Concussion: Policy Effectiveness and Complexity

Many concussions can be described as 'invisible' injuries in that there are no visible signs or damage from the injury and many symptoms don't appear until sometime after the initial accident. This fact, combined with the often erroneously attributed "mild" injury status, makes the condition seem insignificant or superficial. This has traditionally been the case in many elite sports and only recently, at the turn of the century, has there been a change in perception [166- 168]. This change in perception is in turn, a contributing factor to the many concussion policy attempts as discussed in Chapter 1.7.

There are so many factors at play when trying to understand the policy creation process that one needs time, knowledge and resources to be able to brainstorm and come up with an efficient, usable policy in a given timeframe. Frequently, this task is a team effort, especially when there is a need to create a policy from scratch. Ontario school boards had an opportunity to use the OPHEA documentation, government injury resources, the ability to approach their local public health unit (PHU), and access to many U.S. state policies (as examples) to create their own concussion policy. There is a lot of research on this topic already and more studies are

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coming out on a regular basis. It can be considered a hot topic, to say the least, especially considering the recent extensive concussion lobbying campaigns and media focus. The first or main question that arises is then whether or not the created policies are strong enough. Are they actually viable and include all of the key principles or necessary components to be useful in a day-to-day setting or are they just empty shells, carcasses devoid of any meaningful information [169-171]?

To answer this question, it is important to consider two points. First the circumstances surrounding the nature of the PPM launch, especially the short (~10 months) deadline given to all the school boards in the province. Second, the specifics of the so-called OPHEA minimum standards on concussion are debatable. With the short implementation timeframe comes the innate assumption that all school boards have the personnel, knowledge and capability to quickly develop the new policy. While it's true that the OPHEA guidelines could be used as a foundation for their own policy, the boards still must take into account their unique factors and circumstances, such as, for example, the type and diversity of the population, yearly injury prevalence and statistics, sports played at the schools, and of course, budgetary concerns. As pointed out by some respondents in Chapter 2 (Paper 1), some boards were just physically unprepared to develop a concussion policy or didn't have the resources to hire or ask for policy-related help. A few boards also pointed out that time was a big issue, with some of the boards that refused participation hinting at or implying that their policy is not fully implemented to warrant an analysis or an evaluation.

Based on the observed responses, and after looking at the electronically-accessible policies of some school boards, it is the opinion of the primary author of this report that some boards have not actually implemented their policies, especially considering the low response

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rate to this study and the simplistic nature of many of the policies that were available online. Not only do many of them lack the complexity and thoroughness that is inherent in such an important policy that can have potential long-lasting effects on youth health, but they also seem very light on specific steps and/or directions as to what to do during a concussion, how to approach teacher/coach/parent education, how to handle RTP/RTL and other crucial policy components. Some devote pages to roles and responsibilities, but mention nothing about promoting concussion education (either for the teachers, athletes or both), improving sports safety or reaching out to parents and external partners (e.g. community sports clubs, leagues, etc.). There is also frequently no mention of the need to have training for Health and Physical Education teachers/coaches, the presence of trained personnel present at sport events, or just anything in general that could illustrate how the policy will actually be applied.

These findings are not surprising. A recent analysis of the U.S. state laws by the Associated Press revealed that only about 40% contain all of the key principles in the initial bill passed in Washington state in 2009 that is often considered the "Golden Standard" [170]. The analysis also suggests that not only were the laws passed with remarkable speed, but they also had to make multiple sacrifices especially in the areas of costs, enforcement and regulation. As quoted by Jeff Miller, the NFL Senior Vice President of Health and Safety Policy: "Better to get something good, and get something in place, as opposed to shoot for something fantastic in all places - and fail." [170]. This idea is comparable to what was witnessed in our study, whereby many school board policies were created quickly, just to meet the ministry's deadline, but they have many weaknesses that have to be addressed by the boards before they can say that they have a functional concussion policy in place. It is not enough to just have it there on the board's website and to hand out concussion fliers and posters around the schools. The

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policies need to be well-built and detailed enough; clearly outlining the steps or ways to educate teachers and coaches, including a clear protocol on removal from the game after a suspected concussion, the need for mandatory medical clearance to return to play, and effective concussion management procedures (RTP/RTL protocols). Without these critical components, the individual board policies cannot be considered viable, and subsequently cannot be successfully implemented and evaluated or compared.

The outright effectiveness of the school polices cannot be compared because of the novelty of the policies and because the actual OPHEA "minimal standard" has never been evaluated. The protocol has been developed in partnership with the Ministry of Education, the ThinkFirst Concussion Education and Awareness Committee, and the Recognition and Awareness Working Group of the Mild Traumatic Brain Injury/Concussion Strategy, but there are no studies that have looked at the protocol or have evaluated it to a significant extent [172]. Similarly, the nature or the extent to which the individual school policies are actually contributing to a reduction in concussion incidence is unknown. Some individual components of the concussion polices have been shown to work. For example, there is evidence that education about concussion leads to a reduction in the incidence of concussion and improved outcomes from concussion [18, 173]. There is little evidence to suggest that this is happening in Ontario but emergency room findings from Chapter 3 (Paper 2) hint at the possibility that concussion policies have had an effect on halting the increase in yearly concussion prevalence. Using CHIRPP data, we have noticed a sudden, minor decrease in the number of hospital admissions for concussion-related issues, coinciding with the introduction of the PPM in 2014 (Chapter 3, Figure 1). There were more than 300 less suspected concussions in 2014 than in the previous year. The following two years also saw a significant drop in suspected

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concussions, suggesting that something was contributing to these unexpected decreases. Nevertheless, not enough time has passed to make any conclusive statements and more research is necessary to examine the overall effects the individual school board concussion policies have had on concussion-related hospital admissions and overall province-wide concussion incidence rates.