Sidelined for Safety: June 2010

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Editor's note: Some changes were made to this article afterthe print version went to press.

New laws keep student athletes with concussions benched.

By Megan Foreman

The world went dark for Zackery Lystedt when he was only 13.

With two minutes to go in the first half of a junior high football game, he raced up the field to block the opponent’s sprint for the end zone. He made the tackle, but when the dust cleared, Lystedt was on his back in the end zone, holding his helmet and moving his legs slowly. He did not lose consciousness and soon walked off the field.

He returned to the game in the third quarter, taking hits on offense and defense. Just after the game ended, Lystedt’s world went dark. He screamed to his father that he couldn’t see and about the searing pain in his head. Then he collapsed.

When the dust cleared this time, Lystedt had undergone two major brain surgeries and was in a coma on life support. The coma lasted more than a month. For nine months, the only movement he could make was to blink for “yes” and “no.” The feeding tube lasted 20 months.

More than three years later, Lystedt remains in a wheelchair but is able to speak, with some impairment. His sense of humor is intact, but his life and the lives of his parents will never be the same. His catastrophic traumatic brain injury was preventable. If he had not gone back in the game, his first concussion could have healed properly. The Lystedt family is committed to ensuring that another young athlete does not have the same fate.

Groundbreaking Law

The Washington Legislature passed the Zackery Lystedt law in May 2009. The first of its kind, it requires young athletes playing or practicing on public property to be removed from practice or competition if they are suspected of sustaining a concussion or head injury. The athletes must then be evaluated and cleared by a licensed health care provider trained to evaluate head injuries—a definition that includes certified athletic trainers—before returning to play.

Richard Adler is the former president and current chairman of the Brain Injury Association of Washington and one of the lawyers who represented the Lystedt family. He lobbied for the law’s passage.

“Catastrophic brain injuries in sports are preventable,” he says. “We may never be able to prevent concussions in contact sports, but we can prevent kids from returning to play with concussions.”

When it passed, Washington’s law was the strictest return-to-play law in the country, but brain injury experts are encouraged to see other states following suit.

Oregon passed a similar law in July 2009, and so far in 2010, New Mexico, Oklahoma and Virginia passed Lystedt look-alikes.

“As an emergency room doctor, a sports fan and a former school board member, I’m interested in the health of our young athletes. This bill protects coaches who, in the heat of the game, might get pressure from kids or parents to put kids back in too early,” says Oklahoma Representative Doug Cox, an emergency room physician.

“During debate, there was some conversation about the wisdom of mandating another expense for parents. But I think most teams have at least a health care professional who volunteers to work with the team. The legislation limits volunteers’ liability, so I think we addressed the issue.”

Seven states are considering similar legislation. Kentucky recently joined Texas in requiring coaches to receive training on preventing injuries and recognizing the symptoms of head injuries. California, Idaho and Massachusetts are considering bills to require concussion and head injury education for coaches, parents and young athletes.

It’s important to note that all head injuries are not brain injuries or concussions, but the majority of legislation uses “head injury” as a catch-all term.
“Rarely can something so easy and direct as removing young athletes from play make it so much safer,” says Dr. Stanley Herring, co-medical director of the Seattle Sports Concussion Program and the team physician for the Seattle Mariners and the Seattle Seahawks. “This law doesn’t cost anything, but it makes youth sports safer. It saves lives.”

Common Injuries

Tragedies like Lystedt’s are rare, but head injuries and concussions are not. The Centers for Disease Control and Prevention estimates emergency departments treat about 135,000 children and teens with sports- or recreation-related traumatic brain injuries, including concussions, each year.

“I’ve been told our law is the most comprehensive in the country,” says Washington Senator Curtis King, who sponsored the bill in the Senate. “Zackery’s is a sad story. If there had been a law like this in place, the whole situation could have been avoided. It is the right law for the right reasons.”

The law also requires coaches, student athletes and their parents to be educated about head injuries, ranging from courses for coaches to flyers for parents and students. Athletes and their parents must sign a concussion and head injury information sheet before beginning practice each season.

“Educating parents and coaches is really important,” says King, “because coaches are under pressure to win games, the parents want their kids to play, and the kids think they are fine. With this law, coaches may recognize possible concussions and understand that the brain has to recover. Sometimes with concussions, symptoms don’t appear until a young person gets home. So parents need to know what to watch for.”

Adler feels the education aspect to the Lystedt Law is a key component. “Educating parents, athletes, coaches and administrators makes this law happen. It makes it stick. People know: When in doubt, sit them out.”

