The Clinical Implications of Youth Sports Concussion Laws: A Review

Abstract

The recent passage of state youth sports concussion laws across the country introduces clinical implications for health care professionals caring for student-athletes. Although the laws were established to provide protections for student-athletes and prevent adverse outcomes, efforts aimed at implementation have uncovered various challenges in concussion diagnosis and management. Some of the most salient issues include medical evaluation, return to play, and return to learn. For this reason, health care professionals play a pivotal role in determining the critical next steps after a student is removed from play with a suspected concussion. Also, state laws may influence an influx of concussion patients to health care facilities and, thereby, present various unforeseen challenges that can be mitigated with adequate clinical preparation. This is key to helping student-athletes recover and resume regular activities in sports, recreation, and education. This review describes the various components of state youth sports concussion laws relevant to clinical practice and nuances that health care professionals should appreciate in this context. Additionally, concussion tools and strategies that can be used in clinical practice are discussed.

Youth sports concussion is a prominent public health issue in the United States. The topic is widely covered in the media and there has been a proliferation of research on the topic in recent years. Studies have shown that approximately 90% of concussed student-athletes will recover within weeks.^1,2 However, the possibility of long-term impact, including chronic traumatic encephalopathy, remains a public health concern.^2,3 A likely manifestation of this concern among the general public is an increase in emergency department (ED) visits and outpatient visits for sports- and recreation-related (SRR) traumatic brain injuries (TBIs) among youth. ⁴ From 2001 to 2012, there were 3.42 million ED visits for SRR-TBIs, with 70% representing youth aged ≤19 years. The overall rate of SRR-TBI ED visits for all ages increased significantly per 100 000 population from 73.1 in 2001 to 152.0 in 2012. ⁴ ED visits also likely represent a relatively small proportion of concussions in the United States. Emerging evidence from a large, representative pediatric care network suggest that most concussed youth (almost 80%) seek care with their primary care pediatrician. ⁵ A similar trend was reported by 87 independent pediatric practices throughout eastern Massachusetts among youth aged 6 to 21 years, where the rate of outpatient visits for concussions and minor head injuries increased significantly from 16.9 visits per 1000 patient-years in 2007 to 67.0 in 2013. ⁶ The reason for these increases remain unclear and additional research is needed to determine how public awareness and concern for concussion plays a role.^4,7

As early as 2007, states began to respond to the national concern about youth sports concussion by introducing related legislation. ⁸ Since that time, all 50 states and the District of Columbia have enacted various youth sports concussion laws designed to improve the recognition and management of concussion. ⁹ An additional goal is to reduce the risk of catastrophic outcomes, such as second impact syndrome, where diffuse brain edema develops after a second head impact is sustained, but prior to symptom resolution of an initial head impact.^9-11 Youth sports concussion laws generally include 3 core requirements: (1) coaches receive education about how to recognize the signs and symptoms of concussion, (2) athletes are removed from participation when a concussion is suspected, and (3) removed athletes may not return to participation (“return to play” or RTP) until cleared by a health care professional.

The lack of specificity in youth sports concussion laws and evidence-based clinical guidelines add to the challenge of managing concussions, especially for student-athletes. First, state laws vary in their specification of who is qualified to provide clearance for student-athletes attempting to return to play. Second, concussion signs and symptoms are nonspecific and the absence of an objective diagnostic test makes diagnosis challenging. Third, the scientific evidence-base for clinical management is relatively early in its development and recommendations continue to evolve.^12-14 Also, these challenges can be magnified with the implementation of local policy, introducing unique circumstances. As one example, in a recent legal case, the parents of a student-athlete insisted that their son be returned to play prior to the conclusion of the 7-day waiting period outlined in New Mexico’s state law at that time. ¹⁵ In this situation, a physician’s medical evaluation that deemed the student safe to RTP was central to a judge’s decision to waive the RTP waiting period. This example highlights some of the challenges health care professionals might face while providing care for their young patients. The complexity of such cases underscores the importance of becoming familiar with issues that may arise at the intersection of youth sports concussion policies and standard clinical care and management.

