Running Head: CONCUSSIONS 1

Literature Review of Return-to-Play Laws and Their Effect on Concussion Rates for High

School Football Athletes

Tiffany Wilson

A Capstone Presented in Partial Fulfillment

of the Requirements for the Degree

Master of Healthcare Administration

KAPLAN UNIVERSITY

January 2016

CONCUSSIONS 2

Abstract

Concussions and Traumatic Brain Injury (TBI) have become one of the most prevalent and

serious injuries a high school athlete can receive. Due to the potential long-term effects these

types of injuries have, there are now federal laws in place to help protect these athletes. This

theoretical paper will discuss the history of these laws and how the incidence of concussions has

been affected since enactment. Using data analysis from previous research, this paper will

attempt to answer the following research questions. First, has there been a reduction or increase

in concussion injuries since the laws have been enacted? And, secondly, has heightened

awareness caused students, parents, and coaches to be more cautious? Based on research

analysis, it can be concluded that heightened awareness has brought concussion injuries to the

forefront. However, it appears that because the new rules and regulations are present that forces

these types of injuries to be addressed, it seems that there have been more injuries since the laws

have been enacted than less. More longitudinal studies will need to be performed in order to get

accurate data.

CONCUSSIONS 3

Dedication

I want to dedicate this project to my son, Joshua. I have watched you play football since you

were eight years old. You inspire me with your toughness and your tenacity and I am so proud

of you. I hope these laws will protect other young men from sustaining the life-long injuries that

those reflected in this paper have suffered.

I love you more than words.

To my husband, Robert, and daughter, Alyssa…thank you for enduring the long hours and for

giving me the time, space, and quiet needed to not only finish this project, but to see this degree

through to the end.

To my friends and colleagues, new and old, who have supported me, pushed me, and not allowed

me to give up. Your support means more than you will ever know!

CONCUSSIONS 4

Acknowledgements

I want to acknowledge my birth state of Washington. The Washington lawmakers led the way

for all the other Return-to-Play laws in the country to be enacted.

I want to acknowledge our local schools and football coaching staff for following these laws and

protecting our players.

Most importantly, I want to acknowledge my husband, Robert, my children Joshua and Alyssa,

and my friends for supporting me and seeing me through this long road and not letting me give

up.

CONCUSSIONS 5

Table of Contents

Abstract............................................................................................................................................2

Table of Contents.............................................................................................................................5

Background......................................................................................................................................7

General Problem Statement.........................................................................................................9

Specific Problem Statement.......................................................................................................10

Purpose Statement......................................................................................................................10

Research Questions....................................................................................................................10

Definition of Terms....................................................................................................................11

Literature Review..........................................................................................................................12

Overview of State Laws Surrounding Concussion Injuries.......................................................13

Overview of Coaches Involvement in Concussion Regulation.................................................17

Future Research and Literature Gaps.........................................................................................21

Method...........................................................................................................................................24

Research Method and Design Appropriateness.........................................................................24

Population..................................................................................................................................25

Sampling Frame.........................................................................................................................27

Data Collection..........................................................................................................................27

Data Analysis.............................................................................................................................28

Findings.........................................................................................................................................28

Limitations.................................................................................................................................30

Use and Application of Findings...............................................................................................32

Conclusion.....................................................................................................................................35

CONCUSSIONS 6

Appendix 1…………………………………………………………………………………….…38

Appendix 2……………………………………………………………………………………….39

Appendix 3……………………………………………………………………………………….40

References......................................................................................................................................41

CONCUSSIONS 7

Literature Review of Return-to-Play Laws and Their Effect on Concussion Rates for High School Football Athletes

Although concussions and traumatic brain injuries in athletes have occurred for centuries,

it seems to be more of a concern in recent years. In 2006, a series of events transpired which

changed how the nation looked at concussions and traumatic brain injuries. Before then, it

focused on professional athletes, but no real laws, rules, or regulations existed. As of 2014,

every state in the nation, as well as the District of Columbia, has enacted Return-to-Play laws to

help protect child, teenage, college-age, and adult athletes, specifically football players. These

laws focus on the diagnosis, treatment, and long-term effects of traumatic brain injuries and

involve the athlete, parents, coaches, and schools. This paper will discuss the definition of

concussion and traumatic brain injuries, history of nationwide concussion laws, and the effect

that those laws have had on the incidence of concussions on our child and teen athletes.

Background

The following section will discuss the background of concussions and the Return-to-Play

laws that have been developed to help protect our children from lifelong injuries. Concussions

among high school football players have the highest incidence nationwide. One family in the

state of Washington, the Lystedt family, watched their son suffer due to this type of injury. It

was because of their journey that laws have changed across the country.

According to the CDC, a concussion is a mild form of traumatic brain injury caused by

some sort of blow to the head or body which causes the brain to move back and forth, potentially

causing injury, within the skull. Athletes in contact sports, especially football, can have these

types of injuries at any time. The CDC reports that more than 3.5 million sports-related

concussions occur each year in the United States (2015). This number is alarming, considering

CONCUSSIONS 8

the recent passage of state laws to help protect these athletes. Symptoms of concussions are

wide-ranging from headaches and dizziness to memory loss and unconsciousness. These

symptoms vary due to many factors, such as the type of impact, history of previous concussions,

as well as treatment and recovery. Long-term effects also vary from motor deficits, memory

loss, and speech impediments to behavior problems, depression, suicide, stroke, and death. The

variance of long-term effects depend on the severity of the initial concussion, the number of

subsequent head injuries, and the length of time the brain was given to recover.

Zackery Lystedt

The history of concussion laws could not be discussed without knowing about the young

man the initial law revolved around. Zackery Lystedt was a healthy 13-year-old boy playing on

his 8th grade Washington State junior high football team. During one game in 2006, Zack was

injured when his head struck the ground after tackling an opponent. Zack was dizzy and

confused, so his coach had him sit out for several plays. Zack then went back in during the

second half of the football game where he got hit again. After the game, Zack collapsed on the

field, went unconscious, and had to be airlifted to a nearby trauma center for emergency life-

saving surgery to remove the right and left side of his skull in order to relieve the pressure from

his swelling brain (Centers for Disease Control).

