The Impact of Litigation, Regulation, and Legislation on Sport Concussion Management

Submitted by Mr. Gregory B. Bonds1*, William W. Edwards2 PhD*, Brandon D. Spradley3 EdD*, Theodore Phillips4 PhD*

1* Associate Athletic Director for Internal Affairs at Jacksonville State University, Jacksonville Alabama

2* Chair of Sports & Exercise Science at the United States Sports Academy , Daphne Alabama

3* Director of Continuing Education & Executive Director of the Alumni Association, United States Sports Academy, Daphne Alabama

4* Former faculty member of the United States Sports Academy, Daphne Alabama

Mr. Gregory Bonds is the Associate Athletic Director for Internal Affairs at Jacksonville State University and a doctoral student at the United States Sports Academy.

ABSTRACT

Concussion injuries impact approximately 1.7 million Americans annually.  By design, sports such as football, ice hockey, and soccer demand physical contact often resulting in powerful blows to the head.  The impact on concussion management affects participant safety, well-being, and awareness of diagnosis, treatment, playing rules, equipment, education, and technology.  Previous research states that participating high school athletes suffer over 100,000 concussions annually.  In 2009, a study sponsored by the National Football League (NFL) announced that retired players between the ages of 30 and 49 were affected by dementia-type diagnosis 20 times greater than fellow citizens in the same age bracket.  Furthermore, retired players above the age of 50 were affected by dementia-type diagnosis at a rate five times higher than the national average of 1.2%. The culmination of concussion injuries from youth sports to retired professional athletes has accelerated unprecedented litigation, regulation, and legislative activities.  The heightened awareness on the dangers and consequences of concussion trauma has caused sports governing bodies, state legislatures, and federal congressional intervention to enact regulation and legislation to promote the safety of sports participants.  Based on recent legal activity to implement concussion and return-to-play guidelines, sports concussion awareness has risen to national attention.  Lawsuits may be counterproductive if mounting litigation, legal and liability costs outpace protective regulation and equipment able to withstand powerful force application.  The purpose is to review and analyze the impact of litigation, regulation, and legislation on sport concussion management.

Keywords: sport  management, concussion, impact sports, concussion prevention

INTRODUCTION

The recent barrage of concussion litigation, regulation, and legislation threatens the traditional splendor of sports for participants and fans.  By design, sports such as football, ice hockey, and soccer demand physical contact often resulting in powerful blows to the head.  The impact on concussion management affects participant safety, well-being, and awareness of diagnosis, treatment, playing rules, equipment, education, and technology.

Background

Concussion injuries impact approximately 1.7 million Americans annually (Faul, Xu, Wald, & Coronado, 2010).  Previous research states that participating high school athletes suffer over 100,000 concussions annually.  Unfortunately, this figure may be underestimated due to unreported injuries by participants to sports medicine providers (Gessel, Fields, Collins, Dick, & Comstock, 2007).  Intercollegiate sports participants with a positive concussion history are three times more likely to suffer a second or third concussion, which significantly slows neurological recuperation (Guskiewics et al., 2003).  In 2009, a study sponsored by the National Football League (NFL) announced that retired players between the ages of 30 and 49 were affected by dementia-type diagnosis 20 times greater than fellow citizens in the same age bracket.  Furthermore, retired players above the age of 50 were affected by dementia-type diagnosis at a rate five times higher than the national average of 1.2% (Weir, Jackson, & Sonnega, 2009).

Historically, the protocol for rehabilitation from concussion injuries has been variable.  The culmination of concussion injuries from youth sports to retired professional athletes has accelerated unprecedented litigation, regulation, and legislative activities.  The heightened awareness on the dangers and consequences of concussion trauma has caused sports governing bodies, state legislatures, and federal congressional intervention to enact regulation and legislation to promote the safety of sports participants.  Orthopedic rehabilitation of the knee, ankle, elbow, wrist, and shoulder require evaluation, surveillance, treatment, and time away from practice and competition.

