KEEPING YOUR HEAD ON STRAIGHT: 
PROTECTING INDIANA YOUTH ATHLETES FROM 

TRAUMATIC BRAIN INJURIES THROUGH "RETURN-TO­
PLAY" LEGISLATION 

Andrew W. Breck* 

I.INTRODUCTION ....................................................................................... 216 
II. MEDICAL BACKGROUND ....................................................................... 219 

A. Definition and Symptoms of a Concussion .............................. 219 
B. Grades ofConcussion .............................................................. 220 
C. Diagnosis and Testingfor Concussions .................................. 221 

1. American Academy of Neurology ........................................ 221 
2. ImPACT Testing ................................................................... 222 

D. Second Impact Syndrome ........................................................ 223 
E. Long-term Health Effects ......................................................... 224 

ill. ACTIONS BY STATE LEGISLATURES TO PROTECT YOUTII AniLETES 
FROM TRAUMATIC BRAIN INJURY ............................................................. 225 

A. State of Washington's "Lystedt Law" ...................................... 225 
B. Comparing the Lystedt Law with Variations of 
Return-to-Play Legislation E1Jtlcted by Other States ................... 226 

1. Uniform Concussion Guidelines and Distribution 
of Education Materials ............................................................. 221 
2. Training Programs ..................................... : .. ···•·· ................. 228 
3. Informed Consent To Play and Submission of 
Medical History ....................................................................... 229 
4. Immediate Removal From Play ............................................ 230 
5. Return-to-Play Requirements ............................................... 231 
6. Neuropsychological Testing ................................................. 233 

N. CURRENTR.ETURN-TO-PLAYGUIDELINESININDIANA ...................... 233 
V. ANALYSIS OF INDIANA'S CURRENT"R.ETURN-TO-PLAY"LAW ........... 235 

A. Indiana's New Law .................................................................. 235 
1. Uniform Concussion and Head Injury Guidelines ............... 236 
2. Signed Information Sheet and Form .................................... 236 
3. Immediate Removal from Play ............................................. 236 
4. Return-to-Play Protocol: Written Clearance from a 
Licensed Health Care Provider ............................................... 237 

B. Critique of Indiana's Proposed Legislation ............................. 231 
1. Uniform Concussion and Brain Injury Guidelines .............. 238 
2. Mandatory Concussion and Head Injury Training .............. 238 
3. Personal Brain Injury Information Sheet and Form ............ 240 
4. ImPACTTesting ................................................................... 240 
5. Return-to-Play Protocol: Requirements of the Licensed 
Health Care Provider, Gradual Return-to-Play, and a 



216 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

Mandatory Waiting Period ......................... ' ................ .-............ 241 
VI. CONCLUSION •.••••••••••.••••••••••••••••••••••.•••••••••••••.•••.•••••..•.•.•••••..••••• ~ ..•.•....• 244 

I. INTRODUCTION 

Justin Joyce, an Indianapolis-area football player, took a knee to his 
temple in the first game of the 2010 high school football season.1 Joyce felt 
that something was not quite right, but.he continued to play in the game.2 

Although Joyce finished the game, he reported feeling ill after sustaining 
the jarring blow to his head? After taking a minor hit in a game the follow­
ing week, Joyce lost his balance and was removed from competition.4 

Joyce was diagnosed with a concussion the next day.5 

A "concussion is an invisible injury in a lot of cases, [and] therefore 
there is no awareness of the injury.'o6 Although concussions may be invisi­
ble to the naked eye, a recent spike in traumatic brain injuries suffered by 
youth athletes participating in amateur sports has cast a national spotlight 
on the issue. From 2006 to 2009, a study conducted by the National Center 
for Catastrophic Sport Injury Research at the University of North Carolina 
reported that thirty-two high school and youth athletes suffered permanent 
brain damage and nine died from bead injuries. 7 Even more alarming, the 
rate of head injuries in youth athletes reported by the Center nearly doubled 
the total from the. previous four years. 8 

The emerging national initiative to combat traumatic brain injuries 
sustained by youth athletes gained steam following an incident in the state 
of Washington. In October 2006, Zackery Lystedt, a youth athlete from 
Tacoma, Washington, complained of pain in his bead after making a routine 
tackle during a junior high school football game. 9 After minimal inquiry 
and no medical tests, coaches later allowed Lystedt to return to competition 

• J.D. Candidate, 2012, Indiana University Robert H. McKinney School of Law; B.A., 
2006, DePauw University. 

1. Nat Newell, The Hardest Hit, INDIANAPOUS STAR, Oct. 1, 2010, § Local- Metro 
& State, at At. 

2. /d. 
3. /d. 
4. /d. 
5. !d. 
6. Melissa Healy, Sideline Athletes with Concussions, Group Says, Cm. TRm., Nov. 

2, 2010, §News, at 13 (quoting Dr. Jeffi'ey Kutcher from the NeuroSport program at the 
University of Michigan). 

7. Newell, supra note 1, at Al. 
8. /d. 
9. The Zack Lystedt Law: Preventing Brain Injuries in Children, PATIENT PoWER 

(May 14, 2009), http:/lwww.p!Jtientpower.info/programltbe-uck-lystedt-law-preventing­
brain-injuries-in-cbildrenltranscript/2. 



2012] "RETURN-TO-PLAY" LEGISLATION 217 

after halftime. 10 Unbeknownst to anyone, Lystedt had suffered a concus­
sion, and toward the end of the game he collapsed into a coma.11 Emergen­
cy surgery on both sides of Lystedt's brain saved his life, but he suffered 
considerably following the injury.12 Lystedt was unable to speak for nine 
months and could not move his limbs for thirteen months.13 Although he 
has since regained these functions,.Lystedt remains confined to a wheel­
chair, suffering severe cognitive defects.14 More than three years after the 
injury, Lystedt continues to undergo forty hours.oftherapy every week in a 
determined effort to rehabilitate.15 In the years following the incident, the 
Lystedt family along with assistance from the Brain Injury Association of 
Washington successfully lobbied for passage of the Lystedt Law.16 The 
Lystedt Law is the nation's first state statute requiring adherence to a strict 
protocol in allowing youth athletes to return-to-play following an apparent 
brain injury. 17 

Unfortunately, both the Joyce and Lystedt stories are not unique. 
Youth athletes across the nation are suffering concussions with increased 
frequency in recent years. 18 A survey conducted during the 2008-2009 sea­
son by the Indianapolis-based National Federation of State High School 
Associations (''NFHS")19 estimates that 140,000 high school athletes, or 
roughly 1.8% of the total participants, suffer concussions every year.20 The 
issue is not just limited to football. According to the NFHS study, ice 
hockey and women's lacrosse rank second and third, respectively, in con­
cussion rates.21 

The American Academy of Neurology issued a position statement in 
October 2010 supporting implementation of a general policy aimed at pro­
tecting youth athletes from suffering serious brain injuries.22 According to 

10. /d. 
11. Scott Sandsberry, Gray Matter: Attitudes Toward Brain Injuries Changing with 

More Knowledge, YAKIMA IIERALD-REPUBuc (Wash.), Oct. 29, 2010, http:// sportsya­
kima.com/2010/10/gray-matter-attitudes-toward-brain-injuries-changing-with-more­
knowledge/. 

12. The Zack Lystedt Law: Preventing Brain Injuries in Children, supra note 9. 
13. Sandsberry, supra note 11. 
14. The Zack Lystedt Law: Preventing Brain Injuries in Children, supra note 9~ 
15. House Call with Dr. Sanjay Gupta: Concussion Crisis in Football (CNN television 

broadcast Nov. 27, 2010). 
16. Megan Foreman, Sidelined for Sqfety, ST. LEGISLA1UR.ES, June 1, 2010, at 28. 
17. /d. 
18. Concussion, MEDLINEPLUs, http://www .nlm.nih.gov/medlineplus/concussion.html 

(last visited Sept. 24, 2011 ). 
19. See generally About NFHS, NATIONAL FEDERATION OF STATE HIGH SCHOOL 

AsSOCIATIONS, http://www.nfhs.org/Activity3.aspx?id=3260 (last visited Sept. 24, 2011) 
(describing the function ofNFHS as "set[ting] directions for the future by building aware­
ness and support, improving the participation experience, establishing consistent standards 
and rules for competition, and helping those who oversee high school sports and activities"). 

20. Newell, supra note 1, at Al. 
21. Id. 
22. Position Statement on Sports Concussion, AM. ACAD. OF NEUROLOGY (Oct. 2010), 



218 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

the group, the driving force behind advocating for a safer concussion and 
head injury policy is that sports now rank second only to motor vehicle ac­
cidents as a leading cause of traumatic brain injuries in people aged fifteen 
to twenty-four.23 

Congress has recently considered at least two bills that would imple­
ment national guidelines for identifying and managing concussions in youth 
athletes.24 However, federal legislation has yet to be enacted, and there ap­
pears to be a lack of urgency in passing a federal mandate. In fact, the Con­
cussion Treatment and Care Tools Act ("ConTACT Act") unanimously 
passed the House of Representatives in September 2010, but the Senate 
"didn't have much time to finish giving consideration" to the bill before the 
congressional session concluded, thus allowing the proposed legislation to 
expire. 25 

In the absence of federal regulation, it is critical to have state statutory 
guidelines regulating a youth athlete's return to the playing field following 
an apparent head injury. Several states have enacted specific return-to-play 
legislation based on Washington State's Lystedt Law; Indiana passed its 
new law in May 2011, which requires compliance by July 1, 2012.26 

Return-to-play legislation is intended to protect youth athletes from 
the potential long-term or fatal health effects that accompany head injuries. 
It takes young people longer to heal from concussions than adults.Z7 "Kids' 
bodies are still growing; so are their brains. But while they rebound from 
sprains and strains more easily than creaky adults, kids get hurt worse by 
blows to the head and take longer to recover."28 In fact, an injury that may 
take an adult's brain five days to heal could require a younger person's 
brain ten days or even longer to fully recover.29 Furthermore, while youth 
athletes' bodies are growing, they are not in the physical condition to take 
hits to the head as readily as older, more developed athletes. According to 
Chris Nowinski, president of the nonprofit Sports Legacy Institute, "High 
school players generally have weaker necks than college or professional 
players . . . which causes their heads to absorb a greater amount of force 
when hit. "30 

http://www.aan.com/ globals/axon/assets/7913.pdf. 
23. !d. 
24. Darla Carter, Watch Your Head: Concussions Are Serious, Common Injuries -

Don't Ignore Them, CoURIER-JOURNAL (Louisville, Ky.), Sept. 30,2010, at Dl. 
25. Jackie Friedman, ConTACT Act Creators Seek National Guidelines, STAR-LEDGER 

(Newark, N.J.), Feb. 5, 2011, § Sports, at 26 (quoting Rep. Bill Pascrell, a sponsor of the 
ConTACT Act). 

