If you are the parent of a middle-school or high-school athlete, you are probably aware of the intensified concerns involving sports concussions.
While concussions can happen in any sport, medical and sports professionals agree that football leads the pack in sports-related head trauma. Although the number of concussions from soccer, basketball, volleyball, baseball and cheerleading have also seen a rise, officials say the statistics are higher for football due to the popularity of the game, the numbers of players participating, and the violent collisions.
The National Football League has finally owned up to the consequences of years of helmet-to-helmet contact by its players after the suicides of pro athletes such as Mike Webster and Dave Duerson were linked to chronic traumatic encephalopathy. Debilitating head injuries to collegiate players have become public knowledge, and the increase of mild and severe traumatic brain injuries suffered by younger players have become a major concern, as well.
Recently, the NFL began its own program to prevent youth-sports concussions — “Heads Up Football” — and the Centers for Disease Control and Prevention launched a similar program — “Heads Up: Concussion and Youth Sports.” The tide has begun to turn in terms of sports-concussion awareness in professional, collegiate and school football programs.
In Walla Walla and surrounding school districts, several football coaches, athletic directors and athletic trainers say they have been trained to recognize the symptoms of concussion in their players. Coaches are turning any suspicious cases over to their athletic trainers, who assess the athlete and determine if medical follow-up is needed. The new mantra, say these sports professionals, is, “When in doubt, sit it out.”
The Second Impact That Changed Everything
In 2006, Zachery Lystedt, a 13-year-old football player in Auburn, Wash., was sidelined after he smacked his head on the ground in a play during a game. Though Zachery reportedly grabbed his head in pain after the impact, he was back in the game after halftime.
That action — returning to play after an initial concussion — had severe consequences. Zachery later collapsed on the field and was airlifted to Harborview Medical Center in Seattle. He had surgery to remove both sides of his skull to relieve the swelling in his injured brain. Although he survived, Zachery had to endure months of rehabilitation to learn to speak again and is permanently disabled.
Zachery and his parents have turned his disability into a fight for sports-concussion awareness — especially of the “second-impact syndrome” that Zachery suffered. In 2009, Washington state passed the Zachery Lystedt law, which requires any student athlete suspected of having a concussion to leave the field, be assessed by staff trained in concussion signs and symptoms, and be given medical clearance before being allowed to return to play.
The law also requires every student athlete and his or her parents to sign an information sheet saying they have read and understood the risks associated with concussions that may occur while playing a particular sport.
At Walla Walla High School, Coach Eric Hisaw says that the school’s football program has limited the number of organized practices, in accordance with the Washington Interscholastic Athletic Association’s new guidelines, to 20 for the spring and summer. This includes the team’s football camp.
“We do have regular practices with helmets and go full contact, but we do try hard to not go to the ground, and/or have many days that we bang really hard. The first part of the year, we went ‘no pads’ on Tuesday, for about three weeks, and it seemed to have helped us stay healthy.”
Other steps the football program has taken include helmet fittings, an emphasis on year-round physical training and awareness, and training on the part of the coaching staff.
“I personally read the warning/safety label to the team every spring and fall to warn the entire team of the dangers involved with football,” Hisaw says. “We also instruct the players to talk with their position coach first, so we know what is going on, how the athlete feels, when and how anything may have happened. We are around every drill and constantly talk to the kids about keeping their eyes and screws up (the screws of the face mask that attach it to the helmet). We show video of the correct and incorrect ways, and we demonstrate it to kids,” Hisaw says.
In the smaller Southeast 2B League, the DeSales High School football program has an athletic trainer, Anna Taylor, who, like Wa-Hi’s Athletic Trainer Chris Eastep, supervises all the sports at the school. Taylor makes sure all DeSales athletes undergo the Immediate Post-Concussion Assessment and Cognitive Test, known as ImPACT — a computerized test that measures response time and other neurocognitive markers — which forms a baseline for each player. Eastep does the same at Wa-Hi.
DeSales Head Football Coach Mike Spiess attended the 8th Annual Sports Leadership Conference held at the University of Notre Dame last June and came away with a new plan for preventing concussions among his players.
One presenter at the conference, sports concussion expert Dr. Steve Simon, recommended limiting the amount of contact, including during practices, to lower the incidence of concussions and thus, potentially, save lives.
“We work hard on teaching the right technique and emphasize that the helmet is not a weapon,” Spiess says.
Is Spiess concerned that fewer practices with pads and helmets will make his team less competitive? “I observe what the other teams do,” he says. “We’re the only team in our league with an athletic trainer; one team has a doctor on the field during the games. We play teams where there are kids staggering off the field after getting hit. Reducing contact in practice probably does hurt us competitively, but I’ll take that trade-off.”
