A Massachusetts law passed in 2010 with the goal of reducing concussions in student athletes has seen some success, but many school systems still have not complied with reporting requirements and there are scant enforcement options for state health officials to make them comply.
Moreover, a study published in The Journal of Pediatrics this month found that the law needs to be reworked to require better training for students, parents and physicians.
The law was drafted to help prevent, recognize and manage treatment of head injuries in student athletes.
"I think the law is working... It's a good start. Physicians support it. But we have to be careful that we're including training that we know works and not have them train on outdated training mechanisms," said Dr. Michael R. Flaherty, a pediatric critical care physician at Massachusetts General Hospital in Boston and one of the authors of the article in the international medical journal.
The survey was taken in December 2014 by 173 primary care physicians statewide who are within the Partners Community Health Group, owned by Massachusetts General Hospital and Brigham and Women's Hospital. The results were analyzed throughout 2015.
The state's concussion law requires physicians and others who provide the required medical clearance for a concussed athlete to return to activities to verify receipt of training in post-traumatic head injury approved by the state Department of Public Health or the Centers for Disease Control and Prevention, or such training as part of their licensure or continuing education. The training is only required once.
But more than 20 percent of the physicians said they had not taken the mandatory training by three years after implementation of the law. Authors of the study concluded that "broader and more frequent training may be necessary to align current best evidence with clinical care and state-mandated practice."
Dr. Flaherty said with concussion research constantly evolving, not only should doctors be required to do more frequent training, but the state needs to make sure the training is updated regularly.
Physicians in the study cited inadequate training they received as well as the lack of knowledge parents and students have about concussions as main barriers for caring for concussed children. Several doctors said they were pressured by parents to return their child to sports.
"What we're doing to train our children and parents could be better," said Dr. Flaherty.
Omar Cabrera, a DPH spokesman, said the agency recently sent letters to more than 4,000 pediatricians and emergency room doctors reminding them of the training requirements. In addition, DPH is planning more online training for physicians and clinicians in the coming year.
Since 2009, after research on the brains of deceased professional football players revealed the severity of repeated concussions, including leading to chronic traumatic encephalopathy, a degenerative brain disease, all 50 states and the District of Columbia have implemented laws to educate players, parents, coaches, physicians and others about head injuries
Massachusetts in 2010 became the seventh state to pass a law, after a 2009 health survey indicated that 19 percent of high school students and 18 percent of middle school students who responded said they had experienced concussion symptoms in the previous 12 months.
The law directed the state Department of Health to create regulations that became effective June 2011. They require public and private schools that have Grades 6-12 extracurricular sports subject to the rules of the Massachusetts Interscholastic Athletic Association to develop 17-component policies governing the prevention and management of sports-related head injuries.
The policies, among other things, require that before the start of every season each prospective student-athlete, cheerleader and band member and their parents confirm in writing that they have completed online head injury awareness training. In addition, school nurses, coaches, athletic directors and trainers, and game officials must also complete annual training.
School districts have also been slow to comply with the law.
Most of the estimated 700-plus school districts that the regulations may apply to did not submit any of the required data to DPH the first year, the 2011-2012 school year.
The annual data, which includes the number of concussions sustained by student athletes, is due at the end of each school year. But DPH is still trying to collect the required information for the 2015-2016 school year. In a recent interview Linda Brown, program coordinator of sports-concussion activities for DPH, said 450 reports had been received.
"When schools don't comply, the regulations don't state how we can get them to comply, other than to continue to chase after them," she said.
The only sanctions or penalties for noncompliance are what the districts can impose on themselves. Those include, but are not limited to, personnel suspension and forfeiture of games.
Ms. Brown said the incentive for compliance is that it's the law and schools want to keep youth safe. DPH, she said, collects the year-end reports to monitor compliance. But it is also a vehicle to have a collaborative relationship with schools and provide them with technical assistance to help them comply.
"It's a relatively new program. We are participating in a culture change that's been going on for only five years. It takes time to raise awareness and change habits," she said.
Most of the schools or districts contacted for this article, including Gardner, Grafton, Millbury, Leominster and Shepherd Hill Regional High School in Dudley - did not provide data about the number of student-athlete concussions for 2011 through the spring of 2016.
Kathleen M. Pepin, head nurse for Bartlett Junior Senior High School in Webster, said via email the district does not have any compiled data prior to the 2014 school year. She said in 2014-2015, there were two sports-related concussions. The number of sports-related concussion increased to six in 2015-2016, she said.
The increase follows a trend found in a nationwide study Blue Cross Blue Shield released in September. It shows a 71 percent increase in concussions diagnosis for youths 10 through 19 between 2010 and 2015.
Massachusetts had the highest rate, 82 percent. Both BCBS and DPH said the increased number in concussions is because of more awareness and changing attitudes on head injuries.
On the other hand, Shrewsbury, one of the districts that has more closely complied with the state regulation, has seen its sports-related concussions at the high school decrease from 52 in the first year of the law to 28 last school year. In addition to the 28 school sports-related head injuries, 66 students districtwide reported concussions sustained outside of school, including from falls at home and auto accidents.
