The American Journal of Sports Medicine http://ajs.sagepub.com/
Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State Sara P. Chrisman, Melissa A. Schiff, Shana K. Chung, Stanley A. Herring and Frederick P. Rivara Am J Sports Med 2014 42: 1190 originally published online February 7, 2014 DOI: 10.1177/0363546513519073 The online version of this article can be found at: http://ajs.sagepub.com/content/42/5/1190
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Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State Sara P. Chrisman,*yz MD, MPH, Melissa A. Schiff,y§ MD, MPH, Shana K. Chung,y JD, MPH, Stanley A. Herring,k{# MD, and Frederick P. Rivara,yz MD, MPH Investigation performed at the University of Washington, Seattle, Washington, USA Background: Most states in the United States have passed laws regarding concussions, but little is known regarding the implementation of these laws. Hypothesis/Purpose: The purpose of this study was to survey high school coaches 3 years after the passage of a concussion law to evaluate the variation in concussion education and knowledge in the context of this law as well as measure the effects of sport (football vs soccer) and urban versus rural locations. The hypothesis was that concussion education and knowledge would be more extensive in football compared with soccer and in urban locations compared with rural locations. Study Design: Descriptive epidemiology study. Methods: A mixed-methods (paper and online) survey was conducted in 2012 to 2013 on a random sample of public high school football, girls’ soccer, and boys’ soccer coaches in Washington State, stratified by urban and rural locality. The survey covered the extent of concussion education for coaches, athletes, and parents as well as coaches’ concussion knowledge and experience. Results: Of 496 coaches contacted, 270 responded (54.4%). Nearly all coaches answered concussion knowledge questions correctly, and nearly all coaches received education via 2 modalities (written, video, slide presentation, test, and in person). Athlete education was less extensive, with 34.7% exposed to 2 modalities and 29.5% only signing a concussion information form. Parent education was even more limited, with 16.2% exposed to 2 modalities and 57.9% only signing a concussion information form. Significantly more football than soccer coaches gave their athletes an in-person talk about concussions (59.1% vs 39.4%, respectively; P = .002) and provided concussion education to athletes via 2 modalities (44.1% vs 29.7%, respectively; P = .02). Concussion education for coaches and parents was similar between sports, and concussion education for all parties was similar in urban and rural localities. Conclusion: Three years after the passage of a concussion law in Washington State, high school football and soccer coaches are receiving substantial concussion education and have good concussion knowledge. Concussion education for athletes and parents is more limited. Football players receive more extensive concussion education than do soccer players. Clinical Relevance: Clinicians should be aware that athletes and parents may not be receiving significant concussion education. Keywords: concussion; legislation; adolescents; athletics; return to play; education
Estimates suggest that up to 3.8 million people experience traumatic brain injuries (TBIs) each year in the United States,11 most of which are mild TBIs or concussions. In an attempt to reduce the morbidity associated with concussions, Washington State passed a law in 2009 regarding concussion safety (the Lystedt Law5). This law requires that athletes with a possible concussion be removed from practice or game play and not return until cleared in
writing by a licensed health care provider trained in the evaluation and management of concussions. The law also stipulates concussion education for athletes, parents, and coaches and requires that athletes and parents sign a concussion information form annually. The goal of the law was to develop a consistent concussion plan across schools in Washington State to prevent athletes from playing with concussive symptoms.1 Since Washington State passed the Lystedt Law in 2009, many other states have followed suit, and now all but 1 state have a similar law in place.16 However, it is not known whether individual schools comply with these laws, what variations in implementation exist, and how
The American Journal of Sports Medicine, Vol. 42, No. 5 DOI: 10.1177/0363546513519073 Ó 2014 The Author(s)
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such variation affects concussion knowledge. These laws allow for the significant interpretation of ‘‘concussion education,’’ particularly with regard to modality (eg, written, video, slide presentation, online, in person) but also with regard to the frequency and enforcement of administration. From a public health standpoint, it is important to understand how schools have chosen to respond to concussion laws such as the Lystedt Law and whether the implementation of these laws affects concussion knowledge. Coaches’ concussion knowledge is of particular interest because coaches have a significant role in concussion recognition. Even at schools with a licensed athletic trainer (AT), the coach is an important part of the team, ensuring the safety of youth athletes. In addition, the extent of concussion education and the resulting concussion knowledge may vary by sport or by urban or rural locality. The Lystedt Law was designed to apply to any athletic competition involving youth younger than 18 years of age, but historically, there has been greater concussion awareness in sports where athletes are intentionally colliding such as football compared with unintentional collision sports such as girls’ and boys’ soccer.3 Given the scarcity of resources at most public high schools, it is possible that implementation of the law might be prioritized toward sports perceived as being more high risk. It is also likely that resources are scarcer in rural localities, and this may affect the ability of schools to implement a concussion policy. While the law mostly applies to public schools, language was included that generalized its application to organizations that use school property, which affects most private athletic organizations.5 However, for this study, we have chosen to focus on public high schools. The goals of this study were 3-fold: (1) to measure variation in the implementation of a concussion law in Washington State (the Lystedt Law) with regard to required concussion education for high school athletes, parents, and coaches as well as to evaluate enforcement of these education requirements; (2) to evaluate public high school football and soccer coaches’ knowledge of concussion in a state with a concussion law; and (3) to determine whether concussion education or knowledge varies by sport (football vs girls’ soccer vs boys’ soccer) and rural versus urban locality.
MATERIALS AND METHODS We conducted a mixed-methods (web-based and paper) survey of varsity public high school football, girls’ soccer, and boys’ soccer coaches in Washington State from 2012
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to 2013. Our study was approved by the University of Washington’s institutional review board. We obtained a list of all the school districts in Washington State (N = 299) and selected a random sample from that list stratified by urban (n = 87) and rural (n = 212) districts. We then went through each district, removed those schools without all 3 sports, chose a random public high school from the remaining schools, and contacted the school’s athletic director and coaches for participation in an injury research study. If the school was not interested in participating, we chose a school from the next district in the same manner. Schools were first offered participation in a qualitative study involving key informant interviews, and 10 such interviews were conducted. Additional schools were then drawn from the sample for participation in a prospective concussion surveillance trial, which will be reported separately. All surveys were completed at the end of the season. Coaches in the concussion surveillance study (N = 50) were offered a $20 gift certificate to complete the survey, and additional coaches were recruited for the survey by e-mailing a survey link to football, boys’ soccer, and girls’ soccer coaches (N = 446) from all high schools in Washington State with all 3 sports who were not a part of the surveillance study, with a raffle for Starbucks coffeehouse gift cards as an incentive. We sent up to 3 reminder e-mails or telephone calls 1 week apart to nonrespondents. To determine the likely areas of variation in implementation, we first conducted qualitative interviews using a standardized template with a random sample of 10 key informants (coaches and athletic directors) and used these interviews to inform our coach survey. Interviews were conducted over the telephone, digitally recorded, professionally transcribed, and uploaded to Atlas.ti (Atlas.ti Scientific Software Development, Berlin, Germany), which is a software program designed to facilitate qualitative analysis. Transcripts were coded using Atlas.ti to determine areas in which implementation of the Lystedt Law varied. Data from these interviews suggested that the frequency of education, modality in which education was provided, and availability of an AT appeared to vary across schools. Many coaches reported using materials offered on the Washington Interscholastic Activities Association (WIAA) website. The WIAA is an organization that oversees all high school athletics in Washington State, and the concussion resources provided on its website include written materials, a video, a slide (PowerPoint, Microsoft, Redmond, Washington, USA) presentation, and a test.21 We incorporated detailed questions about these areas into the coach survey. We initially developed the survey
*Address correspondence to Sara P. Chrisman, MD, MPH, Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Box 359960, Seattle, WA 98104, USA (e-mail: [email protected]). y Harborview Injury Prevention and Research Center, Seattle, Washington, USA. z Department of Pediatrics, University of Washington, Seattle, Washington, USA. § Department of Epidemiology, University of Washington, Seattle, Washington, USA. k Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA. { Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA. # Department of Neurological Surgery, University of Washington, Seattle, Washington, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: S.A.H. has a nonfinancial role on the medical advisory board for X2 Biosystems, which makes monitors that measure the force of head impacts while playing sports. Support for this study was provided by a grant from the Public Health Law Research Program of the Robert Wood Johnson Foundation.