The objective of this review is to provide a concise summary of state youth sports concussion laws, as well as to describe various nuances that might affect clinical practice, including variation in scope across state laws. This includes considerations for the process of RTP and returning students to school or learning (also known as return to learn [RTL]) after concussion. Relevant, best-available evidence is also described to provide a succinct resource for concussion evaluation and management. This review is focused on providing information to any health care professional who may be responsible for evaluating concussions as they navigate the challenges they may face when caring for a concussed student-athlete in the current policy landscape.

History of Youth Sports Concussion Laws

The first youth sports concussion law was passed by the Texas state legislature in 2007. ⁸ The law, also known as “Will’s Bill,” was influenced by the death of Will Benson who died after sustaining a TBI while playing football.^8,9 The law required coaches, athletic trainers, and others to receive training that would enable them to recognize symptoms of potentially “catastrophic injuries,” which included head and neck injuries, concussions, and injuries related to second impact syndrome. However, the language of the law only required removal from play if a student-athlete became unconscious during sports-related activities. The Texas law was updated in 2011 and now states that a student-athlete must be immediately removed from participation if concussion is suspected. ⁹

In 2009, the state of Washington passed a similar law that has become the foundation for current state youth sports concussion laws in the United States. Washington State’s law was named after Zackery Lystedt, a middle school student who suffered a TBI during a football game.^16,17 Zackery struck his head on the ground during a play and displayed signs of pain but was allowed to resume participation. Unfortunately, he collapsed when the game ended and was hospitalized due to an intracerebral hemorrhage and brain edema. ¹⁷ Zackery survived his brain injury, but sustained significant, permanent physical disabilities. The state of Washington responded to this incident, and the growing concern about youth sports concussion in general, by passing legislation approximately 3 years later. ⁹ The requirements set forth within the law include the core requirements previously mentioned and are widely known as RTP laws or youth sports concussion laws.

Since 2009, all 50 states and the District of Columbia have enacted youth sports concussion laws modeled after the legislation in the state of Washington. ⁹ Generally, the laws are applicable within specific venues, particularly school-sanctioned sporting events, outside normal school operating hours. Concussions that occur during school operating hours, such as physical education and social events, generally do not fall within the purview of the majority of state laws. This is also true of concussions sustained during sports participation outside of the school setting (ie, club sports). However, some states have identified these “gaps” and require RTP policies for concussions occurring during nonschool-related events, such as youth sports clubs (eg, YMCA).

Variation in State Laws

Each state has unique legislative language contributing to important variations in implementation. ⁹ This variability can be particularly relevant to clinical practice, making it vital for health care professionals to understand how this may impact their practice and individual patients. For example, New Mexico’s law states that any student-athlete removed from play for a suspected concussion must sit out for a minimum of 7 days.^15,18 Language such as this may be perceived as an infringement on the concept of individualized care.

The landscape for RTP varies across the United States. Many laws include language stipulating that clearance for RTP be provided by a professional trained in concussion management. However, the laws rarely specify the level of education or type of training required to clear athletes for RTP, so the training requirements are subject to interpretation. With regard to clearance for RTP, a few states—Arizona, Colorado, Kentucky, Louisiana, South Carolina, and Tennessee—allow for immediate RTP if a concussion is ruled out at the sideline by athletic personnel; however, among these, only Arizona states that a licensed health care professional should make that determination. ⁹ Some state laws require clearance to be accompanied by a supervised graduated RTP process that is overseen by trained personnel such as an athletic trainer. States have also identified certain milestones students must reach before being legally allowed to RTP. These can range from a minimum time threshold (eg, 24 hours after injury) or evidence that a student-athlete no longer exhibits concussion signs and symptoms.

Few state youth sports concussion laws include guidance for student-athletes to resume school-based educational activities in addition to RTP. ¹⁹ Commonly referred to as RTL, this guidance generally includes the provision that schools or state agencies must create a process for students returning to the classroom after concussion. Much like the RTP requirements, some laws require health care professionals to provide clearance before a student-athlete begins the RTL process. ²⁰ However, many are broadly written, allowing the creation of RTL policies at the local level. ¹⁹

Medical Evaluation of Suspected Concussion

Youth sports concussion laws provide general guidance to improve the identification of, response to, and management of youth sport-related concussions. Many organizations have responded and implemented strategies that might not have existed otherwise. In accordance with state law and local policies, health care professionals are critical contributors in ensuring that these laws are followed. As such, they can benefit from being prepared to manage student-athletes with concussion through the process of medical evaluation, RTP, and RTL.

