The Risk Assessment Case for Public Health Regulation Worldwide of the Concussion Crisis in Sports
Year: 2026
Type: article
Abstract: INTRODUCTION The support of the medical profession was indispensable in the United States and Canada for enacting legislation addressing public health issues such as drunk driving, smoking, and bicycle helmets. The sports concussion crisis is also another major public health concern in Canada and many other countries. After motor vehicle crashes which have extensive safety regulation, the second leading cause of concussion is sports and recreation.1 Currently, each year, 1 in 100 Canadians suffers a concussion.2 Most Canadian youth play sports. The juvenile brain is particularly vulnerable to concussive injury, and symptoms can be long-lasting, even permanent. Moreover, repetitive concussions can cause lethal complications such as malignant brain swelling, termed second impact syndrome, which caused the death in 2013 of Rowan Stringer, 17-yearold captain of her Ottawa, Canada, school rugby team.3,4 Stringer told no adults that she had suffered concussions in rugby games in the few days preceding her final fatal brain injury, which led to Ontario's 2017 concussion law with its message “Kids Must Tell”.5 Repeated concussions also force great athletes to retire due to persisting symptoms,6 while others develop chronic traumatic encephalopathy, a neurodegenerative condition causing dementia,7 recently also recognized in female athletes.8 Of great importance to every athlete worldwide are the recent dementia consensus statements that traumatic brain injury including concussion is a risk factor for all types of dementia.9,10 For these reasons, we advocate support from the medical profession and other health care professionals in all countries for public health concussion laws or other public health regulation to limit sports concussions. Similarly, we continue to advocate for Rowan's Law in all provinces and districts in Canada. Indeed, in the United States, such efforts led to enactment of concussion laws in all 50 states and the District of Columbia between 2007 and 2014.11,12 These laws increased concussion awareness in school-based and club-based sports and require sport officials to abide by best-practice protocols for removal-from and return-to play. In Ontario, the Ministry of Education enacted concussion public policies in 2014 and proven to have significant benefits.13–15 Indeed, the 2017 Ontario Concussion Law highlighted the seriousness of concussion, stressed primary concussion prevention, and drew attention to potential consequences—medical and legal. Even laws lacking enforcement establish clearly ascertainable standards for negligence, a frequent contributing factor in sports concussions. Besides concussion education and concussion management protocols for athletes, Ontario's law mandates that school and non–school-based sports organizations adopt a concussion code of conduct designed to foster respect and adherence to concussion prevention policies.5 However, Ontario is the only Canadian province to enact a concussion safety law. Opposition from the sports industry which fears regulation and its potential for liability may have played a role. What is regrettable is the ability of opponents of concussion safety laws to claim support for their position on the basis that it is not proven that concussion safety laws work. To be clear, it is not proven that the laws don't work—the argument is simply that it is not yet established whether they work. Such proof is difficult to obtain because concussion laws enhance recognition and reporting of concussions which make it seem like more are occurring. Indeed, the very success of the law in terms of recognition of concussion may impede proof of its success. The worldwide public health policy dilemma is this: what to do under conditions of uncertainty? Implicit in the view of concussion law opponents is a default policy not to enact concussion laws without incontrovertible proof that they work. However, policy decision-making must always weigh the risks of action against the risks of inaction. We ask: is the ‘no legislation without proof’ position justifiable? The authors are unaware of any public health risk resulting from concussion laws. Indeed, we cannot imagine a latent risk in laws providing safety education, codes of safe conduct, and safe management protocols for the injured. The laws, have the force of indicating the right course for the public to follow. By contrast, the risks of inaction are enormous because the laws in Ontario and the United States were enacted to prevent brain injuries bringing severe disability and even death to youth athletes in the case of second impact syndrome. This rare result of concussion is difficult to detect and diagnose. Indeed, a coroner's inquest was needed to prove that it took the life of Rowan Stringer, the Ontario teen whose name the Ontario law memorializes.3,4 Other unexplained deaths occurring in sports may be linked to concussions. As is well known, the effects of concussion are cumulative. Examples include the association between concussions and suicide16 and the definite link between multiple concussions and second impact syndrome3 and some forms of dementia including chronic traumatic encephalopathy.10 Amid the current toll of concussion in sports and considering there is an available prevention measure having no apparent downside, the balance of risks weighs in favor of action. The scientific community is studying concussion safety laws' effectiveness, and the results can be used to improve the laws, or even to repeal them should it turn out that in fact they are not useful. We predict that once the evidence is in, the obvious benefit of concussion safety laws will be seen as a “no brainer” like prior physician-supported public health initiatives against drunk driving, and helmetless bicycling. CONCLUSION Despite its unproven effectiveness, the balance of risks provides grounds for enacting concussion safety legislation worldwide to counter the concussion crisis in sports. We hope that healthcare professionals in all countries support concussion laws as a public health matter requiring urgent attention. This much is certain: waiting for proof that such laws work will only assure the occurrence of further tragic deaths like that of the 17-year-old girl that spurred the legislation in Ontario and like the severe disablement due to brain injury suffered by 13-year-old Zachary Lystedt in the United States that sparked the laws now in force throughout the United States.17 And those tragedies to come will bring inevitable questioning of whether they could have been prevented by concussion laws, and why some provinces and countries decided to act while others did not. KEY POINTS Approximately 400 000 Canadians are concussed every year and not everyone recovers promptly or completely with a small number dying but a large number with longstanding disability. Sports are one of the highest causes of concussions in many countries, and more needs to be done to prevent sports concussions. Public health policy is a proven way in many countries for healthcare professionals to support the prevention of other causes of death and disability due to health problems such as smoking and drunk driving. Concussion laws should be an important aspect of health policy in every country, but so far, only the province of Ontario in Canada and all 50 states in the United States have concussion laws. Balancing the risks of action against those of inaction, all other countries should not wait until the efficacy of concussion laws is proven because tragedies will continue to kill and injure athletes while waiting.
Authors: Mark Moore, Charles H. Tator
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W7166734008