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in paper form and then adapted it for online administration using Catalyst (University of Washington, Seattle, Washington, USA). In the survey, we asked coaches whether they were required to complete concussion education, how often, via which modalities (written, video, PowerPoint, test, or in person), and what occurred if they did not complete this education. We asked coaches similar questions about the education that they provided for athletes and parents, although in this case, we also asked whether athletes and parents signed a concussion information form. This is a standardized form designed by the drafters of the Lystedt Law that lists signs and symptoms of a concussion, details the potential risks of playing with concussive symptoms, and asks parents to alert coaches if their child has symptoms indicating a concussion. Both the parent and athlete must sign this form. We then asked coaches about their experiences with concussions in the previous season, any standardized tests that they or an AT used to recognize a potential concussion, other medical professionals on the sideline, and a few concussion knowledge questions. Although coaches are not responsible for making return-to-play decisions under the Lystedt Law, they are tasked with determining whether an athlete is ‘‘suspected’’ of having a concussion, and we asked coaches about their comfort level in making this decision. We were interested in the presence of other medical professionals on the sideline, as this would affect the amount of responsibility for determining whether athletes were ‘‘suspected’’ of having a concussion that was placed on the coach. The complete text of the survey can be found in Appendix 1 (available in the online version of this article at http://ajsm.sagepub.com/supplemental).
Statistical Analysis We first examined the responses of all coaches and then compared responses by sport (football vs girls’ soccer vs boys’ soccer) and locality (urban vs rural) using the Pearson x2 or Fisher exact test for expected frequencies of less than 5. Because about half the soccer coaches coached both boys’ and girls’ soccer, while only 2 football coaches also coached soccer, we combined the soccer coach groups when there were no differences between these groups. Urban and rural localities were classified using the 2008 Washington State Department of Health designation8 of the district in which the school resided, which is based on population size and proportion of the population commuting for work. All analyses were conducted with a = .05 using STATA v 12 (StataCorp, College Station, Texas, USA).
RESULTS Of 496 coaches approached, 270 completed the survey (54.5%), approximately evenly divided across the 3 sports (93 football, 94 girls’ soccer, and 83 boys’ soccer) and representing 144 high schools across Washington State (Table 1). The majority of coaches were 30 to 50 years of age, 30.5% had more than 20 years’ coaching experience, and
TABLE 1 Demographic Characteristics of High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a n (%) Age, y (n = 265) 20-30 31-40 41-50 511 Years coaching (n = 266) 1-5 6-10 11-15 16-20 211 Female sex Rural school Education (n = 269) High school Some college Bachelor’s degree Master’s degree Doctorate or other Trained in cardiopulmonary resuscitation/first aid
23 83 85 74
(8.7) (31.3) (32.1) (27.9)
18 46 53 68 81 29 86
(6.8) (17.3) (19.9) (25.6) (30.4) (10.7) (31.9)
11 34 72 145 7 264
(4.1) (12.6) (26.8) (53.9) (2.6) (97.8)
a The number of subjects varies slightly for each question as not all survey respondents answered all questions.
10.7% were female (all but 1 of whom coached girls’ soccer). One-third of coaches worked in a rural district, 83.3% had a college degree or higher, and over half had a master’s degree. All but 3 coaches reported being required to complete concussion education (Table 2), and 74.4% reported that this was required before they were allowed to coach. However, 16.9% were allowed to coach without completing concussion education, and 8.7% were unsure of their school’s policy regarding education enforcement. Nearly all coaches were required to complete concussion education annually, and 91.0% received this education via at least 2 modalities (written, video, PowerPoint, test, or in person). Video was the most common educational modality utilized for coaches (83.5%), and about one-third of coaches received concussion education in person. The most commonly used specific educational resources came from the website of the WIAA. Nearly all coaches used at least part of the WIAA website, with the video being most popular (83.6%). About one-third of coaches completed the online concussion training offered by the Centers for Disease Control and Prevention (‘‘Heads Up: Concussion in Youth Sports’’4), and approximately an additional one-third completed the training offered by the National Federation of State High School Associations (‘‘Concussion in Sports: What You Need to Know’’15). Athlete concussion education was less extensive than education for coaches (Table 3). All athletes are required to sign the concussion information form in accordance with the Lystedt Law, and 89.3% of coaches reported that their athletes did so. However, only about one-third of coaches provided athletes with concussion education
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TABLE 2 Concussion Education of High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a n (%) Concussion education required Protocol if concussion education not completed (n = 266) Able to coach, complete training when time permitted Unable to coach until training completed Unknown Frequency of coach concussion education (n = 264) Once a year Every other year Less frequently than every other year Modalities utilized for education (n = 267) Written Video PowerPoint Test In person No. of modalities in which education was provided (n = 267) 1 2 3 4 5 Specific educational resources utilized WIAA video (n = 269) WIAA PowerPoint presentation (n = 269) WIAA test (n = 269) CDC ‘‘Heads Up: Concussion in Youth Sports’’ training (n = 270) NFHS ‘‘Concussion in Sports: What You Need to Know’’ training (n = 269)
267 (98.9)
45 (16.9) 198 (74.4) 23 (8.7) 248 (93.9) 15 (5.7) 1 (0.4) 165 223 163 191 86
(61.8) (83.5) (61.1) (71.5) (32.2)
24 60 80 71 32
(9.0) (22.5) (29.9) (26.6) (12.0)
225 182 210 91
(83.6) (67.7) (78.1) (33.7)
97 (36.1)
a The number of subjects varies slightly for each question as not all survey respondents answered all questions. CDC, Centers for Disease Control and Prevention; NFHS, National Federation of State High School Associations; WIAA, Washington Interscholastic Activities Association.
via 2 modalities in addition to the information form. About half of coaches personally educated their athletes about concussions, 29.1% utilized reading materials, 10.8% directed them to a website, 15.3% showed them a video, and 29.5% reported not providing athletes with any additional education beyond the concussion information form. Parent concussion education was even more limited. Similar to athletes, most parents (82.9%) were required to sign the concussion information form (Table 3). However, only 16.2% of coaches provided parents with concussion education via 2 modalities in addition to the information form. About one-quarter of coaches provided additional reading materials, about one-quarter gave parents a talk about concussions, about 5.9% directed them to a website, 1.6% utilized video, and 57.9% of coaches reported not providing parents with any additional concussion education other than asking them to sign the concussion information form.
