Response of School Districts to the New York State Concussion Awareness and Management Act: Review of Policies and Procedures

Concussion Public Policy in Elementary and High Schools in Ontario, Canada: A Cross-Sectional Survey to Examine Implementation Compliance, Barriers, and Facilitators

BACKGROUND

Concussion public policies have been developed to address the burden of concussions. The aim of the present study was to examine implementation compliance, barriers, and facilitators of Canada's first concussion public policy, Ontario's Policy/Program Memorandum 158: School Board Policies on Concussion (PPM158).

METHODS

An electronic survey was sent to 515 randomly selected elementary and high school principals across specific geographic, language, and publicly funded school types in Ontario. Data were analyzed using both qualitative and quantitative methods.

RESULTS

One hundred and thirty-five principals responded to the survey (26%). Concussion education was provided to teachers in 81% of schools, to students in 83%, and coaches in 79%. Additionally, 89% reported having a return-to-learn protocol in place and 90% reported having a return-to-play protocol. Implementation barriers included difficulties in providing concussion education to parents (42%), obtaining notes from physicians, and maintaining the volume of documentation. Eighty-seven percent of respondents believed that PPM158 improves student well-being.

CONCLUSIONS

Identified implementation barriers and facilitators can inform concussion policy practices to improve student well-being. We recommend: (1) an appointed concussion policy lead at each school, (2) electronic documentation, (3) determining the optimal education format to improve parent/guardian education, (4) fostering relationships between schools and health care professionals, and (5) student concussion education in every grade in Ontario schools.

Mild traumatic brain injury and sports-related concussion

Mild traumatic brain injury (mTBI) and concussion are equivalent terms for the sequela of injury to the head that disrupts brain functioning. Various forces may be causative from seemingly innocuous bumps to the head resulting from sports-related injuries to more severe blows to the head. However, the postconcussive motor, cognitive, emotional, and psychosocial sequelae can be just as devastating and long lasting, leading to loss of independent function and safe performance of activities. Taken together, they pose a significant challenge to recovery, requiring a multifaceted dynamic rehabilitative strategy. The current systems of health care pose challenges to suboptimal management of sports-related concussion (SRC) that goes beyond the acute injury, and into the school setting, failing to be identified by school staff, and inconsistencies in communicating medical information regarding school modifications, follow-up health services, or concussion-related educational services. Children who sustain SRC at different ages face different challenges. Young children face increased vulnerability due to SRC that coincides with periods of brain motor maturation and development.

Youth sport parents’ familiarity and perceptions of concussion legislation

Objectives

In an effort to reduce the negative health consequences often associated with concussions among young athletes, all U.S. states and the District of Columbia enacted youth concussion legislation between 2009 and 2014. This study explored youth sport parents’ (1) familiarity with their state's concussion legislation, and (2) perceptions about the need for additional legislative provisions not currently found in such laws.

Methods

Cross-sectional online survey data were obtained from parents ( n = 430) of youth sport athletes from 22 U.S states.

Results

Primary findings suggest that 67% of parents were moderately to extremely familiar with the removal from play requirement; 69.9% were moderately to extremely familiar with mandatory concussion training for coaches; and 75.1% were moderately to extremely familiar with the medical clearance requirement for athletes to return to play. In regard to perceptions, approximately half (50.2%) believed it is essential to mandate parent/guardian notification when a child suffers a potential concussion; and 42.8% believed it is essential to include a penalty/sanction for violating the statute. Based on the results of a multivariable logistic regression model, a significantly greater familiarity of concussion legislation was found among parents who were White/Caucasian, had advanced degrees, had higher household incomes, or were urban residents.

Conclusions

Our findings suggest that most youth sport parents have a sound understanding of concussion legislation and believe that the laws should be revised to improve best practices in preventing and managing concussions. Parents who face socio-cultural and economic barriers can benefit most from having access to credible information about their state's concussion law.

Compliance with State Concussion Legislation in Non-School-Affiliated Youth Sport Leagues

Youth league administrators (N = 172) documented knowledge of/compliance with state concussion legislation, and were assigned to groups based on whether their state concussion legislation extended to non-school-affiliated (NSA) youth sport leagues: EXTEND (50.6%) or NOT EXTEND (49.4%). Administrators within the EXTEND group were 2.7x more likely to report having a formal concussion policy. Only 90.7% confirmed a policy for removing concussed athletes from play, and 75% required independent medical clearance, and 82% mandated education for coaches, 49.1% for parents, and 35.9% for athletes. These results raise questions regarding compliance with state concussion legislation, especially for NSA youth sports leagues.

Going Beyond the State Law: Investigating High School Sport-Related Concussion Protocols

CONTEXT

State laws provide general guidelines for sport-related concussion (SRC) management, but do not comprehensively address the multiple layers of management for this complex injury. While high schools are encouraged to develop a SRC protocol that includes both state law tenets and additional management practices, the execution of this warrants examination.

OBJECTIVE

To investigate state law compliance and practice components included in high school SRC protocols, and determine whether the degree of sports medicine coverage influenced protocol quality.

DESIGN

Qualitative document analysis.

SETTING

High school athletics.

PARTICIPANTS

In total, 184 Pennsylvania high schools [24.3% of schools statewide; full-time athletic trainer=149, part-time athletic trainer=13, missing=21] voluntarily provided copies of their protocol from the 2018-2019 academic year.

MAIN OUTCOME MEASURES

Four athletic trainers conducted document analyses using a 67-item component analysis guide. Frequencies were computed for included protocol components related to the state law, preparticipation and prevention, recognition and assessment, and management. The difference in the total number of included components (max 60) by sports medicine coverage was assessed using a Mann-Whitney U test.

RESULTS

There was heterogeneity in components included in the submitted protocols. Only 23.4% included all mandatory state law tenets. Immediate removal from play was noted in 67.4% of protocols, while only 1.6% contained prevention strategies. Return-to-play was addressed more frequently than return-to-learn (74.5% versus 32.6%). The sample had a mean of 15.5±9.7 total components per protocol. Schools with full-time sports medicine coverage had significantly more protocol components than those with part-time athletic trainers (15 [8.5-22.5] versus 6 [3-10.5] median components; U = 377.5, p < .001) Conclusions: School-level written SRC protocols were often missing components of the state law and additional best practice recommendations. Full-time sports medicine coverage in high schools is recommended to increase SRC protocol and healthcare quality.

The Socioecological Framework: A Multifaceted Approach to Preventing Sport-Related Deaths in High School Sports

The socioecological framework is a multilevel conceptualization of health that includes intrapersonal, interpersonal, organizational, environmental, and public policy factors. The socioecological framework emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected by various contexts. At present, the sports medicine community's understanding and application of the socioecological framework are limited. In this article, we use the socioecological framework to describe potential avenues for interventions to reduce sport-related deaths among adolescent participants.