Playing It Safe

Law Changes Concussion Management

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Public Health Feature – September 2011

Tex Med. 2011;107(9):37-40.

By Crystal Conde
Associate Editor

Concussions not only robbed former Texas high school star soccer player Natasha Helmick of her dream to play on the U.S. Olympic soccer team, they also stole her childhood memories.

College coaches noticed her talent when she was just 14, but five concussions – the first when she was in the eighth grade – dashed her chances of playing competitive soccer in college and in the Olympics. Worse, she doesn't remember much of her childhood because of repeated sports-related concussions.

"If I knew then what I know now, I would have done things differently," Ms. Helmick, now 19 and studying to become an athletic trainer, told the Texas Senate Health and Human Services Committee during a hearing on concussion management legislation in May. She testified before the Senate committee and the House Public Health Committee to support House Bill 2038 on prevention, treatment, and oversight of concussions affecting student athletes.

She had simple advice to coaches not sure if an athlete is affected by a head injury: "When in doubt, sit them out."

Ms. Helmick's story isn't uncommon. The National Federation of State High School Associations reports about 140,000 high school students suffer concussions annually.

The legislature passed the bill, also known as Natasha's Law, and Gov. Rick Perry signed it June 17.

The new law requires school districts to create concussion oversight teams that must include at least one physician and to establish return-to-play protocols that involve evaluation of the athlete by a physician. Natasha's Law also requires the University Interscholastic League (UIL) and the Texas Department of State Health Services (DSHS) to approve training courses on concussions for coaches and athletic trainers. UIL oversees academic, athletic, and music contests throughout the state. Its Medical Advisory Committee reviews physical examination forms and other sports medicine guidelines for schools, including concussion management protocol.

In addition, passage of House Bill 675 by Rep. Eddie Lucio III (D-Brownsville) to make high school football helmets safer complements HB 2038. (See "Legislature Tackles Helmet Safety.")

The Texas Medical Association created the Ad Hoc Committee on Student Athlete Concussions, made up of eight physicians with expertise in concussion prevention, treatment, and oversight, to review concussion-related bills and to guide lawmakers. (See "TMA Ad Hoc Committee on Student Athlete Concussions.")

Committee member Theodore Spinks, MD, an Austin pediatric neurosurgeon, says one of its goals was to prevent lawmakers from legislating health care.

"It's not the legislature's place to tell physicians how to treat a disease, condition, or injury. Recommendations on concussion management will change over time, so we wanted the bill to carry weight but not dictate how physicians manage each athlete's individual concussion," he said.

HB 2038 author Rep. Walter "Four" Price (R-Amarillo), says he and Sen. Bob Deuell, MD (R-Greenville), who sponsored it in the Senate, involved stakeholders early on through roundtable sessions. They gained the support of coaches, athletic trainers, students, parents, physicians, and professional sports organizations, including the National Football League.

Physician input on HB 2038 by TMA members was "absolutely essential to passing this comprehensive law, which is pro-student athlete, pro-parent, pro-coach, and pro-school district," Representative Price said.

Senator Deuell adds that physician feedback on the legislation was important because "ultimately physicians are the most qualified to diagnose and treat concussions and make the judgment when an athlete can safely return to play."

The TMA ad hoc committee helped highlight the potentially long-lasting effects of concussions, especially multiple untreated concussions, Representative Price says.

"The input of these medical professionals helped crystallize language in our bill that I believe can serve as a model for other states in the future," Representative Price said. "HB 2038 represents the good result that can be achieved when truly knowledgeable and caring individuals work together to draft language for the betterment of our citizens. We can all be proud of Natasha's Law, and I am grateful to TMA and my colleagues for the countless hours many devoted to making the successful passage of this bill possible."

Dr. Spinks applauds Representative Price, Senator Deuell, and other lawmakers for creating a law that ensures proper oversight of concussions in a state-of-the-art fashion without controlling how physicians deliver care.

Physician Oversight

Dr. Spinks says that before HB 2038, management of student athletes with concussions varied widely.

"There wasn't much uniformity in who was treating the concussion. With the legislation, we wanted to bring everyone up to speed on the more current practices in assessing and treating concussions. The new law will help ensure those involved in school sports aren't using 30-year-old guidelines to manage concussions and help prevent inappropriate treatment by those who aren't qualified," he said.

