Concussion LegislationSara P.D. Chrisman, MD, MPHAdolescent Medicine, University of Washington

Outline

• History • Description • Impact• Future

Zackery Lystedt Law—2009

• Stan Herring, MD and Richard Adler, JD

• Education was not working—too difficult to change the culture of sport

• Goal: Prevent athletes from playing with concussive symptoms

Zackery Lystedt Law—2009

1. Removal from play if suspected concussion

2. Written clearance from a health care provider prior to RTP

3. Education for coaches, parents and youth

Zackery Lystedt Law

• Strengths• Litigation protection• Carried out through the Washington Interscholastic Athletic

Association (WIAA)• Allowed ATs to clear athletes

• Limitations• No requirements for clinician training in concussion management• Limited education requirements for coaches, parents and youth• Did not apply to private schools, club sports, or elementary schools• Secondary prevention, not primary prevention

Spread of concussion legislation

Year State

2009 Oregon, Washington

2010 Connecticut, Idaho, Oklahoma, Rhode Island, Massachusetts,New Mexico, New Jersey

2011 Alabama, Alaska, Arizona, District of Columbia, Iowa, Illinois, Indiana, Kansas, Louisiana, Maryland, Missouri, Minnesota, North Carolina, North Dakota, Nevada, South Dakota, Texas, Utah, Virginia, Vermont, Wyoming

2012 California, Colorado, Kentucky, Wisconsin, Maine, Florida, Nebraska,New York, Pennsylvania, Hawaii, Delaware, New Hampshire

2013 Ohio, Montana, Michigan, South Carolina, Arkansas, West Virginia

2014 Georgia, Tennessee, Mississippi

Spread of legislation—2013Traumaticbraininjury.net

Spread of legislation

• Alabama—2011, 2012• Alaska—2011• Arizona—2011• Arkansas—2013• California—2011• Colorado—2011• Connecticut—2010, 2014• Delaware—2011• Florida—2012• Georgia—2013• Hawaii—2012• Idaho—2010, 2012• Illinois—2011• Indiana—2011, 2014• Iowa—2011• Kansas—2011• Kentucky—2012• Louisiana—2011• Maine—2009, 2012

• Maryland—2011• Massachusetts—2010• Michigan—2012• Minnesota—2011• Mississippi—2014• Missouri—2011• Montana—2013• Nebraska—2011, 2014• Nevada—2011• New Hampshire—2012, 2014• New Jersey—2010• New Mexico—2010• New York—2011• North Carolina—2011• North Dakota—2011• Ohio—2012• Oklahoma—2010• Oregon—2009• Pennsylvania—2011

• Rhode Island—2010, 2011, 2014• South Carolina—2013• South Dakota—2011• Tennessee—2013• Texas—2011• Utah—2011, 2013• Vermont—2011, 2013• Virginia—2010, 2014• Washington—2009• Washington DC—2011• West Virginia—2013• Wisconsin—2012• Wyoming—2011

Spread of legislation—Variation

• Variation in laws• Coach education• Parent and athlete education• Specific educational materials • Removal from play criteria• Healthcare practitioner standards• Liability protection

• New measures being added• Coverage below middle school• Mandated graduated RTP (CA and NM)• Return to learn protocol (NV, VA)• Limit on full contact practices in FB (CA)

1. Harvey HH. Reducing traumatic brain injuries in youth sports: youth sports traumatic brain injury state laws, January 2009-December 2012. Am J Public Health. 2013 Jul;103(7):1249-54.2. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and review of current practices in concussion. Neurosurg Focus. 2012 Dec;33(6):E11: 1-9.

Do these laws work?

Impact of legislation—Primary prevention

• Smoking• Ward M1, Currie LM, Kabir Z, Clancy L. The efficacy of different models of smoke-free laws in reducing

exposure to second-hand smoke: a multi-country comparison. Health Policy. 2013 May;110(2-3):207-13.

• Seat belts• Houston DJ1, Richardson LE Jr. Getting Americans to buckle up: the efficacy of state seat belt laws. Accid

Anal Prev. 2005 Nov;37(6):1114-20. Epub 2005 Jul 18.

• Bicycle helmets• Macpherson A1, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head

injuries. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005401.

• Child passenger restraint (car seats)• Evans WN, Graham JD. An estimate of the lifesaving benefit of child restraint use legislation. J Health

Econ. 1990 Sep;9(2):121-42.

Impact of legislation—Secondary prevention

• Goal: To prevent youth from playing with concussion symptoms

Impact of legislation—Education

• Methods: Randomly selected survey of coaches in WA (N=496)• Findings:

• All but 3 coaches reported receiving concussion education, 91% via two or more modalities

• 70% provided athlete education beyond the signed form• FB coaches more likely than soccer coaches to talk to athletes

about concussion• 42% provided parent education beyond the signed form

Chrisman SP1, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health. 2013 Mar;52(3):330-335.e3.