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Three-quarters of coaches had at least 1 athlete who sustained a concussion in the most recent season (see Appendix 2, available online), with 42.5% reporting 2 to 5 athletes with a concussion. Two-thirds of coaches were very comfortable deciding whether an athlete needed further concussion evaluation, and 96.2% were at least somewhat comfortable making this decision. Two-thirds of coaches worked at schools that employed an AT, and 59.2% reported that the AT attended their games most or all the time. The presence of other medical personnel was less common, with one-quarter reporting a physician attended at least half the games and one-quarter reporting the same attendance for an emergency medical technician. Three-quarters of coaches reported that some type of standardized concussion testing was used to evaluate athletes (either by themselves or a medical professional on the sidelines), but almost half could not remember the name of the testing. Less than half reported any kind of baseline testing. Most coaches correctly responded that 10% of concussions involve loss of consciousness (see Appendix 3, available online), 83.3% had heard of the Lystedt Law, and 92.6% believed that concussion laws make sports safer. However, only 55.2% were familiar with the term ‘‘graduated return to play,’’ which is the recommended management for concussion.12 Nearly all coaches answered the concussion knowledge questions correctly: 95.9% understood that one can get a concussion without a blow to the head, 97.4% would not allow an athlete to keep playing if he or she had a headache after a collision, and 95.5% disagreed with returning an athlete to competition if symptoms were brief (\15 minutes). More than 95% of coaches recognized dizziness, headache, nausea or vomiting, balance problems, sensitivity to light, difficulty concentrating, drowsiness, blurry vision, seeming ‘‘in a fog,’’ and memory problems as symptoms of a concussion (see Appendix 4, available online). About 80% also recognized irritability and difficulty sleeping. Coaches less commonly identified being more emotional (68.9%), nervousness or anxiety (61.2%), and sadness (52.1%) as concussive symptoms. We then compared the results of the survey by sport and found coach concussion education in football and soccer was similar for frequency required, enforcement, modalities utilized, and specific type of educational material utilized. Football coaches were more likely to talk to their athletes about concussions than were soccer coaches (59.1% vs 39.4%, respectively; P = .002) and were more likely to provide concussion education using 2 modalities (44.1% vs 29.7%, respectively; P = .02). Parent concussion education was similar between sports. More football coaches than soccer coaches reported that 2 of their athletes had a concussion in the previous season (83.7% vs 38.6%, respectively; P \ .001). Despite this, football and soccer coaches were similar in terms of their comfort deciding whether an athlete required further evaluation for a concussion. Access to an AT was similar by sport, but football coaches reported that ATs attended games most or all of the time more than soccer coaches did (98.4% vs 77.8%, respectively; P \ .001). In addition, 63.0% of football coaches reported that a physician attended at least half their games, while this was rare for soccer coaches (3.0%; P \ .001).
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TABLE 3 Parent and Athlete Concussion Education as Reported by High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a
Required to sign concussion form (n = 270 athlete; n = 263 parent) Only signed a form (n = 268 athlete; n = 254 parent) Modalities utilized for education (n = 268 athlete; n = 254 parent) Reading materials In-person talk from coach In-person talk from another Video Website No. of modalities in which education was provided (beyond the information form) (n = 268 athlete; n = 254 parent) 1 2 3 4 5 a
Athlete Concussion Education, n (%)
Parent Concussion Education, n (%)
241 (89.3) 79 (29.5)
218 (82.9) 147 (57.9)
78 124 56 41 29
(29.1) (46.3) (20.9) (15.3) (10.8)
66 58 17 4 15
(26.0) (22.8) (6.7) (1.6) (5.9)
96 62 18 11 2
(35.8) (23.1) (6.7) (4.1) (0.8)
66 32 7 1 1
(26.0) (12.6) (2.8) (0.4) (0.4)
The number of subjects varies slightly for each question as not all survey respondents answered all questions.
Responses to concussion knowledge questions were similar by sport. Football coaches were statistically more likely to respond that it was acceptable for athletes to return to play if they had a headache after a collision (5.9% vs 0.6%, respectively; P = .003), but these results were based on 6 football coaches and 1 soccer coach. Coaches were similar in terms of their familiarity with the Lystedt Law, knowledge of graduated return to play, and use of standardized concussion assessments. We also compared coach responses by urban or rural locality. Urban coaches were more likely to have access to ATs (86.8% vs 34.9%, respectively; P \ .001) and were more likely to report that a physician attended at least half their games (28.4% vs 16.1%, respectively; P = .03). Coach concussion education was similar, but urban coaches were more likely to report that someone else gave their athletes a talk about concussions (26.9% vs 8.1%, respectively; P \ .001). A greater proportion of urban coaches reported having 2 athletes with a concussion in the most recent season (63.7% vs 33.7%, respectively; P \ .001), but there were no differences between urban and rural coaches regarding their comfort deciding whether an athlete required an evaluation for concussion. Coaches in urban and rural districts were similar in terms of their responses to concussion knowledge questions, standardized testing use, knowledge of graduated return to play, and recognition of concussive symptoms.
DISCUSSION In our survey of public high school football, girls’ soccer, and boys’ soccer coaches in Washington State 3 years after the passage of a concussion law, nearly all coaches reported completing required concussion education annually and in multiple modalities, and most received their
education using the materials provided on the WIAA website. Coach concussion knowledge was high, and nearly all coaches reported that they felt somewhat comfortable or very comfortable deciding whether an athlete required an additional evaluation for concussions. Athlete and parent concussion education was much more limited, with about one-third of athletes and more than half of parents not receiving any additional concussion education beyond signing the concussion information form. Football coaches were more likely than soccer coaches to give athletes a talk about concussions and provide their athletes with education via 2 modalities, but concussion education for coaches and parents did not differ significantly by sport or urban/rural locality. More than two-thirds of coaches reported access to an AT (compared with national estimates of about 40%),14 and ATs were twice as common in urban areas compared with rural areas. To our knowledge, this is the first study to examine the implementation of concussion laws and to describe the variation in concussion education for public high school coaches, athletes, and parents. Two recent studies compared the content of concussion laws across the United States,9,19 but these studies did not examine the extent to which such legislation was implemented or the concussion knowledge of coaches in the years after such implementation. One recent study by Shenouda and colleagues18 examined the effect of the Lystedt Law on concussion knowledge, but they combined responses from coaches and parents, so it was not possible to compare results. Our results suggest that concussion education requirements for coaches are being closely followed by public high schools in Washington State. This is very encouraging but is not surprising. Public schools are motivated to follow the coach education guidelines outlined in the Lystedt Law because it was written in such a way that it provides protection from litigation for these schools if it is followed correctly,
