traumatic Brain Injury) and the Team
Physician: A Consensus Statement[A];
Source: American Academy of Family Physicians, the American Academy of
Orthopaedic Surgeons, the American College of Sports Medicine, the
American Medical Society for Sports Medicine, the American Orthopaedic
Society for Sports Medicine, the American Osteopathic Academy of
Sports Medicine;
Publication year: 2006;
Intended end user: Team physicians;
Focus on high school sports: No; contains broad recommendations for
all athletes[B].
Title: Consensus Statement on Concussion in Sport, 3rd Annual
International Conference on Concussion in Sport[C];
Source: International and domestic experts, including those from the
International Olympic Committee and experts affiliated with the
American College of Sports Medicine and the National Athletic
Trainers' Association;
Publication year: 2009;
Intended end user: Physicians, therapists, certified athletic
trainers, health professionals, coaches, and others involved in the
care of athletes;
Focus on high school sports: No, but includes special considerations
for young athletes[D].
Title: National Athletic Trainers' Association Position Statement:
Management of Sport-Related Concussion[E];
Source: National Athletic Trainers' Association;
Publication year: 2004;
Intended end user: Certified athletic trainers and sports medicine
professionals (physicians and medical personnel caring for athletes);
Focus on high school sports: No, but includes special considerations
for young athletes[D].
Title: Practice Parameter: The Management of Concussion in Sports[F];
Source: American Academy of Neurology;
Publication year: 1997;
Intended end user: Neurologists;
Focus on high school sports: No; contains broad recommendations for
all athletes.
Title: Sports Medicine Handbook, Concussion chapter[G];
Source: National Federation of State High School Associations;
Publication year: 2008;
[Empty];
Intended end user: School administrators, coaches, and high school
sports medicine staff;
Focus on high school sports: Yes.
Source: GAO analysis of guidelines.
[A] S.A. Herring, J.A. Bergfeld, A. Boland, L.A. Boyajian-O'Neil, R.C.
Cantu, E. Hershman, P. Indelicato, R. Jaffe, W.B. Kibler, D.B. McKeag,
R. Pallay, and M. Putukian, "Concussion (Mild Traumatic Brain Injury)
and the Team Physician: A Consensus Statement," Medicine & Science in
Sports & Exercise, vol. 38, no. 2 (2006).
[B] According to the lead author, the consensus statement is primarily
intended to guide the management of concussion in the amateur or high
school athlete, rather than the college, elite, or professional
athlete.
[C] P. McCrory, W. Meeuwisse, K. Johnston, J. Dvorak, M. Aubry, M.
Molloy, and R. Cantu, "Consensus Statement on Concussion in Sport, 3rd
International Conference on Concussion in Sport Held in Zurich,
November 2008," Clinical Journal of Sport Medicine, vol. 19, no. 3
(2009).
[D] This set of guidelines recommends managing young athletes more
conservatively than adults but does not provide any more specific
recommendations.
[E] K.M. Guskiewicz, S.L. Bruce, R.C. Cantu, M.S. Ferrara, J.P. Kelly,
M. McCrea, M. Putukian, and T.C. Valovich McLeod, "National Athletic
Trainers' Association Position Statement: Management of Sport-Related
Concussion," Journal of Athletic Training, vol. 39, no. 3 (2004).
[F] American Academy of Neurology, Quality Standards Subcommittee,
Practice Parameter: The Management of Concussion in Sports Summary
Statement (St. Paul, Minn., 1997). According to officials, the
association is currently in the process of updating the practice
parameter and anticipates publishing it in spring 2011.
[G] National Federation of State High School Associations,
"Concussion," Sports Medicine Handbook, Third Edition (Indianapolis,
Ind., 2008).
[End of table]
Officials from three of the organizations that developed guidelines
told us that their members received information about the guidelines
in a variety of ways. For example, NFHS officials told us that the
association sent its set of guidelines to its member high schools upon
publication and planned to include information on the management of
concussion in its sports rule books, which it publishes every year for
17 sports, beginning with the 2010-2011 school year. Officials from
the American College of Sports Medicine and the National Athletic
Trainers' Association told us that concussion management is a frequent
topic of discussion at their meetings and that their guidelines were
also published in each organization's respective journal.
Mr. Chairman, this concludes my prepared statement. I would be happy
to answer any questions that you or other members of the committee may
have.
GAO Contact and Staff Acknowledgments:
For further information about this statement, please contact Linda T.
Kohn at (202) 512-7114 or kohnl@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this statement. Key contributors to this statement
were Helene F. Toiv, Assistant Director; Kate Blackwell; George
Bogart; Shana R. Deitch; Carolyn Feis Korman; and Roseanne Price.
[End of section]
Footnotes:
[1] National Federation of State High School Associations, 2008-2009
High School Athletics Participation Survey (Indianapolis, Ind., 2009).
NFHS leads the development of education-based sports and activities
for its member associations. NFHS membership consists of the high
school athletic or activity associations of the 50 states and the
District of Columbia, from which it collects information on the
numbers of students participating in high school sports.
[2] According to scientific literature, the increased risk may be due
to the athlete's style of play or to changes in the brain resulting
from the previous concussion.