Diagnosing, managing, and providing clearance guidance for RTP and RTL may be a new and daunting responsibility for many health care professionals. Even with an in-depth understanding of concussion pathology, it is not easily diagnosed and not always simple to manage. This can be complicated further by student-athletes or their parents/guardians who may not provide full disclosure of symptoms or may seek to change steps in the RTP process.^15,21,22 These situations are likely unavoidable, but a planned approach to clinical evaluation is key for any health care professional. ⁵ In particular, a comprehensive understanding of the tools and resources available to diagnose concussion is an essential first step.

Concussion Definition

The American Academy of Neurology (AAN) defines concussion as a “clinical syndrome of biomechanically induced alteration of brain function, typically affecting memory and orientation, which may involve loss of consciousness (LOC).” ¹⁴ This can result from direct or indirect forces to the head. Clinical features of concussion consist of a wide range of nonspecific signs and symptoms, including headache, confusion, dizziness, nausea, and blurred vision. Contrary to popular belief, very few people experience LOC.^23,24 Furthermore, while some signs and symptoms may be present acutely after injury, other symptoms may not manifest until 24 hours or more following the injury. For example, headache and dizziness are commonly reported at the time of injury, whereas deficits in attention and concentration may not become apparent until hours later.^23,24 The manifestation of these signs and symptoms will vary with each patient and no single constellation is pathognomonic of concussion.

Diagnostic Tools

The complexity of concussion underscores the importance of conducting a comprehensive history and physical exam. For each patient with a suspected concussion, health care professionals might find it helpful to determine if an impact or biomechanical force preceded the development of the presenting signs and symptoms. This requires a detailed interview and focused assessment of the various signs and symptoms commonly associated with concussion. Many resources are available for this purpose and health care professionals can familiarize themselves with tools available for clinical use. For example, computerized neurocognitive tests can be used to evaluate various cognitive domains affected by concussion, requiring anywhere from 15 to 30 minutes for testing. However, it may be beneficial for such testing to be administered and interpreted by a professional experienced in using computerized neurocognitive testing. In contrast, symptom checklists provide a validated, brief systematic means of assessing suspected concussions and do not require specialized training for administration. Such checklists include the Postconcussion Symptom Scale (PCS), which has acceptable sensitivity and specificity in identifying concussion symptoms among high school and collegiate athletes.^14,25,26 The Acute Concussion Evaluation Form (ACE) is another option that includes a symptom checklist, a guide for clinical evaluation, sections to collect other pertinent information (ie, the patient’s injury characteristics, symptoms, and risk factors for protracted recovery), and plans for both RTL and RTP. ²⁷

The physical examination for a suspected concussion can not only include a general neurologic examination, but also be focused to identify specific deficits commonly seen following concussion. Several studies suggest that a thorough examination of balance/vestibular and visual/oculomotor function can identify clinical findings indicative of concussion-related brain dysfunction.^23,28-31 A recent study found that approximately 69% of concussed pediatric patients exhibited abnormalities in one or more of the following visual functions: saccades, pursuit, convergence, accommodation, and vestibulo-ocular reflex. This is in contrast to the general pediatric population where less than 10% exhibit these abnormalities. A similar study found that 81% of concussed pediatric patients exhibited signs of vestibular dysfunction, either with abnormal gaze stability or abnormal tandem gait, which are also not generally observed in the general pediatric population.^31-33 As such, a structured vestibular oculomotor screen (VOMS) that assesses smooth pursuits, saccades, vestibular ocular reflex, and convergence may be useful in detecting concussion-related deficits. ³⁴ Another tool that assesses the visual oculomotor system is the King-Devick test, which may be useful as a sideline or clinical assessment tool for detecting eye tracking and saccadic deficits following injury in comparison with a preinjury baseline. It is a simple, timed reading card test that can be administered by lay persons and takes approximately 2 minutes to complete. A concussion may be present when there is any prolongation of reading time, indicative of saccadic deficits, compared with the individual’s preinjury baseline. ³⁵ However, the usefulness of the test without a baseline assessment is undetermined.