26. See IND. CODE§§ 20-34-7-1 to -5 (2011). 
27. Foreman, supra note 16, at 28. 
28. Editorial, Adults Must Use Their Heads in Handling Young Athletes' Concussions, 

FORT WORTH STAR-TELEGRAM, Sept. 6, 2010, available at 
http://www.star-telegram.com/2010/09/06/2448068/adults-must-use-their-heads-in.html. 

29. Foreman, supra note 16, at 28. 
30. Chris Hine, Going to Max Protect: IHSA Has New Concussion Rule, but Some 

Critics Demand More, Cm. TRIB., Aug. 26,2010, §Chicago Sports, at 6. 



2012] "RETURN-TO-PLAY" LEGISLATION 219 

Part II of this Note will discuss concussions from a medical perspec­
tive including a definition and common symptoms of concussion, an expla­
nation of the different grades of concussion, diagnosis and current testing 
methods for concussions, the dangers of Second Impact Syndrome, and the 
long-term health effects associated with traumatic brain injuries. Part III 
will discuss the features of Washington State's Lystedt Law, the first re­
turn-to-play statute passed by any state legislature, and will compare it with 
variations of return-to-play legislation subsequently enacted by other state 
legislatures. Part N will discuss Indiana's current concussion protocol 
along with an analysis of the return-to-play legislation recently passed by 
the Indiana legislature. Finally, Part V of this Note will critique Indiana's 
new return-to-play law and set forth recommendations for improvement 
based on observations of the various permutations of the Lystedt Law 
passed by other state legislatures. 

II. MEDICAL BACKGROUND 

A. Definition and Symptoms of a Concussion 

There is no universal agreement among scientists and medical practi­
tioners on the precise definition of a concussion.31 Generally, though, a 
concussion can be defined as "a complex pathophysiological process affect­
ing the brain, induced by traumatic biomechanical forces."32 The Centers 
for Disease Control and Prevention ("CDC") categorizes a concussion as a 
type of traumatic brain injury ("TBI").33 In fact, "[t]he term 'concussion' is 
often used in the medical literature as a synonym for a mild traumatic brain 
injury."34 A concussion may be caused by several factors including "a di­
rect blow to the head, face, neck, or elsewhere on the body with an 'impul­
sive' force transmitted to the head."35 However, it does not take a complete 
loss of consciousness to suffer a concussion?6 

The CDC categorizes the symptoms of concussions into four main 

31. Robert C. Cantu, Posttraumatic Retrograde and Anterograde Amnesia: Patho­
physiology and Implications in Grading and Safe Return-to-Play, 36 J. ATHLETIC TRAINING 
244, 244 (200 1 ), available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 155413/. 

32. Paul McCrory et al., Consensus Statement on Concussion in Sport: The 3rd Inter­
national Conference on Concussion in Sport Held in Zurich, November 2008, 44 J. 
ATHLETIC TRAINING 434, 435 (2009), available at http://bjsm.bmj.com/content/43/Suppl_l/ 
i76.full.pdf. 

33. Concussion and Mild TBI, CTRS. FOR DISEASE CONTROL & PREVENTION, 
http://www.cdc.gov/concussion/index.html (last updated Aug. 25, 201 0). 

34. DavidS. Kushner, Concussion in Sports: Minimizing the Risk for Complications, 
64 AM. FAM. PHYSICIAN 1007, 1008 (2001), available at http://www.aafp.org/afp/2001/0915/ 
pl007.html. 

35. Paul McCrory et al., supra note 32, at 435. 
36. Editorial, Adults Must Use Their Heads in Handling Young Athletes' Concussions, 

supra note 28. 



220 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

categories: thinking and remembering; physical; emotional and mood; and 
sleep disturbance.37 An individual suffering from a concussion may have 
difficulty thinKing clearly, concentrating, remembering new information, or 
may feel slowed down. 38 Physical symptomS include headache, nausea or 
vomiting, balance problems, dizziness, fuzzy or blurry vision, sensitivity to 
noise or light, or feeling tired and lethargic.39 Some patients with concus­
sions may also complain of a ringing in their ears.40 In more severe cases 
following a traUll'latic brain injury, an individual may lose consciousness or 
suffer the effects of amnesia. 41 Furthermore, an individual may exhibit 
signs of emotional distress or behavioral changes and become irritable, sad, 
nervous, anxious, or more emotional than normal.42 Finally, an individual 
with a concussion may 'suffer disturbances in sleeping patterns including 
sleeping more than usual, sleepingJess than usual, or experiencing difficul­
ty in falling asleep;43 ·· 

Some symptoms of a concussion may appear immediately after im­
pact, while other symptoms may not be iDnnediately ascertainable until 
days, or potentially even months, after the injury.44 In the minutes and days 
following a concussive brain injury, brain cells that are not irreversibly de­
stroyed may remain alive but in a distinctly more vulnerable state.45 

B. Grades of Concussion 

As with the definition of a concussion, there is no universal agreement 
among scientists and medical practitioners on the grading of concussions.46 

In the field of sports medicine, however, the value of grading scales for as­
sessing the severity of ooneussive brain injuries is recognized by medical 
practitioners.47 Medical experts at the American Academy of Netirology 
categorize concussions into three levels: Gradel, Grade 2, and Grade 3.48 

A Grade 1 concussion is characterized by transient confusion, no loss 
of consciousness, and concussion symptoms or mental status abnormalities 

37 . . Concussion, CTRS. FOR DISEASE CoNTROL & PREvENTION, http://www.cdc.gov/ 
concussion!signs_symptoms.btml (last updated Mar. 8, 2010). 

38. /d. 
39. /d. 
40. Concussion, MEDLINEPws, supra note 18. 
41. Paul McCrory et al., supra note 32, at 435. 
42. Concussion, CTRS. FOR DISEASE CONTROL & PREvENTION, supra note 37. 
43. /d. 
44. /d. 
45. Cantu, supra note 31, at 244. 
46. /d. 
47. See AM. ACAD. OF NEUROLOGY, PRACTICE PARAMETER: THE MANAGEMENT OF 

CONCUSSION IN SPORTS 2 (1997), http://www.aan.com/professionals/practice/guidelines/pda/ 
Concussion_ sports. pdf. 

48. /d. at 2-3. 



2012] "RETURN-TO-PLAY" LEGISLATION 221 

that resolve in less than fifteen minutes.49 This grade of concussion is the 
most common yet most difficult to recognize because an individual suffers 
only momentary confusion. 50 A youth athlete may momentarily be dazed 
but quickly respond to questioning by coaches or evaluating medical per­
sonnel. Youth athletes commonly report feeling "dinged" or getting their 
''bell rung."51 

A Grade 2 concussion is characterized by transient confusion and no 
loss of consciousness, but concussion symptoms or mental status abnormal­
ities on examination last longer than fifteen minutes. 52 A persistent Grade 2 
concussion lasting longer than one hour is extremely dangerous and war­
rants immediate medical observation. 53 A youth athlete suffering from a 
Grade 2 concussion may exhibit poor concentration or post·traumatic am­
nesia over an extended period of time. 54 

A Grade 3 concussion involves any loss of consciousness suffered by 
a youth athlete-either brief (lasting only a few seconds) or more prolonged 
(lasting several minutes). ss A Grade 3 concussion is the easiest to recognize 
and warrants immediate medical attention. 56 

C. Diagnosis and Testing for Concussions 

Initially, diagnosis of the grade of a concussion is difficult. It depends 
partly on information from the injured individual, who may not be medical­
ly trained to identify and communicate critical information regarding the 
effects of the injury. Robert Cantu, a leading expert on concussive injuries, 
stated that a "[ c ]oncussion is often referred to as the silent epidemic .... 
It's not always easy to look at somebody and see if they've suffered a con­
cussion."57 

1. American Academy of Neurology 

The American Academy of Neurology provides a breakdown for on· 
site evaluations of concussions, which includes mental status testing, exter­
nal provocative testing, and neurological testing. 58 The mental status read· 

49. !d. 
50. !d. at3. 
51. !d. 
52. Id 
53. Id 
54. Id 
55. Id 
56. !d. 
57. Jack McCluskey, Tackling a Silent Epidemic: New Law Aims at Curbing Sport­

Related Concussions, But Is It Enough?, ESPNBosroN.COM (Aug. 24, 2010 3:37 PM), 
http://sports.espn.go.com/bostonlnews/story?id=5489974. 