‘A Stunt Gone Wrong’
Football is not the only sport that raises the concussion stakes. “Last year, we had approaching 50 teams with 700 athletes. Many of them are two- or three-sport athletes,” Wa-Hi’s Eastep says.
At DeSales, cheerleading is one of the most popular sports. Though the school has just 111 students, 19 are cheerleaders. “The reason so many girls want to cheer is because of the stunts,” says Cheerleading Coach Cathy Hamada. And stunts — all moves where a cheerleader leaves the ground — mean the potential for injury.
Last year, that’s exactly what happened.
“It was a stunt gone wrong,” Hamada says. The girls were doing an advanced stunt, she recounts, one they had just done three times, perfectly. This time, the flyer, or the person in the air, came down sideways, and two girls were hit by the stunting cheerleader’s body and feet.
Luckily for the girls, the coach knew the procedures, and Taylor was called in to assess them. They were given the ImPACT, and the results were measured against the injured cheerleaders’ baseline tests.
Taylor recommended that they see the school’s physician, Dr. Glyn Marsh. Both girls were diagnosed with concussions, and one is still restricted from cheerleading. That student has had two injuries, Taylor says. One kept her out of the 2012/2013 football season; after the second injury, she was out of cheerleading and school for three to four weeks.
This year, she had her second concussion, and was out for almost for seven weeks of the 2013/2014 season, and out of school two to three weeks. The other student was back after a few weeks.
Hamada, still visibly shaken from the experience, called the event “traumatic” and emphasized that what happened was “no one’s fault.” One of the injured athletes was Hamada’s daughter.
For the more advanced stunts, Hamada says, the coaching staff has a checklist, and the girls must progress in a certain order — from simple moves to more complex ones.
She also says that the team does extensive training for stunting, attending a clinic every three years and taking an online class every year.
Wa-Hi’s Eastep describes the potential for injury in cheerleading as serious. “You have an athlete flying 12 to 15 feet in the air,” he says.
When Medical Intervention is Called For
Glyn Marsh Jr., who is the physical medicine and rehabilitation specialist for Providence St. Mary Medical Center, is the go-to physician for Walla Walla and DeSales high schools.
If Taylor determines that a DeSales athlete needs further examination, she has the student transported to the emergency room. If they are stable, she has them make an appointment with Marsh’s office.
“In reality, a concussion and a mild traumatic brain injury are the same thing,” Marsh explains. The distinction is made between mild, and moderate or severe, traumatic brain injury.
“In moderate and severe TBI, you have changes on a MRI. You can see damage to the brain.” says Marsh. With mild TBI or concussion, he says, the MRI will look normal, but the athlete will have some clearly apparent physical symptoms .
Marsh’s simple definition: “A person is diagnosed with a concussion when they have loss of consciousness less than 30 minutes and amnesia lasting less than 24 hours.
“The diagnosis of concussion requires at least one of the four following symptoms: loss of consciousness; loss of memory of the events immediately before or after the injury; altered in mental status at the time of the injury; focal neurological deficits that may or may not be transient.
“A moderate or severe brain injury is diagnosed when a person has loss of consciousness lasting more than 30 minutes or amnesia that last longer than 24 hours.”
For the athletic trainer or doctor on the field, there are good ways to screen for concussion. The SCAT2 — the Sports Concussion Assessment Tool 2 — is a set of simple questions to determine if a person has a concussion, Marsh says. “It’s along the lines of ‘What’s the score? Who’s winning? What quarter is it?’ If there’s any delay, or if the person seems dazed at all — any question that there might have been a concussion — it’s time to pull the child out of play.”
In the clinic setting, Marsh does a physical exam, looking for neurological changes, sensory changes, weakness, neck injuries and, in rare cases, even spinal cord injuries, for which he would get an X-ray done. To determine structural abnormality in the brain, he might ask for an MRI or CT scan. However, with those whose symptoms have subsided, imaging isn’t often required.
As in the case of Zachery Lystedt, a second blow to the head is the worst-case scenario, Marsh says. “There’s a great fear about second-impact syndrome — receiving a second concussion when the first concussion has not yet healed. For some reason, when that occurs, the injury and the changes to the brain can be catastrophic, so catastrophic that if a person has second-impact syndrome, it can result in death. Those who don’t die usually end up with severe disability.” That’s why there is such intense scrutiny focused on players with an initial concussion.
“For a person who has had more than three concussions while participating in a sport, my recommendation is they never play that sport again. The risk of adding more damage on top of those injuries is that they will end up with some kind of permanent disability from it.”
In terms of recovery time, Marsh says, “The old-school thought was that after an impact, it’s all done. But doctors and researchers now know that a concussion is a process, not a moment in time. The changes occur over days and months. The changes to the blood supply and to the energy needs of the brain go up dramatically after a concussion, and certainly after a second concussion.