During his recovery, Zack suffered numerous strokes, seven days on the ventilator and

three months in a coma before he awoke to his new life. Zack had a long road ahead of him as

he spent four weeks in a nursing home and two months in a children’s hospital for rehabilitation.

It was months before he could speak, stand, and perform normal activities like he had before.

Return-to-Play Laws

CONCUSSIONS 9

Before Zack’s injury, there were no laws in Washington that would prevent injured

athletes that were thought to have a concussion from returning to the game without receiving

medical clearance. There seemed, at the time, to be a lack of understanding of the severity these

injuries could have and a “be tough”, macho type of attitude. After Zack’s long recovery, he and

his parents began lobbying for a law that would keep others from going through what he and his

family had to undergo (Lueke, 2011). In 2009, Washington passed House Bill 1824, otherwise

known as the Zackery Lystedt Law, which requires clearance from a medical professional for

any athlete suspected of having a concussion injury before being allowed to return to games,

practices, and training.

Since the Zackery Lystedt Law was passed in the state of Washington in 2009, all 50

states in the nation as well as the District of Columbia have passed some sort of Return-to-Play

law, protecting those student athletes with concussive-type injuries. However, the laws and

requirements vary from state to state.

General Problem Statement

The general problem of this paper is to explain how state laws have affected the

incidence in sports-related concussions and TBI. Concussions are a nationwide problem for our

young athletes. According to the Centers for Disease Control and Prevention (CDC), over the

last 10 years, emergency room visits for sports-related traumatic brain injuries (TBI) and

concussions have increased by 62%. The risk of concussion is the highest for 15-19 year olds

nationally, regardless of gender. The CDC also reports that concussions can occur in any contact

sport, but have a higher prevalence in football and ice hockey (Centers for Disease Control,

2015). Concussions in professional athletes have caused an increased interest nationwide.

CONCUSSIONS 10

However, in recent years, there is now a growing emphasis on early identification and

management in young student athletes, yet limited information on treatment and recovery

(Darling, Freitas, & Leddy, 2015). When the brain is not given enough time to heal after a

concussion, dangerous and often life-altering symptoms may develop. Return-to-Play laws have

been enacted in all 50 states, but have they truly helped the incidence of concussions and TBI in

our youth athletes?

Specific Problem Statement

The specific problem of this paper is how Return-to-Play laws have affected the

incidence of concussions in high school football players. As of 2014, laws have been enacted

across the country regarding concussions and youth sports. Because the Zackery Lystedt Law

(WA House Bill 1824) was the first of its kind to be enacted by Washington State Governor

Christine Gregoire in May of 2009, this paper will focus on concussions and TBI amongst high

school football players in Washington State.

Purpose Statement

The purpose of this research is to determine whether a relationship exists between

Return-to-Play laws, Washington State specifically, and the incidence of traumatic brain injury

amongst high school football players.

Research Questions

This project aims to answer three main questions with regard to concussions and TBI

amongst high school football players. The research addressed the following research questions:

RQ1: How has the incidence of TBI amongst child and teen athletes been affected since

the Return-to-Play laws have been enacted?

CONCUSSIONS 11

RQ2: Has the heightened awareness over the past decade caused players and coaches to

be more cautious?

RQ3: What needs to be done to make laws more consistent and to reduce incidence of

concussions amongst student athletes even more?

Definition of Terms

CDC. CDC is an acronym which stands for The Centers for Disease Control and

Prevention. The CDC is the leading national public health institute of the United States. The

CDC is a federal agency under the Department of Health and Human Services and is

headquartered in Georgia.

Chronic Traumatic Encephalopathy. Chronic Traumatic Encephalopathy, or CTE, is a

form of encephalopathy that is a progressive degenerative disease, which can currently only be

definitively diagnosed postmortem. In March 2014, researchers announced the discovery of an

exosome particle created by the brain which has been shown to contain trace proteins indicating

the presence of the disease.

Concussion. A concussion is a type of traumatic brain injury—or TBI—caused by a

bump, blow, or jolt to the head or by a hit to the body that causes the head and brain to move

rapidly back and forth. This sudden movement can cause the brain to bounce around or twist in

the skull, stretching and damaging the brain cells and creating chemical changes in the brain

(Centers for Disease Control and Prevention, 2015).

Encephalopathy. Encephalopathy is a general term that describes a disease or disease

process that affects the function or structure of your brain.

National Football League. The National Football League, shortened to the NFL, is a

professional American football league, consisting of 32 teams, divided equally between the

CONCUSSIONS 12

National Football Conference (NFC) and the American Football Conference (AFC). The NFL

has made huge strides in supporting laws and financing research regarding traumatic brain injury

in not only their players, but as role models for younger athletes.

Return-to-Play laws. These laws, started with the Zackery Lystedt Law in Washington

State in 2009, have now been enacted in all 50 states and the District of Columbia. These laws

set up specific requirements for athletes deemed to have a concussive injury in order for them to

return to any type of training, practice, or game.

TBI. Traumatic brain injury or TBI is caused by a bump, blow or jolt to the head or a

penetrating head injury that disrupts the normal function of the brain. The severity of a TBI may

range from “mild (a brief change in mental status or consciousness) to “severe,” (an extended

period of unconsciousness or amnesia after the injury) (Centers for Disease Control and

Prevention, 2015).

Literature Review

This section will discuss a review of current literature on the subject of concussions.

Although, there are many topics to compare and analyze, only three will be discussed here. The

first concept will be centered on how the state laws came to be regarding concussions and

athletes, particularly high school athletes. The second concept will discuss how coaches have

had to adopt new practices into their routines when dealing with concussive injuries. Finally, the

research will show that there are many gaps in the literature where future research is needed in

order to determine if the laws have helped or hindered these student athletes, their families, their

coaches, their teams, and their communities.

CONCUSSIONS 13

Overview of State Laws Surrounding Concussion Injuries.

