Medical Professional Publications

State Concussion Laws Appear to Reduce Recurrent Brain Injury

School policies largely reflect key tenets of the laws, but inconsistencies exist.

Concussion laws mandating the removal of athletes from play and strict protocols for their return appear to have resulted in a significant decrease in recurrent brain injuries, a study led by Nationwide Children’s Hospital shows.

“The laws are getting people to report initial concussions and are reducing the rate of recurrent concussions,”  says Jingzhen Yang, PhD, principal investigator at the Center for Injury Research and Policy at Nationwide Children’s, and leader of the research, published in the American Journal of Public Health.

Recurrent concussions are the more dangerous of the two, says Dr. Yang, who is also an associate professor of pediatrics at The Ohio State University College of Medicine. An early return to play before the brain has had a chance to heal carries the greatest risk of another concussion, and potential permanent brain damage.

In a parallel study, published in the Journal of Adolescent Health, Dr. Yang and colleagues found that high schools across the United States have, for the most part, strong policies reflecting the laws, but some inconsistencies.

“Most studies looked into whether a state has the law, but the laws don’t make a difference if schools are not implementing them,” Dr. Yang says.

Dr. Yang called the findings in both studies “encouraging.”

All 50 states and Washington, D.C. enacted concussion or traumatic brain injury laws by 2014. The researchers’ analysis of the national database High School Reporting Injury Online found that soon after the laws took effect, the number of new and recurrent concussions rose.

 But 2.6 years later, the number of recurrent concussions reported began dropping — by about 10 percent.

“The increase we saw after implementation of the laws was probably due to increased recognition and reporting of concussion,” Dr. Yang says. The researchers suggest the decline in recurrent concussions may be due to the effects of mandatory removal or permission requirements to return to play.    

The laws typically mandate athletes be removed from practice or games if they have or are suspected to have a concussion, require they be cleared by a medical professional in order to return to training and playing, and require concussion education for coaches, parents and/or athletes.

In a review of written policies from 71 schools in 26 states and Washington, D.C., researchers found 83 percent included the removal from play tenet. Of those, 89 percent demonstrated strong policy enforcement by using language such as “will,” “must,” or “shall” remove; but only 32 percent clearly stated who was responsible for removing the athlete suspected of having a concussion.

Seventy policies require athletes be cleared by a medical professional before returning to play, but only 39 percent specified that the professional be trained in traumatic brain injury management.  

The greatest variation was found in educational requirements. Only 34 percent of policies required coaches to receive concussion recognition and management training. While nearly 60 percent required schools to give concussion information sheets to athletes and their parents, only half required parents and 39 percent required athletes to read and sign them.

Dr. Yang and her colleagues are continuing to investigate connections among the laws, policies, implementation and injury, to try to determine the most effective means to preventing injury and associated negative consequences.


Yang J, Comstock D, Yi H, Hosea HH, Xun P. New and recurrent concussions in high-school athletes before and after traumatic brain injury laws, 2005-2016.  American Journal of Public Health. 2017 Sep 19. [Epub ahead of print].

Coxe K, Hamilton K, Hosea HH, Xiang J, Ramirez MR, Yang J. Consistency and variation in school-level youth sports traumatic brain injury content. Journal of Adolescent Health. 2017 Sep 27. pii: S1054-139X(17)30329-4.

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