58. See AM. AcAD. OF NEUROLOGY, supra note 47 at 3. 



222 INDIANA HEAL Til LAW REVIEW [Vol. 9:1 

ing assesses: (1) orientation, by asking an individual to recite the time, 
place, person, and situation; (2) concentration, by asking an individual to 
count backwards or recite a sequence of items in reverse order; and (3) 
short-term memory, by asking about recent events, either regarding the ath­
letic competition where the injury was sustained or other newsworthy 
events. 59 

The external provocative test requires the individual to perform an 
athletic maneuver (e.g., push-ups, sprinting, sit-ups, or knee bends) in order 
to evaluate any differences in performance from before the injury.60 If the 
youth athlete exhibits abnormal signs, such as headaches, dizziness, nausea, 
blurred vision, or emotional aberrations, then the sideline medical evalua­
tors will classify the injury as a concussive event 61 

Finally, the neurological testing for a concussion injury includes ex­
amining an individual's: (1) pupils for symmetry and reaction time; (2) co­
ordination, through a finger-nose-finger, in tandem with walking, test; and 
(3) sensation, through a finger-nose, eyes-closed test.62 

2. ImPACT Testing 

A more popular concussion diagnostic tool is called the Immediate 
Post-Concussion Assessment and Cognitive Testing ("ImPACT").63 De­
veloped in the early 1990's, ImPACT "is the first, most-widely used, and 
most scientifically validated computerized concussion evaluation system. "64 

ImPACT is a twenty-minute evaluation that measures an individual's per­
formance across a number of physical, mental, and neurological criteria 
including attention span, working memory, sustained and selective attention 
time, response variability, non-verbal problem solving, and reaction time.65 

The scores of an individual taken post-injury are compared with baseline 
testing performed on the athlete prior to the injury in order to detect abnor­
malities and whether a concussion has occurred.66 A popular feature of Im­
PACT is that it can be conducted by anyone trained to administer the 
baseline testing·including an athletic trainer, school nurse, athletic director, 
team coach, or team doctor.67 

ImP ACT is administered on a computer and monitored by a qualified 

59. Seeid 
60. Seeid. 
61. See id. 
62. Seeid 
63. About ImPACT: Overview and Features of the ImPACT Test, IMPAC'ITEST.COM, 

http:/ /impacttest.com/aboutlbackgrowtd (last visited July 9, 2011 ). 
64. Id 
65. Id 
66. Id. 
67. Id 



2012] "RETURN-TO-PLAY" LEGISLATION 223 

professional trained on the software.68 The test is broken down into five 
separate sections, each compiling a variety of medical data.69 Section 1 re­
quires individuals to insert basic demographic information and answer a 
brief health history questionnaire.70 Section 2 then asks questions pertain­
ing to the current concussion symptoms being experienced.71 Specifically, 
this section asks about the date of the most recent concussion, number of 
hours slept afterward, and current medications taken after the injury. 72 Ad­
ditionally, this section requires individuals to rate the severity of twenty­
two concussion symptoms, which ultimately factor into the individual's 
final score.73 Section 3 is a neurocognitive test and is split into six separate 
modules: (1) word discrimination; (2) design memory; (3) "X's and O's," a 
visual recognition test gauging reaction times to illuminated on-screen ob­
jects; (4) symbol matching; (5) color matching; and (6) a three-letter 
memory task. 74 Then, Section 4 requires a more detailed description of the 
concussive event, including details on loss of consciousness, a description 
of any mouthguard or helmet worn at the time, and the point of contact.75 

Lastly, Section 5 presents the graphical display of data showing and ex­
plaining the individual's overall ImPACT results.76 Using the results from 
the six modules in Section 3 of the test, this section presents a composite of 
the athlete's final scores relative to verbal memory, visual memory, reaction 
time, and impulse control. 77 The final cumulative score then can be used to 
identify a concussed individual suffering from the effects of a traumatic 
brain injury from a non-injured individual. 78 

D. Second Impact Syndrome 

A series of repeated concussions over a short period of time may lead 
to a serious condition commonly referred to as Second Impact Syndrome 

68. /d. 
69. Id. 
70. About ImPACT: Test Features- Questionnaire, IMPACTI'EST.COM, http://impact 

test.com/aboutltest_features/questionaire (last visited Aug. l 0, 2011 ). 
71. About ImPACT: Test Features - Current Symptoms & Condition, IMPACT 

TEsT.COM, http://impacttest.com/aboutltest _features/current_ symptoms (last visited Aug. l 0, 
2011). 

72. /d. 
73. /d. 
74. About ImPACT: Test Features- Neurocognitive Test, IMPACTTEsT.COM, http:// 

impacttest.com/about/test_features/neurocognitive _test (last visited Aug. 10, 2011 ). 
75. About ImPACT: Test Features - Description of the Concussion Injury, 

IMP ACTTEsT.COM, http://impacttest.com/index.php/aboutltest _features/injury_ description 
(last visited Aug. 10, 2011). 

76. About ImPACT: Test Features- Graphic Display of Data, IMPACTTEST.COM, 
http://impacttest.com/index.php/about!test_featureslgraphic _display (last visited Aug. l 0, 
2011). 

77. /d. 
78. /d. 



224 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

("SIS").79 SIS develops when an athlete suffers a second head injury before 
symptoms have fully subsided from. the first brain trauma. 80 A second im­
pact that causes SIS need only be a minor blow and may not even be direct­
ly to the head, but the blow will cause the individual's head to snap and 
"impart accelerative forces to the brain.'.s1 SIS starts with typical post­
concussion symptoms and the individual will generally appear stunned and 
exhibit symptoms of a Grade 1 concussion. 82 Within fifteen seconds to 
several minutes of the second impact, an individual will collapse with rap­
idly dilating pupils, loss of eye movement, and respiratory failure. 83 

Studies have shown that the severity and duration of functional im­
pairment may be significantly'increased with repeated concussions.84 Rob­
ert Cantu stated that "[ o ]nee a player has incurred an initial cerebral 
concussion, his or her chances of incurring a second one are 3 to 6 times 
greater than for an athlete who has never sustained a concussion. "85 

E. Long-term Health Effects 

Long-term outcomes for individuals· suffering concussions and other 
brain injuries include deficits in memory, reasoning, sensation, language, 
and emotion. 86 A Traumatic Brain Injury {''TBf') such as a concussion may 
also cause significant long-term h~th effects including epilepsy and an 
increased risk for Alzheimer's disease, Parkinson's disease, and other brain 
disorders. 87 Repeated, mild TBis occurring over an extended period of 
time, such as within months or years, can cause cumulative neurological 
and cognitive defects. 88 Furthermore, repeated, mild TBis occurring within 
a short period of time, such as within hours, days, or weeks, can be cata­
strophic or even fatal. 89 

79. Kushner, supra note 34, at 1008. 
80. Robert C. Cantu & Robert Voy, Second Impact Syndrome a Risk in Any Contact 

Sport, 23 PHYSICIAN & SPORTSMEDICINE 27 (1995). 
81. !d. 
82. !d. 
83. !d. 
84. Cantu, supra note 31, at 246. 
85. Id 
86. Traumatic Brain Injury: Long-Term Outcomes, CTRS. FOR DISEASE CON'IROL & 

PREvENTION, http:l/www.cdc.gov/fraumaticBtainlnjury/outcomes.html (last visited Mar. 8, 
2010). 

87. Id 
88. !d. 
89. Id. 



2012] "RETURN-TO-PLAY" LEGISLATION 225 

III. ACTIONS BY STATE LEGISLATURES TO PROTECT YOUTH ATHLETES 

FROM TRAUMATIC BRAIN INJURY 

A. State ofWashington's "Lystedt Law" 

The state legislature of Washington passed the Zackery Lystedt law 
("Lystedt Law") in May 2009.90 It was the first state law to implement 
statutory requirements for youth athletes suffering from concussions.91 The 
statute sets forth four key requirements: (1) development of uniform con­
cussion guidelines and distribution of educational materials regarding brain 
injuries; (2) mandatory consent from parents for participation in youth ath­
letics; (3) immediate removal of the youth athlete from competition after 
suffering an apparent brain injury; and (4) mandatory compliance with re­
turn-to-play protocol before allowing the youth athlete to return to athletic 
competition.92 

First, each school district's board of directors must work in concert 
with Washington's state interscholastic activities associations to develop 
guidelines on pertinent information regarding concussions.93 Then, the col­
lective information must be compiled and communicated to coaches, youth 
athletes, and parents or guardians of youth athletes. 94 

The educational system established after passage of the Lystedt Law 
allowed coaches to receive concussion training from online rules clinics, 
which were offered free of charge from the Washington Interscholastic Ac­
tivities Association ("WIAA") website.95 While coaches are not required to 
pass an official state examination or obtain state certification as part of the 
education process, they are responsible for transmitting pertinent infor­
mation to their youth athletes.96 Furthermore, each school district is indi­
vidually responsible for adopting concussion management policies and 
ensuring that all coaches receive proper education on the nature, risks, 
signs, and symptoms of brain injuries prior to the coach's first practice or 
competition. 97 

Second, on an annual basis, each youth athlete and a parent or guardi­
an must jointly sign and return a concussion and head injury information 

90. Foreman, supra note 16, at 28. 
91. /d. 
92. See WASH. REV. CODE ANN.§§ 28A.600.190(2)- (4) (West20ll). 
93. WASH. REv. CODE ANN.§ 28A.600.190(2) (West 2011). 
94. /d. 
95. Publications: Concussion Management Guidelines - Coaching Resources, WASH. 

INTERSCHOLASTIC ACTIVITIES Ass'N, http://www.wiaa.com/subcontent.aspx?SeciD=624 (last 
visited Sept. 24, 2011). 

96. /d.. 
97. Publications: Concussion Management Guidelines - School Resources, WASH. 

INTERSCHOLASTIC ACTIVITIES ASS'N, http://www.wiaa.com/subcontent.aspx?SeciD=627 (last 
visited Aug. 12, 2011). 