Purpose

The purpose is to review the impact of litigation, regulation, and legislation on concussion management.  Based on recent legal activity to implement concussion and return-to-play guidelines, sports concussion awareness has risen to national attention.  In May 2009, the state of Washington became the first state to formally adopt youth sports concussion legislation with the Zackery Lystedt Law (Zackery Lystedt Law, 2009).  The Ivy League (Ivy League, 2011) and the Pacific 12 (Pacific 12 Conference, 2014) became the first National Collegiate Athletic Association (NCAA) conferences to restrict football contact during spring practices and the regular season.  In June 2012, concussion class-action and personal lawsuits from former NFL players against the NFL were combined into one lawsuit entitled In Re National Football League Players’ Concussion Injury Litigation (In Re National,2012).  Sports participants, parents, coaches, administrators, and sports medicine professionals are more knowledgeable on the risks of participation, rigorous return-to-play protocols following a concussion, and the long-term neurocognitive consequences of concussion trauma.

REVIEW OF LITERATURE

Federal Litigation

The unfortunate suicides of former NFL players Junior Seau, Dave Duerson, and Ray Easterling draw attention to the destructive long-term effects of concussions.  Subsequent class-action and personal lawsuits opposing the NFL resulted in the merger of multiple concussion cases permissible under 28 U.S.C. § 1407.  The United States District Court for the Eastern District of Pennsylvania was designated as the location for Judge Anita B. Brody to preside over the merged concussion cases.  Judge Brody was selected primarily based on past assignments with six related cases.  On June 7, 2012, a total of 81 concussion lawsuits connecting 2,200 former players were combined into one lawsuit titled In Re National Football League Players’ Concussion Injury Litigation (In Re National, 2012).

A primary complaint of former players was that the NFL withheld evidence connecting concussions and brain damage, did not notify the players, nor applied playing rules to further protect the players.  Additionally, the players accused the NFL of dishonesty for appointing a Mild Traumatic Brain Injury Committee to study the impact of concussions and not sharing the results with the players.  The NFL denied the accusations.  As a defensive legal strategy, the NFL responded with the statutory precedent known as Section 301 of the Labor Management Relations Act (LMRA).  Specifically, Section 301 grants federal law to exercise authority over state-law petitions relative to collective bargaining agreements.  As a result, the NFL would probably withstand any legal challenges from the NFL Players Association (NFLPA) in a court of law.  However, collective bargaining agreements between the NFL and the NFLPA have traditionally contained definitive provisions to address player health and safety concerns and include grievance procedures for disagreements.  Team physicians and certified athletic trainers are employed by NFL franchises to administer the assessment, diagnosis, treatment, recovery, physical condition, and hospital health care needs of the players (In Re National, 2012).

Based on precedent, the complex federal labor laws continue to favor the NFL.  However, former players affected by concussions continue to suffer from debilitating brain injuries and illnesses, with current players risking a similar fate.  With legal precedent supporting the NFL, balancing the duty of care obligations of the NFL with the NFL players necessitates a bilateral solution.  Foreseeing the complexities of this concussion lawsuit, Judge Brody endorsed the idea for a negotiated settlement between the NFL and the former players. On July 8, 2013, Judge Brody ordered the two sides to mediation with court-appointed mediator Layn Phillips (In Re National, 2014).

On August 29, 2013, mediator Layn Phillips publicized that the NFL and more than 4,500 former players had reached a $765 million settlement agreement (pending court approval) for medical benefits, injury costs, research, and legal costs.  Retired players diagnosed with a cognitive injury by an appropriate physician would be eligible to receive financial assistance.  Reactions regarding the settlement proposal received mixed reviews from legal scholars and former players, with legal scholars tending to side with the NFL.  With annual revenue estimated at $10 billion per year, former players received instant medical attention.  Former players would receive immediate medical assistance by avoiding lengthy court proceedings, and risk losing due to statutory precedent of Section 301 of the LMRA (In Re NFL, 2014).