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and schools employ the coaches and thus have the ability to enforce education requirements. These schools also fall under the auspices of the WIAA and thus are motivated to adhere to guidelines that are administered by the WIAA. The Lystedt Law contains a clause that extends its purview to not only public high school athletes but also to all athletes who compete on public high school grounds. By these means, the law pertains to many private athletic organizations. Our own experience has been that most private athletic organizations are following this law, but we did not survey coaches of private schools or private athletic organizations, and this would be an interesting area for future research. It is concerning that athlete and parent education was not more extensive, but this is also within the guidelines of the law. The language of the Lystedt Law is vague in regard to educational requirements for athletes and parents, likely a necessary compromise due to the lack of funding provided to institute any such education. While educational materials are provided to the schools, there is no funding available for the inevitable costs that come from attempting to institute and enforce an educational intervention, and these costs may be more extensive when attempting to educate parents, whose schedules are more difficult to accommodate. Our hope is that further revisions of this law may include additional educational requirements for athletes and parents. This is particularly important for parents, given the pivotal role of parents in regard to sports safety. Parents of high school athletes attend their child’s games, watch their child closely during game play, and are acutely attuned to changes in their child’s behavior. Educating parents about signs and symptoms of concussions could potentially decrease the likelihood of athletes playing with concussive symptoms. We also found an interesting variation in educational modality, with a greater focus on multimodal learning for coaches than for athletes. Data regarding the ideal presentation of educational materials suggest that multimodal presentations are generally more impactful than those using a single modality,7 although the ideal modality may depend on the material to be learned. It also appears to be more difficult for learners to take in information when it is presented amidst distracting information or when too many messages are communicated, resulting in cognitive overload.20 Finally, the ideal learning environment seems to be affected by age, sex, culture of origin, and other individual factors.10 The most effective programs would likely involve multiple modalities and would focus on a few key messages but might need to be tailored to the group being educated. One of the limitations of this study is that we primarily measured concussion education and knowledge, and it is unclear whether improved concussion knowledge affects concussion safety. Two research groups have studied concussion education interventions with youth using multimedia in-person educational sessions, and both reported an improvement in concussion knowledge.2,13 However, with concussive injuries, athletes need to report concussive symptoms to be removed from play, and several recent studies have revealed significant barriers to athletes reporting concussive symptoms that are not knowledge based, such as a concern that they would be removed from game play
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or pressure from their teammates or coach.6,17 Education is an important piece of any intervention to improve concussion safety, but further research is needed to understand how education can be most effective toward preventing athletes from playing with concussive symptoms and thus improving safety. There may be certain messages that are more likely to encourage athletes to report concussive symptoms, such as focusing on short-term outcomes (concussions affect one’s ability to play well) rather than long-term outcomes (playing with a concussion can cause brain damage). Involvement of an AT is also an interesting aspect of this law. The Lystedt Law was written in such a way that ATs are capable of clearing athletes to return to play, and it is possible that schools have chosen to respond to the Lystedt Law by employing ATs. We found a higher proportion of schools in our sample had ATs than is reported for the country (more than two-thirds vs 40%, respectively),14 but unfortunately, no data are available regarding the prevalence of ATs in Washington State before the law. The presence of an AT could affect multiple areas of concussion safety, from the likelihood of concussion detection to appropriate management, and could provide opportunities for further athlete concussion education. It is unclear whether employing an AT can improve concussion safety, and it deserves further study. Our study was limited by a moderate response rate of about 50%, and it is thus difficult to know whether our sample is representative of all coaches in Washington State. However, it was a relatively large random sample (n = 270) and contained coaches from across the state. In addition, while it is encouraging that football and soccer coaches appeared to have a good fund of knowledge about concussions (this was not reported to be the case before passing the law1), it is not clear that this translates into appropriate concussion management, and further studies will be needed to ascertain the true effect of the law on concussion safety. Finally, coaches may not have been aware of all of the concussion education that occurs at their school for athletes and parents, and this may thus be an underestimate of concussion law implementation. In conclusion, public high school football and soccer coaches in Washington State (the first state to pass comprehensive concussion legislation) receive significant training on concussion management and have good concussion knowledge. However, athletes and parents receive much less concussion education. Given that concussions are difficult to diagnose and often require either athlete reports or parental concerns to come to the attention of the coach,6 educating athletes and their parents about the risks of a concussion and safe management is an essential part of preventing athletes from playing with concussive symptoms. Future studies will need to address whether changes made in response to concussion laws have altered the proportion of athletes playing with concussive symptoms.
ACKNOWLEDGMENT The authors thank the athletic staff of the participating schools, the athletes, and their parents for their
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participation in the study. They also thank the research staff of Matthew Vaughn, Katherine Lepere, Adam Strizich, Asha Thomas, Charla Jones, Denise Hopkins, Sierra Rotakhina, Melissa Rudd, Adessa Churape, Rachel Silverstein, Reba Blissell, Jennifer Maeser, and Christopher Mack for their dedication and work. REFERENCES 1. Adler RH, Herring SA. Changing the culture of concussion: education meets legislation. PM R. 2011;3(10 Suppl 2):S468-S470. 2. Bagley AF, Daneshvar DH, Schanker BD, et al. Effectiveness of the SLICE program for youth concussion education. Clin J Sport Med. 2012;22(5):385-389. 3. Broglio SP, Vagnozzi R, Sabin M, Signoretti S, Tavazzi B, Lazzarino G. Concussion occurrence and knowledge in Italian football (soccer). J Sports Sci Med. 2010;9:418-430. 4. Centers for Disease Control and Prevention. Heads up: concussion in youth sports. Available at: http://www.cdc.gov/concussion/Heads Up/online_training.html. Accessed May 8, 2013. 5. Chopp F, Owen B, Gregoire C. Youth sports: head injury policies. Engrossed House Bill 1824. Effective date: July 26, 2009. Available at: https://docs.google.com/viewer?url=http%3A%2F%2Fapps.leg. wa.gov%2Fdocuments%2Fbilldocs%2F2009-10%2FPdf%2FBills %2FHouse%2520Bills%2F1824.E.pdf. Accessed March 27, 2013. 6. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health. 2013;52(3):330-335.e3. 7. Ginns P. Meta-analysis of the modality effect. Learning and Instruction. 2005;15(4):313-331. 8. Hailu A, VanEenwyk J. Guidelines for using rural-urban classification systems for public health assessment. Available at: https://docs.google.com/ viewer?url=http%3A%2F%2Fwww.doh.wa.gov%2FPortals%2F1%2F Documents%2F5500%2FRuralUrbGuide.pdf. Accessed June 14, 2013. 9. Harvey HH. Reducing traumatic brain injuries in youth sports: youth sports traumatic brain injury state laws. Am J Public Health. 2013;103(7):1249-1254.
10. Heffler B. Individual learning style and the learning style inventory. Educ Stud. 2001;27(3):307-316. 11. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378. 12. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Sci Med Sport. 2009;12(3):340-351. 13. Miyashita TL, Timpson WM, Frye MA, Gloeckner GW. The impact of an educational intervention on college athletes’ knowledge of concussions. Clin J Sport Med. 2013;23(5):349-353. 14. National Association of Athletic Trainers (NATA). Athletic trainers fill a necessary niche in secondary schools. March 12, 2009. Available at: http://www.nata.org/NR031209. Accessed July 5, 2013. 15. National Federation of State High School Associations. Concussion in sports: what you need to know. Available at: http://www.nfhs learn.com/electiveDetail.aspx?courseID=38000. Accessed May 8, 2013. 16. National Football League. The Zackery Lystedt Law. Available at: http://www.nflevolution.com/article/The-Zackery-Lystedt-Law?ref= 270. Accessed July 5, 2013. 17. Register-Mihalik JK, Linnan LA, Marshall SW, McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj. 2013;27(7-8):878-886. 18. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion legislation one year later: what have we learned. A descriptive pilot survey of youth soccer player associates. PM R. 2012;4(6):427-435. 19. 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;33(6):E11:1-9. 20. Van Merrie¨nboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44:85-93. 21. Washington Interscholastic Activities Association. Concussion management guidelines. Available at: http://www.wiaa.com/subcontent .aspx?SecID=623. Accessed April 19, 2013.
