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

Letter

Available Information about the Occurrence of Concussion in High School Sports Cannot Provide an Overall National Estimate

We identified three national databases that, as part of broader data collection efforts, collect information on the occurrence of concussion in high school sports, but they do not provide an overall national estimate of occurrence. These databases are the NCCSI database, the CPSC’s National Electronic Injury Surveillance System (NEISS), and the Center for Injury Research and Policy’s High School RIO. (See table 1 for descriptions of the databases.)

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.

The Primary Federal Program Directed Specifically at Preventing Concussion in High School Sports Is CDC’s Heads Up: Concussion

CDC’s Heads Up: Concussion in High School Sports is the primary federal program directed specifically at preventing concussion in high school sports. The program, which is one of CDC’s educational initiatives, is intended to provide educational materials for coaches, athletic trainers, athletic directors, parents, and athletes to prevent concussion. 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.

Concussion Education and Return-to-Play Requirements Are the Focus of Key State Laws, but Exact Requirements Differ

The three key state laws regarding the management of concussion that were identified by federal officials and experts all include requirements related to concussion education and athletes’ return to play. (See table 2.) The education components of the key state laws—those of Oregon, Texas, and Washington—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.

Voluntary Nationwide Guidelines for Managing Concussion Incurred in High School Sports All Recommend Assessing Concussion on an Individual Basis, with Gradual Return to Play

Federal officials and experts we spoke with identified five sets of voluntary nationwide guidelines that address the management of concussion in sports. (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.

GAO Contact and Staff Acknowledgments

For further information about this statement, please contact Linda T. Kohn at (202) 512-7114 or kohnl@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Key contributors to this statement were Helene F. Toiv, Assistant Director; Kate Blackwell; George Bogart; Shana R. Deitch; Carolyn Feis Korman; and Roseanne Price.

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