Procedurally, Judge Brody must consider and determine the settlement proposal and financial data in the approval process.  Additional hearings will determine initial and final approvals of settlement.  In January 2014, Judge Brody denied preliminary approval of the settlement proposal because of concern that $765 million may not be enough to cover the medical expenses of the former players.  Additional financial data was requested to support arguments that the settlement proposal is substantial for all medical costs (In Re NFL,2014).

On Monday, July 7, 2014, Judge Brody gave initial approval to recompense over 4,500 former NFL players for concussion-related assertions after the NFL consented to eliminate the restriction on damages.  Judge Brody stated the benefits of settlement were more desirable versus years of continued expensive litigation while the mental and physical health of retired players deteriorated.  The settlement is to continue for at least 65 years and protect retirees who may become stricken with amyotrophic lateral sclerosis (ALS) or other neurological infirmities.  Even though the overall settlement cap was removed, an individualized disbursement formula remained based on age and affliction (In Re National, 2014).

In this case, the impact of litigation and settlement appears to be a successful triumph for both the NFL and the former players.  The NFL can move forward and away from the negative limelight, legal expenses, and admissions of liability.  The former players can avoid the uncertainty of lengthy litigation and focus on receiving medical attention.  Judge Brody deserves credit for completing a settlement in this complex case.  Avoiding prolonged litigation was in the best interest of the plaintiff and defendant, eliminating the financial cap, while promoting the medical funding for the former players (In Re National, 2014).

Helmet Manufacturer Litigation

Intertwined but separate in the NFL concussion lawsuit is the litigation involving the NFL and the helmet manufacturer Riddell.  Since 1989, Riddell has been considered the endorsed helmet of the NFL and has become a primary litigation target.  This lawsuit persists with a court mandated gag order precluding remarks from legal representatives associated with the case.  Maxwell v. National Football League (C.A. No. 2:11-08394) was the first lawsuit recorded against the NFL and Riddell connected with concussions.  In 2011, Vernon Maxwell led 75 plaintiffs in a lawsuit charging the NFL and Riddell of knowing the dangers of concussion injuries and withholding that risk information from the players. The grievance declared that multiple concussions produced Chronic Traumatic Encephalopathy (CTE) and caused premature death of former players.  Additionally, this lawsuit declares that Dr. Bennet Omalu detected CTE in the brain of former NFL player Mike Webster during an autopsy in 2002.

The NFL Committee on Mild Traumatic Brain Injury (MTBI) claimed no confirmation of the long-term effects of compounding concussions, with the NFL admission in 2010 that concussions may contribute to dementia, loss of memory, CTE, and other neurocognitive injuries.  This case was initially filed in the state court of California and was eventually combined to multidistrict litigation (MDL) in the Eastern District of Pennsylvania assigned to Judge Anita Brody.  The MDL setting would provide opportunities for the legal representatives to collect information and try to find concussion answers to what the NFL and Riddell may have known about former and current players.  The lawsuit declared that the NFL knew of the detriment of concussion injuries as far back to the 1920s, but hid the information until 2010 (In Re National, 2012).

The plaintiffs argued that the AF2 and the VSR4 helmets were lined without adequate padding to safeguard against concussion injuries.  As a result, the helmets should have been declared substandard and hazardous to give protection against the risks of traumatic brain injuries.  In testimony before Congress on January 4, 2012, P. David Halstead, a former employee of the NFL, NFLPA and helmet manufacturers, stated that additional padding in the Revolution helmet would be inadequate.  Furthermore, the plaintiffs’ asserted that Riddell had the means and technological capability to produce a safer helmet.  The former players declare that Riddell disregarded 18 years of research on the short-term and long-term dangers of concussion injuries until 2002.  A warning label was subsequently affixed to the player helmets.  The former players rebuked Riddell for failing to include adequate concussion warnings on this label.  The accusations of negligence and failure to warn on the part of Riddell remained.  Riddell was accused of knowing the dangers of concussion injuries but failed to warn the players.  Negligence was also implicated in the areas of testing, assembly, construction, and marketing of helmets and in the lack of success in the reduction of traumatic brain injuries.  Further scrutiny existed in 2002 when the Riddell Revolution helmets were supplied with the Head Impact Telemetry System to observe the severity of a hit and the number of head contacts.  The helmet was also marketed to the public as a means to reduce concussion injuries by 31% (In Re National, 2012).