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Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State Sara P. Chrisman, Melissa A. Schiff, Shana K. Chung, Stanley A. Herring and Frederick P. Rivara Am J Sports Med 2014 42: 1190 originally published online February 7, 2014 DOI: 10.1177/0363546513519073 The online version of this article can be found at: http://ajs.sagepub.com/content/42/5/1190
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Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State Sara P. Chrisman,*yz MD, MPH, Melissa A. Schiff,y§ MD, MPH, Shana K. Chung,y JD, MPH, Stanley A. Herring,k{# MD, and Frederick P. Rivara,yz MD, MPH Investigation performed at the University of Washington, Seattle, Washington, USA Background: Most states in the United States have passed laws regarding concussions, but little is known regarding the implementation of these laws. Hypothesis/Purpose: The purpose of this study was to survey high school coaches 3 years after the passage of a concussion law to evaluate the variation in concussion education and knowledge in the context of this law as well as measure the effects of sport (football vs soccer) and urban versus rural locations. The hypothesis was that concussion education and knowledge would be more extensive in football compared with soccer and in urban locations compared with rural locations. Study Design: Descriptive epidemiology study. Methods: A mixed-methods (paper and online) survey was conducted in 2012 to 2013 on a random sample of public high school football, girls’ soccer, and boys’ soccer coaches in Washington State, stratified by urban and rural locality. The survey covered the extent of concussion education for coaches, athletes, and parents as well as coaches’ concussion knowledge and experience. Results: Of 496 coaches contacted, 270 responded (54.4%). Nearly all coaches answered concussion knowledge questions correctly, and nearly all coaches received education via 2 modalities (written, video, slide presentation, test, and in person). Athlete education was less extensive, with 34.7% exposed to 2 modalities and 29.5% only signing a concussion information form. Parent education was even more limited, with 16.2% exposed to 2 modalities and 57.9% only signing a concussion information form. Significantly more football than soccer coaches gave their athletes an in-person talk about concussions (59.1% vs 39.4%, respectively; P = .002) and provided concussion education to athletes via 2 modalities (44.1% vs 29.7%, respectively; P = .02). Concussion education for coaches and parents was similar between sports, and concussion education for all parties was similar in urban and rural localities. Conclusion: Three years after the passage of a concussion law in Washington State, high school football and soccer coaches are receiving substantial concussion education and have good concussion knowledge. Concussion education for athletes and parents is more limited. Football players receive more extensive concussion education than do soccer players. Clinical Relevance: Clinicians should be aware that athletes and parents may not be receiving significant concussion education. Keywords: concussion; legislation; adolescents; athletics; return to play; education
Estimates suggest that up to 3.8 million people experience traumatic brain injuries (TBIs) each year in the United States,11 most of which are mild TBIs or concussions. In an attempt to reduce the morbidity associated with concussions, Washington State passed a law in 2009 regarding concussion safety (the Lystedt Law5). This law requires that athletes with a possible concussion be removed from practice or game play and not return until cleared in
writing by a licensed health care provider trained in the evaluation and management of concussions. The law also stipulates concussion education for athletes, parents, and coaches and requires that athletes and parents sign a concussion information form annually. The goal of the law was to develop a consistent concussion plan across schools in Washington State to prevent athletes from playing with concussive symptoms.1 Since Washington State passed the Lystedt Law in 2009, many other states have followed suit, and now all but 1 state have a similar law in place.16 However, it is not known whether individual schools comply with these laws, what variations in implementation exist, and how
The American Journal of Sports Medicine, Vol. 42, No. 5 DOI: 10.1177/0363546513519073 Ó 2014 The Author(s)
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such variation affects concussion knowledge. These laws allow for the significant interpretation of ‘‘concussion education,’’ particularly with regard to modality (eg, written, video, slide presentation, online, in person) but also with regard to the frequency and enforcement of administration. From a public health standpoint, it is important to understand how schools have chosen to respond to concussion laws such as the Lystedt Law and whether the implementation of these laws affects concussion knowledge. Coaches’ concussion knowledge is of particular interest because coaches have a significant role in concussion recognition. Even at schools with a licensed athletic trainer (AT), the coach is an important part of the team, ensuring the safety of youth athletes. In addition, the extent of concussion education and the resulting concussion knowledge may vary by sport or by urban or rural locality. The Lystedt Law was designed to apply to any athletic competition involving youth younger than 18 years of age, but historically, there has been greater concussion awareness in sports where athletes are intentionally colliding such as football compared with unintentional collision sports such as girls’ and boys’ soccer.3 Given the scarcity of resources at most public high schools, it is possible that implementation of the law might be prioritized toward sports perceived as being more high risk. It is also likely that resources are scarcer in rural localities, and this may affect the ability of schools to implement a concussion policy. While the law mostly applies to public schools, language was included that generalized its application to organizations that use school property, which affects most private athletic organizations.5 However, for this study, we have chosen to focus on public high schools. The goals of this study were 3-fold: (1) to measure variation in the implementation of a concussion law in Washington State (the Lystedt Law) with regard to required concussion education for high school athletes, parents, and coaches as well as to evaluate enforcement of these education requirements; (2) to evaluate public high school football and soccer coaches’ knowledge of concussion in a state with a concussion law; and (3) to determine whether concussion education or knowledge varies by sport (football vs girls’ soccer vs boys’ soccer) and rural versus urban locality.
MATERIALS AND METHODS We conducted a mixed-methods (web-based and paper) survey of varsity public high school football, girls’ soccer, and boys’ soccer coaches in Washington State from 2012
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to 2013. Our study was approved by the University of Washington’s institutional review board. We obtained a list of all the school districts in Washington State (N = 299) and selected a random sample from that list stratified by urban (n = 87) and rural (n = 212) districts. We then went through each district, removed those schools without all 3 sports, chose a random public high school from the remaining schools, and contacted the school’s athletic director and coaches for participation in an injury research study. If the school was not interested in participating, we chose a school from the next district in the same manner. Schools were first offered participation in a qualitative study involving key informant interviews, and 10 such interviews were conducted. Additional schools were then drawn from the sample for participation in a prospective concussion surveillance trial, which will be reported separately. All surveys were completed at the end of the season. Coaches in the concussion surveillance study (N = 50) were offered a $20 gift certificate to complete the survey, and additional coaches were recruited for the survey by e-mailing a survey link to football, boys’ soccer, and girls’ soccer coaches (N = 446) from all high schools in Washington State with all 3 sports who were not a part of the surveillance study, with a raffle for Starbucks coffeehouse gift cards as an incentive. We sent up to 3 reminder e-mails or telephone calls 1 week apart to nonrespondents. To determine the likely areas of variation in implementation, we first conducted qualitative interviews using a standardized template with a random sample of 10 key informants (coaches and athletic directors) and used these interviews to inform our coach survey. Interviews were conducted over the telephone, digitally recorded, professionally transcribed, and uploaded to Atlas.ti (Atlas.ti Scientific Software Development, Berlin, Germany), which is a software program designed to facilitate qualitative analysis. Transcripts were coded using Atlas.ti to determine areas in which implementation of the Lystedt Law varied. Data from these interviews suggested that the frequency of education, modality in which education was provided, and availability of an AT appeared to vary across schools. Many coaches reported using materials offered on the Washington Interscholastic Activities Association (WIAA) website. The WIAA is an organization that oversees all high school athletics in Washington State, and the concussion resources provided on its website include written materials, a video, a slide (PowerPoint, Microsoft, Redmond, Washington, USA) presentation, and a test.21 We incorporated detailed questions about these areas into the coach survey. We initially developed the survey
*Address correspondence to Sara P. Chrisman, MD, MPH, Harborview Injury Prevention and Research Center, 325 Ninth Avenue, Box 359960, Seattle, WA 98104, USA (e-mail: [email protected]). y Harborview Injury Prevention and Research Center, Seattle, Washington, USA. z Department of Pediatrics, University of Washington, Seattle, Washington, USA. § Department of Epidemiology, University of Washington, Seattle, Washington, USA. k Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA. { Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, Washington, USA. # Department of Neurological Surgery, University of Washington, Seattle, Washington, USA. One or more of the authors has declared the following potential conflict of interest or source of funding: S.A.H. has a nonfinancial role on the medical advisory board for X2 Biosystems, which makes monitors that measure the force of head impacts while playing sports. Support for this study was provided by a grant from the Public Health Law Research Program of the Robert Wood Johnson Foundation.
