The document summarizes concussion legislation, beginning with the Zackery Lystedt Law passed in Washington in 2009. This law required immediate removal from play for suspected concussions, written clearance from a healthcare provider before return to play, and education for coaches, parents and athletes. Since then, similar laws have spread to all 50 states, though they vary in requirements. Studies show these laws have increased concussion reporting and diagnosis, though many athletes still play with symptoms. Future efforts aim to improve education, return-to-learn protocols, and limit full contact practices to further protect young athletes from concussions.

1. Concussion Legislation
Sara P.D. Chrisman, MD, MPH
Adolescent Medicine, University of Washington

2. Outline
• History
• Description
• Impact
• Future

3. Zackery Lystedt Law—2009
• Stan Herring, MD and
Richard Adler, JD
• Education was not
working—too difficult to
change the culture of
sport
• Goal: Prevent athletes
from playing with
concussive symptoms

5. Zackery Lystedt Law—2009
1. Removal from play if
suspected concussion
2. Written clearance from a
health care provider prior to
RTP
3. Education for coaches,
parents and youth

6. Zackery Lystedt Law
• Strengths
• Litigation protection
• Carried out through the Washington Interscholastic Athletic
Association (WIAA)
• Allowed ATs to clear athletes
• Limitations
• No requirements for clinician training in concussion management
• Limited education requirements for coaches, parents and youth
• Did not apply to private schools, club sports, or elementary schools
• Secondary prevention, not primary prevention

7. Spread of concussion legislation
Year State
2009 Oregon, Washington
2010 Connecticut, Idaho, Oklahoma, Rhode Island, Massachusetts,
New Mexico, New Jersey
2011 Alabama, Alaska, Arizona, District of Columbia, Iowa, Illinois, Indiana,
Kansas, Louisiana, Maryland, Missouri, Minnesota, North Carolina, North
Dakota, Nevada, South Dakota, Texas, Utah, Virginia, Vermont, Wyoming
2012 California, Colorado, Kentucky, Wisconsin, Maine, Florida, Nebraska,
New York, Pennsylvania, Hawaii, Delaware, New Hampshire
2013 Ohio, Montana, Michigan, South Carolina, Arkansas, West Virginia
2014 Georgia, Tennessee, Mississippi

8. Spread of legislation—2013
Traumaticbraininjury.net

9. Spread of legislation
• Alabama—2011, 2012
• Alaska—2011
• Arizona—2011
• Arkansas—2013
• California—2011
• Colorado—2011
• Connecticut—2010, 2014
• Delaware—2011
• Florida—2012
• Georgia—2013
• Hawaii—2012
• Idaho—2010, 2012
• Illinois—2011
• Indiana—2011, 2014
• Iowa—2011
• Kansas—2011
• Kentucky—2012
• Louisiana—2011
• Maine—2009, 2012
• Maryland—2011
• Massachusetts—2010
• Michigan—2012
• Minnesota—2011
• Mississippi—2014
• Missouri—2011
• Montana—2013
• Nebraska—2011, 2014
• Nevada—2011
• New Hampshire—2012, 2014
• New Jersey—2010
• New Mexico—2010
• New York—2011
• North Carolina—2011
• North Dakota—2011
• Ohio—2012
• Oklahoma—2010
• Oregon—2009
• Pennsylvania—2011
• Rhode Island—2010, 2011, 2014
• South Carolina—2013
• South Dakota—2011
• Tennessee—2013
• Texas—2011
• Utah—2011, 2013
• Vermont—2011, 2013
• Virginia—2010, 2014
• Washington—2009
• Washington DC—2011
• West Virginia—2013
• Wisconsin—2012
• Wyoming—2011

10. Spread of legislation—Variation
• Variation in laws
• Coach education
• Parent and athlete education
• Specific educational materials
• Removal from play criteria
• Healthcare practitioner standards
• Liability protection
• New measures being added
• Coverage below middle school
• Mandated graduated RTP (CA and NM)
• Return to learn protocol (NV, VA)
• Limit on full contact practices in FB (CA)
1. Harvey HH. Reducing traumatic brain injuries in youth sports: youth sports traumatic brain injury state laws,
January 2009-December 2012. Am J Public Health. 2013 Jul;103(7):1249-54.
2. Tomei KL, Doe C, Prestigiacomo CJ, Gandhi CD. Comparative analysis of state-level concussion legislation and
review of current practices in concussion. Neurosurg Focus. 2012 Dec;33(6):E11: 1-9.

11. Do these laws work?

12. Impact of legislation—Primary prevention
• Smoking
• Ward M1, Currie LM, Kabir Z, Clancy L. The efficacy of different models of smoke-free laws in reducing
exposure to second-hand smoke: a multi-country comparison. Health Policy. 2013 May;110(2-3):207-13.
• Seat belts
• Houston DJ1, Richardson LE Jr. Getting Americans to buckle up: the efficacy of state seat belt laws. Accid
Anal Prev. 2005 Nov;37(6):1114-20. Epub 2005 Jul 18.
• Bicycle helmets
• Macpherson A1, Spinks A. Bicycle helmet legislation for the uptake of helmet use and prevention of head
injuries. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005401.
• Child passenger restraint (car seats)
• Evans WN, Graham JD. An estimate of the lifesaving benefit of child restraint use legislation. J Health Econ.
1990 Sep;9(2):121-42.