Subsequent research by Rowson et al. (2014) found that distinctions exist in the capacity to lessen concussion risk between football helmet models.  Helmet design types seek to increase safety, while evidence from this study supports the possibility for a decrease in the number of concussion injuries.  From 2005 to 2010, Rowson et al. (2014) studied concussion data for 1,833 intercollegiate football student-athletes at Virginia Tech, University of North Carolina, University of Oklahoma, Dartmouth College, Brown University, University of Minnesota, Indiana University, and University of Illinois.  The student-athletes were assigned Riddell VSR4 or Riddell Revolution helmets equipped with accelerometers to record real-time impact force at all practices and games.  Every concussion was diagnosed by a certified athletic trainer or team doctor at each respective college or university (Rowson et al., 2014).

The Rowson et al. (2014) study exhibits that helmet design and models can make a difference to decrease the risk of concussions in the sport of football.  The data revealed that 64 concussions were confirmed out of 1,281,444 documented contacts to the head.  The breakdown included 27 concussions from 322,725 head contacts for the Riddell VSR4 helmet and 37 concussions from 958,719 head contacts for the Riddell Revolution helmet.  Participants wearing the Riddell VSR4 helmet suffered 8.37 concussions per 100,000 head impacts and participants wearing the Riddell Revolution helmet suffered 3.86 concussions per 100,000 head impacts.  The threat of enduring a concussion with the Riddell Revolution helmet contrasted with the Riddell VSRF helmet was 46.1% (95% CI 28.1% – 75.8%).  The findings also show that a considerable disparity exists between concussion rates for participants in the Riddell VSR4 and Revolution helmets (χ² = 4.68, p = .0305).  Furthermore, as a retrospective analysis of accessible data, concussion diagnosis could not be subjective toward a particular helmet brand (Rowson et al., 2014).

Additional litigation against Riddell included the April 2013 case involving Rhett Ridolfi.  Ridolfi was awarded $11.5 million in damages after enduring a concussion during practice in 2008 that contributed to critical brain damage and paralysis of the left side of the body.  Ridolfi was permitted to return to practice after complaining of a headache.  Later in practice, Ridolfi collapsed and was transported to the hospital.  Emergency surgery was performed to ease swelling and bleeding of the brain.  The jury declared a guilty verdict against Riddell for being negligent in failure to warn, and declared Riddell responsible for $3.1 million of the damages.  Interestingly, the jury did not accept the accusation of design flaws against Riddell.  Following the verdict, Riddell upheld the commitment to provide safe protective football headwear for participants (Belson, 2013).

Another class-action concussion lawsuit against the NCAA was registered by former collegiate student-athletes John DuRocher and Daren Harris.  Riddell and holding company, Easton-Bell Sports, are also identified in the lawsuit.  Similar to the previous lawsuits, the former players alleged that the NCAA was aware of the risks linked to concussion injuries but withheld the information from the players.  Riddell is implicated in this lawsuit due to the allegation of using blemished NFL research to design and market a helmet that would diminish concussions in youth sports.  An investigation by the Federal Trade Commission ruled that the Riddell declaration was untrue.  Lawyers for the NCAA assert that the allegations in this lawsuit mirror the vernacular and issues to previously filed class action lawsuits (Axon, 2013).

Associational Legislation

On September 12, 2011, former Eastern Illinois University (EIU) football player Adrian Arrington filed a class action lawsuit against the NCAA.  During his playing career, Arrington experienced multiple concussions.  After each occurrence, the EIU team physician cleared Arrington to return to play the next day.  Sports medicine professionals at EIU arranged an appointment for Arrington to meet with a neurologist after Arrington began to suffer memory loss and seizures following the third concussion.  Arrington professed he was never instructed on safe tackling techniques by coaches or provided literature or presentations about the dangers of concussions or head-injury prevention.  Subsequently, Arrington endured two more concussions and stopped playing football to focus on completing his degree requirements.  Unfortunately, Arrington had to withdraw from several classes due to memory loss, depression, and migraines because of the lasting effects of head injuries (Arrington v. NCAA, 2011).