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in paper form and then adapted it for online administration using Catalyst (University of Washington, Seattle, Washington, USA). In the survey, we asked coaches whether they were required to complete concussion education, how often, via which modalities (written, video, PowerPoint, test, or in person), and what occurred if they did not complete this education. We asked coaches similar questions about the education that they provided for athletes and parents, although in this case, we also asked whether athletes and parents signed a concussion information form. This is a standardized form designed by the drafters of the Lystedt Law that lists signs and symptoms of a concussion, details the potential risks of playing with concussive symptoms, and asks parents to alert coaches if their child has symptoms indicating a concussion. Both the parent and athlete must sign this form. We then asked coaches about their experiences with concussions in the previous season, any standardized tests that they or an AT used to recognize a potential concussion, other medical professionals on the sideline, and a few concussion knowledge questions. Although coaches are not responsible for making return-to-play decisions under the Lystedt Law, they are tasked with determining whether an athlete is ‘‘suspected’’ of having a concussion, and we asked coaches about their comfort level in making this decision. We were interested in the presence of other medical professionals on the sideline, as this would affect the amount of responsibility for determining whether athletes were ‘‘suspected’’ of having a concussion that was placed on the coach. The complete text of the survey can be found in Appendix 1 (available in the online version of this article at http://ajsm.sagepub.com/supplemental).
Statistical Analysis We first examined the responses of all coaches and then compared responses by sport (football vs girls’ soccer vs boys’ soccer) and locality (urban vs rural) using the Pearson x2 or Fisher exact test for expected frequencies of less than 5. Because about half the soccer coaches coached both boys’ and girls’ soccer, while only 2 football coaches also coached soccer, we combined the soccer coach groups when there were no differences between these groups. Urban and rural localities were classified using the 2008 Washington State Department of Health designation8 of the district in which the school resided, which is based on population size and proportion of the population commuting for work. All analyses were conducted with a = .05 using STATA v 12 (StataCorp, College Station, Texas, USA).
RESULTS Of 496 coaches approached, 270 completed the survey (54.5%), approximately evenly divided across the 3 sports (93 football, 94 girls’ soccer, and 83 boys’ soccer) and representing 144 high schools across Washington State (Table 1). The majority of coaches were 30 to 50 years of age, 30.5% had more than 20 years’ coaching experience, and
TABLE 1 Demographic Characteristics of High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a n (%) Age, y (n = 265) 20-30 31-40 41-50 511 Years coaching (n = 266) 1-5 6-10 11-15 16-20 211 Female sex Rural school Education (n = 269) High school Some college Bachelor’s degree Master’s degree Doctorate or other Trained in cardiopulmonary resuscitation/first aid
23 83 85 74
(8.7) (31.3) (32.1) (27.9)
18 46 53 68 81 29 86
(6.8) (17.3) (19.9) (25.6) (30.4) (10.7) (31.9)
11 34 72 145 7 264
(4.1) (12.6) (26.8) (53.9) (2.6) (97.8)
a The number of subjects varies slightly for each question as not all survey respondents answered all questions.
10.7% were female (all but 1 of whom coached girls’ soccer). One-third of coaches worked in a rural district, 83.3% had a college degree or higher, and over half had a master’s degree. All but 3 coaches reported being required to complete concussion education (Table 2), and 74.4% reported that this was required before they were allowed to coach. However, 16.9% were allowed to coach without completing concussion education, and 8.7% were unsure of their school’s policy regarding education enforcement. Nearly all coaches were required to complete concussion education annually, and 91.0% received this education via at least 2 modalities (written, video, PowerPoint, test, or in person). Video was the most common educational modality utilized for coaches (83.5%), and about one-third of coaches received concussion education in person. The most commonly used specific educational resources came from the website of the WIAA. Nearly all coaches used at least part of the WIAA website, with the video being most popular (83.6%). About one-third of coaches completed the online concussion training offered by the Centers for Disease Control and Prevention (‘‘Heads Up: Concussion in Youth Sports’’4), and approximately an additional one-third completed the training offered by the National Federation of State High School Associations (‘‘Concussion in Sports: What You Need to Know’’15). Athlete concussion education was less extensive than education for coaches (Table 3). All athletes are required to sign the concussion information form in accordance with the Lystedt Law, and 89.3% of coaches reported that their athletes did so. However, only about one-third of coaches provided athletes with concussion education
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TABLE 2 Concussion Education of High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a n (%) Concussion education required Protocol if concussion education not completed (n = 266) Able to coach, complete training when time permitted Unable to coach until training completed Unknown Frequency of coach concussion education (n = 264) Once a year Every other year Less frequently than every other year Modalities utilized for education (n = 267) Written Video PowerPoint Test In person No. of modalities in which education was provided (n = 267) 1 2 3 4 5 Specific educational resources utilized WIAA video (n = 269) WIAA PowerPoint presentation (n = 269) WIAA test (n = 269) CDC ‘‘Heads Up: Concussion in Youth Sports’’ training (n = 270) NFHS ‘‘Concussion in Sports: What You Need to Know’’ training (n = 269)
267 (98.9)
45 (16.9) 198 (74.4) 23 (8.7) 248 (93.9) 15 (5.7) 1 (0.4) 165 223 163 191 86
(61.8) (83.5) (61.1) (71.5) (32.2)
24 60 80 71 32
(9.0) (22.5) (29.9) (26.6) (12.0)
225 182 210 91
(83.6) (67.7) (78.1) (33.7)
97 (36.1)
a The number of subjects varies slightly for each question as not all survey respondents answered all questions. CDC, Centers for Disease Control and Prevention; NFHS, National Federation of State High School Associations; WIAA, Washington Interscholastic Activities Association.
via 2 modalities in addition to the information form. About half of coaches personally educated their athletes about concussions, 29.1% utilized reading materials, 10.8% directed them to a website, 15.3% showed them a video, and 29.5% reported not providing athletes with any additional education beyond the concussion information form. Parent concussion education was even more limited. Similar to athletes, most parents (82.9%) were required to sign the concussion information form (Table 3). However, only 16.2% of coaches provided parents with concussion education via 2 modalities in addition to the information form. About one-quarter of coaches provided additional reading materials, about one-quarter gave parents a talk about concussions, about 5.9% directed them to a website, 1.6% utilized video, and 57.9% of coaches reported not providing parents with any additional concussion education other than asking them to sign the concussion information form.
