Return to Play Policies for Young Athletes

Post-Concussion Legislation, Guidelines, and Best Practices.

When 13-year-old football player Zackery Lystedt struck his head in the first half of his junior high school game, he was sidelined through halftime. Despite intense head pain, however, he returned to play in the fourth quarter. After the game ended, Zack collapsed.

He was airlifted to a nearby Seattle hospital, where he underwent emergency brain surgery. Though the surgery was a success, Zack spent several days on life support and several months in a coma, and it was nearly three years before he was able to stand again.

Zack had suffered a concussion in the first half of the game, which had progressed into a catastrophic brain injury by the time he left the field. In the years after his accident, Zack and his family became leading voices in the campaign to protect young athletes and raise awareness about the dangers of Sports-Related Concussions (SRCs). Their work inspired significant change and, three years after the concussion that changed his life, Zack and his parents sat next to the governor of Washington State as she signed into law House Bill 1824, otherwise known as the Zackery Lystedt Law (2009).

Paving the way for protective legislation

The Zackery Lystedt Law contains important provisions for players, coaches, parents, and healthcare professionals working to mitigate the long-term effects of SRCs on young athletes. Included in the Lystedt Law are a few key points:

• A call for school boards and athletic associations to “develop the guidelines . . . to inform and educate coaches, youth athletes, and their parents and/or guardians of the nature and risk of concussion and head injury, including continuing to play after concussion or head injury.”
• Removing any student-athlete who is suspected of having sustained a concussion from play.
• Requiring all athletes who’ve been removed from play to obtain written clearance from a licensed healthcare professional trained in concussion management before a return to play.

The first legislation of its kind, the Lystedt Law paved the way for other states to follow suit. By 2017, all 50 states had enacted legislation regarding SRCs.

A high-risk group

With more than 44 million U.S. adolescents regularly participating in sports, the risk of SRCs for those athletes under 18 is significant. Experts estimate this group suffers between 1.1 million and 1.9 million concussions annually.

Though a concussion can happen during any activity, the sports with the highest incidence of concussion are soccer, American football, basketball, lacrosse, cheerleading, ice hockey, and softball, with concussions occurring more frequently during gameplay than in practice. According to a national report from the Centers for Disease Control and Prevention (CDC), adolescents 15 to 19 years of age are at the highest risk for concussion, regardless of gender.

For PTs and PTAs: Developing Effective Concussion Education for Coaches, Parents, and Athletes

Evaluating ‘Return -to-Play’ policies

Though all states have enacted some form of legislation designed to protect student-athletes from long-term effects of SRCs, the individual laws vary.

Not long after the Lystedt Law was passed, the National Center for Injury Prevention and Control conducted an evaluation of Return to Play policies at work in two pioneer states: Washington and Massachusetts. The study reviewed the effectiveness of the policies in these early adopter states, with the goal of providing clear, evidence-based best practices surrounding Return to Play implementation.

A few considerations surfaced during the study:

• Stakeholder roles and responsibilities: An important question to ask from the outset is, “Who’s responsible for what?” From school nurses to athletic trainers to physical therapists to parents, all stakeholders should be involved when discussing Return to Play policies.
• Implementation requirements: When it comes to establishing an effective Return to Play policy, logistical details matter. Obtaining early input from high levels (like departments of health or education) to grassroots levels (like parents and coaches) will help maximize the program’s efficiency.
• Knowledge and awareness: Athletes may be reluctant to report symptoms of a concussion in the belief that they can — and should — tough it out. Educating athletes and their families about the severe and possibly lifelong consequences of SRCs is an important step in implementing Return to Play policies.
• Medical clearance and accessibility: Clearly stating who is able to provide medical clearance to athletes after a concussion or suspected concussion is critical. Some states may require a physician or neurologist to sign the athlete’s clearance, while others may only require a licensed healthcare professional. In both cases, it’s important to take accessibility into consideration. Though rural school districts may not have access to large hospitals or specialists, they nevertheless require someone trained in the best practices for concussion management.

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Staying ahead

A growing body of data around SRCs in young athletes has accompanied the institution of Return to Play policies. The study of concussions and concussion management is ever-evolving, and it’s vital for healthcare professionals who interact with young athletes to understand and stay up-to-date with the latest research.