May 23 2013
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Reducing Traumatic Youth Sports Injuries: Q&A with Hosea Harvey

file Hosea Harvey, Temple University Beasley School of Law

As school winds down and camps and sports prepare for the summer season, a new study funded by the Robert Wood Johnson Foundation and published in the American Journal of Public Health on sports-related traumatic brain injuries in youth sports, is generating deserved attention.

The study, by Hosea Harvey, JD, PhD, Assistant Professor of Law at the Temple University Beasley School of Law, found that while forty four states and Washington, D.C.,  passed youth sport TBI laws  between 2009 and 2012, none of the laws focus on preventing the injuries in the first place. The laws on the books deal primarily with increasing coaches’ and parents’ ability to identify and respond to traumatic brain injuries and reducing the immediate risk of multiple brain injuries.

>>Read more in a Q&A with the Babe Ruth League Inc. about how youth sports leagues are making strides to prevent injuries.

Harvey’s conclusion is that continued research and evaluation is needed to develop a more comprehensive reduction in youth sport traumatic brain injuries.

NewPublicHealth: What did your study address?

Hosea Harvey: I looked at traumatic brain injury (TBI) laws that were passed at the state level that purported to deal with the problem of youth TBIs in sports statewide. I looked at every related state law passed between 2009 through the end of 2012, though most states only had one law that they passed that dealt with youth sports TBIs during that period.

NPH: And your study found that no state that right now has a law that says this is what you have to do in order to prevent these concussions in the first place?

Hosea Harvey: Precisely, and that’s what’s so interesting. The article describes  the laws as being drive by this galvanizing incident of Zackery Lystedt of Washington State, who in 2006 suffered multiple concussions during a junior high school football game, resulting in severe brain trauma. The impact of what happened to Zackery is already felt by millions of young athletes across the nation who are now protected by laws inspired by him  and designed to help prevent others from suffering the same tragedy.

Because these laws flowed from that event and because the Washington state law was the first, it really focuses on what happens after you get your first youth sports concussion. Various state brain injury associations, as well as the National Football League, played a large part and decided that an initial focus on secondary prevention was a useful way to begin to address the problem. However, as the paper makes clear, no state chose to deal with how to prevent the injuries in the first place in organized youth sports. Other reasons that states chose to focus on subsequent TBIs is that there’s some scientific agreement  that once one gets a first concussion, a subsequent second concussion has severe health consequences. So, focusing on eliminating the second concussion is a goal that everyone shares. Regarding initial concussions, for a variety of reasons, including fear about over-regulating youth sports, the fact that youth sports have a certain culture, that they have certain norms that have lasted over time, legislatures have been a bit more hesitant about taking more direct primary intervention.

But there’s also a lot of evidence that’s lacking about how exactly one would go about regulating sports directly. There are debates about, for example, in football whether or not helmets actually help to prevent concussions. In soccer, certainly it seems that banning heading might decrease the risk of youth TBIs but that rule change would have a dramatic effect on the ability to actually play the game as it was historically designed. And so I think there’s a hesitation to intervene because of issues concerning sports culture which has some validity. The thinking has been that sports have evolved slowly and with ground level consensus over time. As a result, making drastic and fundamental changes—rooted in legal mandates—might be more than most states are willing to do.

NPH: Are there any states working on a primary prevention law?

Hosea Harvey: At the moment, none that I know of. However, there are a few states that have been a bit more aggressive about gathering information.. But, there are youth sports and coach associations that have tried to take a more active role, and so another response from legislators might be to watch what the organizations are doing. Their thinking may be: these associations can better set rules, so why should we?

NPH: From a public health perspective, do you think play regulations that might be set by an association, could be as strong or followed as a law that a state might set?

Hosea Harvey: Absolutely. Actually, there’s  a bit of a myth that law, has to be a solution to all public health problems, and that may not be the case here for a variety of reasons. For one thing, as I’ve tried to explain in the paper, a lot of these laws are already scientifically uninformed, and so to the extent that you get even further removed from the science, why would we trust the legislature would get that right? Instead, we have a wide variety of very active youth sports regulating voluntary associations that organize coaches, teams and competitions, and they’re closer to the action and can set rules across state lines for competing in sports. However, obviously sports associations suffer from the same public pressure that legislators do and that is that parents and students athletes might not want the rules of a sport to change in order to accommodate fears of youth TBIs.

NPH: Looking at some of the injuries that have occurred, what do you hope will happen from a public health perspective?

Hosea Harvey: First, we need to do a substantially better job just gathering comprehensive TBI data at the state and county level across every state. One of the things that we learned during the course of the study is that most states don’t have effective, accurate data about the number and scope of youth sports TBIs and so because they don’t have that data it becomes hard to figure out what to do. A starting point would be to require that all organized youth sports have mechanisms for gathering and reporting data about TBIs across various youth sports.

Second, the science is clear that TBIs happen in different ways across different sports and across gender and even across rural and urban areas and there’s no systematic data that we’ve gathered to date to deal with those uncertainties. If we were to begin and just aggregate data from generic numbers, , and compare that to something more specific such as TBIs in youth football and what causes those, you could have the beginnings of solutions at the primary prevention level.

The level of sophistication about prevention of youth sport injuries also varies by region and by sport and I think digging down more into that data would be helpful.

The bottom line is that we need a lot more data.

NPH: Do you see anything happening over the summer in time for fall sports or summer sports?

Hosea Harvey:. First of all, one hope is that when people look at this study, one of the things they’ll notice is that, for example, a large number of states have medical clearance provisions that allow for someone who is not trained in TBIs to clear a student to return to play.

Another broad trend that’s kind of troubling is that many states have waived liability for certain persons involved in implementing or enforcing portions of youth sports TBI laws. It’s not clear to me that liability waivers will add anything to preventing youth TBIs, and so it’s not clear why they exist or what their backers are trying to accomplish. I hope we take a closer look at the value-add of such waivers.

The last thing is the issue of a 24-hour minimum waiting period before athletes who are suspected of having a concussion or brain injury during practice or play can return to play. This is standard across all of these  laws. There is simply no evidence that that is the appropriate starting point. There is evidence that the starting point might as well be 72 hours or even week later to ensure maximum likelihood of recovery. Youth athletes have still developing brains, and so the idea that these laws specify only a 24-hour minimum (plus clearance) before returning to play  is arbitrary. Legislatures may need to begin to rethink why they use that as a baseline and whether or not that’s the most appropriate baseline to use.

NPH: How should that baseline be determined?

Hosea Harvey: That’s a great question. Frankly, one of the largest policy movers here for these laws was the NFL and I think they, now that many of these laws have passed, have to begun to think more about the next step in this agenda. I think one of the big things that all people involved in advocating for such laws need to do  is think more critically about the science. I think there are a number of state brain injury associations that were very involved in this process and they were great. They need to push people like the NFL (also a strong advocate for such laws) to be more sensitive to distinctions between types of sports and types of athletes and rates of recovery. But in addition to that, I think that one of the great things that’s come out of this process is that voluntary sports associations have created their own guidelines separate from state laws that are, in some ways, stricter than many state laws. And I think that these voluntary associations, whether they’re coaches or statewide athletic associations, can fill the gap because they’re closest to the issue and they see more of the consequences of youth sports TBIs. And I also think that as they get more involved you’ll see them leading in more proactive way.

Tags: Adolescents (11-18 years), Children (6-10 years), Disease Prevention and Health Promotion, Injury Prevention, Pediatrics, Public health law