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Three-quarters of coaches had at least 1 athlete who sustained a concussion in the most recent season (see Appendix 2, available online), with 42.5% reporting 2 to 5 athletes with a concussion. Two-thirds of coaches were very comfortable deciding whether an athlete needed further concussion evaluation, and 96.2% were at least somewhat comfortable making this decision. Two-thirds of coaches worked at schools that employed an AT, and 59.2% reported that the AT attended their games most or all the time. The presence of other medical personnel was less common, with one-quarter reporting a physician attended at least half the games and one-quarter reporting the same attendance for an emergency medical technician. Three-quarters of coaches reported that some type of standardized concussion testing was used to evaluate athletes (either by themselves or a medical professional on the sidelines), but almost half could not remember the name of the testing. Less than half reported any kind of baseline testing. Most coaches correctly responded that 10% of concussions involve loss of consciousness (see Appendix 3, available online), 83.3% had heard of the Lystedt Law, and 92.6% believed that concussion laws make sports safer. However, only 55.2% were familiar with the term ‘‘graduated return to play,’’ which is the recommended management for concussion.12 Nearly all coaches answered the concussion knowledge questions correctly: 95.9% understood that one can get a concussion without a blow to the head, 97.4% would not allow an athlete to keep playing if he or she had a headache after a collision, and 95.5% disagreed with returning an athlete to competition if symptoms were brief (\15 minutes). More than 95% of coaches recognized dizziness, headache, nausea or vomiting, balance problems, sensitivity to light, difficulty concentrating, drowsiness, blurry vision, seeming ‘‘in a fog,’’ and memory problems as symptoms of a concussion (see Appendix 4, available online). About 80% also recognized irritability and difficulty sleeping. Coaches less commonly identified being more emotional (68.9%), nervousness or anxiety (61.2%), and sadness (52.1%) as concussive symptoms. We then compared the results of the survey by sport and found coach concussion education in football and soccer was similar for frequency required, enforcement, modalities utilized, and specific type of educational material utilized. Football coaches were more likely to talk to their athletes about concussions than were soccer coaches (59.1% vs 39.4%, respectively; P = .002) and were more likely to provide concussion education using 2 modalities (44.1% vs 29.7%, respectively; P = .02). Parent concussion education was similar between sports. More football coaches than soccer coaches reported that 2 of their athletes had a concussion in the previous season (83.7% vs 38.6%, respectively; P \ .001). Despite this, football and soccer coaches were similar in terms of their comfort deciding whether an athlete required further evaluation for a concussion. Access to an AT was similar by sport, but football coaches reported that ATs attended games most or all of the time more than soccer coaches did (98.4% vs 77.8%, respectively; P \ .001). In addition, 63.0% of football coaches reported that a physician attended at least half their games, while this was rare for soccer coaches (3.0%; P \ .001).
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TABLE 3 Parent and Athlete Concussion Education as Reported by High School Football and Soccer Coaches (n = 270) in Washington State, 2012-2013a
Required to sign concussion form (n = 270 athlete; n = 263 parent) Only signed a form (n = 268 athlete; n = 254 parent) Modalities utilized for education (n = 268 athlete; n = 254 parent) Reading materials In-person talk from coach In-person talk from another Video Website No. of modalities in which education was provided (beyond the information form) (n = 268 athlete; n = 254 parent) 1 2 3 4 5 a
Athlete Concussion Education, n (%)
Parent Concussion Education, n (%)
241 (89.3) 79 (29.5)
218 (82.9) 147 (57.9)
78 124 56 41 29
(29.1) (46.3) (20.9) (15.3) (10.8)
66 58 17 4 15
(26.0) (22.8) (6.7) (1.6) (5.9)
96 62 18 11 2
(35.8) (23.1) (6.7) (4.1) (0.8)
66 32 7 1 1
(26.0) (12.6) (2.8) (0.4) (0.4)
The number of subjects varies slightly for each question as not all survey respondents answered all questions.
Responses to concussion knowledge questions were similar by sport. Football coaches were statistically more likely to respond that it was acceptable for athletes to return to play if they had a headache after a collision (5.9% vs 0.6%, respectively; P = .003), but these results were based on 6 football coaches and 1 soccer coach. Coaches were similar in terms of their familiarity with the Lystedt Law, knowledge of graduated return to play, and use of standardized concussion assessments. We also compared coach responses by urban or rural locality. Urban coaches were more likely to have access to ATs (86.8% vs 34.9%, respectively; P \ .001) and were more likely to report that a physician attended at least half their games (28.4% vs 16.1%, respectively; P = .03). Coach concussion education was similar, but urban coaches were more likely to report that someone else gave their athletes a talk about concussions (26.9% vs 8.1%, respectively; P \ .001). A greater proportion of urban coaches reported having 2 athletes with a concussion in the most recent season (63.7% vs 33.7%, respectively; P \ .001), but there were no differences between urban and rural coaches regarding their comfort deciding whether an athlete required an evaluation for concussion. Coaches in urban and rural districts were similar in terms of their responses to concussion knowledge questions, standardized testing use, knowledge of graduated return to play, and recognition of concussive symptoms.
DISCUSSION In our survey of public high school football, girls’ soccer, and boys’ soccer coaches in Washington State 3 years after the passage of a concussion law, nearly all coaches reported completing required concussion education annually and in multiple modalities, and most received their
education using the materials provided on the WIAA website. Coach concussion knowledge was high, and nearly all coaches reported that they felt somewhat comfortable or very comfortable deciding whether an athlete required an additional evaluation for concussions. Athlete and parent concussion education was much more limited, with about one-third of athletes and more than half of parents not receiving any additional concussion education beyond signing the concussion information form. Football coaches were more likely than soccer coaches to give athletes a talk about concussions and provide their athletes with education via 2 modalities, but concussion education for coaches and parents did not differ significantly by sport or urban/rural locality. More than two-thirds of coaches reported access to an AT (compared with national estimates of about 40%),14 and ATs were twice as common in urban areas compared with rural areas. To our knowledge, this is the first study to examine the implementation of concussion laws and to describe the variation in concussion education for public high school coaches, athletes, and parents. Two recent studies compared the content of concussion laws across the United States,9,19 but these studies did not examine the extent to which such legislation was implemented or the concussion knowledge of coaches in the years after such implementation. One recent study by Shenouda and colleagues18 examined the effect of the Lystedt Law on concussion knowledge, but they combined responses from coaches and parents, so it was not possible to compare results. Our results suggest that concussion education requirements for coaches are being closely followed by public high schools in Washington State. This is very encouraging but is not surprising. Public schools are motivated to follow the coach education guidelines outlined in the Lystedt Law because it was written in such a way that it provides protection from litigation for these schools if it is followed correctly,
