There is good news and bad news in a first-of-its-kind study about implementation of the nation's first youth sports concussion safety legislation .
The good news is that football and soccer coaches at public high schools in Washington State nearly all reported completing the required concussion education annually, concussion knowledge among coaches was high, and nearly all reported being somewhat comfortable or very comfortable in deciding whether an athlete needed an additional evaluation for a suspected concussion.
The bad news is that concussion education of athletes and parents was much less extensive, with about a third of athletes and more than half of parents not receiving any concussion education beyond signing a concussion and head injury information sheet . While not considered significant enough to warrant extended discussion, only a little more than half (55.2%) were familiar with the term "graduated return to play," which is the recommended management for concussion .
Lead author Sara Chrisman of the Harborview Injury Prevention and Research Center in Seattle, Washington, viewed the finding that concussion education requirements for coaches under the state's first-in-the-nation "Lystedt Law" were being closely followed by public high schools in Washington State as "very encouraging but not surprising," noting that schools had an incentive to follow the law because it provides legal immunity from litigation for schools that follow it correctly.
Chrisman said, however, that the study's finding that athletes and parents received much less concussion education was "concerning."
"Given that concussions are difficult to diagnose and often require either athlete reports or parental concerns to come to the attention of the coach," they said, "educating athletes and their parents about the risks of a concussion and safe management is an essential part of preventing athletes from playing with concussive symptoms ."
Parents play what they characterized as a "pivotal role " in concussion safety. Because "parents of high school athletes attend their games, watch their child closely during game play, and are accutely attuned to changes in their behavior ... [e]ducating parents about signs and symptoms," they said, "could potentially decrease the likelihood of athletes playing with concussion symptoms."
While the study found that high schools in the state were meeting the law's minimum guidelines - likely left purposefully vague as a necessary legislative compromise for an unfunded mandate - Chrisman and her co-authors thus expressed the hope that further revisions of the law would beef up the educational requirements for athletes and parents.
Because the study measured concussion education and knowledge, Chrisman admitted that it was unclear whether improved concussion knowledge led to improved concussion safety. She noted that several recent studies , including one on which she was the lead author (Chrisman, 2013), and the others by researchers at Wake Forest, the University of North Carolina at Chapel Hill, and A.T. Still University in Mesa, Arizona (Register-Mahalik JK, Guskiewicz KM 2013; Register-Mihalik JK, Linnan LA 2013), had revealed "significant barriers" to athletes reporting concussion symptoms that are "not knowledge-based, such as a concern that they would be removed from game play or pressure from their teammates or coach."
She said further research was needed to understand how education can be most effective toward preventing athletes from playing with concussive symptoms, and thus improving safety. "There may be certain messages that are more likely to encourage athletes to report concussive symptoms, such as focusing on short-term outcomes (concussions affect one's ability to play well) rather than long-term outcomes (playing with a concussion can cause brain damage).
An interesting aspect of the Lystedt Law, said Chrisman, was that it allows athletic trainers (ATs) to clear athletes to return to play after concussion. Two-thirds of the football, girl's soccer, and boys' soccer coaches surveyed reported working at schools that employed an AT, and six in ten reported that the AT attended games most or all of the time, although the percentage was much higher for football than soccer (98.4% versus 77.8%).
The study found the presence of other medical personnel, such as team doctors, or EMTs, less common, with one quarter reporting a physician attending at least half the games and one-quarter reporting the same attendance for an emergency medical technician.  Again, the number was much higher for football (63.%) than soccer, where attendance by a doctor was rare (3.0%), this despite the fact that statistics show that soccer, both boys' and especially girls, have concussion rates among the highest of all high school sports.
Three-quarters of coaches reported that some type of standardized concussion testing was used to evaluate athletes, but almost half could not remember the name of the testing. Less than half reported any kind of baseline testing.
Because researchers speculated that schools have chosen to respond to the law by employing ATs, but the lack of data regarding the prevalence of ATs in the state before the law's passage in 2009 prevented comparison.
While the study acknowledges that the presence of an AT "could effect multiple areas of concussion safety,  from the likelihood of concussion detection to appropriate management, and could provide opportunities for further athlete concussion education," Chrisman says it was "unclear whether employing an AT can improve concussion safety, and it deserves further study."
Chrisman SP, Schiff MA, Chung SK, Herring SA, Rivara FP. Implementation of Concussion Legislation and Extent of Concussion Education for Athletes, Parents, and Coaches in Washington State. Am J Sports Med. 2014;20(10). DOI:10.1177/0363546513519073.
Chrisman SP, Quitiquit C, Rivara FP. Qualitative study of barriers to concussive symptom reporting in high school athletics. J Adolesc Health 2013;52:330-5 e3.
Register-Mihalik JK, Guskiewicz KM, Valovich McLeod TC, Linnan LA, Meuller FO, Marshall SW. Knowledge, Attitude, and Concussion-Reporting Behaviors Among High School Athletes: A Preliminary Study. J Ath Tr. 2013;48(3):000-000. DOI:10.4085/1062-6050-48.3.20 (published online ahead of print)
Register-Mihalik JK, Linnan LA, Marshall SW, Valovich McLeod TC, Mueller FO, Guskiewicz KM. Using theory to understand high school aged athletes' intentions to report sport-related concussion: Implications for concussion education initiatives. Brain Injury 2013;27(7-8):878-886.