Herring says the new law has been well received. “We’ve been thanked by coaches because it relieves the pressure they felt to be sideline doctors, or to bend to the will of overbearing parents who want their kids to play.”

School officials also have been receptive, he says, and now operate under a standard return-to-play policy that will likely reduce their liability for injuries.

Tough to Diagnose

A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head that affects normal functioning. After such an injury, any change in a young person’s behavior, thinking or physical functioning is cause for concern. Symptoms may not occur immediately and can take hours or even days to show up.

Herring says that after a concussion, a young person should be checked every 15 minutes for about two hours, and should not be left alone. Athletes should never play with concussion symptoms.

“All concussions are brain injuries, and brain injuries are potentially serious,” says Herring. “Return to play is a medical decision. It is not a coaching decision. It’s not a parenting decision. It’s a medical one.”

Herring also cautions that if an athlete receives an additional blow when he already has a concussion, “the results can be catastrophic.”

Athletes who have had a concussion are at an increased risk for future ones. A repeat concussion that occurs before the brain recovers from the first—usually within a short period of time—can slow recovery or increase the likelihood of long-term problems. Repeat concussions can be fatal in extreme cases. Young people take more time to heal from concussions than adults. An injury that may take an adult’s brain five days to heal may take a young person’s brain 10 days or longer.

Athletes should never play with concussion symptoms. One study of high school and collegiate football players showed, among those who died or were seriously impaired by a head trauma, 40 percent were playing with symptoms from an earlier concussion.

In some cases, concussions can affect school performance because they can cause difficulty in concentrating or remembering. Since the only remedy for a concussion is rest, students may not be able to do homework or even go to school.

Since recognition and proper response to concussions when they first occur can prevent further injury or even death and may also help young people perform better in school, the Centers for Disease Control recommends athletes suspected of having a concussion be removed from play immediately and not allowed to return until evaluated by a health care professional.

“The Lystedt Law makes sense from a scientific standpoint, based on what we know about head injuries,” Herring says. “It is solid public health policy and costs little to nothing to implement.”

Megan Foreman tracks adolescent health issues for NCSL.


Watch For Symptoms

A young athlete who may have suffered a concussion should be watched closely. Symptoms may not occur immediately.

Red flags include:

  • Losing consciousness, even briefly.
  • Appearing confused, stunned or dazed
  • Answering questions slowly
  • Forgetting instructions or complaining of physical symptoms such as headache, dizziness, vomiting, double or blurry vision
  • Trouble concentrating.

What Is a Traumatic Brain Injury?

The Centers for Disease Control and Prevention estimates that 1.7 million people sustain a traumatic brain injury every year, causing more than 1.3 million emergency department visits, 275,000 hospitalizations and more than 50,000 deaths.

A traumatic brain injury is caused by a bump, blow or jolt to the head or an object penetrating the head that disrupts the normal function of the brain. Such injuries can range from mild to severe. Estimates put the direct medical and indirect costs, such as lost productivity, at $60 billion annually.

The causes of traumatic brain injury and those most at risk include:

  • Children. More than 50 percent of injuries among children under age 4 are the result of falls. A quarter are caused by the child being struck or running into an object. Other causes include abusive head trauma, including shaken baby syndrome.
  • Adolescents. Motor vehicle crashes are the leading cause of death for young people ages 15 to 19. Homicide and suicide are the second and third leading causes, respectively. In these situations, traumatic brain injuries are common and often fatal. Young athletes also are at increased risk for head injuries.
  • Adults. Motorcyclists who do not wear helmets are more likely to die in a crash. If all motorcyclists had worn a helmet in 2008, 823 lives could have been saved. Among those age 75 and older, falls cause the highest rates of traumatic brain injury-related hospitalization and death.
  • Military personnel. The Department of Defense estimates 169,738 U.S. service members sustained a traumatic brain injury between 2000 and 2009, many caused by bomb blasts.

To address the problem, states have:

  • Passed laws to prevent child mistreatment and abusive head trauma and adopted safety standards for consumer products, such as playground equipment.
  • Passed laws in seven states for elderly fall prevention efforts.
  • Enacted traffic safety laws in all states that require child restraints and seat belts and limits on driving while distracted or intoxicated.
  • Passed laws in 20, the District of Columbia and Puerto Rico requiring all motorcyclists to wear helmets.
  • Created task forces and pilot programs, organized and appropriated funds to state agencies, and established special education and criminal justice-related policies to appropriately care for patients with brain injuries.
  • Received Medicaid Home- and Community-based Services waivers to target patients with traumatic brain injury.