13. Impact of legislation—Secondary prevention
• Goal: To prevent youth
from playing with
concussion symptoms

14. Impact of legislation—Education
• Methods: Randomly selected survey of coaches in WA (N=496)
• Findings:
• All but 3 coaches reported receiving concussion education, 91% via
two or more modalities
• 70% provided athlete education beyond the signed form
• FB coaches more likely than soccer coaches to talk to athletes
about concussion
• 42% provided parent education beyond the signed form
Chrisman SP1, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school
athletics. J Adolesc Health. 2013 Mar;52(3):330-335.e3.

15. Impact of legislation—Concussion diagnosis and health
care utilization
Author (Year) Population Findings Limitations
Bompadre (2014) AT high school
injury data
2x RR, N= 48 concussions
before, 114 and 111 after
Only started working in
schools 1 year before
law
Makenzie (2015) ER data 2x incidence after law No RR reported
Gibson (2015) Insurance data 92% increase in states with
laws, 75% in states without
Only insured patients

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

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

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

19. Impact of legislation—Athletes playing with symptoms
Author (Year) Population Findings Limitations
Rivara (2013) HS football and
soccer (N=778)
70% played with sxs
after law
No before data
O’Kane (2014) MS soccer (N=351) 70% played with sxs
before vs. 56% after (ns)
N=11 vs. N=48, no
power
LaRoche (2015) HS football (N=1532
vs. N=206)
47% reported before vs.
70% after
Self-report
1. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions
among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203.
2. O'Kane JW, Levy MR, Neradilek M, Polissar NL, Schiff MA. Evaluation of the Zachery Lystedt Law among female youth soccer players. Phys
Sportsmed. 2014 Sep;42(3):39-44.
3. LaRoche AA, Nelson LD, Connelly PK, Walter KD, McCrea MA. Sport-Related Concussion Reporting and State Legislative Effects. Clin J
Sport Med. 2015 Apr 17. [Epub ahead of print]

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

21. Social Ecological Model
Brofenbrenner 1970

22. Theory of Planned Behavior (arises out of the Health
belief model)
Ajzen et al 1991

23. Concussive symptom reporting and TPB
Intention
to report
symptoms
Skills and
abilities
Environment
Coach
Response
Reporting
Symptoms
Subjective norms
Attitudes
Perceived
behavioral control
Culture of
Sport
Teammates
Chrisman et al 2013

24. Prototype Willingness Model—Risk behavior is not
planned
Gibbons & Gerrard 1995

25. Our team
• Frederick P. Rivara, MD, MPH
• Ali Rowhani, MD, MPH, PhD
• Celeste Quitiquit, MD
• Stan Herring, MD
• Christine Mac Donald, PhD
• Melissa Schiff, MD, MPH
• Seth Friedman, PhD
• Jalal Andre, MD
• Monica Vavilala, MD
• Emily Kroshus, PhD
• Randal Ching, PhD
• Cari McCarty, PhD
• Christina Schwien, MPH
• Elizabeth Stein, BA
• Matthew Holm, BA
• Leah Concannon, BA
• Michelle Nemetz, BA
• Deana Rich, BA
• Sarah Dean, BA

26. Thank you!

27. Impact of legislation—Do athletes play with symptoms?
• Prospective cohort study1
• Rivara 2013, N=778 high school football and soccer players, N=83 concussions
• 69% reported playing with concussive symptoms
• Prospective cohort study, before and after (natural history)2
• O’Kane 2014, N=351 female middle school soccer players (N=11 concussions before law, N=48 after)
• No change in rate of concussions before vs. after
• No sig change in proportion play with symptoms (70% vs. 56%)
• 2x more likely to be diagnosed concussion if seen by provider
• Cross sectional survey, before and after (natural history)3
• La Roche 2015, N=1532 vs. N=206 (before and after law) high school football players
• No change in proportion sustaining concussion season before (15% vs. 17%)
• 47% reported before vs. 71% after. (p=0.011)
1. Rivara FP, Schiff MA, Chrisman SP, Chung SK, Ellenbogen RG, Herring SA. The effect of coach education on reporting of concussions
among high school athletes after passage of a concussion law. Am J Sports Med. 2014 May;42(5):1197-203.
2. O'Kane JW, Levy MR, Neradilek M, Polissar NL, Schiff MA. Evaluation of the Zachery Lystedt Law among female youth soccer players. Phys
Sportsmed. 2014 Sep;42(3):39-44.
3. LaRoche AA, Nelson LD, Connelly PK, Walter KD, McCrea MA. Sport-Related Concussion Reporting and State Legislative Effects. Clin J
Sport Med. 2015 Apr 17. [Epub ahead of print]

28. SPORT CONCUSSION
SUMMIT
September 24, 2015#uminjuryctr