226 INDIANA REALm LAW REviEW [Vol. 9:1 

sheet circulated by the school district before the youth athlete is allowed to 
participate in any sporting practice or competition.98 If a youth athlete is 
suspected of sustaining a concussion or head injury in a practice or game, 
the youth athlete must be immediately removed from the practice or game 
at that time.99 Moreover, a youth athlete may not be allowed to return-to­
play until both of the following criteria are met: the youth athlete is evaluat­
ed by a licensed health care provider trained in the evaluation and manage­
ment of concussions, and the youth athlete receives written clearance to 
return to play from that licensed health care provider.100 The statute allows 
a volunteer to act as the health care provider for a school district responsible 
for both the initial concussion evaluation and management, as well as for 
the subsequent written authorization for the youth athlete to return to com­
petition.101 

Furthermore, following passage of the Lystedt Law, the WIAA specif­
ically identified which licensed health care providers could conduct the re­
turn-to-play protocol: medical doctors, doctors of osteopathy, advanced 
registered nurse practitioners, physician assistants, and licensed certified 
athletic trainers. 102 The WIAA is currently researching other medical pro­
viders who may qualify for return-to-play authorization and will communi­
cate any changes directly to all schools in the state.103 

B. Comparing the Lystedt Law with Variations of Return-to-Play Legisla­
tion Enacted by Other States 

Eight other states have since passed specific return-to-play legislation 
for youth athletics modeled in some part after Washington's Lystedt Law 
including: Oregon, Oklahoma, Virginia, New Mexico, Connecticut, Rhode 
Island, Idaho, and New Jersey. Texas previously enacted sport safety laws 
in 2007 before passage of the Lystedt Law;104 however, its requirements are 
more lenient than the state statutes modeled after the Lystedt Law, focusing 
only on annual head injury training for coaches and athletic trainers and 
providing no explicit return-to-play protocol.105 

98. WASH.REV.CODEANN. § 28A.600.190(2)(West2011). 
99. WASH. REV. CODE ANN.§ 28A.600.190(3) (West 2011). 

100. WASH. REv. CoDE ANN.§ 28A.600.190(4) (West 2011). 
101. Id. 
102. Publications: Concussion Management Guidelines - Health Care Providers, 

WASH. INTERSCHOLASTIC ACTIVITIES AsS'N, http://www.wiaa.com/subcontent.aspx?SeciD= 
628 (last visited Sept. 24, 2011 ). 

103. Id. 
104. Editorial, Adults Must Use Their Heads in Handling Young Athletes' Concussions, 

supra note 28. 
105. See TEx. Eouc. CODE ANN. § 33.202 (West 2011 ). 



2012] "RETIJRN-TO-PLAY" LEGISLATION 227 

1. Uniform Concussion Guidelines and Distribution of Education Ma­
terials 

Seven states require uniform concussion guidelines to be developed 
and implemented by local school districts; however, the states differ on the 
specific collaborative efforts needed to develop the guidelines. In Washing­
ton106 and Oklahoma,107 the local school districts work in concert with the 
states' respective youth interscholastic athletic activities associations to de­
velop concussion guidelines. New Mexico requires the state's activities 
association and local school districts to develop the guidelines and training 
programs as well as collaborate with the state's brain injury advisory coun­
cil. lOs 

In contrast, other state statutes require no involvement of local school 
districts in the guideline development process. For example, the Virginia 
Board of Education is the sole entity charged with developing concussion 
guidelines and distributing such guidelines to the local school districts in a 
top-down directive approach. 109 In contrast, Rhode Island's statute requires 
both the state's department of education and department of health to work 
jointly with the state's interscholastic athletic association to develop the 
guidelines on concussions and other head injuries. 110 Idaho also requires 
collaboration between the state's board of education and the state's high 
school athletic association.111 Idaho provides the most lenient standard and 
only requires the brain injury guidelines and other pertinent educational 
forms to be posted and easily retrievable on the state's board of education 
website;112 Idaho does not require actual direct distribution of the material 
to local school districts.113 

Finally, New Jersey requires its Commissioner of Education to devel­
op a model policy on sports-related concussion guidelines.114 This model 
policy, along with policies established by other organizations specializing 
in the prevention and treatment of sports-related concussions, 115 must be 
reviewed by each school district in developing an individualized written 

106. WASH. R:Ev. CODE ANN.§ 28A.600.190(2) (West 2011). 
107. OKLA. STAT. ANN. tit. 70, § 24-155(A) (West 2011). 
108. N.M. STAT. A."<N. § 22-13-31(0) (West 2011). 
109. VA. CODE ANN.§ 22.1-271.5(A)(West 2011). 
llO. R.I. GEN. LAWS ANN.§ 16-9l-3(a)(West2011). 
111. IDAHO CODE ANN. § 33-1625{1) (West 2011 ). 
112. IDAHO CODE ANN.§ 33-1625(2)(West 2011). 
113. See id. 
114. N.J. STAT. ANN.§ 18A:40-41.3(b) (West 2011). 
115. N.J. STAT. ANN. § 18A:40-41.3(a) (West 2011) (listing the various organi7.ational 

policies to consider as "the New Jersey State Interscholastic Athletic Association, the Na­
tional Collegiate Athletic Association, and the recommendations made by the Brain Injury 
Association of New Jersey Concussion in Sports Steering Committee, [and] the Athletic 
Trainers' Society ofNew Jersey"). 



228 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

policy for that district regarding head injuries sustained by youth athletes.116 

Further, in an effort to ensure availability of the most up-to-date infor­
mation, each school district's policy must be annually reviewed and updat­
ed as necessary. 117 

The current Oregon and Connecticut statutes do not require develop­
ment of uniform guidelines for concussion management, but they do require 
development of some form of standardized concussion training. Oregon 
charges the state's board of education with establishing the appropriate head 
injury training requirements along with implementing a timeline for com­
pletion of this training prior to the start of each athletic season. 118 Connect­
icut requires the training guidelines to be developed by the state's board of 
education in conjunction with the state's intramural and interscholastic ac­
tivities association, an appropriate organization representing licensed athlet­
ic trainers, and an appropriate organization representing county medical 
associations. 119 

2. Training Programs 

Several states currently require some form of organized concussion 
training program. However, the states differ regarding the type of training 
required, who must participate, and the frequency of training. Oregon's 
statute is the least stringent ·and requires only coaches to receive annual 
training on the recognition of concussion symptoms.120 The Oregon statute 
does not otherwise require any education or organized training program for 
other school officials, parents or guardians of youth athletes, or the youth 
athletes themselves. 121 Connecticut also requires only coaches to complete 
initial training, but imposes stricter requirements by requiring the coach to 
review training materials annually and to complete a refresher course every 
five years.122 

New Mexico requires each coach participating in school athletic activ­
ities to receive training on the nature and risk of brain injury, recognition of 
symptoms of brain injury, understanding when it is critical to contact medi­
cal professionals, and the importance of following medical direction from 
professionals.123 However, the New Mexico statute does not impose a fre­
quency requirement for the training.124 The New Mexico statute goes fur-

116. /d. 
117. Id. 
118. OR. REv. STAT. ANN.§ 336.485(2) (West 2011). 
119. CoNN. GEN. STAT. ANN.§ 10-149b(bX1) (West 2011). 
120. OR. REv. STAT. ANN. § 336.485(2Xa) (West 2011 ). 
121. See id. 
122. CoNN. GEN. STAT. ANN.§§ 10-149b(aX2)-(3) (West 2011). 
123. N.M. STAT. ANN.§§ 22-13-31(C)- (D)(1) (West 2011). 
124. See N.M. STAT. ANN. § 22-13-31 (West 2011). 



2012] "RETURN-TO-PLAY" LEGISLATION 229 

ther than the Oregon statute by mandating that the state's athletic activities 
association develop and distribute educational materials on brain injuries to 
a wider cross-section of individuals, including coaches, student athletes, 
and parents or guardians of student athletes.125 

Rhode Island requires schools to make use of specified training mate­
rials made available by the Centers for Disease Control and Prevention 
("CDC").126 Rhode Island's Department of Education must post the train­
ing materials on its website, making the information. readily available to 
each school district.127 Additionally, the Rhode Island statute requires all 
coaches and volunteers involved in youth athletic activities subject to the 
state's athletic association to complete a training course on concussions and 
traumatic brain injuries.128 Rhode Island requires the coaches and volun­
teers to complete a refresher course on an annual basis thereafter.129 

New Jersey's statute mandates that the state's department of education 
develop and implement an interscholastic athletic head injury safety. train­
ing program.130 The statute requires school physicians, any coach of a pub­
lic or nonpublic school interscholastic sport, and all athletic trainers of 
public and nonpublic school interscholastic programs to complete . such 
training.131 Furthermore, the New Jersey Department of Education is re­
quired to update the training program. When necessary to ensure the appro­
priate education is provided to the proper individuals.132 

The Texas statute requires coaches, trainers, and sponsors for extra­
curricular athletic activities to satisfactorily complete a safety-training pro­
gram, 133 which includes certification requirements of all participants from 
the American Red Cross, American Heart Association, or a similar organi­
zation under the state's youth interscholastic athletic associatimi!34 Infor­
mation that must be presented within the training and later provided to 
student athletes includes recognizing symptoms of catastrophic injuries 
specifically related to the head and neck, concussions, and Second Impact 
Syndrome. 135 

3. Informed Consent To Play and Submission of Medical History 

A majority of states require some form of informed consent or sub-

125. N.M. STAT. ANN.§ 22-13-31(DX2) (West 2011). 
126. R.I. GEN. LAws ANN.§ 16-91-3(b)(West 2011). 
127. Id. 
128. /d. 
129. Id. 
130. N.J. STAT. ANN.§ 18A:40-412(a)(West2011). 
131. !d. 
132. N.J. STAT. ANN.§ 18A:40-412(b) (West2011). 
133. TEx. Eouc. CoDE ANN.§ 33.202(bX1)(West 2011). 
134. TEx. Eouc. CoDE ANN.§ 33.202(cXl)(West20ll). 
135. TEx. Eouc. CODE ANN.§§ 33.20i(cX2)(D),(dXl)(West2011). 