Neurocognitive Testing

There is currently no single test for concussion, but computerized neurocognitive tests have become widely available as a tool to assist with assessment. Neurocognitive tests are often used to establish pre-injury measures of cognitive domains, such as memory and reaction time, to provide a comparison for post-injury measures. It may be helpful, however, to understand the nature of neurocognitive testing as a performance measure, which may be affected by many factors such as hunger, sleep, anxiety, and conditions such as attention deficit syndrome. ³⁶ These factors can influence both pre- and postinjury testing, limiting its utility as a stand-alone diagnostic test. Similar issues occur in the absence of baseline testing where post-injury results are compared with normative data. ³⁷ As such, neurocognitive testing can be thought of as a performance test to assess neurologic function in the areas of memory and reaction time and may be used with other objective measures in concussion diagnosis. Last, there is some evidence that symptom recovery may precede neurocognitive recovery in some patients, ²⁵ making accessible and timely computerized neurocognitive testing a useful tool in the management of patients with concussion.

The use of any symptom checklist, vestibular/balance visual/oculomotor assessment, or computerized neurocognitive testing may be interpreted within the clinical context. Each are designed to add complementary data to assist in the evaluation for concussion and can be used in conjunction with the clinical history to determine if a concussion diagnosis is supported. The AAN concussion guideline suggests that a combination of selected tests will likely be the most useful in making the probabilistic diagnosis of concussion. ¹⁴

Imaging

Structural neuroimaging, such as computed tomography (CT) or magnetic resonance imaging (MRI), is generally not contributory to diagnosing concussion. Less than 10% of children with minor blunt head trauma will have positive CT imaging findings. ³⁸ The injury typically does not produce structural damage that can be detected by standard clinical imaging modalities such as CT or MRI, indicating that concussion is primarily an alteration in brain function. ¹³ Therefore, clinical judgment is necessary to determine when CT is indicated to avoid unnecessary radiation exposure. Studies indicate that children 18 years and younger with minor blunt head trauma are at a low risk of having imaging findings or pathology requiring acute intervention, particularly when there is an absence of specific clinical predictors. Predictors suggesting a higher likelihood of acute intervention vary by age and include abnormal mental status, LOC, skull fracture, scalp hematoma, and severe headache.^38,39 Validated prediction rules for children at very low risk of “clinically important” blunt head trauma for whom CT can be avoided have been published by the Pediatric Emergency Applied Research Network (PECARN). ³⁹ The prediction rules are a valuable clinical decision support tool for evaluating patients with blunt head trauma and help limit unnecessary CT imaging following minor blunt head trauma.

In summary, having a concussion “tool box” can be beneficial for creating an objective and systematic approach to diagnosing concussion. With the widespread enactment of youth sports concussion laws, many students will experience stressful circumstances associated with concussion recovery, removal from play, RTP, and RTL. This may result in several unintended consequences, leading student-athletes to conceal symptoms, and families pressuring health care professionals to provide clearance prematurely. Under these circumstances, objective tools are particularly helpful in providing a consistent standard of care and aids the RTP and RTL decision-making process. The information obtained from objective tools will also provide documentation of patient presentation for clinical and legal purposes.

Concussion Management

In addition to medical evaluation, it may be helpful if health care professionals have an understanding of concussion management best practices to assist with the implementation of RTP. This will enable them to proficiently evaluate a student-athlete with suspected concussion and initiate management that is consistent with the current standard of care. This may include, but is not limited to, the management of acute concussion symptoms followed by a gradual return to learning and athletics. Many of the standards outlined in the state law may only be the minimum requirement and local policies may include additional actions for RTP. For example, some schools may require the health care provider to complete a form to document medical evaluation and clearance but the form itself may not be necessary to fulfill state law. Furthermore, some youth sports concussion laws specify that health care professionals should provide RTP guidance, in addition to final clearance for full sports participation. In cases with prolonged symptom recovery, management might also involve referral for specialized care and rehabilitation services.