“If someone has a first concussion, they are at higher risk for a second concussion — we don’t know exactly why this is. They may have been just more susceptible to a concussion in the first place. It may have to do with play style, the type of sport they play, or their neck-muscle mass isn’t as big, which may have helped cause the first injury, and the brain is more apt to receive more damage. Once a person has a first one, they could be more susceptible to brain injury at any point in their life,” Marsh says.
Which are the Riskiest Sports?
“In terms of the highest risk, boxing is the most dangerous — the goal is to give your opponent a concussion. Fortunately, our nation doesn’t have a large number of young athletes boxing,” Marsh says.
But, because of the nation’s love of the game and the sheer numbers of players, Marsh says, football has the highest percentage of concussions. “There are statistics that the average high-school student playing football has 1,000 to 2,000 helmet-impacts a season. That’s huge. Each one of those hits could result in a concussion.”
According to the American Academy of Pediatrics Committee on Sports Medicine and Fitness, sports are broken down into three categories: non-contact, limited contact, and contact or collision sports.
In collision sports such as football, ice hockey and soccer, the players deliberately hit other players, or hit the ground, with great force. Non-contact sport is free of bodies colliding or regularly hitting the ground. Archery, dance and badminton are categorized as “non-contact.” Basketball, however, is in the limited-contact category, even though collisions occur with regularity — and with some intent.
DeSales Girls’ Basketball Coach Tim Duncan says that basketball has become more of a collision sport. Duncan blames the officials for that.
Basketball has become a more physical sport, in part because of the increased athletic ability of the athletes, Duncan says. “Because of this, the game has become more difficult to officiate and has become more physical,” he says. “Because athletes have become faster, there is more contact going after loose balls and more contact out front. Some of the contact is hard to control because it is hard to see who is doing what. Athletes can also jump higher now, which creates more contact in rebounding situations. The more physical contact usually comes from players playing out of control while going after loose balls. An official can make a call, but it’s after the fact.”
Training the Trainers
Coaches, athletic trainers and medical professionals who deal with youth sports are increasingly aware of the potential for concussion and most are being proactive in getting training in recognizing and treating concussions and having the confidence to send the athlete for medical follow-up care, if necessary.
Every state, except Mississippi, has adopted the Zachery Lystedt law, though how many parts of the law they follow varies.
Locally, the schools that have followed this protocol and have taken seriously the call to action by the CDC, the Washington State Interscholastic Association and the University of Washington include DeSales High School, Walla Walla High School, Touchet High School and Waitsburg (Prescott) High School. (Parents should check with their child’s school for its compliance with this regulation.)
There is no reason for people working with student athletes not to be knowledgeable. There are free sports-concussion courses for coaches, athletic trainers and nurses, and information for parents and the public is available on the CDC website. The Walla Walla School District and DeSales High School are working with Marsh and Providence St. Mary Inpatient Rehabilitation Center’s Tim Conley, a physical therapist and an athletic trainer, to inform students and parents about the risks and warning signs of concussion, guidelines for returning to play, and what to expect from the concussed student athlete.
“Teachers have to be on board, too,” Conley says. “A student with a concussion is probably not going to be able to keep up with their schoolwork as easily as they did before the concussion.”
What Should a Concerned Parent Do?
“There is no sport that is risk-free from concussion,” Marsh says. “In North America, after football, hockey is ranked very high, and there’s evidence that heading the soccer ball puts a person at risk for concussion. I discourage heading the ball, though in the course of a game, the player is probably going to do that.”
There are, however, ways to minimize the risks: “Making sure whoever is coaching is thoroughly educated in concussion. Even though young athletes recover remarkably well, coaches need to make sure they don’t get a second concussion. If in doubt, sit it out,” Marsh says.
“We’ve seen improvements in professional sports. In hockey, the larger, bigger hits, hitting people from behind, are heavily penalized or [players] are forced to leave the game without pay, and officials are discouraging those high-risk behaviors. They do some of the same things in football.”
But in terms of youth sports, Marsh says, more needs to be done. “Making sure football goals have enough padding, because athletes sometimes run into them. At younger ages, we need to rule out certain kinds of hits — helmet-to-helmet hits. But it would really take a movement among the nation, and parents taking an active role trying to shape and change the rules, especially for our young athletes.
“I would want to make sure that whoever is coaching or monitoring the game should be educated. Young brains recover remarkably well, given the appropriate amount of time. What worries me about parents is they need to realize it will take a couple of days for the symptoms to appear.
“The worst thing to have happen is a child athlete become disabled, [have concussion] affect their memory, their IQ. As parents, we get overzealous — ‘My kid’s going to go all-state, he’s gonna go pro.’ The reality is that most of the kids who play high school football don’t go on to play college or professional football.”
