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OBJECTIVE: To examine the effect of state youth traumatic brain injury (TBI) legislation on pediatric emergency department (ED) utilization for sports and recreation-related mild TBIs (mTBIs). PARTICIPANTS: ED visits by children ages 5 to 18 years between 2006 and 2014 in the Pediatric Health Information System database (N = 452 900). DESIGN: Retrospective analysis. MAIN MEASURES: Rates of ED visits, and injury comparison groups (mTBI, moderate to severe TBI, minor head injury, and long bone fracture). RESULTS: Of the 452 900 ED visits, 123 192 (27.2%) were for mTBI, along with visits for moderate to severe TBIs (n = 5190), minor head injuries (n = 54 566), and long bone fractures (n = 269 952). ED visits for mTBIs were more common among males (67.5%), children ages 10-14 years (42.1%), and the privately insured (50.6%). The proportion of mTBI ED visits increased significantly, particularly from 5 years prelegislation to immediately postlegislation (57.8 to 94.8 mTBI visits per 10 000 ED visits). A similar trend was observed for minor head injuries; however, no significant changes were observed for moderate to severe TBIs and long bone fractures. CONCLUSION: Pediatric ED utilization trends for the injury comparison groups differed from each other, and from pre- and post-TBI legislation. Further research assessing effects of TBI legislation on healthcare utilization is warranted.

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OBJECTIVE: We sought to examine the prevalence, scope, and specificity of provisions governing school reintegration in current state concussion laws. METHODS: State concussion laws as of May 2016 were independently assessed and classified by 2 trained coders. Statutes were classified as "Return-to-Learn" (RTL) laws if they contained language mandating institutional action at the state, district, or school level related to academic reintegration of youth who have sustained a concussion. All statutes classified as RTL laws were further analyzed to determine scope, required actions, and delineation of responsibility. RESULTS: RTL laws were uncommon, present in only 8 states. Most (75%) of these laws held schools responsible for RTL management but mandated RTL education for school personnel was less frequent, present in only one-quarter of the laws. None of the RTL laws provided guidance on support of students with persistent postconcussive symptoms, and only 1 recommended an evidence-based standard for RTL guidelines. CONCLUSIONS: Our review of state concussion laws indicates scant and vague legal guidance regarding RTL. These findings suggest an opportunity for legislative action on the issue of RTL, and reveal the need for better integration of laws and research, so that laws reflect existing best-practice recommendations and remain current as the evidence base develops.

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There are an estimated 1.6 to 3.8 million sports and recreation-related concussions annually in the United States, with an average annual increase in incidence of 15.5% from 1998 to 2007. From 2009 to 2014, all 50 states enacted youth concussion legislation. This study clarifies core elements common to state concussion legislation and State Interscholastic Athletic Association (SIAA) implementation. A concussion literature, legislative, and SIAA concussion bylaw review was performed for all 50 U.S. states. Mandated concussion education varies in the frequency of certification and method of education. Student athletes and their parents/guardians in a majority of states are required to sign annual educational information sheets. Forty-nine states specifically mandate removal from play. Return-to-play protocols vary with regard to the timeline, content, and health care professional that can provide written clearance. In conclusion, it is important for sports medicine clinicians to stay abreast of current and revised concussion legislation in the jurisdictions in which they provide care.

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Currently, all 50 states and the District of Columbia have youth concussion laws based on the core principals of the 2009 Lystedt Law of Washington State. On April 23, 2013, the state of Georgia signed into law House Bill 284, "The Return to Play Act of 2013" and became one of the last states to pass youth concussion legislation. This Act became effective on January 1, 2014. The purpose of this report is to highlight the legislative process of enacting Georgia House Bill 284 and compare it to the legislation of other states.

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While provisions of youth sports concussion laws are very similar, little is known as to how they are being implemented, factors that promote or impede implementation, or the level of compliance in each jurisdiction. We aimed to describe state experiences with implementation in order to inform ongoing efforts to reduce the harm of sports-related traumatic brain injury and to guide future evaluations of the laws' impacts and the development of future public health laws. We conducted key-informant interviews in 35 states with recently enacted concussion legislation. States varied considerably in their readiness and capacity for implementation. Factors facilitating implementation included existing partnerships, procedures, and resources; centralized implementation authority; prior related efforts; and involvement in the policymaking process by those now charged with implementation. Inhibitors included ambiguous statutory language, unclear delegation of authority, and compliance difficulties. Ongoing challenges persist, including primary prevention; determining which providers are qualified to make return-to-play assessments and contents of those assessments; compliance difficulties in rural and under-served areas; and unclear responsibility for enforcement. Despite the similarity of youth sports concussion laws, early evidence suggests there is considerable variation in their implementation. These findings are critical for ongoing empirical investigations to accurately evaluate the laws' provisions and to identify successful legal approaches to protecting young athletes.

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The framing of the risks of experiencing mild traumatic brain injury in American football and ice hockey has an enormous impact in defining the scope of the problem and the remedies that are prioritized. According to the prevailing risk frame, an acceptable level of safety can be maintained in these contact sports through the application of technology, rule changes, and laws. An alternative frame acknowledging that these sports carry significant risks would produce very different ethical, political, and social debates.

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