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and schools employ the coaches and thus have the ability to enforce education requirements. These schools also fall under the auspices of the WIAA and thus are motivated to adhere to guidelines that are administered by the WIAA. The Lystedt Law contains a clause that extends its purview to not only public high school athletes but also to all athletes who compete on public high school grounds. By these means, the law pertains to many private athletic organizations. Our own experience has been that most private athletic organizations are following this law, but we did not survey coaches of private schools or private athletic organizations, and this would be an interesting area for future research. It is concerning that athlete and parent education was not more extensive, but this is also within the guidelines of the law. The language of the Lystedt Law is vague in regard to educational requirements for athletes and parents, likely a necessary compromise due to the lack of funding provided to institute any such education. While educational materials are provided to the schools, there is no funding available for the inevitable costs that come from attempting to institute and enforce an educational intervention, and these costs may be more extensive when attempting to educate parents, whose schedules are more difficult to accommodate. Our hope is that further revisions of this law may include additional educational requirements for athletes and parents. This is particularly important for parents, given the pivotal role of parents in regard to sports safety. Parents of high school athletes attend their child’s games, watch their child closely during game play, and are acutely attuned to changes in their child’s behavior. Educating parents about signs and symptoms of concussions could potentially decrease the likelihood of athletes playing with concussive symptoms. We also found an interesting variation in educational modality, with a greater focus on multimodal learning for coaches than for athletes. Data regarding the ideal presentation of educational materials suggest that multimodal presentations are generally more impactful than those using a single modality,7 although the ideal modality may depend on the material to be learned. It also appears to be more difficult for learners to take in information when it is presented amidst distracting information or when too many messages are communicated, resulting in cognitive overload.20 Finally, the ideal learning environment seems to be affected by age, sex, culture of origin, and other individual factors.10 The most effective programs would likely involve multiple modalities and would focus on a few key messages but might need to be tailored to the group being educated. One of the limitations of this study is that we primarily measured concussion education and knowledge, and it is unclear whether improved concussion knowledge affects concussion safety. Two research groups have studied concussion education interventions with youth using multimedia in-person educational sessions, and both reported an improvement in concussion knowledge.2,13 However, with concussive injuries, athletes need to report concussive symptoms to be removed from play, and several recent studies have revealed significant barriers to athletes reporting concussive symptoms that are not knowledge based, such as a concern that they would be removed from game play
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or pressure from their teammates or coach.6,17 Education is an important piece of any intervention to improve concussion safety, but further research is needed to understand how education can be most effective toward preventing athletes from playing with concussive symptoms and thus improving safety. There may be certain messages that are more likely to encourage athletes to report concussive symptoms, such as focusing on short-term outcomes (concussions affect one’s ability to play well) rather than long-term outcomes (playing with a concussion can cause brain damage). Involvement of an AT is also an interesting aspect of this law. The Lystedt Law was written in such a way that ATs are capable of clearing athletes to return to play, and it is possible that schools have chosen to respond to the Lystedt Law by employing ATs. We found a higher proportion of schools in our sample had ATs than is reported for the country (more than two-thirds vs 40%, respectively),14 but unfortunately, no data are available regarding the prevalence of ATs in Washington State before the law. The presence of an AT could affect multiple areas of concussion safety, from the likelihood of concussion detection to appropriate management, and could provide opportunities for further athlete concussion education. It is unclear whether employing an AT can improve concussion safety, and it deserves further study. Our study was limited by a moderate response rate of about 50%, and it is thus difficult to know whether our sample is representative of all coaches in Washington State. However, it was a relatively large random sample (n = 270) and contained coaches from across the state. In addition, while it is encouraging that football and soccer coaches appeared to have a good fund of knowledge about concussions (this was not reported to be the case before passing the law1), it is not clear that this translates into appropriate concussion management, and further studies will be needed to ascertain the true effect of the law on concussion safety. Finally, coaches may not have been aware of all of the concussion education that occurs at their school for athletes and parents, and this may thus be an underestimate of concussion law implementation. In conclusion, public high school football and soccer coaches in Washington State (the first state to pass comprehensive concussion legislation) receive significant training on concussion management and have good concussion knowledge. However, athletes and parents receive much less concussion education. Given that concussions are difficult to diagnose and often require either athlete reports or parental concerns to come to the attention of the coach,6 educating athletes and their parents about the risks of a concussion and safe management is an essential part of preventing athletes from playing with concussive symptoms. Future studies will need to address whether changes made in response to concussion laws have altered the proportion of athletes playing with concussive symptoms.
ACKNOWLEDGMENT The authors thank the athletic staff of the participating schools, the athletes, and their parents for their
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participation in the study. They also thank the research staff of Matthew Vaughn, Katherine Lepere, Adam Strizich, Asha Thomas, Charla Jones, Denise Hopkins, Sierra Rotakhina, Melissa Rudd, Adessa Churape, Rachel Silverstein, Reba Blissell, Jennifer Maeser, and Christopher Mack for their dedication and work. REFERENCES 1. Adler RH, Herring SA. Changing the culture of concussion: education meets legislation. PM R. 2011;3(10 Suppl 2):S468-S470. 2. Bagley AF, Daneshvar DH, Schanker BD, et al. Effectiveness of the SLICE program for youth concussion education. Clin J Sport Med. 2012;22(5):385-389. 3. Broglio SP, Vagnozzi R, Sabin M, Signoretti S, Tavazzi B, Lazzarino G. Concussion occurrence and knowledge in Italian football (soccer). J Sports Sci Med. 2010;9:418-430. 4. Centers for Disease Control and Prevention. Heads up: concussion in youth sports. Available at: http://www.cdc.gov/concussion/Heads Up/online_training.html. Accessed May 8, 2013. 5. Chopp F, Owen B, Gregoire C. Youth sports: head injury policies. Engrossed House Bill 1824. Effective date: July 26, 2009. Available at: https://docs.google.com/viewer?url=http%3A%2F%2Fapps.leg. wa.gov%2Fdocuments%2Fbilldocs%2F2009-10%2FPdf%2FBills %2FHouse%2520Bills%2F1824.E.pdf. Accessed March 27, 2013. 6. Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health. 2013;52(3):330-335.e3. 7. Ginns P. Meta-analysis of the modality effect. Learning and Instruction. 2005;15(4):313-331. 8. Hailu A, VanEenwyk J. Guidelines for using rural-urban classification systems for public health assessment. Available at: https://docs.google.com/ viewer?url=http%3A%2F%2Fwww.doh.wa.gov%2FPortals%2F1%2F Documents%2F5500%2FRuralUrbGuide.pdf. Accessed June 14, 2013. 9. Harvey HH. Reducing traumatic brain injuries in youth sports: youth sports traumatic brain injury state laws. Am J Public Health. 2013;103(7):1249-1254.
10. Heffler B. Individual learning style and the learning style inventory. Educ Stud. 2001;27(3):307-316. 11. Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil. 2006;21(5):375-378. 12. McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Sci Med Sport. 2009;12(3):340-351. 13. Miyashita TL, Timpson WM, Frye MA, Gloeckner GW. The impact of an educational intervention on college athletes’ knowledge of concussions. Clin J Sport Med. 2013;23(5):349-353. 14. National Association of Athletic Trainers (NATA). Athletic trainers fill a necessary niche in secondary schools. March 12, 2009. Available at: http://www.nata.org/NR031209. Accessed July 5, 2013. 15. National Federation of State High School Associations. Concussion in sports: what you need to know. Available at: http://www.nfhs learn.com/electiveDetail.aspx?courseID=38000. Accessed May 8, 2013. 16. National Football League. The Zackery Lystedt Law. Available at: http://www.nflevolution.com/article/The-Zackery-Lystedt-Law?ref= 270. Accessed July 5, 2013. 17. Register-Mihalik JK, Linnan LA, Marshall SW, McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes’ intentions to report sport-related concussion: implications for concussion education initiatives. Brain Inj. 2013;27(7-8):878-886. 18. Shenouda C, Hendrickson P, Davenport K, Barber J, Bell KR. The effects of concussion legislation one year later: what have we learned. A descriptive pilot survey of youth soccer player associates. PM R. 2012;4(6):427-435. 19. 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;33(6):E11:1-9. 20. Van Merrie¨nboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44:85-93. 21. Washington Interscholastic Activities Association. Concussion management guidelines. Available at: http://www.wiaa.com/subcontent .aspx?SecID=623. Accessed April 19, 2013.
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