Introduction
Over the past decade, concussion has emerged as an important public health concern that affects millions of people annually worldwide.Reference Cusimano, Cho and Amin 1 - Reference Meehan and Mannix 3 Among youth, a significant proportion of injuries will occur during participation in sports and recreational activities. The majority of children and adolescents who suffer a concussion will make a complete neurological recovery and return to school and sports activities; however, concussion can lead to significant consequences, including fatal injuries from second impact syndrome and long-term effects such as postconcussion syndrome.Reference Ellis, Leddy and Willer 4 - Reference Tator and Davis 6 These outcomes have led all 50 American states and the District of Columbia to enact legislation that aims to optimize concussion education, prevention, and management in youth sports.Reference Simon and Mitchell 7 The principal components of these laws include concussion education for coaches, trainers, and athletes; immediate removal from play of any athlete with a suspected concussion; and mandatory documentation of medical clearance by a medical professional before a return to play.Reference Tomei, Doe, Prestigiacomo and Gandhi 8 Despite evidence of increasing rates of concussion identified in numerous youth sport and recreational activities popular in Canada, there is no enacted concussion legislation that addresses these important issues at the present time.
In this article, we review attempts to introduce youth concussion legislation in Canada and discuss a conceptual framework and make recommendations to guide the development and implementation of future youth sport concussion laws.
Review of Introduced and Enacted Youth Concussion Legislation in Canada
Youth concussion laws introduced and enacted in Canada were identified by online Internet searches of federal, provincial, and territorial legislature websites. Searches were carried out from July 26 and 27, 2016. Internet searches revealed six bills introduced in provincial legislation, including two in the provinces of Ontario and Nova Scotia and one each in British Columbia and Quebec. 9 - 14 Only one of these bills has been passed into provincial law, and it was not actual concussion legislation but rather a framework for possible enactment of legislation. 10 Two bills were introduced into federal parliament, but neither has been enacted as law. 15 , 16 A summary of the content and current status of these bills is provided in Table 1.
Table 1 Summary of introduced and enacted youth concussion laws in Canada
*Explanatory notes in these bills are not included this table.
Conceptual Framework and Recommendations
At the time of this study, only the province of Ontario has passed legislation that involves concussion in youth athletes, but it is limited to a study of possible legislation. Although Ontario’s Rowan’s Law Advisory Committee Act (2016) represents an important initial step towards examining how the recommendations of a provincial inquest can be implemented in Ontario, 10 there is presently no provincial or federal concussion legislation that directly legislates concussion education, prevention, or management in youth sports in Canada.
We are in favor of youth concussion legislation to optimize concussion education, prevention, management, and policy in Canada and recommend that these laws include several important components related to youth concussions. Accordingly, we present a conceptual framework and recommendations that can be used to establish future youth concussion laws in Canada (Figure 1). Although there is wide variability among existing state youth concussion legislation in the United States, the vast majority of laws do address the three recommendations we make for Canadian youth concussion laws as discussed in the following sections.Reference Simon and Mitchell 7 , Reference Tomei, Doe, Prestigiacomo and Gandhi 8
Figure 1 A conceptual framework to guide the development and implementation of future provincial youth sport concussion laws in Canada.
Recommendation 1: All Coaches, Trainers, Parents, and Athletes Involved in Sport Should Undergo Annual Concussion Education
Despite increased public, media, government, and academic attention focused on concussion, recent studies continue to demonstrate a persistent need for concussion education and awareness among coaches, athletes, medical trainees, and health care professionals.Reference Burke, Chundamala and Tator 17 - Reference Stoller, Carson and Garel 19 Optimizing the primary and secondary prevention of youth concussion depends highly on educating all youth sport stakeholders on measures that can prevent concussion and more serious forms of head injury as well as how to identify and manage a youth athlete with a suspected concussion. It is important that concussion education reflects current evidence-based standards in the field and is made widely available to all stakeholders. Concussion education should include information on the definition of concussion, potential mechanisms of injury, presenting signs and symptoms, what to do when an athlete has suffered a suspected concussion, what measures should be taken to ensure proper medical evaluation, an outline of the return-to-play guidelines and medical clearance requirements, and steps that can be taken to prevent concussions and other injuries from occurring in sport (e.g. proper equipment, adherence to rules and regulations). In Canada, evidence-based materials and resources developed by Parachute Canada and Hockey Canada meet these criteria and should be considered.Reference Tator 5 Importantly, procedures should be put in place to ensure all coaches, trainers, parents, and athletes complete this education on an annual basis. A standardized concussion information form that is signed and submitted by both the parent and athlete at the start of each season is one example that has been employed in some American states.Reference Tomei, Doe, Prestigiacomo and Gandhi 8
Recommendation 2: All Youth Athletes With a Suspected Concussion Should Be Immediately Removed From Play
Given the risk of second-impact syndrome and prolonged recovery associated with premature return to play following a concussion,Reference Tator 5 it is imperative that all youth athletes with a suspected concussion be immediately removed from play and not be allowed to return to any sporting activity on the same day that a suspected concussion has occurred. Although the formal diagnosis of concussion should be left to a medical doctor, all youth sport stakeholders including athletes, parents, teachers, coaches, and officials are responsible for identifying and reporting athletes who demonstrate visible signs of a concussion or who report concussion symptoms. This is particularly important because many sports and recreation venues will not have access to onsite medical personnel. A concussion should be suspected in any athlete who experiences a loss of consciousness, lies motionless on the field, or demonstrates confusion, unsteadiness, or a dazed or blank look.Reference McCrory, Meeuwisse and Aubry 20 At present, there are available standardized assessment tools (such as the Sport Concussion Assessment Tool-3) that can assist in the sideline assessment of these athletes; however, the results of testing can be normal in the setting of acute concussion.Reference McCrory, Meeuwisse and Aubry 20 As such, these tools can be used by qualified health care professionals (such as athletic therapists or nurses) to document initial neurological status, but should not be used to make sideline return-to-play decisions.