230 INDIANA HEAL Til LAW REVIEW [Vol. 9:1 

mission of medical history prior to allowing a youth athlete to participate in 
sporting activities. Currently, the return-to-play laws require only a youth 
athlete and the athlete's parent or guardian to annually sign a generic head 
or brain injury information form developed by either the state or the local 
school district. Five states require signature of these basic informational 
forms: Washington,136 Virginia, 137 Oklahoma, 138 New Mexico, 139 and New 
Jersey.140 Rhode Island's statute is even more stringent, requiring the gen­
eral concussion and brain injury information form to be signed and returned 
prior to the start of every sport season, which requires a multi-sport athlete 
and their parent or guardian to sign and return the form before the start of 
each separate sport season.141 

Specifically, these general concussion and brain injury infortnation 
forms communicate the symptoms, risks, and long-term health effects rela­
tive to head injuries and are required to be signed and returned to the school 
or coaches prior to the athletic season to document receipt of the infor­
mation. Therefore, none of the current return-to-play statutes mandate that 
a youth athlete provide any personal head injury or concussion history in­
formation either to the coaches or to any school district officials prior to 
participation in athletic competition. 

4. Immediate Removal From Play 

A critical piece of all return-to-play legislation involves the immediate 
removal of a youth athlete suffering from an apparent head injury from the 
field of play. Several states currently require an athlete to be immediately 
removed from practice or competition if they appear to have suffered a head 
injury or concussion. These states include Washington,142 Oregon,143 Vir­
ginia,144 Oklahoma,'45 New Mexico,'46 Connecticut,147 New Jersey,'48 and 
Rhode Island.149 These eight states take a more stringent approach to youth 
athlete head injuries, in that a youth athlete will be immediately removed 
from play after a head injury, even if the athlete does not suffer uncon­
sciousness. By contrast, the current Idaho laws do not address or require 

136. WASH. REV. CODE ANN. § 28A600.190(2) (West 2011 ). 
137. VA. CODE ANN. § 22.1-271.5(BX1) (West 2011). 
138. OKLA. STAT. ANN. tit. 70, § 24-155(A) (West 2011). 
139. N.M. STAT. ANN.§ 22-13-31(E) (West 2011). 
140. N.J. STAT. ANN.§ 18A:40-41.2(c) (West 2011). 
141. R.I.GEN.LAWSANN. § 16-91-3(c)(West2011). 
142. WASH. REV. CODE ANN.§ 28A.600.190(3) (West 2011). 
143. OR.. REv. STAT. ANN.§ 336.485(3Xa) (West 2011). 
144. VA. CoDE ANN.§ 22.1-271.5(BX2)(West 2011). 
145. OKLA. STAT. ANN. tit. 70, § 24-155(B) (West 2011). 
146. N.M. STAT. ANN.§§ 22-13-31(AX1)-(2) (West 2011). 
147. CoNN. GEN. STAT. ANN.§§ 10-149c(aX1XA)-(B) (West2011). 
148. N.J. STAT. ANN.§ 18A:40-41.4 (West 2011). 
149. R.I. GEN. LAws ANN.§ 16-91-3(d)(West 2011). 



2012] ''RETURN-TO-PLAY" LEGISLATION 231 

immediate removal of a youth athlete when he or she appears to have suf­
fered either a head injury or concussion.150 

5. Return-to-Play Requirements 

Several states require a youth athlete who appears to have suffered a 
head injury or concussion to be evaluated before returning to athletic prac­
tice or competition. The Rhode Island statute e~bits the least restrictive 
language by requiring an evaluation from a licensed physician and written 
clearance before the youth athlete may return to play.151 The New Mexico 
statute is virtually the same and mandates medical clearance by a licensed 
health care provider.152 Oregon's statutory language is similarly broad, re­
quiring the youth athlete to be evaluated and medically released by a health 
care professiona1.153 These three statutes do not explicitly mandate that the 
licensed medical personnel who are evaluating and medically clearing the 
youth athlete have any specific training in concussion or head injury man­
agement. 

Other state statutes are more strict and require youth athletes suspect­
ed of sustaining a head injury to be evaluated by a licensed medical health 
care provider specifically trained in concussion evaluation and management 
and receive written clearance from that licensed health care provider prior 
to returning to competition. These states include Washington,154 Oklaho­
ma, 155 Connecticut, 156 and New Jersey.157 These additional requirements 
ensure that the medical evaluator has specific training in concussion man­
agement and provide a safeguard to ensuring appropriate medical decision­
making. 

Two states provide even more demanding requirements, such as ex­
plicitly identifying the medical licenses appropriate to evaluate and manage 
concussions of youth athletes under return-to-play protocols. New Mexi­
co's statute clearly mandates that the health care professional conducting 
the return-to-play protocol meet one of the following state licensing re­
quirements: practicing physician or physician assistant licensed under the 
state's Medical Practice ·Act, practicing osteopathic physician, practicing 
certified nurse practitioner, practicing osteopathic physician's assistant, 
practicing psychologist, or practicing athletic trainer.158 Connecticut's stat­
ute also mandates that the health care professional meet one of the follow-

150. See IDAHO CoDE ANN.§ 33-1625 (West 2011). 
151. R.I. GEN. LAWS ANN.§ 16-91-3(e)(West 2011). 
152. N.M. STAT. ANN.§ 22-13-31(B)(2) (West 2011). 
153. OR. REV. STAT. ANN.§ 336.485(3)(b)(B) (West 2011). 
154. WASH. REv. CODE ANN.§ 28A.600.190(4)(West2011). 
155. OKLA. STAT. ANN. tit. 70, § 24-155(C) (West 2011). 
156. CONN. GEN. STAT. ANN.§§ 10-149c(a)(2), (a)(3)(B) (West 201 1). 
157. N.J. STAT. ANN.§ 18A:40-41.4 (West 2011). 
158. N.M. STAT. ANN. § 22-13-31(F)(5) (West 2011). 



232 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

ing state statutory licensing requirements: licensed physician, licensed phy­
sician assistant, licensed advanced practice registered nurse, or a licensed 
athletic trainer.159 

Virginia's return-to-play law requires a youth athlete who appears to 
have suffered a head injury or concussion to be evaluated by a licensed 
health care provider and receive written clearance from that health care 
provider prior to returning to competition.160 However, the statute also re­
quires that the licensed health care provider be deemed .. appropriate," as 
determined by the state's board of education.161 This language provides 
flexibility in allowing the state board of education to determine the proper 
medical credentials necessary to perform concussion evaluation and man­
agement in youth athletics without providing an exhaustive listing of licens­
ing requirements within the statute itself. 

Additionally, Washington, 162 Virginia, 163 and Oklahoma, 164 all explic­
itly allow volunteers to be the licensed medical health care providers re­
sponsible for evaluating and authorizing the youth athlete to return to play. 
By allowing volunteers, these state statutes provide an element of flexibility 
for school districts to fully comply with return-to-play legislation in a more 
cost-effective manner. 

In addition to regulating the requirements of health care providers per­
forming return-to-play protocol, some state statutes impose a mandatory 
waiting period before allowing a youth athlete to return to sporting competi­
tion. Specifically, Oregon requires a youth athlete to sit out at least one day 
after the injury before returning to athletic competition.165 Even more pre­
cautionary, New Mexico does not allow a youth athlete to return to compe­
tition for at least one week after sustaining a brain injury.166 

Connecticut's statute is unique in incorporating a two-tiered approach 
in its return-to-play protocol. Initially, a youth athlete may be granted writ­
ten medical clearance from a licensed health care professional to engage in 
supervised physical exertion.167 Following initial clearance from the li­
censed health care professional to engage in restricted and supervised phys­
ical exertion, a youth athlete must receive a second written clearance from 
that licensed health care professional in order to·fully participate in athletic 
competition without any limitations on contact and physical exertion.168 

Accordingly, Connecticut requires that coaches gradually introduce the 

159. CONN. GEN. STAT. ANN.§ 10..149c(c) (West 2011). 
160. VA. CODE ANN.§ 22.1-271.5(8)(2) (West 2011). 
161. Id. 
162. WASH. REv. CODE ANN.§ 28A.600.190(4) (West 2011). 
163. VA. CODE ANN.§ 22.1-271.5(B)(2) (West2011). 
164. OKLA. STAT. ANN. tit. 70, § 24-155(C)(West2011). 
165. OR. REv. STAT. ANN.§§ 336.485(3)(a)-(b) (West 2011). 
166. N.M. STAT. ANN.§ 22-13-3l(B) (West2011). 
167. CoNN. GEN. STAT. ANN.§ 10..149c(a)(~) (West 2011). 
168. CONN. GEN. STAT. ANN.§ 10..149c(a)(3) (West 2011). 



2012] "RETURN-TO-PLAY" LEGISLATION 233 

youth athlete back into athletic activity by mandating an initial limitation on 
physical exertion and continually monitoring the athlete's increased expo­
sure to physical contact and exertion over time. 

6. Neuropsychological Testing 

Rhode Island's statute also encourages, but does not mandate, that 
schools perform baseline neuropsychological testing .· on student athletes to 
aide in concussion management.169 No other state's return-to-play protocol 
explicitly mandates or encourages any specific form of brain testing to be 
conducted in the evaluation and management of concussions in youth ath­
letes. 