[3] M. Field, M.W. Collins, M.R. Lovell, and J. Maroon, "Does Age Play
a Role in Recovery from Sports-Related Concussion? A Comparison of
High School and Collegiate Athletes," Journal of Pediatrics, vol. 142,
no. 5 (2003). M.W. Kirkwood, K.O. Yeates, and P.E. Wilson, "Pediatric
Sport-Related Concussion: A Review of the Clinical Management of an
Oft-Neglected Population," Pediatrics, vol. 117, no. 4 (2006). J.
Gilchrist, K.E. Thomas, M. Wald, and J. Langlois, "Nonfatal Traumatic
Brain Injuries from Sports and Recreation Activities, United States,
2001-2005," Morbidity and Mortality Weekly Report, vol. 56, no. 29
(2007).
[4] For the purposes of this statement, we are excluding sports played
as part of physical education classes.
[5] Specifically, we interviewed officials from CDC, CPSC, Education,
HRSA, NIH, the American Academy of Pediatrics, the American College of
Sports Medicine, the National Athletic Trainers' Association, NFHS,
and others. We also interviewed officials from these federal agencies
and organizations to answer our remaining research questions.
[6] E.E. Yard and R.D. Comstock, "Compliance With Return to Play
Guidelines Following Concussion in US High School Athletes, 2005-
2008," Brain Injury, vol. 23, no. 11 (2009).
[7] Certified athletic trainers are health care professionals who have
a bachelor's or master's degree in and are board certified in athletic
training. The National Athletic Trainers' Association estimates that
approximately 42 percent of high schools have access to a certified
athletic trainer. Schools may have a full-time certified athletic
trainer on staff, share a trainer with other schools, or receive the
services of a trainer who volunteers on a part-time basis.
[8] J. Gilchrist, K.E. Thomas, M. Wald, and J. Langlois, "Nonfatal
Traumatic Brain Injuries From Sports and Recreation Activities--United
States, 2001-2005," Morbidity and Mortality Weekly Report, vol. 56,
no. 29 (2007).
[9] CDC officials told us that the agency developed the Heads Up:
Concussion in High School Sports program to follow up on its Heads Up:
Brain Injury in Your Practice program, which CDC released in 2002 for
primary care physicians.
[10] The Surgeon General, whose office is in the Office of the
Secretary of HHS, has responsibilities for public health education and
promotion, including the promotion of special departmental health
initiatives, among other duties.
[11] CDC conducted an evaluation of the Heads Up: Concussion in High
School Sports initiative in 2008, in which the agency surveyed
eligible high school coaches who received the tool kit from September
2005 to July 2006. More than one-third of responding coaches reported
that they learned something new about concussions from the tool kit,
and half of responding coaches noted that the tool kit made them view
concussions more seriously.
[12] CDC also makes the materials available for download on its Web
site.
[13] In 2007, CDC launched the Heads Up: Concussion in Youth Sports
program to provide educational prevention materials for coaches of
youth athletes ages 5 through 18 participating in organized and
unorganized sports. In March 2010, CDC released the Heads Up to
Clinicians program to provide emergency department health
professionals with information on the management of brain injuries in
adults. In addition, CDC is planning to release in spring 2010 its
Heads Up to Schools: Know Your Concussion ABCs program for grades K
through 12 school professionals--such as school nurses, counselors,
and administrators--and parents.
[14] These governing bodies may also provide support, skill
development, and education to college or adult amateur athletes.
[15] 2009 Or. Laws, ch. 661; 2007 Tex. Sess. Law. Serv., ch. 1296
(West); and 2009 Wash. Sess. Laws, ch. 475. Other states may have laws
or may be considering legislation related to concussion incurred in
high school sports.
[16] The Texas law requires education on the recognition of a broad
range of potentially catastrophic injuries, including but not limited
to concussion.
[17] According to a WIAA official, the association is incorporating
concussion education into a cardiopulmonary resuscitation (CPR) course
that coaches are required to take every other year. The official told
us that WIAA mandated that in 2010 all coaches take the CPR course
with the concussion information, regardless of whether they are
current on their CPR training.
[18] WIAA is a private, nonprofit organization and rule-making body
formed in 1905 to create equitable playing conditions between high
school teams in Washington. The association has approximately 800
member high schools and middle schools, both public and private.
[19] UIL is a voluntary-membership, nonprofit organization created by
the University of Texas at Austin to provide leadership and guidance
to public school debate and athletic teachers. The purpose of UIL is
to organize and properly supervise contests. UIL provides services to
its member schools in the organization and administration of regional
and state championships in 14 sports.
[20] UIL policy states that failure to comply with UIL rules can
result in a variety of sanctions ranging from reprimand to
disqualification from UIL activities and competitions.
[21] The American Academy of Pediatrics published an additional set of
guidelines for the management of concussion among children. However,
an official from this association told us that the guidelines, which
were published in 1999, are no longer in use, and that the association
was in the process of developing a clinical report on sports-related
concussion.
[22] These sets of guidelines were all developed by organizations that
conduct work in the area of high school athletics or sports medicine;
officials and experts did not identify any guidelines developed by
federal agencies.
[End of section]
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