Youth Sports and Concussions: Preventing Preventable Brain Injuries. One Client, One Cause, and A New Law

Effective concussion prevention and management for youth athletes requires both education and legislation. Education alone effectively begins the awareness of an issue, but does not change behavior. Education and legislation are required to prevent preventable concussion and brain injuries in youth athletes.

On Thursday October 12, 2006, 13-year-old Zackery Lystedt, like many youth athletes, had just finished his school day and was continuing with after-school sports. Zack was a good student with a 3.5 grade point average and was also considered an outstanding athlete. He played many sports and was participating on his school’s football team, just south of Seattle, Washington. On this day, Zack and his team traveled to a nearby middle school for a game.

Zack was the fullback on offense, and played outside linebacker on defense. The fateful play was at the end of the first half of the game with Zack in his linebacker role. The opposing team handed the ball to its fullback who cut to the sidelines (away from Zack’s position) and began heading down the sidelines toward the end zone. Zack sprinted diagonally across the field and caught up to this player at the goal line. He leaped, lunged, and tackled the player. In the process, Zack’s airborne body rotated and he landed with the back of his helmet hitting the ground. When the dust cleared, as captured by sideline parent-video, Zack remained on his back in the end zone holding his helmet with both hands. He was moving his legs slowly, but he did not lose consciousness. A referee called a time-out. Per league rules at that time, Zack was required to sit out only for the next play. Zack was able to walk off the field on his own with the coach by his side. He was kept out for the next 2 plays, and then it was halftime. Zack played most of the third and fourth quarters, taking hits on offense and defense. Despite his teammates (but not his coaches) noting changes to his usual play and behavior on the field, he continued to play and was credited with scoring the go-ahead touchdown for his team as well as causing a fumble against the opposing team attempting a come-from-behind score late in the game. There were no health care professionals on the sidelines to assess Zack’s condition.

At the end of the game, and after handshakes and high fives across the 50-yard line, Zack began walking off the field with his father next to him. His world then went dark. He screamed to his father that he could not see and about the searing pain in his head. He collapsed on the field in his father’s arms and was airlifted to Harborview Medical Center, a Trauma I hospital in Seattle, Washington, where he underwent emergency brain surgery. Immediately following surgery, Zack developed recurrent cerebral hemorrhage and was returned to the operating room to complete bilateral craniotomies and decompressions. He was in a coma for approximately 1 month. He was not able to move any limb or even blink for a period of 9 months. He was fed via percutaneous gastrostomy for 20 months.

October 2011 marks the fifth anniversary of Zack’s traumatic brain injury and his premature return to play following a mild traumatic brain injury. His life and the lives of his parents will never be the same. However, his strength of character, determination toward wellness, and sense of humor inspire all those around him. Zack’s injury propelled me, his legal team, community leaders, organizations, and the state of Washington into action to prevent future preventable brain injuries in youth sports.

How did this event move from tragedy to legislative action? What remains to be done to protect youth sports participants? These issues and others are discussed in this article.

Scope of the problem and urgency of the public health response

Concussions are one of the most commonly reported injuries in children and adolescents who participate in sports and recreational activities. Children and teens are among those at greatest risk for concussion. Most sports-related and recreation-related concussions seen in emergency departments each year (65%) occur among youth aged 5 to 18 years. More than 38 million boys and girls, aged 5 to 18 years, participate in organized youth sports in the United States. Concussions can occur in any organized or unorganized sport or recreational activity. Although youth sports concussions often are associated with football, the rate of concussion in girl’s high school soccer is almost as high. Concussions are likely inevitable in youth sports (see the article by Jinjugi elsewhere in this issue for more details). Although many of these injuries are considered mild, they can result in more serious impacts on a young developing brain and can result in functional impairment with thinking, memory, emotional, or behavioral changes. The wider community must decide whether to accept the risk that comes from an ill-informed understanding of the consequences of the premature return to practice or competition following a concussion. However, the issue of accepting the risks and consequences of traumatic brain injury in youth sports assumes that school administrators, coaches, parents, and student athletes are properly educated and informed. In Zack’s situation, no one was informed, risks were taken unnecessarily, and with catastrophic consequences resulted.

The world of youth sports is large, diverse, and decentralized. Most coaches in youth sport programs are volunteers (either parents or other interested persons) who have minimal or no training in coaching or injury identification or management (including concussion), and are often juggling many commitments including full-time jobs and families. Youth sports coaches are on the front line to identify and respond to concussions. They play an important role in sharing safety and injury-prevention information with athletes and parents. However, who is training the school administrators, athletic directors, coaches, the parents, and the youth athletes? Who is training the sport organization’s board of directors, leaders, and managers?

A youth player must be removed from any sport following concussion because a brain injury is more dangerous than a knee injury. No one has died or been catastrophically injured from the premature return-to-play decision regarding the knee, ankle, or shoulder. An injury above the chin must be treated differently and more cautiously. But why has it been difficult to have this message absorbed, taken seriously, and adopted by all?

In Zackery Lystedt’s situation, there existed a vacuum of knowledge in which tragedy filled the void.

A new path to concussion prevention and management: education and legislation

Effective concussion prevention requires both education and legislation. Both are embodied in the first-in-the-nation law from the state of Washington, more commonly referred to as the Zackery Lystedt Law, which is serving as the prototype and model for other states’ efforts to protect youth athletes. The process and participants involved, and the barriers encountered in implementing this 2-pronged approach to concussion prevention, are described in this article.

A new path to concussion prevention and management: education and legislation

Education: getting the word out

Champions

Any effort to change the culture of acceptance surrounding concussions requires a champion to challenge current thinking and reach out to aligned organizations and key individuals to engage in meaningful dialog. My advocacy started with an educational push on youth sports concussion through the Brain Injury Association of Washington (BIA-WA), and my colleagues who are clinicians and researchers at the University of Washington. Initial educational attempts focused on the BIA-WA Web site, newsletter, social media sites, and media releases that focused on a few clear messages.

Messages

1.

Athletes who have concussions are at an increased risk for future concussions.
2.

Repeat concussions occur before the brain has time to heal from the first one, and this often occurs within a short period of time.
3.

Concussions can slow recovery or increase the likelihood of long-term problems.
4.

Repeat concussions can be fatal.
5.

Young people take more time to heal than adults.
6.

Athletes should never play with concussion symptoms (one study of high school and college football players showed that, among those who died or were seriously impaired by a head trauma, 40% were playing with symptoms from an early concussion).
7.

Concussions can affect school performance because they cause difficulty in concentrating or remembering.
8.

The only remedy for concussion is rest.
9.

Proper recognition and proper response to concussions when they first occur can prevent further injury or even death and can help young people perform better in school.

The organizational partnership started between BIA-WA and the Centers for Disease Control (CDC), who began the production of educational materials for use on a national basis.

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