As was discussed previously, Return-to-Play laws came into the nation’s consciousness

because of a brave young man from Washington and his family. After seeing what their son

had to endure, the Lystedt family decided to take action and force lawmakers to look at the

current laws in order to make a change. Before this law was in place, there was a lack of

understanding and awareness regarding the effects that concussive injuries could have (Hodge &

Kadoo, 2014). Washington’s House Bill 1824, otherwise known as the Zackery Lystedt Law

was enacted in 2009 and was the first of its kind. This original law had specific guidelines for

players, parents, coaches and other school officials, as well as physicians and treating facilities.

The original Lystedt law had several components. First, if a concussive injury is

suspected, the athlete must be removed from play, whether a game situation or practice

(Foreman, 2010). Secondly, the athlete must then be evaluated and cleared by a licensed health

care professional that is specially trained to assess head injuries before being able to return to

play. This could be a physician, athletic trainer, or other professional who has received the

necessary training (Schwartz, 2013). Finally, education and training of schools, coaches,

parents, and players must take place to improve awareness and increase the likelihood of

noticing signs and symptoms of head injuries.

The Lystedt Law, with the support of the National Football League and other influential

stakeholders, set a precedence spurned change across the nation. By 2014, there was some form

of a Return-to-Play law in every state in the nation and the District of Columbia. Each state has

some variation of these two basic concepts, but all have some combination of the following

rules: mandatory removal of play; mandatory bench times; required medical clearance; required

CONCUSSIONS 14

training and education for coaches, parents, and athletes; and informed consent of athletes and

their parents (Centers for Disease Control, 2015).

The thought behind the laws were to reduce intensity of the injury, by removing the

affected athlete and prevent further injury from occurring. Although it could never be proven,

health care professionals and lawmakers agree that if there was a law like this one in place prior

to Lystedt’s injury, he may have not suffered the irreversible damage that he currently has. The

Centers for Disease Control have also taken up the Head’s Up campaign to assist schools,

coaches, parents, and players with understanding the reasoning behind these rules and

regulations (Centers for Disease Control and Prevention, 2015).

This seems like a simple concept to grasp, but the literature has shown that there are more

issues with this simple act than first realized. In a research study by Lowrey & Morain,

interviews were conducted in 35 of the 42 states that had enacted laws as of 2012. These

informants were chosen to be representatives of the organizations and agencies responsible for

implementation of their state’s concussion law. Results from this study showed many issues

with having such a variation in the laws. There were many states that were uncertain in defining

which individuals and activities the law should cover. For example, what age groups does the

term “youth athlete” include? Is an 18 year old who is still in high school still considered a

youth athlete, or are they now considered adult? If an 18 year old is indeed covered, then these

laws may need to be extended to include collegiate athletes as well (Andrews, 2013).

There were two main issues that were concluded by Lowery & Morain (2014):

ambiguous definitions and an unclear assignment of power. An ongoing concern for many states

is trying to conclude which providers are adept in making Return-to-Play assessments. This

study also found that there is no consistency in enforcement in order to ensure that these rules

CONCUSSIONS 15

and regulations are being followed. Some states have gone so far as to impose penalties on

schools, coaches, and athletes if they are non-compliant. The informants indicated that there

were three overall barriers to compliance with these state laws. Provider access, especially in

rural areas was one of the biggest hurdles. There has been some concern amongst legislators,

sports administrators, and others that compliance to these laws in rural areas may prove difficult

without the appropriation of resources (Faure, Moffitt, & Schiess, 2015). Finding appropriately

trained medical personnel to evaluate and treat the student athletes can be extremely difficult.

Secondly, parental involvement was a large concern. Those interviewed indicated many parents

shopped around for practitioners until they found one that would clear their child, whether they

were healthy enough to play or not. Finally, general awareness of the laws themselves was a key

factor (Lowrey & Morain, 2014).

In 2013, Hosea Harvey conducted a research review on every state that had a sports TBI

law enacted between 2009 and 2012. Harvey (2013) conducted a comprehensive survey and

found, at the time of the study, 44 states and Washington D.C. had enacted one or more youth

sports TBI laws. At the time, there were 6 states that had no such law, but we know now that

during the 2 years following, the remaining states also enacted their version of a Return-to-Play

law (Refer to table in Appendix 1). Of the 44 states with laws, 41 of those as well as

Washington D.C. require coaches to remove athletes from play if they were suspected to have

TBI. All of those, with the exception of Wisconsin and Ohio required a minimum of 24 hours

for a player to sit out. Only Delaware mandated a removal of greater than 24 hours (Harvey,

2013). Harvey’s study also found that an athlete must be cleared by a third party in 40 of the

states and Washington D.C. There are several different categories that a health care professional

could fall into. Permitted roles include certified athletic trainer, physician, physician trained in

CONCUSSIONS 16

concussion management, health professional certified with experience in concussion

management, nurse, or neuropsychologist. Harvey found no consensus as to which health care

professional was better equipped to evaluate these young athletes across the states. Another

interesting finding was that amongst the states that require medical clearance by a health care

professional, only 26 of the 45 jurisdictions require that the practitioner be trained in TBI

assessment and management (Harvey, 2013). Informed consent was the third most common

element in the provisions found during this study. 34 of the 45 jurisdictions hand out

information to parents and players about concussions most require a parent and student signature.

The information dispersed varied from state to state, however the CDC’s widely circulated

material was mentioned in several of the state’s regulations.

In a third study by Gibson, Herring, Kutcher, and Broglio (2015), a different approach

was undertaken. This study involved analyzing insurance claims for TBI to evaluate whether

there has been an increased prevalence in concussions and head injuries occurring since the laws

have been enacted. This study attempted to analyze health care utilization rates for concussions

from 2006 to 2012. There were two main research questions posed for the study. First, due to

mandatory removal from play and requiring medical clearance before returning, would fewer

cases be reported because athletes may want to hide their symptoms in order to continue

playing? Secondly, have the concussion laws led to an increased interaction between athletes

and medical professionals for injury diagnosis or clearance to return to play? (Gibson, Herring,

Kutcher, & Broglio, 2015). Gibson et al., (2015) studied children ranging in age from age 12-

18, the age group most likely to be affected by concussion legislation. The results of this study

indicated a 92% increase in health care utilization in states that had concussion laws in effect

between the 2008-2012 school years. In states without concussion legislation, there was still a

CONCUSSIONS 17

75% increase in the identification and treatment of concussion (Gibson, Herring, Kutcher, &

Broglio, 2015). The increased media coverage as well as National Football League and CDC

involvement may have had something to do with the increase nationwide, whether a state had a

law in effect or not. This poses another question: Do the laws themselves have an impact on

health care utilization for concussions or are we as a country and society just more aware of the

problem?