Recommendation 3: All Youth Athletes With a Suspected Concussion Should Undergo Evaluation and Clearance by a Knowledgeable Medical Doctor Before Returning to Sporting Activities
To provide comprehensive evaluation of children and adolescents with a suspected concussion, a clinician must rule out more serious traumatic brain injury (TBI) and spine injuries, must rule out medical and neurological conditions that can present with concussion-like symptoms, and must make the diagnosis of concussion based on features of the clinical history and physical examination and the evidence-based use of adjunctive tests.Reference Ellis, Leddy and Willer 21 Patients with a diagnosed concussion should be managed according to proper return-to-learn and return-to-play guidelines.Reference McCrory, Meeuwisse and Aubry 20 Because medical doctors are the only licensed health professionals in Canada with the training and expertise to meet these needs, all children and adolescents with a concussion should undergo evaluation and receive written medical clearance by a medical doctor before returning to sports.
Although in recent years there has been a dramatic increase in advertised concussion health care providers and clinics across Canada, research suggests that the majority of these providers do not have appropriate access to an onsite medical doctor or have access to health care professionals with licensed training in TBI (neuropsychologists, neurologists, sports medicine physicians, neurosurgeons).Reference Ellis, Ritchie, Selci, Chu, McDonald and Russell 22 In geographic regions of Canada with poor access to physicians (i.e. rural or northern communities), a licensed health care professional (such as a nurse practitioner) with prearranged access to a medical doctor can facilitate this role. More recently, the Canadian Concussion Collaborative has recommended that each sport organization develop youth concussion protocols that communicate to all stakeholders the steps that should be taken to ensure proper evaluation and medical management of children who suffer a suspected concussion during sports.Reference Frémont, Bradley, Tator, Skinner and Fischer 23
Given the potential serious and life-threatening consequences of head injuries sustained during sports, it is imperative that provinces ensure that qualified medical resources are available to facilitate immediate evaluation (within hours of injury) and follow-up care of athletes with suspected concussion. Provinces and regions with access to physician-led multidisciplinary pediatric concussion programs or clinics operated by experts in TBI may also benefit from close collaboration between these centers and local sports organizations, emergency departments, and primary care physicians that can help facilitate timely and coordinated care of pediatric concussion patients.
Additional Considerations
For youth concussion legislation to protect the health and safety of all youth athletes within a given province or territory, it is recommended that provincial government leaders in health, sport, and education partner to ensure that these laws are equally applied to all youths participating in school-based sports in both public and private schools and non-school–based sports including organized private and nonorganized sport settings. An important additional consideration for youth concussion laws is the issue of compliance and law enforcement. Although there is precedence for enforcing injury prevention legislation in Canada (e.g. seat belts, bike helmets, infant car seats), the vast majority of youth concussion laws in the United States do not include a penalty for noncompliance.Reference Tomei, Doe, Prestigiacomo and Gandhi 8
Preliminary evidence suggests that Ontario public schools have been moderately compliant with a recent nonlegislative policy (PPM 158) to enhance concussion education and management in youth athletes and that such policies were beneficial in enhancing staff and student concussion education.Reference Hachem, Kourtis, Mylabathula and Tator 24 However, implementation of compliance monitoring procedures will likely require additional funding and must be weighed against the risk of increasing registration fees, which could have a detrimental impact on youth sport participation. Last, it is unclear to what extent the adoption of youth concussion legislation leads to improvements in concussion recognition, reductions in injury rates, or improvements in youth concussion patient outcomes. Accurate assessment of the effectiveness of legislation will require involving the country’s system of surveillance of concussions through hospital discharges, ambulatory settings such as emergency departments and doctors’ offices, and consistent and thorough record-keeping at both school-based and non-school–based venues. Preliminary studies in the United States suggest that the implementation of youth concussion legislation is associated with an increase in health care utilization for pediatric concussionReference Gibson, Herring, Kutcher and Broglio 25 , Reference Mackenzie, Vivier, Reinert, Machan, Kelley and Jacobs 26 ; however, there are mixed results about what effect these laws have had on knowledge translation.Reference Carl and Kinsella 27 - Reference Shenouda, Hendrickson, Davenport, Barber and Bell 29
Conclusion
To date, there is no provincial or federal concussion legislation that has had a direct impact on Canadian youth athletes. Consequently, there remains an urgent need for legislation that can help promote the safety of youth sport and optimize concussion education, prevention, management, and policy in Canada. The conceptual framework and recommendations presented here can help government, medical, and community stakeholders identify essential issues that must be addressed in future youth sport concussion laws.
Disclosures
CHT is the founder of Think First Canada, an injury prevention organization that has joined Parachute Canada, a national charitable program devoted to injury and concussion awareness. CHT, MJE, and SB are members of the Expert Advisory Committee on concussion for Parachute Canada. CHT is also a member of the Canadian Concussion Collaborative. The authors have no financial conflicts of interest to disclose.
Statement of Authorship
KR, MJE, SB, and CHT conceptualized and designed the study, drafted the initial manuscript, critically reviewed and revised the manuscript, and approved the final manuscript as submitted. MJE and KR carried out data collection for the study. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