In this complaint, Arrington claimed negligence and inaction by the NCAA relative to concussion injuries.  Additional claims were the NCAA failed to promote proper tackling techniques, failed to implement return to play protocols for student-athletes who had suffered concussion injuries, failed to apply association-wide guiding principles for baseline screening and recognition of head injuries, failed to apply legislation directed at rehabilitation and eligibility of student-athletes who suffered numerous concussions while participating, and failed to employ a long-term assistance program for injured players (Arrington v. NCAA, 2011). Consequently, this class action lawsuit sought medical oversight and monetary assistance for long-term and lasting injuries, economic loss, expenditures, and imperceptible misfortune by the NCAA’s haphazardness, negligence and hiding of facts (Arrington v. NCAA, 2011).

In September 2013, the plaintiff and defendants in the Arrington lawsuit were directed to begin mediation in November 2013.  Layn Phillips, previously a federal judge who officiated the $765 million settlement between the NFL and former players, was assigned to administer the NCAA case.  Similar to In Re National Football League Players’ Concussion Injury Litigation (In Re National, 2014), the Judicial Panel on Multidistrict Litigation (MDL) held hearings in Las Vegas, Nevada on December 5, 2013.  This panel made the decision to merge nine ongoing concussion-related lawsuits with the Arrington case to a federal court in the Northern District of Illinois (Arrington v. NCAA, 2011).

At a subsequent hearing in February 2014, NCAA lawyers sought peace from 10 class-action concussion lawsuits and stated the desire to attain a far-reaching settlement encompassing intercollegiate student-athletes from every sport, era, and states.  Elizabeth Fegan, an attorney representing Arrington, reported progress between the plaintiff, defendant, and Judge Phillips.  Successful mediation between the NCAA and the plaintiffs would provide a meaningful breakthrough for all student-athletes regarding medical observation and care (Arrington v. NCAA, 2011).

In response to the Arrington case, the NCAA Board of Directors voted on August 12, 2012 to require all active member institutions to implement a concussion management plan for NCAA student-athletes.  Components of the concussion management plan include a yearly course of action which makes certain that student-athletes are educated about the signs and symptoms of concussions.  Student-athletes must validate obtaining documentation regarding the signs and symptoms of concussions and have a duty to report concussion-related signs, symptoms, injuries, and ailment to the sports medicine personnel or medical staff.  Additionally, procedures must be in place which certifies that a student-athlete displaying signs, symptoms, or actions of a concussion to be withdrawn from strength and conditioning workouts, practice or competition and receive a medical evaluation by a sports medicine professional.  Furthermore, policies must exist which prohibits a concussed student-athlete from returning to strength and conditioning workouts, practice, or competition for at least the rest of that calendar day.  Finally, policies must exist which mandate medical clearance for a student-athlete diagnosed with a concussion to return to play to be determined by a physician (NCAA Bylaw 3.2.4.18, 2014-15 NCAA Manual).  On July 29, 2014, a proposed $75 million settlement was reached.  Among the provisions of the settlement is the mandate for NCAA member institutions to implement return to play protocols, preseason baseline concussion testing for all athletes, presence of medical personnel at all games involving contact sports, reporting concussions, and rules education for faculty members (Arrington v. NCAA, 2011).

In an effort to curtail the incidence and subconcussive head contact in the sport of football, The Ivy League (The Ivy League, 2011)  and the Pacific 12 Conference (Pac-12 Conference, 2013) adopted regulation limiting contact during practices.  The regulations established by The Ivy League in 2011 include a restriction to the number of practices in which contact can occur and full-pad gear worn during the football season.  During preseason practice, full pads can be worn only once when two practices occur during a day.  During the regular season, no more than two full-contact days may occur.  Further recommendations also include an educational component addressing appropriate tackling techniques, signs and symptoms of concussions, and the possible short-term and long-term effects of recurring head trauma.