Overview of Coaches Involvement in Concussion Regulation

The second concept to be discussed is how concussion legislation has affected coaches,

as well as schools and communities. As discussed earlier, when Zackery Lystedt was lying on

his back holding his helmet, the coach pulled him from the game. He sat out for three plays

before his coach allowed Lystedt to return to the game. It is unclear if this was strictly the

coach’s decision, whether he was feeling pressure from Lystedt’s family and the other fans, or

whether Lystedt was begging him to return to the game. The general public may never know

what the exact scenario was. What is known is that coaches all across the country have a huge

responsibility to not only teach our children how to play the game, but to keep them safe from

injury. As parents, one would cling to the idea that our child’s coach truly wants to do the right

thing. Parents trust them that when our child is on the football field, that coach knows what he

or she is doing and has had the necessary training to recognize injuries when they occur.

So, now that there are concussion laws nationwide, what exactly is the coach’s

responsibility? One of the key components present in almost all of the state concussion laws

include training of coaching staff to not only recognize early signs of TBI, but also how to

manage those players already injured. Harvey (2013) found that only 25 of the states with

concussion legislation actually had explicit coach education guidelines. Most of these programs

CONCUSSIONS 18

included symptom recognition, but the training requirements ranged from annually to every few

years. Only a few of the states had general guidelines for what was included in coaching

training, and none of them indicated who was responsible for providing the training. Although

guidelines can be vague, some voluntary membership associations require a more vigorous

training than the state or school boards require, meeting this requirement for the state laws.

With enactment of concussion legislation still being fairly new, the last state law was just

enacted last year; implementation has been found to be limited. This means that many coaches,

even those who are active in states with concussion laws, may receive inconsistent and limited

education and training. Covassin, Elbin, and Sarmiento (2012) found that only 61% of coaches

could correctly identify the signs and symptoms of concussive injury. This number does not

indicate that appropriate education is being performed despite numerous educational materials

being available to coaches at the high school level.

Many educational materials are present in the form of educational videos, posters, fact

sheets and web sites (Covassin, Elbin, & Sarmiento, 2012). A study of New England high

school coaches indicated that 80% of coaches in the area found the educational materials

provided to at least be moderately helpful in recognizing the signs of concussion, how to prevent

further injury from occurring and how to respond should an injury occurs (Guilmette, Malia, &

McQuiggan, 2007).

After the Lystedt Law was enacted in Washington and subsequent states followed suit,

the CDC initiated the “Head’s Up: Concussion in Youth Sports” campaign in 2007. The goal of

this initiative was to provide education to sports coaches on prevention, recognition, and

response to sports-related concussion. The website offers a variety of educational opportunities

including: a free online training course, fact sheet, customizable action plan, concussion facts

CONCUSSIONS 19

and contact numbers, main message poster, signs and symptoms poster, fact sheet for coaches,

clipboard concussion information sheet and sticker (refer to Appendix 2), and concussion poster

(Centers for Disease Control and Prevention, 2015). During the course of the study, Covassin et

al., (2012) indicated that the CDC’s materials were found to be the most useful source of

information among high school football coaches. After being properly educated, such as after

utilizing the Heads Up materials, many coaches have felt that they learned something new

regarding concussion recognition, treatment, and prevention.

Many states have opted to incorporate concussion training into their already existing

coach education. The state of California, for example, has incorporated “Chapter 173” into their

pre-existing guideline. Chapter 173 requires CPR and first-aid training for all high school

coaches to include a basic understanding of the signs and symptoms of concussions and the

appropriate response when concussive-injury occurs (Hunsucker, 2013). This allows for

consistent training across the entire state and poses another question. If we want to decrease

incidence of concussions, prevent further injuries from occurring, and expect coaching staff to

have the proper training and education, then why are there not consistent and mandatory

guidelines nationwide?

The answer to that question may not appear for many more years. However, as the

incidence of head injuries in student athletes continues to rise, lawmakers are realizing the

importance of consistent and regulated guidelines. As of 2010, only 5 states: Connecticut, Idaho,

Oregon, Texas, and Washington have passed laws to establish minimum concussion education or

management guidelines. Other states have begun to get on board, such as New Jersey.

Representative William Pascrell (D-NJ) has attempted to amend Title III of the Public Health

Service Act for many years (Faure, 2010). His bill, “Concussion Treatment and Care Tools Act”

CONCUSSIONS 20

would establish and implement national concussion management guidelines for children ages 5-

18.

These studies and other literature have cemented the idea that proper training and

education of coaches are a necessity when concussed athletes are in their care. There are times

when athletes will hide their injuries because they want to play. An anonymous online survey

described in Neurology Clinical Practice indicated that 43% of the 262 collegiate athlete

respondents with a history of concussion said they had hid symptoms in order to continue

playing (Schwartz, 2013). They may downplay their symptoms so as not to disappoint their

coaches, their parents, or themselves. Younger athletes don’t understand or realize the long-term

effects of these types of injuries. Adolescents who have already suffered TBI have an increased

incidence of sustaining another injury at some point in their lifetimes (Guskiewicz, 2015).

Research has shown that child and adolescent brains take longer to recover than adult brains

(Faure, 2010), which makes it even more important to make sure that the guidelines are

followed. Young athletes, who just feel a little dizzy may opt to go back in because their team

needs them, not realizing they may be suffering a serious brain injury leading to permanent brain

damage or even death (Tarshis, 2011).

This is the time when coaches need to be proactive, assess their players, rely on their

training, and follow the guidelines laid out for them. First and foremost, coaches are there to

teach their players proper technique. In the game of football, learning how to tackle and how to

be tackled to prevent injury is the key. The proper use and care of equipment is also essential in

preventing injury. Having a routine in place to check equipment such as helmets and pads

regularly and having a policy in place when equipment needs repair will go a long way.