Concussion Pathophysiology

The pathophysiology of concussion is central to the rationale for acute concussion management recommendations. With concussion, an external biomechanical force exerts shear strain that compromises neuronal and axonal membrane integrity thereby initiating a cascade of cellular events. These events lead to a widespread release of excitatory neurotransmitters and the ensuing influx of calcium ions into nerve cells. This ionic influx causes metabolic dysfunction and the uncoupling of cellular energy demand from energy production.^40,41 In addition, there is uncoupling of cerebral blood flow from metabolic energy demand and, together, these factors contribute to a mismatch of energy supply and demand in the brain, also known as the “metabolic mismatch of concussion.” ⁴¹ This is, in part, the basis for the recommended brief period of physical and cognitive rest for acute concussion management. ¹³

Role of Physical and Cognitive Rest

Limiting physical exercise and cognitive demands during the early metabolic mismatch phase of concussion may facilitate recovery. Evidence from preclinical and clinical studies suggests that a brief period of rest may minimize acute concussion symptoms and improve cognitive function in the postinjury period.^42,43 As such, physical and cognitive rest is the cornerstone of management recommended by various professional organizations and experts.^13,14,44 Activities, such as playing video games and texting, that involve intense concentration and attention may cause a significant exacerbation of symptoms and may need to be limited for a brief time period. Physical rest from activities that involve heavy physical exertion and have an increased risk of head injury may also be helpful in the early postinjury period. However, scientific evidence to support these suggestions is nascent and there is increasing concern that protracted physical and cognitive rest may have negative effects on patient outcomes. Extended periods of rest can result in unnecessary restrictions from physical activity and academic participation, possibly contributing to protracted symptomatology. A brief break from intense academic work may be helpful to allow acute concussion symptoms to abate, but protracted absence from school can have negative academic and psychosocial effects. ⁴⁵

Management of Protracted Recovery

Youth sports concussion laws do not provide specific guidance for student-athletes who may experience protracted recovery and face unique challenges in RTP and RTL. Studies indicate that approximately 10% of concussed student-athletes will experience symptoms lasting several weeks despite the implementation of physical and cognitive rest. ¹ For these students, recovery might become complicated compared to others where rest and gradual resumption of activity is effective. Health care professionals may benefit from being aware that such challenges may occur and require additional strategies to ensure satisfactory health outcomes.

Risk Factors

A host of factors associated with protracted concussion recovery have been identified. Findings from various studies indicate that they broadly include premorbid characteristics, physical examination findings, and patient symptoms. For example, signs and symptoms like LOC, dizziness, abnormal convergence and vestibular oculomotor function have been associated with protracted recovery, perhaps reflecting a more complicated injury or greater concussion burden.^46,47 Additionally, age appears to be a risk factor, with adolescents generally taking longer to recover than adults. ⁴⁸ However, the precise effect of age is unclear, since young children may recover more quickly than adolescents. ⁴⁹

Many concussion studies are limited in their generalizability to children. Studies are needed to identify predictors of concussion outcome in children. However, a recent prospective study of pediatric concussion patients conducted in Canada shows promise in addressing this problem. A 12-point persistent postconcussion symptom (PPCS) risk score was identified as having a modest ability to discriminate patients who will and will not have PPCS at 28 days postinjury (area under the curve: 0.71). ³ Risk factors included in the model were female sex, age of 13 years or older, physician-diagnosed history of migraines, history of prior concussion with symptoms lasting longer than 1 week, sensitivity to noise, fatigue, answering questions slowly and 4 or more errors on the Balance Error Scoring System tandem stance. The study provides additional evidence for previously identified risk factors and suggests that patients with any of the above risk factors may require more specialized approaches such as rehabilitation. Further research is needed to determine if the PPCS risk score is a useful tool in clinical settings.