Finally, The Ivy League will emphasize and conduct a rigid post-game review of helmet-to-helmet contact and targeting.  Targeting an opposing player is a serious offense and can result in critical injuries, especially to a defenseless competitor.  Rule 9-1-3 from the NCAA Football 2013 and 2014 Rules and Interpretations rule book states “no player shall target and initiate contact against an opponent with the crown of his helmet” (NCAA, 2013).  Furthermore, NCAA targeting rule 9-1-4 states that “no player shall target and initiate contact to the head or neck area of a defenseless opponent with the helmet, forearm, hand, fist, elbow, or shoulder” (NCAA, 2013).

Similar to The Ivy League, the Pacific 12 Conference passed regulations in 2013 limiting institutions to two full-contact practices each week during the regular season.  During preseason practice, in which two practices occur, institutions are limited to one full-contact practice.  During spring practice, of the eight permissible full-contact practices, only two of the full-contact practices may occur each week (Pacific 12 Conference, 2013).  In June 2014, the Pacific 12 Conference created the Pac-12 Head Trauma Force.  The purpose of this working group is to assess data from the conference football contact reduction policy initiative, move forward on a comprehensive conference concussion management policy, and research projects for conference sponsored sports other than football (Pacific 12 Conference, 2014)..

The NCAA Sport Science Institute (SSI) released new guidelines on July 7, 2014 to enhance the safety and protection for intercollegiate student-athletes.  The guidelines were the result of six months of collaboration between the NCAA, the College Athletic Trainers’ Society, intercollegiate football coaches, administrators, conference commissioners, and medical organizations.  Declared publicly as inter-association guidelines, the three components include independent medical attention for participants, diagnosis and administration of sport-related concussion, and limited football practice contact throughout the year.  Although these inter-association guidelines are not currently mandated by the NCAA, the consensus follows The Ivy League and Pacific 12 Conference by limiting the maximum number of regular season full contact practices to two per week.  Preseason practice is limited to one practice of contact on days when two practices are conducted.  Spring practice should only have eight practices, of the permissible 15, that includes live contact and still be limited to two per week and not on consecutive days.

The independent medical attention for participants calls for the assignment of a physician as the medical director and oversee the actions of the sports medicine personnel.  The medical director should have the safety and well-being of the student-athlete first and foremost, and have full control of medical administration and return to play decisions.  NCAA member schools should also display concussion management plans in prominent locations such as brochures and websites.  Return to play protocols should prohibit participation for the remainder of the day in which a suspected concussion occurs and gradual return to play physical activities supervised by a team physician (Burnsed, 2014).  The concussion management initiatives and regulations championed by The Ivy League, Pacific 12 Conference, and the NCAA is validation that the safety and well-being of student-athletes is genuine.  The relentless pursuit to prevent, protect, and treat intercollegiate participants from concussion injuries will resonate from youth sports participants through the professional ranks.

State Legislation

Washington became the first state to formally adopt youth sport concussion legislation with the Zackery Lystedt Law in May 2009.  Zackery sustained a catastrophic brain injury playing football in 2006.  The severity of the injury resulted in staying on life support for seven days, loss of speech for nine months, minimal arm movement after 13 months, two years of a feeding tube, and minimal leg movement after four years (Zackery Lystedt Law, 2009).  This law was spearheaded by Representative Jay Rodney, parents Victor and Mercedes Lystedt,  the Brain Injury Alliance of Washington (BIAWA), with the support of the Center for Disease Control and Prevention (CDCP), the Seattle Seahawks, the Washington Interscholastic Activities Association (WIAA), the Washington State Youth Soccer Association, the Washington State Athletic Trainers Association, Cannfield & Associates Risk Managers, Harborview Medical Center, the University of Washington, and the Seattle Children’s Hospital (Zackery Lystedt Law, 2009).