Marsh says that he understands the impulse of the athlete to get back in the game. “You want to get out there — to sit out on the sidelines can be really discouraging. But players sometimes minimize their symptoms. They say, ‘Coach, I’m fine, put me back in.’ But they need to take the time to recover. Most concussions go undetected. Athletes need to be aware of what a concussion feels like — a little dazed, headache, a little nauseous, having a hard time focusing in class, or feeling overly fatigued — they could have a concussion. I encourage athletes to be aware of those symptoms. The month it might take you to recover is worth it.”
For Conley, everyone connected to youth sports needs to be educated in the risks and to take them seriously. “I’m astounded at parents and coaches who aren’t experienced in this, coaches and parents who don’t understand why an athlete with a head injury has to be out.
“If someone breaks an arm or leg, there’s no question that’s an injury that will keep them out for the season, but with a head injury they look normal, and they might not realize they have a concussion. It can take days for it to come to the surface. Teachers and parents should recognize it: if they’re thinking more slowly, hesitating and trying to think of the right word to say. Parents should be on alert for a difference in their behavior. Teachers should, as well.”
As concerned as Marsh is about the risk of concussion, he would not discourage students from playing a certain sport. Still, he says, “There is no athletic game that’s worth a child’s life or their function, their IQ or their ability to function, or get a good job.”
WIAA Concussion Guidelines
Each school district's board of directors shall work in concert with the Washington Interscholastic Activities Association (WIAA) to develop the guidelines and other pertinent information and forms to inform and educate coaches, youth athletes, and their parent(s)/guardian(s) of the nature and risk of concussion and head injury including continuing to play after concussion or head injury.
On a yearly basis, a concussion and head injury information sheet shall be signed and returned by the youth athlete and the athlete's parent and/or guardian prior to the youth athlete's initiating practice or competition.
A youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time.
A youth athlete who has been removed from play may not return to play until the athlete is evaluated by a licensed health care provider trained in the evaluation and management of concussion and receives written clearance to return to play from that health care provider.
The Return-to-Play Progression
There are five gradual steps — adapted from the International Conference on Concussion in Sport Consensus Statement — to help safely return an athlete to play.
As the baseline step, the athlete needs to have completed a physical and cognitive test and should not be experiencing concussion symptoms for a minimum of 24 hours. Keep in mind that the younger the athlete, the more conservative the treatment. These are the five steps of the RTP progression:
Step 1: Light aerobic exercise
The goal is to increase the athlete’s heart rate. Exercise time is 5 to 10 minutes and includes exercise bike, walking or light jogging — absolutely no weightlifting, jumping or hard running.
Step 2: Moderate exercise
The goal is to limit body and head movement. Exercise time is reduced from a typical routine. Activities include moderate jogging, brief running, moderate-intensity stationary biking and moderate-intensity weightlifting.
Step 3: Non-contact exercise
The goal is more intensity, but without contact. Time should be close to the athlete’s typical exercise routine, and activities can include running, high-intensity stationary biking, the player’s regular weightlifting routine and non-contact, sport-specific drills. This stage may add some cognitive component to practice, in addition to the aerobic and movement components introduced in steps 1 and 2.
Step 4: Resume practice
The goal is to reintegrate in full contact practice.
Step 5: Return to play
The goal is to return to competition.
It is important to monitor symptoms and cognitive function carefully during each increase of exertion. Athletes should progress to the next level of exertion only if they are not experiencing symptoms at the current level. If symptoms return at any step, the athlete should be instructed to stop the activity, because this may be a sign that the athlete is pushing too hard. Only after additional rest, when the athlete is no longer experiencing symptoms for a minimum of 24 hours, should the athlete begin again at the step during which symptoms were experienced.
The RTP process is best conducted through a team approach and by a health professional who knows the athlete’s physical abilities and endurance level. By gauging the athlete’s performance on each individual step, you will be able to determine how far the athlete can progress on a given day. In some cases, you may be able to work through one step in a single day. In other cases, it may take several days to work through an individual step. It may take several weeks to months to work through the entire five-step progression.
Before the start of the season, learn about your state, league or sports governing body’s laws or policies on concussion. Some policies may require the athlete to take a training program or provide written clearance as part of the RTP process.
While most athletes will recover quickly and fully following a concussion, some will have symptoms for weeks, or longer. You should consider referral to a concussion specialist if the symptoms worsen at any time, symptoms have not gone away after 10 to 14 days, or the patient has a history of multiple concussions or risk factors for prolonged recovery. These may include a history of migraines, depression, mood disorders or anxiety, as well as developmental disorders such as learning disabilities and attention deficit hyperactivity disorder.