N. CURRENT RETURN-TO-PLAY GUIDELINES IN INDIANA 

Return-to-play legislation was introduced in the Indiana Senate on 
January 5, 2011, and was passed by both houses in April2011.170 The gov­
ernor signed the bill on May 10, 2011, and it became effective .July 1, 
2011.171 The Indiana High School Athletic Association ("IHSAA") is the 
primary authority foneturn-to-play issues within Indiana's youth· interscho­
lastic athletics until mandatory compliance of this law becomes effective 
during the 2012-2013 high school athletic season, at which time, regulating 
return-to-play will be the state's responsibility. 

The IHSAA requires member institutions to follow the concussion 
guidelines promulgated by the National Federation of State High School 
Associations (''NFHS").172 The current IHSAA protocol requires all mem­
ber school districts to immediately remove a player from a contest who ex­
hibits signs, symptoms, or behaviors consistent with a . concussion, 
including loss of consciousness, headache, dizziness, confusion, or balance 
problems.173 Under the new Indiana law, the statutory language is more 
specific than the IHSAA protocol. Currently. the IHSAA protocol requires 
immediate removal only if the injury occurs during an athletic "contest."174 

Indiana's new law extends the requirement to include removal of a youth 

169. Rl. GEN.LAWSANN. § 16-91-3(c)(West2011). 
170. Action List: Senate Bill 0093, INDIANA GENERAL AsSEMBLY, http://www.in.gov/ 

apps/lsa/sessionlbillwatcblbillinfo?year=2011&request=getActions&doctype=SB&docno=O 
093 (last visited July 11, 2011 ). 

171. /d. 
172. Newell, supra note 1, at At. 
173. Quick Resources: Concussion Protocol, IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, http://www.ihsaa.orgldnn!Home/tabid/38/Default.aspx (last visit­
ed Mar. 10, 2011). 

174. /d 



234 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

athlete from the playing field during a practice as well. 175 

Additionally, the current IHSAA protocol requires a youth athlete to 
be cleared by a "designated health care professional" before returning to 
competition.176 More specifically, the protocol requires game officials who 
observe a player suffering from an apparent concussion to inform coaches 
and to advise that the player be removed from competition to be evaluated 
by the school's designated health care professiona1.177 Under the new Indi­
ana law, the responsibility of removing the youth athlete from competition 
for medical evaluation is not specifically designated to game officials and, 
therefore, this responsibility would be more evenly spread among both 
coaches and game officials alike. 178 

The IHSAA protocol clearly defines a "designated health care provid­
er" who may perform the initial screening of a youth athlete removed from 
competition as any of the following licensed professionals: medical doctor 
("MD") or doctor of osteopathic medicine ("DO") who holds an unlimited 
license to practice medicine in the state of Indiana; or a certified athletic 
trainer ("ATC/L") licensed in the state oflndiana.179 By contrast, the new 
Indiana law provides less restrictive language by allowing the initial medi­
cal evaluation to be performed "by a licensed health care provider trained in 
the evaluation and management of concussions and head injuries"180 with­
out listing any specific licensing or certification requirements. Indiana's 
new law provides additional flexibility by allowing the licensed health care 
provider to be a volunteer health care provider. 181 

According to current IHSAA protocol, if the designated health care 
provider determines that the youth athlete did not sustain a concussion and 
clears the athlete for play, then the head coach may advise game officials of 
the athlete's medical clearance from the MD, DO, or ATC/L.182 The offi­
cial may then immediately allow the athlete to return to competition. 183 In 
contrast, the new Indiana law does not include any explicit reference as to 
whether a youth athlete may immediately return to play following removal 

175. IND. CODE§ 20-34-7-4 (2011). 
176. Quick Resources: Concussion Protocol, IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, supra note 173. 

177. Id. 
178. See IND. CODE§ 20-34-7-4 (2011). 
179. Quick Resources: Concussion Protocol, IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, supra note 173. 

180. IND. CODE§ 20-34-7-S(a)(l) (2011). 
181. IND. CODE§ 20-34-7-S(b) (2011). 
182. Quick Resources: Concussion Protocol, IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, supra note 173. 

183. Id. 



2012] "RETURN-TO-PLAY., LEGISLATION 235 

and a subsequent negative initial diagnosis for concussion or head injury. 184 

If the designated health care provider does not authorize the youth ath­
lete to return to competition, then the lllSAA protocol mandates the follow­
ing requirements be satisfied before the youth athlete may return to play: (1) 
only a MD or DO may clear the individual to return to competition; (2) the 
medical clearance must be in writing; and (3) the medical clearance may not 
be on the same date on which the athlete was removed from play.185 There­
fore, if the youth athlete is initially diagnosed as exhibiting signs of a con­
cussion or brain injury, an ATC/L cannot authorize the subsequent medical 
clearance for the youth athlete to return to play.186 

On the other hand, the new Indiana law provides a less strict protocol. 
In the event a youth athlete is diagnosed with an apparent concussion or 
brain injury, the licensed health care provider must still provide written 
clearance for the youth athlete to return-to-play;187 however, there is no ex­
plicit requirement for a mandatory sit-out period. 

Under the current lllSAA protocol, the official who decided to re­
move the youth athlete from competition must file a report of the incident 
with the local school district's athletic director.188 The official must file this 
report regardless of whether the athlete is allowed to return-to-play follow­
ing removal.189 Furthermore, the school's athletic director is then required 
to file the report and make it available to the lllSAA website. 190 The new 
Indiana law requires no formal documentation of the incident to be prepared 
or retained on file. 191 

V. ANALYSIS OF INDIANA'S CURRENT "RETURN-TO-PLAY" LAW 

A. Indiana's New Law 

On January 5, 2011, return-to-play legislation was first introduced on 
the floor of the Indiana Senate by Senator Travis Holdman.192 The Senator 
consulted with the lllSAA, NFL, American College of Sports Medicine, 
USA Football, and a neurodevelopmental pediatrician at Riley Hospital for 

184. See IND. CODE§ 20-34-7-5 (2011). 
185. Quick Resources: Concussion Protocol. IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, supra note 173. 

186. Id. 
187. IND. CODE§ 20-34-7-5 (2011). 
188. Quick Resources: Concussion Protocol, IHSAA Protocol for Implementation of 

National Federation of State High School Associations (NFHS) Sports Playing Rules for 
Concussions, IHSAA.ORG, supra note 173. 

189. Id. 
190. Id. 
191. See IND. CODE§ 20-34-7-5 (2011). 
192. Action List: Senate Bill 0093, INoiANA GENERAL AsSEMBLY, supra note 170. 



236 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

Children in Indianapolis, Indiana prior to introducing the legislation.193 The 
new return-to-play statute is based on requirements already in place under 
IHSAA rules. 

The new return-to-play statute will require the following: (1) devel­
opment and communication of uniform concussion and head injury guide­
lines; (2) submission and retrieval of signed head injury information sheets; 
(3) immediate removal of a youth athlete from athletic competition after 
sustaining an apparent concussion or head injury; and (4) satisfaction of 
specific return-to-play protocol before allowing a youth athlete to partici­
pate again in athletic competition. Each requirement is discussed in detail 
below. 

1. Uniform Concussion and Head Injury Guidelines 

First, the new Indiana law requires the Indiana Department of Educa­
tion to consult with the state's interscholastic athletic association to develop 
guidelines, information sheets, and forms on the nature and risk of concus­
sions and head injuries.194 Next, the Department of Education must dissem­
inate the information to the schools for distribution to coaches, student 
athletes, and parents of student athletes. 195 

2. Signed Information Sheet and Form 

The new law further requires that prior to beginning practice for each 
interscholastic or intramural sport, a concussion and head injury infor­
mation sheet and form must be given to the student athlete and the athlete's 
parent.196 The information sheet and formis to be developed by the De­
partment of Education.197 In order to acknowledge and document receipt of 
the educational material, both the student athlete and the athlete's parent 
must sign and return the form to the student athlete's coach.198 The coach 
must then maintain the signed forms on file at the school. 199 

3. Immediate Removal from Play 

The new Indiana law also requires that any student athlete suspected 
of sustaining a concussion or head injury must be immediately removed 

193. Nat Newell, Concussion Bill Would Follow IHSAA 's Lead, INDY.COM (Jan. 5, 
2011 ), http://www .indy.com/posts/concussion-bill-would-follow-ihsaa-s-lead. 

194. IND. CODE§ 20-34-7-2(a)(20ll). 
195. !d. 
196. IND. CODE§ 20-34-7-3(1)(2011). 
197. Id. 
198. IND. CODE§ 20-34-7-3(2)(2011). 
199. IND. CODE§ 20-34-7-3 (2011). 



2012] "RETURN~ TO~PLA Y" LEGISLATION 237 

from the practice or game at the time of the injury.200 Furthermore, the 
youth athlete is not allowed to return to athletic competition until the speci~ 
fied return~to~play protocol is satisfied.201 

4. Return-to-Play Protocol: Written Clearance from a Licensed 
Health Care Provider 

If a student athlete is removed from practice or competition, the new 
law then requires the youth athlete to be evaluated by a licensed health care 
provider trained in the evaluation of concussions and head injuries.2°2 The 
student athlete will not be allowed to return to athletic competition until 
receiving written medical clearance from the same licensed health care pro~ 
vider who evaluated the student athlete immediately following the injury.203 

Finally, the new law allows a licensed health care provider to volunteer his 
or her services for both the initial evaluation of the youth athlete and the 
subsequent medical clearance of the youth athlete prior to returning to com­
petition.204 

B. Critique of Indiana's Proposed Legislation 

Although the proposed return-to-play legislation in Indiana covers the 
basic concussion and head injury issues for youth athletes enacted in other 
states, it misses the mark in terms of necessary safety precautions. The leg­
islation is almost directly modeled after the original Washington statute,205 

but suffers from the same ailments as its Washington forebear. Namely, 
critics argue the Washington legislation is too weak, stating that "[t]he 
Lystedt Law, and other state legislation like it, still allows for mismanage­
ment of injuries. ,,z06 Therefore, the following recommendations would suc­
ceed in bolstering the Indiana return-to-play legislation, in both providing 
the necessary protection for youth athletes and establishing Indiana at the 
forefront of increased safety standards regarding concussion and head inju­
ry management in youth athletics. 