The purpose of the Zackery Lystedt Law was to mandate that coaches, parents, and youth participants are trained about concussions and complete a concussion and head injury information form before beginning practice or competition.  Furthermore, the law states that all youth participants playing in public facilities and exhibiting concussion symptoms to be escorted from the field, and forbidden to return to play until the injured player is medically cleared to participate by a medical professional (Zackery Lystedt Law, 2009).

In 2011, the state of Texas adopted concussion management legislation known as Natasha’s Law.  This law is named on behalf of Natasha Helmick for her spirit and gallantry to help ratify this legislation to promote the prevention, treatment, and administration of concussions throughout public school interscholastic sports.  Main features of Natasha’s Law are the requirement for school districts to assign a concussion management panel and develop return to play procedures.  The concussion management panel must be comprised of at least one physician and at least one certified athletic trainer, advanced practice nurse, neuropsychologist, or physician assistant.  Members of this panel are required to receive training in the evaluation, treatment, and management of concussions (Natasha’s Law, 2011).

Removal from play and return to play protocols are important components of Natasha’s Law.  Sports participants must annually sign documentation with parents or legal guardian verifying that they received and read safety principles detailing concussion prevention, signs and symptoms, treatment, and management.  Sports participants are mandated to leave practice or competition if a coaching staff member, physician, licensed health care professional, or parent suspects a concussion may have occurred.  Sports participants are not allowed to return to practice or competition until evaluated by a physician, a parent, or legal guardian authorized to make medical decisions.  The established necessities outlined in the return to play procedures include written permission received from the attending physician with concession by the parents or legal guardians of their son or daughter meeting the return to play protocols.  Training is another important component of Natasha’s Law.  Coaches, licensed health care professionals, and physicians must complete training courses every two years (Natasha’s Law, 2011).  The successful passage of the Zackery Lystedt Law and Natasha’s Law created momentum for other states to follow the lead of Washington and Texas.  As of April 2014, all 50 states and the District of Columbia have followed suit by enacting concussion safety laws (National Conference of State Legislatures, 2014)

In September and October 2010, Shenouda, Hendrickson, Davenport, Barber, and Bell (2012) attempted to measure the awareness level of youth soccer parents, coaches, and officials on concussions and return-to-play principles, described in the Lysted Law in Washington State.  Surveys were disseminated through the monthly youth soccer association newsletter.  Links accessing the survey were also made available by the use of social media on the Washington Youth Soccer Facebook and Twitter outlets.  The response to the survey included 391 adults.  The breakdown included 63% parents, 20% coaches, and 17% noncoaching personnel such as officers, officials, or volunteers.  Overall, 96% recognized that concussions were associated with traumatic brain injury, 93% categorized concussions as serious, and 93% were aware that losing consciousness was not common.  Furthermore, 98% associated neurological distress with concussion injuries, 90% elected to postpone returning to play if concussions signs and symptoms existed, 85% were familiar with the Lystedt Law, but only 73% realized that participants must receive written authorization before returning to play.

Ultimately, 88% of the respondents knew that a parent or legal guardian was prohibited to authorize an injured participant to return to play if a qualified professional was unavailable.  Respondents to the survey were unsure of the Washington Youth Soccer’s rules for submitting return to play medical consent approvals to appropriate leadership (Shenouda et al., 2012).  The results of this survey indicate that parents, coaches, and officials in the Washington Youth Soccer leagues possess much knowledge in the Lystedt Law and the dangers of concussion injuries. Additional areas for research and review will add to the knowledge and application of reducing concussion injuries in youth soccer (Shenouda et al., 2012).

Federal Legislation

The United States Congress has been an advocate for former NFL players by conducting hearings concerning the impact of concussion injuries.  Led by House Judiciary Committee Chairman John Conyers, committee members heard testimony from NFL Commissioner Roger Goodell, medical professionals, and former players on October 28, 2009.  The setting of the hearing received critical comments from Congresswoman Maxine Waters and Congresswoman Linda Sanchez accusing the NFL of failing to adequately protect the players (Legal Issues Relating, 2009).  The hearing was initiated by the latest University of Michigan study linking football participation with long-term brain injuries.  Phone interviews were conducted to a stratified random sample of 1,063 retired NFL players.  The questionnaire was structured to delineate age and ethnicity comparisons between retired NFL players with a national populace (Weir et al., 2009).