Role of Rehabilitation

Active rehabilitation approaches may be helpful for recovery especially when a student-athlete experiences concussion symptoms lasting longer than a few weeks. At that point, active rehabilitation methods can be used to address lingering deficits. For example, vestibular deficits involving balance and the vestibular ocular reflex may persist following concussion and can be particularly debilitating. Vestibular therapy to address these deficits improves motion sensitivity and is useful in reducing symptoms of dizziness and imbalance. ⁵⁰ In addition, convergence insufficiency and oculomotor deficits in smooth pursuits and saccades may also persist, ⁵¹ and as such, oculomotor exercises targeting these functions can be incorporated into vestibular therapy to improve these functions. Patients with more severe visual oculomotor symptomatology, particularly convergence insufficiency, may benefit from targeted binocular vision therapy. ⁵²

An adjunct to vestibular and vision rehabilitation is aerobic rehabilitation. Studies suggest that aerobic exercise may be beneficial for patients with protracted concussion recovery. ⁵³ In studies using animal models, rats that voluntarily exercise immediately after injury have poorer outcomes compared to rats that are sedentary up to 6 days after injury.^43,54 As such, early exercise restriction, including removal from sports activities with a risk for head injury may be important immediately following injury. In contrast, in patients with protracted symptoms following concussion, studies have shown that they may actually benefit from a progressive increase in exercise. Hence, a postacute phase of return to aerobic activities with low head injury risk may actually be advisable. Exercise testing using a protocol such as the Buffalo Concussion Treadmill Test with an exercise prescription in the chronic phase of recovery may also aid in the improvement of protracted concussion symptoms. ⁵³

Therapeutic approaches are also useful for other symptoms that patients may experience in protracted recovery. This includes migraine-type headaches, anxiety, depression, sleep disturbance, and deficits in attention, concentration, and cognition. For severe chronic daily headache, it is important to educate patients and families about the inappropriate, prolonged use of over-the-counter medications, as this may lead to medication overuse headache. ⁵⁵ Other medications for severe chronic headache, like amitriptyline and topiramate, may be used with caution to minimize adverse effects such as sedation or cognitive slowing.^56,57 In some cases, activity modification and targeted rehabilitation therapies are indicated to address contributors of headache, such as vestibular or visual deficits. Children with ongoing attention and cognitive issues may benefit from traditional interventions for attention deficit disorder, including behavioral management and medication therapy. Speech therapy, tutoring, and executive function training are additional useful strategies. ⁵⁸ Anxiety, depression, and insomnia in children with concussion are also excellent targets for cognitive behavioral therapy where indicated. ⁵⁹ Referral for specialty management, including psychiatry, psychology and neuropsychology, is often beneficial for the aforementioned symptoms, highlighting the importance of interdisciplinary care for student-athletes with prolonged concussion symptomatology.

Clinical Management of Return to Play

Once the student-athlete exhibits signs of recovery, a health care professional must consider the steps for RTP. Current best practice for RTP is based on expert consensus recommendations from the 4th International Conference on Concussion in Sport. ¹³ RTP processes were designed to prevent premature return to activities at high risk of head injury and to prevent recurrent head injury during the acute recovery phase. As such, once concussion symptoms resolve in the immediate post-injury period, the athlete is permitted to begin a graduated RTP process and must remain asymptomatic to advance through each step. ¹³ Clearance is required to participate in full contact training activities before full RTP. This general guidance may be helpful to minimize repeat injury risk and adverse outcomes. RTP processes, however, were not intended to restrict patients from routine daily activities or even exercise at low risk for head injury, especially for those with prolonged persistent symptoms. Therefore, RTP processes are not intended to be used as a rationale for prolonged activity restriction beyond the immediate acute postinjury period for those with prolonged symptomatology.

The term “return to play” is used in the 4th International Conference on Concussion in Sport consensus recommendations to refer to full participation in sport activity such as competition. The primary goal is to prevent premature return to sports with a high risk for repeat head injury. RTP protocols may be particularly useful for student-athletes who experience a straightforward recovery with complete symptom resolution within a few days or weeks. Unfortunately, this RTP process has been misapplied in some instances where students experience prolonged symptoms. When students experience persistent symptoms and protracted recovery, specialists can be consulted to implement rehabilitation to assist with patient management.