Under the law:  

  • Each school year, students and parents must sign a form that explains concussion prevention, symptoms, treatment, and oversight and that includes guidelines for safely resuming participation in athletics after a concussion. UIL must approve the form.
  • School districts must create concussion oversight teams with at least one physician member and, if at all practical, one or more athletic trainer, advanced practice nurse, neuropsychologist, or physician assistant. Members must be trained in evaluating, treating, and overseeing concussions.
  • The concussion oversight team must establish a return-to-play protocol.
  • The school district superintendent is responsible for ensuring that the athletic trainer complies with the return-to-play protocol.
  • A physician on a concussion oversight team shall to the greatest extent practicable take an appropriate continuing medical education course on concussions.

C. Mark Chassay, MD, MBA, a member of the UIL Medical Advisory Committee and the TMA concussion committee, says physicians can be part of a school's oversight team by letting the district know they're interested.

"Each team and district will need physicians well educated and trained in concussion issues to help with evaluations of students on the field in addition to follow-up in their medical practices on athletes' progress," he said.

Natasha's Law also addresses return to play and requires a student to be removed immediately from play if a coach, physician, advanced practice nurse, athletic trainer, neuropsychologist, physician assistant, or the student's parent suspects a concussion. The student cannot practice or compete again until:   

  • He or she has been evaluated, using established medical protocol based on peer-reviewed scientific evidence, by a treating physician chosen by the student or by the student's parent;
  • He or she has successfully completed each requirement of the return-to-play protocol established by the concussion oversight team;
  • The treating physician has provided a written statement indicating that, in his or her professional judgment, it is safe for the student to return to play; and
  • The student and the student's parent acknowledge that the student has completed the requirements of the return-to-play protocol.

Education is a big component of the new law. The statute provides that UIL will approve at least two hours of training on concussions, including evaluation, prevention, symptoms, risks, and long-term effects. The league will maintain an updated list of individuals and organizations authorized by UIL to provide the training.

The law says coaches and health care professionals who are on a concussion oversight team and who either volunteer or work for the school district must take a training course at least once every two years.

The DSHS Advisory Board of Athletic Trainers is responsible for courses for athletic trainers.

Out With Old Guidelines

According to Dr. Spinks, a panel of international experts developed the most authoritative consensus statement on concussion and presented it at the 3rd International Conference on Concussion in Sport held in Zurich in November 2008. The panel recommends a multidisciplinary treatment team develop individualized return-to-play and return-to-school guidelines for each patient, he says. The Clinical Journal of Sport Medicine published the consensus statement in May 2009.

"House Bill 2038 was clearly written with this plan in mind, and for that reason, it is laudable for promoting state-of-the-art management over older, 'rule-of-thumb' type guidelines," Dr. Spinks told the House Committee on Public Health in March. "However, our understanding of concussions is still evolving and has changed markedly over the past several years. Because of this, one of the greatest challenges at the state level is to create a system that is flexible enough to incorporate new scientific guidelines as they develop."

A big shift in concussion management occurred about seven years ago, Dr. Spinks says. A study published in the January 2004 American Journal of Sports Medicine by the University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program found the injury grading scales and return-to-play guidelines for mildly concussed high school athletes allowed them to return to play too quickly and increased their risk of additional injury.

Past guidelines permitted athletes whose on-the-field symptoms vanished within 15 minutes to return to play immediately. In a study of 43 mildly concussed athletes, UPMC researchers discovered that in all but four athletes, memory decline and/or other symptoms continued for days following the game in which they were injured.

Other studies on concussion show athletes can generally recover from mild concussions when their brains have time to heal before playing contact sports again. That first concussion, though, makes an athlete prone to more serious brain damage and reinjury, studies say.

"Concussions, even if they're mild, have lingering neurocognitive effects on student athletes," Dr. Spinks said. "Subsequent studies have revealed that kids seem to recover more slowly from concussion than adults, and we don't know why. We've also learned that loss of consciousness associated with a concussion, although important, is not the greatest predictor of recovery rate."