200. IND. CODE§ 20-34-7-4(1)(2011). 
201. IND. CODE§ 20-34-7-4(2)(2011). 
202. IND. CODE§ 20-34-7-5(a)(l) (2011). 
203. IND. CODE§ 20-34-7-5(a)(2) (2011). 
204. IND. CODE§ 20-34-7 -5(b )(20 11 ). 
205. Compare WASH. REv. CODE ANN.§§ 28A.600.190(2)- (4) (West 2011), with IND. 

ConE§§ 20-34-7-1-20-34-7-5 (showing similarity in the statutory language employed with 
only minor differences noted in terms of organization of the statutory requirements). 

206. Alan Schwarz, Despite Law, Town Finds Concussion Dangers Lurk, N.Y. TIMES, 
Sept. 23,2010, at B15. 



238 INDIANA HEALTH LAW REvmW [Vol. 9:1 

1. Uniform Concussion and Brain Injury Guidelines 

The new Indiana law requires the Department of Education to develop 
and disseminate the concussion and head injury guidelines with only the 
assistance of the lliSAA and merely suggests consultation with outside 
medical professionals.207 The new Indiana law should further address in­
volvement in the development process of uniform guidelines. Specifically, 
the law should mandate that representatives from local school districts work 
in concert with both Indiana's Department of Education and the lliSAA to 
develop standard guidelines. Additionally, the law should require that input 
and research be obtained from other sources with specialized knowledge of 
concussion and head injury treatment and management including local med­
ical professionals. The key to the uniform guidelines' success will lie in 
adopting rules that adequately protect youth athletes but also allow school 
districts with limited financial resources the ability to comply. By requiring 
Indiana's Department of Education, the lliSAA, local school districts, and 
state medical professionals to collaborate, all voices will be heard and the 
appropriate provisions can be determined with all parties representing their 
unique positions. 

A second recommendation is to mandate rather than suggest that the 
guidelines be readily accessible from the lliSAA's website, similar to the 
Idaho statutory mandate that requires information be posted on the state 
board of education website.208 Additionally, legislation should require an 
annual review of the uniform concussion and head injury guidelines by the 
lliSAA and Department of Education, similar to New Jersey's statutory 
requirement. 209 Furthermore, any intermittent updates to the uniform guide­
lines that occur during the year should be communicated from the lliSAA 
directly to local school districts when appropriate to provide the most up­
dated safety information. 

2. Mandatory Concussion and Head Injury Training 

Indiana's new return-to-play law does not currently mandate any for­
mal educational training on concussion and head injury evaluation and 
management. The language in the. new law only requires information on 
the nature and risk of concussion be "disseminated" by Indiana's Depart­
ment ofEducation.210 This language is simply not strong enough to effect a 
proper mandate of concussion and head injury education to youth athletes 
and coaches. 

207. IND. CODE§§ 20-34-7-2(a)- (b) (2011). 
208. Compare IND. CoDE§ 20-34-7-2(c) {2011) with IDAHO CODE ANN. § 33-1625(2) 

(West20ll). · 
209. N.J. STAT. ANN.§ 18A:40-41.3(a) (West20ll). 
210. IND. CODE§§ 20-34-7-2(a) (20ll). 



2012] "RETURN-TO-PLAY" LEGISLATION 239 

Prior to the beginning of each athletic season, Indiana's law should in­
clude mandatory training for all coaches and youth athletes subject to Indi­
ana's interscholastic athletic association. The American Academy of 
Pediatrics' Council on Sports Medicine and Fitness purports that 
"[ r ]ecognition and education are paramount, because although proper 
equipment, sport technique and adherence to rules . . . may decrease the 
incidence or severity of concussions, nothing has been shown to prevent 
them."211 

Awareness of the signs and symptoms of concussions is critical to 
proper head injury evaluation and management. Without proper education, 
youth athletes are not in the best position to recognize symptoms of concus­
sions and head injuries and to adequately protect themselves from potential 
long-term negative health effects. Anonymous questionnaires released to 
high school football players after the season ended yielded information that 
15% of athletes admitted to sustaining a concussion.212 Through the same 
study, the number increased to about 50% when the word concussion was 
omitted and only concussion symptoms were listed.213 Furthermore, 35% 
of the players reported suffering from two or more incidents of head trau­
ma.2I4 

Even more troubling is that youth athletes tend to shy away from self­
reporting injuries for fear of being perceived as weak by coaches and fellow 
teammates.215 Furthermore, "[m]any athletes fear they will be stigmatized 
or demoted if they admit to being hurt, so they lie about their condition!'216 

Therefore, "it is important not only to inform athletes, coaches and parents 
of the risks of concussion but also to impress upon them the benefits of re­
porting and recovering from a concussion early on."217 

A statute mandating annual concussion training would accomplish the 
necessary goal of educating coaches and youth athletes about the symptoms 
and dangers of not properly managing a head injury. The state mandate 
should provide school districts with a number of ways to train athletes on 
concussion and head injury awareness in a number of ways in order to bet­
ter accommodate various school budget constraints. For example, the train­
ing could be offered free online via the IHSAA website. The statutory 
language should not place a heavy administrative burden on individual 

211. Editorial, Adults Must Use Their Heads in Handling Young Athletes ' Concussions, 
supra note 28. 

212. Alan Schwarz. Silence on Concussions Raises Risks of Injury, N.Y. TIMES, Sept. 
15, 2007, at Al, available at http://www.nytimes.com/2007/09/15/sports/footballl 
15concussions.html? r= 1. 

213. Id. -
214. Id. 
215. See id. 
216. Rachel Blount, Mayo Clinic Out to Check Sports Concussions, STAR TRIBUNE 

(Minneapolis, Minn.), Oct. 21,2010, at 01A. 
217. McCluskey, supra note 57. 



240 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

school districts to develop any sophisticated training, as it is unlikely that 
school districts of limited financial means would be able to comply. In 
short, the goal should be to equip coaches and youth athletes with general 
awareness of concussion symptoms and to stress the importance of seeking 
proper medical management if head injury symptoms present themselves 
during athletic competition. 

3. Personal Brain Injury Information Sheet and Form 

The new Indiana law only requires that the youth athlete and a parent 
of the youth athlete sign and return an information sheet and form providing 
general education on concussions and head injuries.218 This check-the-box 
type of requirement does not go far enough in providing proper concussion 
and head injury care. The statute should require every youth athlete to 
submit to the school district's athletic department a personal brain injury 
information form identifying any past history of concussion or other head 
injuries suffered by the youth athlete. Also, the youth athlete's personal 
brain injury information form should be signed by both the youth athlete 
and his or her respective parent or guardian prior to participation in each 
athletic season. In order to relieve any additional administrative burden, the 
personal brain injury information could be reported as a section of the in­
formational sheet and form already required under the new law. 

The personal brain injury information form should be developed joint­
ly by the lliSAA, Indiana's Department of Health, and Indiana's Depart­
ment of Education. The form should be reviewed annually along with the 
uniform concussion guidelines and updated as necessary to provide for the 
utmost safety of youth athletes. Furthermore, for ease of access and to as­
sist with compliance, the lliSAA should make the personal brain injury in­
formation form readily available on its website. 

Overallt the cost of filling out the personal brain injury form would be 
marginaL Moreover, this provision would allow for local school athletic 
departments, coaches, and designated medical professionals to be aware of 
critical head injury history. In turn, this knowledge of a youth athlete's per­
sonal medical history will provide for better evaluation and management of 
the athlete in the event of a subsequent head injury. 

4. ImPACTTesting 

Presently, the Indiana law does not require any form of testing to as­
sist in concussion and head injury management. To further enhance proper 
medical decision-making, the Indiana statute should require athletes from 
all IHSAA member schools to undergo baseline ImP ACT testing by a li-

218. IND. CODE§ 20-34-7-3 (2011). 



2012] "RETURN-TO-PLAY" LEGISLATION 241 

censed medical professional trained in concussion management before the 
start of every athletic season. This regulation would -allow all youth athletes 
to have a uniform testable basis from which a licensed health care provider. 
responsible for concussion evaluation and management could accurately' 
determine the proper course of action if an injury were to occur during the 
athletic season. 

If an injury occurs during a game or practice, Indiana law should re­
quire a post-injury ImPACT test to be conducted,. and those results should 
be measured against the youth athlete's baseline score. ImPACT reduces 
the speculation in determining when a youth athlete is no longer suffering 
the effects of a brain injury and can return to the field. 219 "In fact, neu­
rocognitive testing has recently been called the 'cornerstone' of proper con­
cussion management by an international panel of sports medicine 
experts.'.no 

Return-to-play legislation is not intended to add an expense to families 
of youth athletes or local school districts by requiring a potentially costly 
medical evaluation. The ImP ACT test is an inexpensive twenty-minute test 
that can be conducted by "anyone trained to administer the baseline test­
ing.''221 Local school districts may purchase the ImP ACT tool on a yearly 
subscription for $500 to $1,000 depending on the anticipated number :of 
baseline tests and post-injury tests required 222 Furthermore, additional 
baseline or post-injury ImP ACT tests in excess of the purchased package 
can be bought as needed in incremental costs of two dollars for each base­
line test and ten dollars for each post-injury test.223 

Already, "[a]pproximately two-thirds of ·the schools in Indiana use 
ImPACT" according to Dr. Dan Kraft, co-director of the Irrdiana Sports 
Concussion Network.224 This statistic suggests that only a minority of 
IHSAA member schools would need to implement baseline and post-injury 
ImP ACT testing to achieve participation by all member schools. Thus, a 
statutory mandate would be a useful mechanism of ensuring statewide im­
plementation of ImP ACT. 