While having a clear definition of RTP may be critical to understanding when clearance from a health care provider is required, state youth sports concussion laws and local policies neither provide such clarification nor are necessarily in alignment with the 4th International Conference on Concussion in Sport consensus recommendations. Typically, state laws are broadly written and often do not provide the details described in the consensus recommendations to clarify the definition of RTP. Therefore, implementation according to state law is open for interpretation, where clearance for RTP might refer to gradual resumption of sports activity or full participation in competition. It is likely that this has led to important variations throughout the United States and has important implications for clinical practice. Health care professionals may benefit from being diligent to look for any policies that contradict the consensus recommendations and every effort should be devoted to providing the best standard of care.

Consensus recommendations provide a useful source of information but may not address various individual concerns that may arise with student-athletes. Regardless, health care professionals can continuously monitor their patients and maintain communication with all parties responsible for RTP implementation since coaches and parents may have questions throughout the process. In particular, athletic trainers within the school setting serve as an important collaborative resource for health care providers in the RTP and clearance process, given their direct, frequent contact with the recovering athlete. An athletic trainer’s ability to closely monitor the RTP process obtains invaluable information that is helpful in determining optimal timing for full return to a head injury risk–bearing sport. Consultation with other specialists can be sought where students experience protracted recovery with symptoms lasting longer than a few weeks.

Clinical Management of Return to Learn

Besides the clinical responsibility of concussion diagnosis, management, and RTP, health care professionals may also assist in returning student-athletes to learning. Some state laws outline requirements for a student-athlete’s return to academic activity, but academics will be a concern for all students regardless of the presence or absence of state law or local policy. RTL processes were developed with the recognition that most student-athletes have academics as their primary vocation. The protocol can conceptually mirror RTP processes, returning a student gradually to academics. The objective is to reintroduce cognitive and visual workloads in a stepwise fashion while minimizing symptom exacerbation.^60,61 This process is then usually followed by a formal, sport-specific, RTP plan. However, while student-athletes are gradually increasing cognitive activity, a commensurate increase in physical activity is permitted. Only the formal RTP protocol and sports training is delayed until there is a full return to learning with the resumption of full academic activity.

Recognizing oculomotor/visual deficits can be critical to the successful implementation of a RTL protocol. ³⁰ The visual nature of learning in modern education, with the use of electronic interfaces and technology, results in substantial cognitive and visual workloads that can be challenging for patients who have visual oculomotor dysfunction following concussion. Therefore, accommodations can be designed to break workloads into small cognitive tasks while also minimizing eye-tracking tasks. ⁶² This approach might require the patient to build some cognitive stamina at home with manageable academic activities and then advance to partial school days before eventually attending full-time.^60,63 While attending school, the patient might need to pace themselves by taking intermittent breaks throughout the day to manage cognitive and oculomotor visual workloads and concomitant symptoms. Teachers may also provide preprinted notes in large font to help minimize symptoms related to oculomotor tracking and convergence deficits. Taking such factors into account is essential to designing personalized academic accommodations.^30,64

A full return to academics is important to many student-athletes. School administrators, teachers, health care professionals and many others should contribute to the development of classroom reintegration approaches. Some student-athletes will gradually return to full learning after a brief period of physical and cognitive rest, which allows for symptom resolution. In these straightforward cases, only temporary academic adjustments may be needed, including breaks to minimize symptom exacerbation and a reasonable catch-up plan for missed work. However, some student-athletes will experience a more complicated recovery due to protracted symptoms. Health care professionals and schools that are prepared to address concussion-associated issues with formal academic accommodations may increase their likelihood of success in supporting a student’s return to learning.