New Law Protects Athletes

Jason Terk, MD, chair of the TMA Council on Science and Public Health and a Keller pediatrician, says primary care physicians who treat school-age patients are typically familiar with sports-related concussions. He says health care professionals now understand a concussion is a potentially serious traumatic event to the brain.

Strong scientific evidence supports a standardized approach to the care of athletes who experience concussions, says Dr. Terk, who was a member of the TMA committee on concussions.

"Patients who have this kind of injury commonly experience headache, nausea, and a clouded sensorium that can last for days, even when no loss of consciousness occurs at the moment of impact. This can have an effect on patients' ability to perform tasks when working or attending school and can affect how they respond to others around them," Dr. Terk said.

Dr. Spinks is all too familiar with the short-term health effects of concussions in children. He serves as codirector of the Dell Children's Medical Center and Seton Healthcare Family Concussion Program.

"I see a lot of kids who haven't been treated appropriately and in whom concussions haven't been recognized. Many times they don't realize they have a concussion. Their symptoms include poor academic performance in school, daily headaches, light or noise sensitivity, nausea, balance problems, or dizziness," he said.

Dr. Spinks hopes Natasha's Law will facilitate proper assessment and treatment of concussions in Texas student athletes.

"Because some athletes don't know they're concussed, they'll keep participating in sports or other activities and reinjure themselves. It's very dangerous. In severe cases, they can wind up unconscious and on a ventilator," Dr. Spinks said.

Representative Price says "Texas' student athletes deserve better protection."

Before Natasha's Law, Representative Price explains, state law protected only those student athletes knocked unconscious during practice or a game. Under previous law, an athlete knocked out during practice or competition could not return to the sport until being medically evaluated and cleared by a physician's written authorization.

"While that is sound practice, the law did not require intervention when an athlete suffered a concussion but did not lose consciousness," Representative Price said. "This was troubling to me given that medical statistics reveal the overwhelming majority of athletes who sustain concussions do not present in an unconscious state."

With passage of HB 2038, he says, all student athletes suspected to have sustained a concussion now will receive timely medical evaluation and be cleared by a physician before they can resume play.

"Quite simply, I believe this protocol will save lives," Representative Price said.

Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email.


TMA Ad Hoc Committee on Student Athlete Concussions

Sara Austin, MD, Chair, Austin
C. Mark Chassay, MD, MBA, Austin
Jesse De Lee, MD, San Antonio
Randolph Evans, MD, Houston
William S. Gilmer, MD, Houston
Javier "Jake" Margo Jr., MD,    Rio Grande City
Theodore Spinks, MD  , Austin
Jason Terk, MD, Keller

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  Legislature Tackles Helmet Safety  

A new law now sets standards on ensuring periodic inspection of football helmets and elimination of worn-out helmets.

House Bill 675 by Rep. Eddie Lucio III (D-Brownsville) and sponsored by Sen. Eddie Lucio Jr. (D-Brownsville) prohibits school districts from using football helmets 16 years or older. Under the new law, which took effect Sept. 1, school districts must ensure that each helmet 10 years or older is reconditioned at least once every two years.

School districts also must maintain and make available to parents documentation indicating the age of each football helmet and the dates on which each helmet is reconditioned.

HB 675 authorizes the University Interscholastic League (UIL) to adopt rules necessary to implement the law.

In a statement of intent by Representative Lucio and Senator Lucio, they wrote, "Football helmets are the first line of defense in preventing head injuries among Texas high school athletes, and many of them are several years old as they have been passed down from one year to the next."

They explained that UIL didn't have any rules regarding the age of a helmet or how often it had to be reconditioned.

Jason Terk, MD, chair of the Texas Medical Association Council on Science and Public Health and a member of the TMA Ad Hoc Committee on Student Athlete Concussions, says the new laws on prevention, treatment, and oversight of concussions, as well as football helmet safety requirements, will benefit student athletes in Texas public schools in many ways.

"We now have a statewide roadmap, which was crafted with the input of expertise from a TMA task force, for care of the student athlete who suffers a concussion. From what care is needed at the moment of injury, through the point of deciding when it is appropriate to return that athlete to participation, the new law puts the safety of the student athlete first," he said.

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