At the secondary school level there are several layers of laws and policies to consider. Each state has its own concussion law and those laws vary in requirements. Some laws are very straightforward and just direct the department of education to develop a statewide policy.

1. Education of athletes
2. Informed consent of parents
3. Requirements for removal from play
4. Requirements for written clearance to return

There may be other areas including liability, baseline assessments, and youth sports that are included in some. With respect to written clearance. Some states use language of “licensed healthcare provider” some with and without the caveat of “with training in concussion.” Other states list specific providers that may provide written clearance. In Arizona, we talked with colleagues in Washington state as we were drafting our language. They had the general licensed HCP in their law (they were the first to pass) and said it had caused some unintended consequences—parents shopping for clearance from anyone with or without expertise in concussion. Their recommendation to us was to be specific in credentials. We included physician (MD, DO), physician assistant, nurse practitioner, and athletic trainer. We had a lot of support to include ATs as many physicians acknowledged our knowledge level around concussion was likely higher than some physicians and we work under the direction of a physician per BOC and our state license. Other states do not allow ATs to make final clearance decisions, which is unfortunate. The language of the law will often not provide specifics as a law is hard to amend once passed. The next level of policy is the interscholastic association and these policies may be more specific. For example, in Arizona, our state law just notes that written clearance must be provided for an athlete to return, but our AIA policy dictates that the athlete must go through a stepwise return to activity progression. This allows for some flexibility for the school’s AT and directing physician to hold athletes who they feel may not be quite ready to return, but had a clearance note from an outside provider. They can accept the clearance note as clearance to begin the RTA progression and may keep the athlete at lower stages until they are confident they are ready to approve. Our state law also says nothing about return to learn, but our AIA policy addresses this issue with some specifics about ensuring schools have a RTL progression and that the student-athlete must be fully returned to the classroom prior to being fully cleared for competition.

The next level is at the school district or school level and the specific policy at that intuition. These polices are often more detailed than the interscholastic policy to allow for local considerations and roles of the school level concussion management teams. These may include specifics about how the school handles RTL, whether preseason assessments are required, and specific assessments used. Some school level policies also include language the the AT and directing physician can override external clearance notes when they do not feel the athlete is ready to fully return. Lastly, the AT should have standing orders with their directing physician that describes what they are able to do with respect to concussion. Some directing physicians may want to evaluate every concussion patient and make the final clearance and others may just want to have a phone call with the AT to talk through the case. We have a unique program in AZ called Second Opinion that ATs can access through the Barrow Concussion Network to have conversations with concussion experts about patients. This works great for our rural areas and our ATs who may have an orthopedic physician as their directing physician who feel less confident in concussion evaluation. Examples of standing orders are in the optional reading section.

1. Parsons Neurol Handbook: Dr. Parsons is the Director of the NCAA Sports Science Institute and works on most NCAA health and safety policies.
2. Beidler et al J Athl Train: Dr. Beidler and colleagues evaluated secondary school concussion protocols in Pennsylvania through a content analysis. As you will read, many protocols were missing elements of the PA state law, PIAA policy, and best practice recommendations.
3. Baugh et al Am J Sports Med: In this article Dr. Baugh and co-authors evaluated the concussion policies of NCAA member institutions and determined compliance and areas of needed improvement.
4. Review the CDC law and policy link

What is negligence?

Medicolegal considerations (Notes, Transcript)