Concussion in High School Sports: Overall Estimate of Occurrence Is Not Available, but Key State Laws and Nationwide Guidelines Address Injury Management
Published: 2010-05-20T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: 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.
section_title: What GAO Found
paragraphs: 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

section_title: Letter
paragraphs: 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). 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. 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.
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 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. 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.
subsections: section_title: Available Information about the Occurrence of Concussion in High School Sports Cannot Provide an Overall National Estimate
paragraphs: 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.)
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, based on its sample of 100 high  schools with certified athletic trainers. 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. 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.
section_title: The Primary Federal Program Directed Specifically at Preventing Concussion in High School Sports Is CDC’s Heads Up: Concussion
paragraphs: 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. 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. 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. Agency officials  estimate that CDC distributed more than 300,000 Heads Up: Concussion High School Sports materials overall by the end of December 2009.
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. 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 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.
section_title: Concussion Education and Return-to-Play Requirements Are the Focus of Key State Laws, but Exact Requirements Differ
paragraphs: 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—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.
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. 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.
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. 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). 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.
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.
section_title: Voluntary Nationwide Guidelines for Managing Concussion Incurred in High School Sports All Recommend Assessing Concussion on an Individual Basis, with Gradual Return to Play
paragraphs: Federal officials and experts we spoke with identified five sets of  voluntary nationwide guidelines that address the management of  concussion in sports. (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. 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.
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.
section_title: GAO Contact and Staff Acknowledgments
paragraphs: 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.
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