However, no matter how trained the athlete is, accidents will happen. It becomes the state’s, the

CONCUSSIONS 21

community’s, the school’s, the parent’s, the coach’s, and the athlete’s responsibility to ensure

protocols are followed, and when an injury does occur, that the correct steps are taken in order to

prevent further injury from happening. So education for coaches only does not seem to be

enough. There needs to be regular training to all of those involved from lawmakers to the

players themselves in order to fully understand current rules and regulations.

Future Research and Literature Gaps

This section will discuss the future of research linked with sports-related concussions and

gaps in the literature on this subject. To date, research has primarily focused on defining

concussions and traumatic brain injury (TBI). Definitions, causes, long-term effects, prevention

strategies, and management techniques have all been discussed over and over again. There have

been many research studies focusing on state laws, the differences and variances between states,

and what individual states are doing to strengthen their concussion guidelines. Because the

interest and focus has only been present seriously for the past decade, little research has been

completed regarding how we as a country are doing. Have the laws really helped to decrease

incidence of concussions in high school football players or are we becoming more aware?

Concussive injuries are not new; in fact, concussions have been known about for

centuries. However, with the NFL making these types of TBI more in the forefront and cases

such as Zackery Lystedt making national news, we as a society are more aware of what

concussions look like, what the long-term effects are, and what we can do to better prevent them

from occurring. Much remains unknown, however, about the long-term effects concussions can

have, especially on our youth athletes.

Erdtmann (2015) discusses the lack of data regarding the overall incidence in sports-

related concussions, particularly in youth athletes. Due to the Return-to-Play laws and

CONCUSSIONS 22

guidelines requiring education and training, there is more of an awareness regarding concussions

and a better recognition of symptoms (Erdtmann, 2015; Noble & Hesdorffer, 2013). Recently,

the Institute of Medicine and the National Research Council, as well as numerous government

agencies and private groups assembled an expert committee to examine the logistics behind

sports-related head injuries and how it relates to our school-age and adolescent populations. This

committee called on the CDC to begin collecting data which would help determine the incidence

of concussions. Many factors would need to be taken into account such as demographics, sports

equipment used, history of previous concussions; as well as the cause, nature, and extent of the

injury and signs and symptoms observed (Chrisman et al., 2013; Erdtmann, 2015).

Another area for future research would be studies on the physiologic changes in the brain

chemistry when concussions occur in young athletes (Noble & Hesdorffer, 2013; Semple et al.,

2015). Also needed are studies that discuss the impact that repetitive injuries have on the brain

and what long-term effects that can incur. We have seen the damage that happens with

professional football players, hockey players, and boxers in the media. The symptoms range

from depression, garbled speech, and slower cognition to mental retardation, and even suicide.

However, more studies are needed to discuss scientifically what happens to the brain itself when

repetitive injuries happen (Erdtmann, 2015). McKee et al. (2013) performed an analysis of

postmortem brains to attempt to identify patterns of brain injury amongst former athletes,

military veterans, and civilians. That study included football players in the athlete group and

was divided into age ranges. The results of this study indicated that although professional

athletes make up the majority of CTE cases, high school football players also could be diagnosed

with the disease, even with their limited TBI exposure. Although most high school subjects were

diagnosed 20 or more years after their athletic careers were over, there were a handful of cases of

CONCUSSIONS 23

high school players who died prior to age 20 (Maroon, et al., 2015). These results indicate that

trauma to a young brain can be even more dangerous than to an adult.

Little has been discussed regarding sports equipment, especially helmet design. If we

want to protect the brain from jarring injuries, adequate helmet protection should be number one

on the priority list. The current design of football helmets yields a rigid exterior with a padded

interior, intended to protect the head from impact. Many football players, especially young

athletes who have not yet been adequately trained, are inclined to lead with their heads as an

offensive play, validating their actions with the premise that their heads are protected (Noble &

Hesdorffer, 2013). This change to a harder helmet in order to protect heads from injury may

actually have a negative effect; encouraging players to hit with their heads (Nakatsuka &

Yamamoto, 2014). More research is needed to assess whether the current football helmet design

is protecting the heads of our student athletes or causing them more harm.

One major hurdle when discussing current concussion guidelines is which one to follow.

For adult sports, there are 16 different concussion-related guidelines. These range from simple

monitoring of the athlete to much more strict and rigorous routines. This makes standardizing

treatment extremely difficult. The guiding principle of the rules is that any athlete remaining

symptom-free for seven days and does not demonstrate any remaining neurologic deficits may be

allowed to return to the field and participate again (Hodge & Kadoo, 2014). There are no

standardized grades and testing for concussions. Each guideline also has varying requirements

as to when an athlete can return to play. Hodge and Kadoo (2014) indicate that a more uniform

management system would better serve the needs of the athletes, take pressure off of the coaches

and health care professionals caring for them, and are able to track these cases much more

fluidly. Having systematized statewide efforts aimed at concussion education, management, and

CONCUSSIONS 24

prevention is needed in order to identify, prevent, and maximize recovery of sports-related

concussion injuries (Conder & Conder, 2015).

Method

This section will discuss the effect that Return-to-Play laws have had on concussion rates

in high school football players. Over the past decade, many research studies have been

completed looking at how these rates have increased and the potential causes. It appears that the

rates have risen vastly, but the question remains: what is the cause? This section will break

down the populations studied, what type of research was completed, and how data was collected

and analyzed.

Research Method and Design Appropriateness

In studying the effect of Return-to-Play laws on the incidence of concussions in student

athletes, there are many avenues to take. Due to the newness of the laws (the final states with

enacted laws only came into effect last year), there is very little raw data. Also, because the laws

vary state to state in their wording and descriptions as well as their inclusions of factors, it would

prove difficult to perform a quantitative study at this point in time. However, using medical

coding and insurance claims data, it would be possible to perform this type of statistical research

in the upcoming years, when there is data available to compare.