5. Return-to-Play Protocol: Requirements of the Licensed Health 
Care Provider, Gradual Return-to-Play, and a Mandatory Waiting Period 

A key point of contention in the passage of return-to-play legislation 

219. Newell,supranote l,atAl. 
220. About ImPACT: Overview and Features of the ImPACT Test, IMPACTfEsT.COM, 

supra note 63. · · 
221. /d. 
222. Purchase: Order Forms- For Academic Institutio71S, High Schools, Colleges, and 

Universities, IMPACTfEST.COM, http://impacttest.com/purchase (last visited Aug. 16, 2011). 
223. /d. 
224. Newell, supra note 1, at AI. 



242 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

in other states has been defining the individuals qualified to evaluate and 
authorize a youth athlete's return to competition. In Pennsylvania, pending 
legislation requires that return-to-play protocol be conducted "by a licensed 
or certified health care practitioner whose scope of practice includes the 
management and evaluation of concussions.'.ns Dr. Mike Cordas, former 
football team physician at Penn State, believes the terminology is danger­
ously unrestrictive, and he advises that "[y]ou have to have more than a sur­
face knowledge of concussions ... otherwise you're going to hurt 
somebody."226 

As a result of this criticism, Indiana should clearly defme and limit the 
class of individuals who can perform the initial evaluation and subsequent 
authorization to return-to-play to only those who specialize in brain injury 
evaluation and management. The new Indiana law requiring evaluation and 
clearance by a "licensed health care provider trained in the evaluation and 
management of concussions and head injuries'.n7 teeters on the brink of 
those dangers noted by Dr. Cordas relative to the proposed Pennsylvania 
statute. The qualifying word "trained" in Indiana's new law provides too 
loose of a standard to ensure proper brain injury evaluation and injury man­
agement. It is imperative to include explicit language in the Indiana statute 
that clearly identifies the specific medical professionals allowed to perform 
return-to-play procedures, including a non-exhaustive list of the types of 
appropriate state-licensed or state-certified medical personnel. Amending 
the law to include a non-exhaustive list of qualified medical personnel 
would put the Indiana statute on par with statutes in Connecticuf'Z8 and 
New Mexico.229 

A second recommendation concerning Indiana's proposed return-to­
play protocol involves instituting a two-tiered approach to a youth athlete's 
return to competition similar to the Connecticut statute. 230 The Connecticut 
statute focuses on a supervised, gradual introduction to physical exertion. 
After sustaining a concussion, athletes should not return to play until symp­
toms have fully subsided, both before and after gradually increasing physi­
cal activity.231 More specifically, concussion experts advise that athletes 
"should follow a guided exercise progression for seven days after becoming 
symptom-free before returning to full participation.'.232 

225. Chuck Finder, PA. House Concussion Bill Draws a Mrxed Reaction Congress Also 
Wrestling with Issue of Brain Injuries, PITI'SBURGHPOST-GAZETIE, Sept 30,2010, at Bl. 

226. /d. 
227. IND. CODE§ 20-34-7-5(a)(2011). 
228. CONN. GEN. STAT. ANN.§ l0-149c(c) (West 2011). 
229. N.M. STAT. ANN.§ 22-13-31(F)(5) (West 2011). 
230. CoNN. GEN. STAT. ANN.§§ l0-149c(aX2)-(3) (West20ll). 
231. Schwarz, supra note 206, at B 15. 
232. Louise Continelli, Sharing Insight on Sports-Related Concussions, BUFFALO NEWS 

(N.Y.), Feb. 6, 2011, § Niagara Week, at 1 {quoting Dr. Anthony Surace, director of sports 
medicine at the University Sports Medicine ofNiagara Concussion Clinic). 



2012] "RETURN-TO-PLAY'' LEGISLATION 243 

The sponsor of Indiana's new law, Senator Travis Holdman, stated 
that "doctors around the state are still seeing kids go back to sports too ear­
ly."233 Accordingly, the law in Indiana should mandate a youth athlete be 
first granted an initial written medical clearance from an appropriate li­
censed health care professional allowing engagement in limited, supervised 
physical exertion. Following this initial clearance from the appropriate li­
censed medical professional to re-engage in limited physical activity, a 
youth athlete should then be required to receive a second written clearance 
from the same licensed medical professional authorizing full participation 
in athletic competition. The ability to monitor a youth athlete's recovery 
through gradual increases in physical exertion will better safeguard the ath­
lete from returning too quickly and decrease the likelihood of sustaining a 
subsequent and potentially more dangerous medical injury. 

Finally, with the difficulty in gauging concussion symptoms and the 
medical uncertainty regarding concussions and head injuries, it seems the 
most risk-averse approach would be for the proposed Indiana legislation to 
be amended to institute a mandatory waiting period even after concussion 
and head symptoms subside. As Dr. Joseph O'Neil of Riley Hospital in 
Indianapolis advocates: 

The more we have learned about the effects of a con­
cussion on a young brain, the more we are concerned 
that the brain needs time to rest and heal. ... If we al­
low the student-athlete to get back into competition or 
practice too soon it slows down the healing process 
and also puts the young person at risk for greater inju­
ry.234 

Concussion specialists have recently emphasized the critical need for a 
rest period even after an athlete is asymptomatic.235 Specifically, one con­
cussion expert advised that patients should wait seven to ten days after they 
become symptom-free before returning to full athletic competition, stating 
that "[t]here are biochemical changes occurring in the brain that must return 
to baseline before returning to full participation.'.236 

Therefore, Indiana's new law should be amended to include amanda­
tory waiting period. The waiting period should be imposed immediately 
after a youth athlete is removed from competition and is initially deemed to 
have suffered a concussion or head injury. While Oregon's statute requires 

233. Niki Kelly, State Law on Concussions Proposed: Bill Tightens Rules for Student-
Athletes Who Get Hurt, JOURNALGAZETIE(Ft. Wayne, Ind.), Dec. 30,2010, at lC. 

234. !d. 
235. Continelli, supra note 232, at 1. 
236. !d. {quoting Dr. Anthony Surace, Director of Sports Medicine at the University 

Sports Medicine ofNiagara Concussion Clinic). 



244 INDIANA HEALTH LAW REVIEW [Vol. 9:1 

a youth athlete to sit out at least qne day following injury,237 New Mexico's 
more expansive one-week standard238 would provide an even greater oppor­
tunity to, properly evaluate a youth athlete's progression through recovery. 
Furthermore, a mandatory one-week waiting period would aid in allowing 
the youth athlete ample time to be monitored and evaluated through the 
suggested two-tiered gradual return-to-play protocol described above. 

VI. CONCLUSION 

It is without question that the issue of concussions and other head in­
juries in youth athletes is a major issue nationwide. The U.S. Congress 
tried to enact federal legislation last year, but failed to do so, citing a lack of 
time to give the bill full consideration.239 In the absence of a federal man­
date, a handful of states have either specific return-to-play legislation or 
general concussion management statutes currently in force. Numerous oth­
er states have proposed similar legislation. Although Indiana youth athletic 
programs tied to the IHSAA already have a protocol in place based on 
guidelines promulgated by the NFHS, the current measures do not go far 
enough and would not carry the weight and breadth of protection that a 
statutory mandate can provide. 

Currently, the new Indiana law provides only basic precautions that 
must be strengthened to eliminate potential inefficiencies and loopholes. A 
wider circle of minds should be involved in the development of statewide 
uniform concussion and head injury guidelines. Specifically, representa­
tives from local school districts should be consulted along with other organ­
izations possessing specialized knowledge in the treatment and 
management of concussion and other head injuries. 

Additionally, amending the legislation to include a mandate for a con­
cussion and head injury safety-training program would put coaches, youth 
athletes, and parents or guardians on notice of the dangers of playing sports 
with regard to traumatic brain injuries. The recommended improvements to 
Indiana's current return-to-play legislation described in this Note would 
also mandate baseline and post-injury ImP ACT testing for all school athlet­
ic programs, which will provide a uniform and more accurate way to evalu­
ate and manage all youth athletes suffering from potentially dangerous head 
and brain injuries. 

Furthermore, the suggested enhancements to Indiana's new law out­
lined in this Note would streamline the return-to-play process by clearly 
defining the specific medical professionals qualified to conduct the youth 
athlete's initial evaluation and subsequent written authorization to return-to-

237. OR. REv. STAT. ANN.§ 336.485(3)(b) (West 2011). 
238. N.M. STAT. ANN.§ 22-l3-3l(B) (West 2011). 
239. Friedman, supra note 25, at 26. 



2012) "RETURN-TO-PLAY" LEGISLATION 245 

play, establishing a two-tiered return-to-play protocol focusing on a super­
vised, gradual return to athletic competition and establishing a uniform 
mandatory waiting period within which. to appropriately evaluate a youth 
athlete's recovery from a concussion or suspected brain injury. 

Although a youth athlete may resist being removed from athletic com­
petition due to a suspected concussion or head injury, the state must consid­
er whether the reward of winning a game is really worth the potential long­
term health risks of not removing that athlete from play. Zackery Lystedt's 
family valiantly fought for passage of the first state statutory mandate for 
concussion and head injury protection and they "know only too well the 
ramifications of hoping for the best when, in fact, the worst may be just the 
next hit away."240 It is imperative for Indiana to amend its current return­
to-play law to provide effective yet fiscally manageable requirements in the 
name of protecting youth athletes from serious harm. As Kathy Malone 
Sparks, sports medicine services coordinator for Indianapolis Public 
Schools puts it, "[y]ou only have one brain, and you'll need it later in 
life."24I 

240. Sandsberry, supra note 11. 
241. Newell, supra note 1, at Al.