The mental and psychological well-being of NFL players and retirees has been an area of concern because of assertions of brain injuries and advance rates of depression and dementia.  In the University of Michigan study, some interviews were conducted with a proxy reporter which was typically the spouse of the player who was incapable of answering questions.  No cognitive testing or neurological examinations were administered to the players.  When asked if diagnosed with dementia, Alzheimer’s disease or other any other ailment, NFL retirees reported yes at a high rate of 6% (Weir et al., 2009).

The cohort for the University of Michigan study consisted of 6,983 former NFL players who earned privileges into the NFL pension system by actively playing for 3 or 4 years.  The cohort was subsequently narrowed to 1,063 with a stratification sample.  A portion of the survey gauged the mental health of the retirees since brain trauma may result in a higher proportion of depression and dementia.  On March 27, 2012, Congresswoman Sanchez recommended new hearings to address the physical force, expense of care, and legal matters associated with brain injuries in amateur and professional sports.  Congresswoman Sanchez submitted her request following the allegations that members of the New Orleans Saints organization participated in a bounty system that recognized and compensated players for deliberately wounding a competitor during contests (Weir et al., 2009).

On July 31, 2014, United States Representative Lois Capps from California introduced H.R. 5324.  H.R. 5324, titled Supporting Athletes, Families and Educators to Protect the Lives of Athletic Youth Act (SAFE PLAY), is an amendment to the Public Health Service Act and the Elementary and Secondary Education Act of 1965.  Specifically, the purpose of the SAFE PLAY Act is to mandate local educational agencies (LEAs) to effectuate formal concussion management plans in public schools, exhibit information relating to the signs, symptoms, and protocols in the event of a concussion, parent notification if suspicion of concussion exists with a participating student, preclude further student participation pending written authorization and release from a certified health care provider, and allot applicable academic accommodations for students who have suffered a concussion.  The SAFE PLAY Act continues through the legislative cycle process. As recently as November 17, 2014, the SAFE PLAY Act was referred to the Subcommittee on Early Childhood, Elementary, and Secondary Education for review and consideration (H.R. 5324, 2014).

 

SUMMARY AND CONCLUSIONS

The impact of litigation, regulation, and legislation on concussion management has a tremendous influence on many sports and ages of sports participants.  From levels beginning with youth sports, effects transcend to the interscholastic, intercollegiate, and professional ranks.  In recent years, federal, state, and associational enactments are mandating organizations and federations to establish concussion management protocols to ensure the safety and well-being of participants.  The claims from medical professionals of debilitating short-term and long-term effects from concussions and traumatic brain injuries are currently under investigation with ongoing research.  As a result, the gap is shrinking between the uninformed and the knowledgeable for concussion awareness and management.

The influence of President Barack Obama is also directing attention to the mounting hazards of concussions in youth sports.  On May 29, 2014, the White House hosted the Healthy Kids and Safe Sports Concussion Summit.  The purpose of the Summit was to promote research on sports-related concussions in youth sports and increase awareness on actions to inhibit, recognize, and respond to concussions in youth.  President Obama advised caution and commended organizations such as the NCAA, the Department of Defense, the NFL, and the National Institute of Standards and Technology for taking a lead research role in the area of head and brain injuries (Hudson, 2014).

Progressive strides in concussion management awareness are endangered by lawsuits targeting helmet manufacturers.  The strategy of lawsuits may be counterproductive if mounting litigation continues and the escalating legal and liability costs outpace manufacturer willingness to produce football helmets.  Influential and affluent sports organizations such as the NFL and the NCAA must partner or invest in ownership in helmet manufacturers to ensure the safest possible protective headwear.  Protective headwear will reduce but not eliminate concussion injuries.  However, without this type of investment, helmet manufacturers face the risk of extinction due to incessant liability and litigation.


ACKNOWLEDGMENTS

None

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