The CDC estimates that between 1.6 million and 3.8 million concussions occur in sports

or recreational activities annually (Dompler, et al., 2015). However, this number is largely

inaccurate. There are numerous reasons this injury is underreported. First, if the injury is mild,

many players do not seek medical attention. Without being officially reported, the CDC is

unable to include these athletes in their overall total numbers. Secondly, as discussed in the

literature review, many athletes and parents “shop around” to find the right health care

CONCUSSIONS 25

professional that will clear the athlete in order to return to play faster. This phenomenon skews

the data. Finally, the varying degrees of concussions including location of impact, symptoms

involved, and recovery time, makes comparisons difficult. This quantitative approach to

analyzing the numerical and statistical incidence in concussion rates may not provide an accurate

reporting of the data for years to come.

For the purposes of this paper, a qualitative approach was taken. Using and comparing

previous research as well as current trends by continuously asking the question “why?” is how

this reviewer will attempt to get to the cause of the increased incidence in concussions amongst

high school football players. Qualitative research involves exploration and description in order

to find meaning in specified social settings (Forister & Blessing, 2016). This paper focused on

the literature already surrounding the topic of concussions in athletes, incorporating findings

from other researchers, provide areas for future research, and attempt to determine whether these

new laws have made a difference in rates of concussions.

This descriptive research project compared available literature on concussions and

focused on those that discussed incidence, state laws, and future research opportunities on the

topic of high school athletes. Data comparisons, analysis, and results were compared to

determine if there was a common theme regarding recent concussive injuries.

Population

The study population for this project involves high school football players who have

suffered a concussive-type injury during the course of a game or practice. During the course of

the research, it was determined that one cannot discuss this younger group without first

incorporating cases from the National Football League. Numerous retired NFL players have

been diagnosed with brain disease resulting from concussions they received while they were

CONCUSSIONS 26

playing football (Tarshis, 2011). Research has shown that these professional athletes have

suffered memory loss, blurred vision, chronic headaches, dementia, and depression all making up

a rather new diagnosis of chronic traumatic encephalopathy (CTE), a degenerative disease

involving repeated head trauma.

A few cases to point out would be that of Jovan Belcher, Junior Seau, and Mike Webster;

all who suffered chronic traumatic encephalopathy, ultimately resulting in their deaths. Belcher,

a Kansas City Chiefs linebacker shot and killed himself after killing his girlfriend. Pathology

after his death confirmed he suffered from repeated head trauma resulting in CTE. Junior Seau,

retired New England Patriots linebacker, suffered depression and ultimately took his own life at

the age of 43, where testing also confirmed CTE (Drysdale, 2013). Finally, Mike Webster,

veteran center for the Pittsburgh Steelers suffered from amnesia, depression, and dementia after

his 17 years in the league. He was the first confirmed diagnosis of CTE, spurring the NFL to

make changes to their policies, procedures, and definitions of concussions. His case inspired

more research to be done, better ways to protect these athletes, and have even inspired a new

movie which premiered on Christmas Day 2015, starring Will Smith and entitled “Concussion”

(See Appendix 3).

Because of the studies stemming from the deaths of these elite athletes and the findings

of CTE, the NFL has made drastic changes in how they are attempting to protect their players.

For example, the NFL has changed the length of kickoffs, enforced new rules to limit head and

neck contact with defenseless players, and have now required consultation with a neurologist if a

concussion is suspected (Drysdale, 2013). The NFL has also donated millions of dollars to fund

research surrounding TBI and the connections between concussions and long-term brain disease

(Tarshis, 2011).

CONCUSSIONS 27

Sampling Frame

With the changes the NFL has made, also brings the responsibility to mold and

shape younger football players as well. The NFL has served as role models to young athletes on

many levels. Now, due to the changes the NFL has made as well as organizations like the

CDC’s Heads Up campaign, regulations in collegiate and high school sports programs have been

altered as well. Taking the professional NFL athletes into account, this paper utilized a stratified

purposeful sampling strategy aimed to focus on high school football players as the subgroup of

the overall population. The Zackery Lystedt Law in the state of Washington caused a ripple

effect across the country, initiating Return-to-Play laws being enacted in every state in the nation

and Washington D.C. by 2014. This paper attempted to narrow the sampling down even more

by focusing specifically on how the Washington state law affected incidence in student athletes

of that state. This proved difficult, however, due to limited research available. One study

actually focused on that population, finding that there indeed was an increased incidence in

concussive injuries post-Lystedt Law initiation (Bompadre, et al., 2014). There were, however,

many limitations mostly due to lack of data.

Data Collection

For this qualitative research project, data was collected utilizing scholarly articles and

periodicals, as well as peer-reviewed sources. Websites such as Google Scholar and Kaplan

University Online Library were used in order to search for relevant resources. Search terms such

as “concussions in high school football players”, “traumatic brain injury in football players”,

“state laws on concussion”, and “concussion in student athletes” were used. These articles were

read, and sorted by topic such as state laws, coaches’ perspectives, and concussions in order to

organize the outline of the paper as well as attempt to answer the research question. Content

CONCUSSIONS 28

analysis was performed by narrowing down the main topics in order to create categories and

define the theme of this paper (Forister & Blessing, 2016). Sources were united and sectioned so

that the main research questions were covered and a final theme revealed.

Data Analysis

Data analysis was achieved after articles were read and carefully sorted into the main

topics. Attempts were made to incorporate literature that supported this reviewer’s thoughts and

ideas as well as those that disagreed in order to bring both sides to light. Research that had

similar conclusions was combined to form cohesive answers to the research questions. Many

studies indicated the need for future research and these were also combined. Research that did

not fit into the created outline was then discarded so as to keep this paper from being too broad

and disjointed. Once all research was organized, sorted, and outlined, a final formulation was

attained and generalizations were made.

Findings

The purpose of this paper was to discuss the Return-to-Play laws and how the incidence

of sports-related concussions in high school football players has changed since enactment.

Previous research has shown that there has been an increase in concussive injuries. The

following section will discuss the implications of the research conducted, limitations of the

research, and recommendations for future study.

This project predicted that the incidence of concussive injuries in high school football

players would increase after the Return-to-Play laws were in effect nationwide. This theory

proved true after a literature review. The reasons why, however, remain alarming, implicating

that much more research needs to be done on the topic. There were several theories as to why

CONCUSSIONS 29

concussions have risen steadily since 2009 when the Lystedt Law was enacted in Washington in

2009, however the main reason that frequented the literature was an increased awareness about

the diagnosis, new rules and regulations surrounding concussions, and how to prevent future

injuries from occurring.