Impact of legislation—Concussion diagnosis and health care utilization

Author (Year) Population Findings Limitations

Bompadre (2014) AT high school injury data

2x RR, N= 48 concussions before, 114 and 111 after

Only started working in schools 1 year before law

Makenzie (2015) ER data 2x incidence after law No RR reported

Gibson (2015) Insurance data 92% increase in states with laws, 75% in states without

Only insured patients

Impact of legislation

Gibson TB, Herring SA, Kutcher JS, Broglio SP. Analyzing the effect of state legislation on health care utilization for children with concussion. JAMA Pediatr. 2015 Feb;169(2):163-8.

Impact of legislation

Gibson TB, Herring SA, Kutcher JS, Broglio SP. Analyzing the effect of state legislation on health care utilization for children with concussion. JAMA Pediatr. 2015 Feb;169(2):163-8.

Impact of legislation

Gibson TB, Herring SA, Kutcher JS, Broglio SP. Analyzing the effect of state legislation on health care utilization for children with concussion. JAMA Pediatr. 2015 Feb;169(2):163-8.

Impact of legislation—Athletes playing with symptoms

Author (Year) Population Findings Limitations

Rivara (2013) HS football and soccer (N=778)

70% played with sxs after law

No before data

O’Kane (2014) MS soccer (N=351) 70% played with sxs before vs. 56% after (ns)

N=11 vs. N=48, no power

LaRoche (2015) HS football (N=1532 vs. N=206)

47% reported before vs. 70% after

Self-report

1. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203.

2. O'Kane JW, Levy MR, Neradilek M, Polissar NL, Schiff MA. Evaluation of the Zachery Lystedt Law among female youth soccer players. Phys Sportsmed. 2014 Sep;42(3):39-44.

3. LaRoche AA, Nelson LD, Connelly PK, Walter KD, McCrea MA. Sport-Related Concussion Reporting and State Legislative Effects. Clin J Sport Med. 2015 Apr 17. [Epub ahead of print]

Oxford Handbook of Behavioral Economics and the Law, Eyal Zamir & Doron Teichman (Eds.), 2014

Social Ecological Model

Brofenbrenner 1970

Theory of Planned Behavior (arises out of the Health belief model)

Ajzen et al 1991

Concussive symptom reporting and TPB

Intention to report

symptoms

Skills and abilities

Environment

Coach

Response Reporting Symptoms

Subjective norms

Attitudes

Perceived behavioral control

Culture of Sport

Teammates

Chrisman et al 2013

Prototype Willingness Model—Risk behavior is not planned

Gibbons & Gerrard 1995

Our team

• Frederick P. Rivara, MD, MPH• Ali Rowhani, MD, MPH, PhD• Celeste Quitiquit, MD• Stan Herring, MD• Christine Mac Donald, PhD• Melissa Schiff, MD, MPH• Seth Friedman, PhD• Jalal Andre, MD• Monica Vavilala, MD• Emily Kroshus, PhD

• Randal Ching, PhD• Cari McCarty, PhD• Christina Schwien, MPH• Elizabeth Stein, BA• Matthew Holm, BA• Leah Concannon, BA• Michelle Nemetz, BA• Deana Rich, BA• Sarah Dean, BA

Thank you!

Impact of legislation—Do athletes play with symptoms?

• Prospective cohort study1 • Rivara 2013, N=778 high school football and soccer players, N=83 concussions• 69% reported playing with concussive symptoms

• Prospective cohort study, before and after (natural history)2

• O’Kane 2014, N=351 female middle school soccer players (N=11 concussions before law, N=48 after)• No change in rate of concussions before vs. after• No sig change in proportion play with symptoms (70% vs. 56%)• 2x more likely to be diagnosed concussion if seen by provider

• Cross sectional survey, before and after (natural history)3

• La Roche 2015, N=1532 vs. N=206 (before and after law) high school football players• No change in proportion sustaining concussion season before (15% vs. 17%)• 47% reported before vs. 71% after. (p=0.011)

1. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203.

2. O'Kane JW, Levy MR, Neradilek M, Polissar NL, Schiff MA. Evaluation of the Zachery Lystedt Law among female youth soccer players. Phys Sportsmed. 2014 Sep;42(3):39-44.

3. LaRoche AA, Nelson LD, Connelly PK, Walter KD, McCrea MA. Sport-Related Concussion Reporting and State Legislative Effects. Clin J Sport Med. 2015 Apr 17. [Epub ahead of print]

SPORT CONCUSSION SUMMIT

September 24, 2015 #uminjuryctr