Going beyond the state law: Investigating high school sport-related concussion protocols.

Beidler E, Welch Bacon CE, Hattrup N, Powers C, Saitz L, McLeod TV. J Athl Train. 2020 Jun 18. doi: 10.4085/1062-6050-0505.20. Epub ahead of print. PMID: 34129675.
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Take-Home Message

Less than 25% of sport-related concussions (SRC) protocols in the state of Pennsylvania fully complied with the state concussion law.


All states have passed some form of SRC law, which focuses on education, removal from injury, and return to participation. However, it is unclear how many high schools have SRC protocols that adhere to the guidelines in the state law.

Study Goal

Beidler and colleagues completed a qualitative analysis of SRC protocols from high schools in Pennsylvania to investigate the compliance of these protocols to state law and guiding documents (e.g., position statements).


The researchers invited all 757 high schools in the Pennsylvania Interscholastic Athletic Association (PIAA) to participate. They sent email invitations and follow-up communications to the superintendent, high school principal, and athletic director. Participants submitted an electronic copy of their high school’s SRC protocol and indicated if their athletics program had an athletic trainer (yes/no; if yes, what level of coverage). Of the 404 schools that replied, 26 (6%) replied that they had no SRC protocol, and 184 schools sent a copy of their SRC protocol. To evaluate compliance, the research team created an assessment tool and then submitted it to external reviewers with backgrounds in SRC research and clinical practice. Four independent certified athletic trainers were then trained in the tool and analyzed the 184 SRC protocols. The assessment tool had 67 items, including 7 that verified compliance with Pennsylvania state law and 60 items based on consensus/position statements and other guiding documents for concussion education, preparticipation assessment, prevention and reducing exposure to head trauma, on-field recognition, off-field assessment, general follow-up care, and return to learning or participation.


Only 23.4% (n = 43) fully complied with the state law. The most common legal requirement in the protocols was requiring written medical clearance before returning to participation. The least common component of the state law included in the SRC protocols was the penalties for coaches who violated the removal or return to participation guidelines (25%). While many protocols (75%) addressed return to participation, only 1 in 3 protocols addressed return to learning. Interestingly, schools that reported hiring a full-time athletic trainer had better adherence to the state guideline than schools that hired part-time athletic trainers or no athletic trainers.


This study is a critical step in ensuring proper care for high school athletes who may sustain an SRC. While laws can be passed, adherence to those laws is of the utmost importance and should be clearly documented. It is concerning that only 23.4% of the submitted protocols fully complied with the state law. However, many protocols had some level of compliance, which is positive, but room for significant improvement exists. Also interesting, the presence of a full-time certified athletic trainer improved the level of compliance. While not surprising, this study provides evidence to those who advocate for more sports medicine coverage.

Clinical Implications

Ultimately, this study suggests that while complete compliance with state law is uncommon, having a full-time certified athletic trainer increases compliance. High school sport medicine teams should perform an internal audit to better align their SRC protocols with the current law.

Questions for Discussion

Have you reviewed your SRC protocols recently to ensure they comply with state laws? How often do you review or update your SRC protocols?

Written by: Kyle Harris
Reviewed by: Jeffrey Driban

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