Rise in Awareness

Since the first Return-to-Play law went into effect in Washington, all the other states in

the nation as well as Washington D.C. have legislated similar laws to help protect these student

athletes from irreparable harm. With backing from the NFL and the CDC, as well as other

groups and organizations, concussions have become a primary focus on the football field

amongst coaches, players, and parents alike. The NFL has made major changes in the past

decade to reduce the incidence of concussions. The organization has enacted their own rules and

regulations as well as contributed to scientific research studying the cause of long-term effects on

concussive injuries on brain function. The CDC has created the Heads Up campaign which has

educational and informative resources for coaches, parents, and athletes.

With all of the media reports circling around concussions as well as state legislation, it is

no wonder that communities are more aware of concussions and that the incidence has increased.

The majority of the literature points to an overall increase in the rates of concussions since the

Return-to-Play laws have been enacted. Gibson et al. (2015) reports a 92% rise in health care

utilization in states with concussion laws in effect during the 2008-2012 school years. Even

those states with no law yet enacted during that time had an increase in reported concussive

diagnoses among young athletes. However, the question still remains, are there truly more

concussions or are there just more reported due to rules, regulations, and reporting requirements?

CONCUSSIONS 30

In fact, some may argue that the United States, as a country, are too aware. The term

concussion has become such the focus in recent years that people no longer think of the term

itself and what it entails. Because the symptomatology differs between patients and often are

undetected on imaging, these types of injuries are often brushed off (Stephenson, 2014). As

stated earlier, many athletes falsify symptoms just so they can go back in and play. As a society,

communities are very aware of those patients who have long-term brain damage, those in comas,

and those who have committed violent acts against themselves or others. What must be

remembered is that the minor injuries can affect young athletes, just as much, especially when

repeated injury occurs and the brain is not given enough time to recover. Has awareness done

more harm than good when it comes to recognizing, treating, and preventing concussive injuries

in our young athletes?

Limitations

Being more aware is always a positive trait to have. But, has improved awareness

improved the long-term effects of concussions? And, has being more aware been able to prevent

further injuries from occurring? The study of traumatic brain injury in football players is multi-

faceted as there are multiple factors playing into the diagnosis, treatment, prevention, and

education. These factors can lead researchers on wild goose chases looking for a particular

answer, where one answer does not exist. This paper attempted to narrow down the focus to

discuss the Return-to-Play laws themselves and their impact on concussions in high school

football players. Even with those specific topics, it was difficult to not bring in stories and

research surrounding professional athletes as well as physiologic and anatomical discussions

regarding the injuries themselves.

CONCUSSIONS 31

The first limitation to this study was the variances in state laws. The difference between

state laws made it difficult to compare apples to apples. For example, as previously stated, a

large number of states used vague terminology making it easy for alternative interpretation of the

laws themselves (Harvey, 2013). Some states require an athlete to be assessed by a physician,

while others only require evaluation by a school nurse or athletic trainer. This can cause a

discrepancy between who diagnoses an actual concussion and who does not, based on education

and training.

Other limitations include the population itself. The initial population was football players

in general. The sample was framed to specifically discuss high school athletes. Much of the

research reviewed did discuss high school athletes, however not just football players. Many of

the researchers also discussed athletes who participate in other sports such as rugby, soccer,

wrestling, and basketball. Also, this paper focused on football players, but did not specify

gender. It was assumed that the literature would focus on high school boys, since that is the

major group that participates in this particular sport. However, there are a number of girls that

play football and more are joining their junior high and high school teams every year. The

literature also discussed the increased incidence of concussions among female athletes, which

was not reviewed for this paper.

Finally, time provided a major constraint when performing literature review on this topic.

The Return-to-Play laws are still only a few years old. There is very limited data available to

truly compare pre-law rates versus post-enactment rates of concussion. As the CDC continues to

collect data and progresses their Heads Up campaign, it will be easier to determine causality of

the injuries, age ranges, which sports had the higher incidence, how long the athlete was

removed from play, and what the long-term effects of the injuries are.

CONCUSSIONS 32

Use and Application of Findings

The use and application of these findings may contribute to future research on

concussions in high school football players by incorporating what we know today and what we

need to know for the future. Since Zackery Lystedt and his family so bravely fought for a state

law to help other athletes from suffering the brain damage he has incurred, every state in the

nation has enacted some form of a Return-to-Play law. The basic premise of these laws is if a

player is suspected of having a concussion, they are immediately removed from play. That

player must then be evaluated by a trained professional and cleared prior to coming back and the

coaching staff must go through a specific concussion-related training. The problem with

researching if these laws have had an effect on concussions in this population is that there are so

many different interpretations of the law. The basic concepts are concrete; however the wording

regarding the degree of concussion and who needs to evaluate the athlete has come into question.

There is more awareness of TBI suffered by athletes than there was even ten years ago.

However, there is so much more that needs to be known in order to help young athletes from

suffering permanent damage. By using the guidelines set forward by the NFL and the CDC, the

following recommendations for future research could improve recognition and diagnosis,

treatment, and recovery of sports-related concussions in high school football players.

Recommendation: There should be a national protocol to assist states and schools with

concussions.

The research has shown that due to the differences between state laws, it is difficult to

have consistent data to compare state incidences of concussions among student athletes. If every

state had the same rules, the same education and training for parents, coaches, and kids, and the

same consequences for a breakdown in these rules, it would be much easier to analyze data.

CONCUSSIONS 33

Some states have minimal time an athlete must be out before returning to play, while others are

much stricter. Most states have minimal basic training for coaching staff, while others have

much more in-depth education. Also, very few states actually have consequences for schools,

coaches, or athletes for breaking these rules. If these were the same across the board, everyone

involved would know what the rules are. All coaches would be required to participate in

mandatory training regarding concussions including the most up-to-date regulations. The

problem with this recommendation is that there are many more opportunities for schools in urban

communities. In more rural areas, it may prove difficult with funding and opportunities to

provide these necessary services. Also, research has shown that finding qualified health care

professionals to evaluate these athletes in the timeframe allotted can be difficult. All in all, the

rules need to become more consistent in order for research to progress.

