Los espacios libres de humo

The existing concussion safety laws in the U.S. and the proposed policies in Canada are an important first step in protecting young athletes from concussion but there are a few major limitations that would make it unwise to rely solely on federal legislation. The first problem is with uniform acceptance, standardization and implementation. Simply put, concussion safety laws should be the same across every province and state. This would not only ensure that athletes get the same standard of care wherever they go, but it would also increase the ease of statistical comparisons, as well as policy modifications and improvements. For example, in the case of "Rowan's Law" would only apply to the province of Ontario. Other provinces might develop potentially similar laws or they might not. Similarly, many U.S. states differ not only on the wording of their respective concussion policies but also on some very key specifics. For example one study that looked at RTL across different states found that only 8 states (16% of total) had a RTL law or RTL-related guidance in the state concussion policy [154]. What's worse, none of the laws actually provided any guidance on athletes suffering extensive post-concussive symptoms and only 1 recommended an evidence-based standard for RTL guidelines [154].

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Another study found major differences in terms of mandated concussion education (for coaches, trainers and ATs), and RTP protocols with regard to the timeline, content, and health care professional that can provide written clearance [155].

Another problem that faces concussion legislation or, in fact, any nation-wide injury policy is the lack of specialist medical personnel in many towns, rural areas or remote locations. In addition, larger cities might have long waiting lists for these health care professionals. There is no mandate in most current concussion safety laws that requires field medical personnel to have any specialized concussion treatment training (outside of the First-Aid components) [73]. Training front-line medical personnel, especially in the rural areas could be expensive and time- consuming but it would improve and standardize care [156-158]. However, it would improve and make the game safer in locations where there were previously no such safety measures. Some state's laws, such as Connecticut's law (Senate Bill 456) are strict and require mandatory training for coaches and continuing education follow-up courses every few years, while others such as Illinois (House Bill 200) only mentions that educational material needs to be made available to school districts in order to educate coaches as well as parents and student athletes [73]. In theory then, some towns in Illinois can "implement" their version of the mandated concussion policy by handing out necessary info pamphlets on concussions.

The final major limitation to concussion legislation is that it is very difficult to implement. Policy implementation takes time especially so, in the absence of clear and precise guidelines. For example, there are coroner's recommendations as to what to do in "Rowan's Law", but there are no steps or instructions to getting there. Dr. Pierre Fremont, chair of the Canadian Concussion Collaborative, thinks that results of the policies directed at children's safety are conflicting and confusing [159]. Sure it's useful to promote concussion safety and

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increase awareness but Dr. Fremont thinks that many of the current U.S. policies are difficult to implement and police [159]. No one is regulating sports teams and schools to ensure that there is enough "awareness" and even if there is, how would you go about measuring it [159]? It is simple to draw-up an awareness pamphlet or give a short talk on concussion prevention but how would that transfer to an actual field setting? While the state laws mandate that a medical note needs to be shown before returning to action, who is inspecting and tracking these notes, and is there even a system in place to keep track of recurring injuries? Some researchers promote the so-called knowledge-to-action policy framework whereby knowledge transfer should be user- specific, context-specific, impact-oriented and an interdisciplinary process [160-161]. It could help get information across in an expedited, easier-to-understand and helpful way, contributing to more effective policy implementation.

A few additional minor limitations will be briefly mentioned in this paragraph. First, concussion education is a strong component of most concussion laws but research has not shown no evidence of the effect of these interventions on behavior [73]. This is especially important in improving concussion attitudes and beliefs, and subsequently improving concussing reporting habits. Given the recent nature of all these concussion laws, protocols and guidelines, it is not clear what constitutes good "concussion prevention training" and what the expectations are for all sports training personnel (coaches, Health and Physical Education teachers, athletic trainers, etc). Canadian jurisprudence states that coaches "must take all of the necessary steps to avoid placing a young athlete at risk of sustaining or aggravating an injury" but and that their responsibilities may vary "according to the risks of the activity, accepted business practices and applicable professional guidelines or standards" [162]. In this sense the coach has the most important position in the concussion policy stakeholder "pyramid" as they are the ones that can

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directly influence how the game is played (rules, safety equipment used, injury prevention strategies), how the athletes feel about the game (e.g. respect each other, respect the coach, report injuries) and how new guidelines, polices or rules are introduced and implemented.

The next chapter will present the 3-paper evaluation of the PPM. The researchers hope to gain a better understanding of concussion policy effectiveness in youth athletes by analyzing the Ministry of Education's PPM # 158 in terms of its uniqueness, impact and school board adherence. Information gained from these studies will hopefully be used to develop other injury- related policies and advance sport and injury-prevention development. It will also serve to educate students and their parents on the serious nature of head injuries and hopefully help reduce future incidences of concussion