	Available Information about the Occurrence of Concussion in High School Sports Cannot Provide an Overall National Estimate

We identified three national databases that, as part of broader data  collection efforts, collect information on the occurrence of concussion in  high school sports, but they do not provide an overall national estimate of  occurrence. These databases are the NCCSI database, the CPSC’s National  Electronic Injury Surveillance System (NEISS), and the Center for Injury  Research and Policy’s High School RIO. High School RIO provides  national estimates of the occurrence of concussion in 20 sports for high  schools with certified athletic trainers, based on its sample of 100 high  schools with certified athletic trainers. The third database, NCCSI, provides  information on cases of concussion with serious complications, but it  cannot provide national estimates of occurrence of all concussions. For example, High School RIO gathers information  only on concussions that are reported to or observed by a certified athletic  trainer, but, according to officials from an athletic trainers’ association,  athletes may be reluctant to report symptoms of possible concussions to  athletic trainers to avoid being removed from play. Similarly, NEISS gathers  information only on concussions in patients who are treated in emergency  departments, but not all athletes with a concussion go to an emergency  department for treatment. The Primary Federal Program Directed Specifically at Preventing Concussion in High School Sports Is CDC’s Heads Up: Concussion

CDC’s Heads Up: Concussion in High School Sports is the primary federal  program directed specifically at preventing concussion in high school  sports. As  part of the agency’s promotional activities for its national roll-out, CDC  developed press kits and other promotional materials, and to promote the  program, it partnered with 14 public and private organizations, including  Education, physician associations, and other organizations that conduct  work in high school athletics or sports medicine. These  initiatives are not targeted exclusively at high school sports, but are  directed more broadly at sports and recreation safety for youth and adults. For example, CPSC developed a brochure on which helmets to wear for a  variety of activities, such as football, baseball, and bicycling, to prevent  head injuries, including concussion. Concussion Education and Return-to-Play Requirements Are the Focus of Key State Laws, but Exact Requirements Differ

The three key state laws regarding the management of concussion that  were identified by federal officials and experts all include requirements  related to concussion education and athletes’ return to play. The education components of the key state laws—those of Oregon, Texas,  and Washington—vary in terms of targeted group and frequency of  training. The return-to-play requirements of the key state laws vary with  respect to the conditions under which the requirements apply and the  personnel who may authorize return to play. The educational requirements of the Oregon law are targeted at  coaches. The Washington law is the only one that  requires that parents, in addition to coaches and athletes, receive  education. The  Washington law requires that an athlete suspected of having a concussion  be evaluated and cleared to return to play by a health professional  specifically trained in the evaluation and management of concussion. Voluntary Nationwide Guidelines for Managing Concussion Incurred in High School Sports All Recommend Assessing Concussion on an Individual Basis, with Gradual Return to Play

Federal officials and experts we spoke with identified five sets of  voluntary nationwide guidelines that address the management of  concussion in sports. All sets  of guidelines also recommend returning an athlete to play on a gradual  basis, tailored to the individual athlete’s recovery and based on the  athlete’s signs and symptoms and the results of various concussion  assessment tools, such as tests of memory, cognition, balance, and  physical exertion.
Why GAO Did This Study

Participation in school sports can benefit children but also carries a risk of injury, including concussion. Concussion is a brain injury that can affect memory, speech, and muscle coordination and can cause permanent disability or death. Concussion can be especially serious for children, who are more likely than adults both to sustain a concussion and to take longer to recover. These factors may affect return-to-play decisions, which determine when it is safe for an athlete to participate in sports again. GAO was asked to testify on concussion incurred in high school sports. This statement focuses on (1) what is known about the nationwide occurrence of concussion, (2) federal concussion prevention programs, (3) the components of key state laws related to the management of concussion, and (4) the recommendations of voluntary nationwide concussion management guidelines. To do this work, GAO conducted literature searches; reviewed injury databases, state laws, and documents from federal agencies and organizations that conduct work in high school athletics or sports medicine; and interviewed federal officials and experts who identified key state laws and nationwide guidelines and provided other information. GAO shared the information in this statement with the relevant federal agencies.

What GAO Found

GAO identified three national databases that, as part of broader data collection efforts, collect information on the occurrence of concussion in high school sports, but they do not provide an overall national estimate of occurrence. Although the High School Reporting Information Online database provides national estimates of occurrence of concussion, it covers only 20 sports for high schools with certified athletic trainers. It may underestimate occurrence because some athletes may be reluctant to report symptoms of a possible concussion to avoid being removed from a game. The Consumer Product Safety Commission's (CPSC) National Electronic Injury Surveillance System provides national estimates only on concussions treated in an emergency room. The National Center for Catastrophic Sports Injury Research database provides information only on cases of concussion with serious complications and cannot provide national estimates of the occurrence of all concussions. The Centers for Disease Control and Prevention's program, Heads Up: Concussion in High School Sports, which began in September 2005, is the primary federal prevention program directed toward concussion. In addition, CPSC carries out prevention initiatives that include distributing educational materials, but these initiatives are directed more broadly at sports and recreation safety, such as appropriate helmets for football, baseball, and bicycling. The three key laws regarding the management of concussion in high school sports that were identified by federal officials and experts--those of Oregon, Texas, and Washington--all address concussion education and return to play, but their specific requirements vary. The education requirements vary with respect to who is to receive the education. For example, the Washington law targets coaches, athletes, and parents, while the Oregon law targets coaches only. There is also variation with respect to the content and frequency of education. The return-to-play requirements vary in the conditions under which athletes may return to play and in who may authorize it. For example, the Texas requirements apply specifically to athletes who lose consciousness, which excludes many concussions, and the Washington law requires return-to-play authorizations to be made by health professionals specifically trained in the evaluation and management of concussion. GAO found five sets of voluntary nationwide guidelines, which were developed by organizations that conduct work in high school athletics or sports medicine, that address the management of concussion in high school sports. All recommend monitoring an athlete with a concussion on the sidelines and assessing cognitive function regularly for signs of deterioration. All guidelines also recommend returning an athlete to play on a gradual basis, tailored to an individual's recovery and based on symptoms and the results of memory, cognition, and balance tests