Recommendation: Longitudinal studies need to be performed to evaluate the effects of

head injuries in student athletes over time.

Many studies have been done on the effects of TBI on professional athletes, such as those

in the NFL. However, very few have been accomplished on the long-term effects on young

athletes. Researchers have indicated that younger brains heal much differently than adult brains

and that repeated trauma to a young brain can have devastating long-term effects. Further

research needs to be performed to understand the adolescent brain and the consequences of

multiple concussions on growth and development on this still growing vital organ. It is known

that adult TBI can cause memory loss, depression, speech difficulties, and progress to brain

damage and even death. It is also known that the more repetitive injuries an athlete suffers, the

more damage can be done, often irreversible. Research has been conducted on CTE in adults,

however less has been shown regarding if there are similar diagnoses for young athletes. With

CONCUSSIONS 34

the newer Return-to-Play laws, knowledge about these effects on younger brains can aid in

development of better and safer equipment. It can aid lawmakers in updating and renewing

these laws to help protect these young people.

Recommendation: Parents and students need more education on concussion and traumatic

brain injuries.

Part of the Return-to-Play laws is a specific component referring to education and

training. This element primarily referred to coaching staff. However, in order to truly inform

everyone involved. Mandatory education should be available to parents and players as well.

Currently, most parents sign a piece of paper saying they read the concussion policy. Most

parents, when asked, rarely read this form. Having parents and students sign a form may help to

meet the liability that schools incur. However, it does little to really educate those signing about

what concussions are and the protocols in place. Information regarding their child’s health

should be available to parents. This would not be in the same form that it is to coaches. One

way this could be achieved is at parent night for any contact sports. A short public service

announcement by former NFL players, coaches, athletic trainers, etc. could be shown in the form

of a video. This PSA could describe symptoms and long term effects as well as what the

necessary steps are that would be taken in the event that a concussive injury occurred. The

parents and players would then sign that they had watched the PSA. The CDC also provides

information for athletes and their parents, however if they are unaware that the information

exists, they more than likely would not voluntarily go there to look for it. Players need to know

what could happen to them if they continue to play with head injuries and what will be expected

of them if they show signs and symptoms.

CONCUSSIONS 35

Conclusion

This capstone project focused on concussion injuries in high school athletes, primarily

football players. The NFL has been funding research to get to the bottom of traumatic brain

injuries for many years. However, it has only been recently that laws have been put in place for

our younger players. The Lystedt Law from Washington State set the ball rolling after a young

player suffered lifetime injuries after repetitive head injuries during a junior high football game.

It was because of this boy and his courageous family that there are now nationwide Return-to-

Play laws.

The purpose of this paper was to answer several research questions. First, how has the

incidence of concussive injuries changed since the enactment of these laws? Secondly, has

heightened awareness caused coaches, parents, and athletes to be more cautious? And finally,

what needs to be done to make laws more consistent and to reduce incidence of concussions

amongst student athletes?

To answer these questions, a qualitative literature review was performed. These state

laws are still fairly new, however many studies have already occurred. Research has shown that

the incidence has steeply risen over the past decade for many reasons. The primary reason found

in the literature is that there is a heightened awareness of these types of injuries. Many

professional football players have been in the media who have suffered from long-term effects of

injuries, some ultimately succumbing to their injuries. There is even a recent movie that has

come out discussing some of these players and the research that has occurred. The Return-to-

Play laws are in every state and have rules for every high school player. Coaches, parents, and

athletes are more aware, but these laws vary statewide and have differing interpretations, thus

making consistency difficult.

CONCUSSIONS 36

Because of the newness of these laws and the lack of comparable data, future research is

necessary to truly make a difference in the incidence of concussions. The biggest gap in the

literature involves the study of the adolescent brain and what the long-term effects of repetitive

injuries have been. The diagnosis of CTE has been determined postmortem on numerous

professional athletes, however very few studies have been performed to determine long-term

effects on young athletes. Longitudinal studies are needed in order to conclude the best way to

protect these young brains from long-term harm.

Based on this literature review, several recommendations were made. First, due to the

variance in state law requirements, there needs to be a nationwide consistent policy in place. It

shouldn’t matter if you are living on the west coast, east coast, north or south; if a high school

athlete suffers from a head injury, there should be consistent protocols in place. There should be

clear definitions of what concussions are, who evaluates and treats the athlete, and how long the

player remains out of play. To date, these factors vary greatly, not only making data mining and

analysis difficult, but potentially causing harm to these young people.

Secondly, it was recommended that consistent education and training needs to occur.

Coaches should all have to have the same education and training when it comes to traumatic

brain injury. They should know how to recognize signs and symptoms, what steps need to be

taken in order to get that player healthy again, and what the consequences will be if those rules

aren’t followed. Currently, state laws fluctuate immensely with regard to coach education and

concussions. This recommendation also applies to education to parents and players as well.

There should be mandatory education for all players and parents at the beginning of every sports

season. This reviewer indicated a public service announcement in the form of a video featuring

NFL players, leading researchers, athletic trainers and coaches may get players’ attention, so

CONCUSSIONS 37

they take the information seriously. Those involved need to understand the importance of the

protocols and not just look at it as another form that needs signed. It needs to be taken more

seriously.

In conclusion, concussions are one of the most prevalent and damaging injuries a high

school football player can face. There have been great strides over the past decade to help

safeguard our adolescent athletes from harm. However, so much more can be done. These

future players are our future, and we must protect them as parents, as coaches, as communities,

and as a nation.

CONCUSSIONS 38

Appendix 1

Table 1 - States Enacting Return-to-Play Laws by Year

(Gibson, Herring, Kutcher, & Broglio, Analyzing the Effect of State Legislation on Health Care Utilization

for Children With Concussion, 2015)

CONCUSSIONS 39

Appendix 2

Clipboard Concussion Information Sheet and Sticker

CONCUSSIONS 40

(Centers for Disease Control and Prevention, 2015)

Appendix 3

CONCUSSIONS 41

Link to movie trailer “Concussion”

https://youtu.be/aTaBHJoDJQ4

CONCUSSIONS 42

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