Noelle Freeman, Shrewsbury's director of nursing, attributes the reduction to increased awareness and the work of the district's licensed athletic trainer.
"That probably has had an effect on our numbers. Time will tell moving forward," she said.
Dr. John Stevenson, director of Sports Medicine/Family Medicine at UMass Memorial Medical Center in Worcester and physician for several high school and college sports teams, said Massachusetts should require school districts to have licensed athletic trainers on staff. Athletic trainers specialize in prevention, diagnosis and management of head injuries. It's a requirement in many states that have the so-called "shake-it-off" or "return-to-play" laws.
Richard L. Pearson, associate director of MIAA, estimates that because of the cost, only about 30 percent of districts have licensed athletic trainers. According to the Athletic Trainers of Massachusetts, the average salary of a high school licensed athletic trainer is about $57,600.
Often it's the school districts that can't afford them that need them the most, Dr. Stevenson said, because of populations with language barriers and challenging home lives where accessing health care is more difficult.
Worcester Public Schools, which has more than 2,000 middle and high school athletes, does not employ licensed athletic trainers on a regular basis. Superintendent Maureen Binienda said the district cannot afford the cost.
Debra McGovern, coordinator of nursing services of WPS, said when she and the district's athletic director, David Shea, gave a presentation on how they are implementing the guidelines at a state school nurse leadership quarterly meeting last year, the key thing that people noticed was that WPS do not have licensed athletic trainers.
After doing some research, she recommended that the district hire trainers. She said the law requires students' physicians to provide the schools with data regarding a follow-up action plan for a concussed student and what steps the student should follow in order to safely return to sports and other activities. But that does not always happen, she said. The Journal of Pediatrics article said that "physicians reported limited communication with schools." It also said that training was significantly associated with better compliance with developing individualized treatment plans" for concussed student athletes.
"If we had an athletic trainer there would be much better control over this to minimize some of these long-range concerns about brain injuries," she said.
Dominique M. Ross, president of Athletic Trainers of Massachusetts, said without an athletic trainer or medical personnel on site, concussions or other injuries may be missed. If a concussed athlete returns to play when they shouldn't, they could sustain further and more serious injury, she said.
"Having athletic trainers accessible to all athletes is critical. Although there's a higher prevalence of serious injuries in contact sports, it doesn't mean concussions don't happen in other sports. They should receive the same high level of care," Ms. Ross said.
MIAA requires medical personnel in attendance only for football and ice hockey games during the regular season. Medical coverage for baseball, basketball, field hockey, lacrosse, soccer, softball and volleyball is only required during tournaments at the end of the season.
Even though concussion laws nationwide require students with symptoms of concussions to be removed from play for at least 24 hours, 38 percent of student athletes who sustain a concussion continue to play, according to a study that the American Academy of Pediatrics presented at its national conference Oct. 22.
Meagan Sabatino, senior clinical research coordinator at Texas Scottish Rite Hospital for Children in Plano, Texas, where the study was done, said it is being expanded to try to determine if having licensed athletic trainers and other trained professionals on the sidelines will have an impact on the number of concussed students continuing to play.
Ryan L. Farrell, a 2009 Hopedale High School graduate who suffered a traumatic brain injury during a cheerleading event in her freshman year in college, said hiring licensed athletic trainers would be money well spent.
"If these schools are gong to pride themselves on their athletic teams, the safety of their student-athletes should be above everything … above winning games … a state championship title," she said.
Ms. Farrell said she did not suffer any head injuries when she played soccer at Hopedale High. She was on the school's 2005 Cinderella State Championship team. In 2010, while a freshman at Marist College in New York she was part of the base of a stunt the cheerleaders were doing. Something went wrong and a cheerleader at the top of the formation fell and landed on her, causing her to suffer a TBI. As a result, she can't remember the accident or the month leading up to it, but she was told that she laid on the mat, crying in obvious pain.
"They told me the coach told me to get back up and stop making such a scene," said Ms. Farrell. "I did what I was instructed to do and went back in. A short time later, I collapsed."
Marist, at the time, she said, did not have any licensed athletic trainers who could have quickly determined that she was severely injured and needed immediate medical attention.
"There's no way of knowing what would have happened if I had been given proper medical attention. I probably still would have suffered a traumatic brain injury, a collapsed lung and fractured vertebrae in my neck. But, we do not believe it would have been a severe, life-threatening, nearly life-ending traumatic brain injury," she said.
A year after the accident, Ms. Farrell returned to Marist and graduated in 2014 with a BA in communication with a concentration in radio, TV and film. She continues to recover and she has not landed a job yet, but she volunteers with the Westboro-based Massachusetts Brain Injury Association, speaking to high school students, coaches and parents about her experience.
"I tell them when in doubt to sit it out," she said. "You only get one brain. And it's up to you to take care of that brain. You do not get a do-over."
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