Coordination between health care professionals, school personnel, and parents or guardians is critical for an effective RTL strategy, but can be difficult to establish. The transfer of information among various persons responsible for the student-athlete alone is a substantial challenge; issues regarding student privacy and ethical considerations may arise. ⁶⁵ Programs have been created to address these issues and assist with many other challenges associated with concussion recovery and RTL. Some exemplar programs include the BrainSTEPS (Strategies Teaching Educators, Parents, and Students) program, which is a collaboration between the Pennsylvania Departments of Health and Education and the Brain Injury Association of Pennsylvania. ⁶⁶ BrainSTEPS is a school reentry consulting program that trains Concussion Management Teams consisting of an academic monitor (school psychologist or guidance counselor) and symptom monitor (school nurse) from each school district. The teams assist with school reentry for students by providing in-school assistance during the acute concussion phase. If the student experiences a more chronic course, then BrainSTEPS becomes involved to assist with issues requiring long term academic support. REAP (Reduce, Educate, Accommodate, Pace) is another model program that was originally funded by an Education Grant from the Colorado Traumatic Brain Injury Trust Fund. ⁶⁷ This program also employs a multidisciplinary approach to address concussion management. The integration of the REAP Family, Medical, and School Teams reflect the multiple areas of a student’s life affected by concussion and supports are integrated across these domains. The School Team is composed of the School Cognitive Team and the School Physical Team in recognition of the dual academic and athletic tasks that students have at school. An integrated team approach to support student-athletes in their return to full activities may be an important aspect to the recovery process following concussion.

Health care professionals may benefit from being aware of best practices and resources available to implement RTL plans. Such knowledge may not only enable them to provide the best care for patients but may also be critical for compliance with state law. For example, 7 states—Hawaii, Maryland, Massachusetts, Nebraska, New York, Vermont, and Virginia—have included specific language for RTL in their youth sports concussion law. ¹⁹ Recently, the New Jersey Assembly considered a new bill that would require concussed students to obtain a health care provider’s written approval before returning to school and beginning the RTL process. ²⁰ Regardless, in the absence of RTL language in many state laws, programs have been implemented in local jurisdictions to respond to this need. It is important for clinicians to be aware of any RTL programs that may be in existence in their catchment area. Coordination with these programs can better ensure a smooth transition back to school for a patient after a concussion.

Summary of Possible Action Steps

Although concussion is considered a “mild” TBI, and typically results in an uncomplicated recovery, there are a plethora of considerations that will vary from person to person. Clinical management may be straightforward in many cases but multiple factors may complicate other cases and require tailored approaches to initiate RTL and RTP. Complicating factors may include, protracted patient recovery, school policy (eg, 7-day waiting period for RTP), and parent or guardian requests for exceptions to the RTP processes. A summary of possible action steps for health care professionals to effectively implement within the context of youth sports concussion laws from this review can include the following:

• Reaching out to the local health department, school, or community organization to understand how your state’s youth sports concussion law is being interpreted

• Monitoring changes to state and local legislation and school policies that might impact clinical practice

• Becoming familiar with RTP clearances required by local school districts and sports organizations

• Utilizing a comprehensive approach to concussion assessment. Various tools are available to assist with diagnosis and follow-up

• Considering rehabilitative strategies and consultation with specialized health care professionals to manage student-athletes with protracted recovery

• Developing and implementing accommodations across family, academic, and sports settings to support students during their recovery

• Coordinating closely with parties responsible for RTL and RTP while abiding by relevant ethical and legal responsibilities

• Identifying best practices in RTL to assist with recommendations and partner with stakeholders in the academic community to support student-athletes in their return to academics

• Consulting other specialists for challenging cases and other issues not addressed by existing expert guidance, and considering promising rehabilitation options

Conclusion

Youth sports concussion laws were developed to assist with an important public health effort. The primary aim of policy enactment is to protect student-athletes, but there may be some unanticipated implications for clinical care. One such potential unintended consequence is the increase in ED and outpatient office visit rates for youth sports concussion and other TBIs. As a result, more health care professionals than before may face challenges associated with concussion and may be expected to manage injured student-athletes within the purview of RTP and RTL language. Furthermore, amendments to state law and policy may occur, suggesting that keen awareness among health care professionals may be helpful because student-athletes and families may not be knowledgeable or may seek clearance that is contrary to that which is permitted by law. Preparation and education may be key to enable health care professionals to fulfill these duties and effectively manage expectations of student-athletes and parents/guardians.