Editor’s note: This is the first of a two-part series on concussions in high school athletics. This part focuses on concussion protocol, prevention, safety, diagnosis and awareness. The second part will focus on the stories of student-athletes who have suffered concussions and how the injury affected their lives.

A concussion can be a deceptive injury.

After a hard hit, an athlete can seem fine, but hours or as much as days later he can be walking around in a fog, dazed, confused, complaining of a headache, nausea, and trouble concentrating, just to name a few symptoms.

Football players are likely the first athletes to come to mind but kids who play soccer, basketball, who wrestle or baseball and fastpitch players who collide at a base or home plate are also prone to concussions.

Barry Smith, a certified athletic trainer who teaches sports medicine at Kentlake High, said he also sees gymnasts suffer concussions on occasion. He’s also seen two different cross country runners get concussed while skateboarding without a helmet.

“One of my favorite examples I use with kids, a cross country runner when I was at Enumclaw, skateboard injury,” Smith said. “Honors student in the fall, D student in the spring. He had a subdural hematoma. Nobody even knew he had a head injury. It wasn’t until his progress report in the spring semester when he was a different kid. Now we have much better technology and techniques. Most of it is just awareness.”

THE PROTOCOL

When a student-athlete suffers a concussion in the Kent School District, there is a well-developed protocol for diagnosis which has evolved during the past three or four years, according to Dave Lutes, athletic director for the district.

In May 2009 the Zackery Lystedt Law was signed by Gov. Christine Gregoire.

Zackery Lystedt suffered a severe brain injury in October 2006 when he took a hard hit to the head during an eighth grade football game in Maple Valley then returned to the game and hit his head again on the last play making a touchdown-saving tackle.

After the game, Lystedt, then 13, collapsed. He spent months in a coma and didn’t speak again for nine months. It took him years to learn how to walk again, how to function. Since then, he has become a passionate advocate for concussion safety, prevention and awareness so no one has to go through what he did.

As a result of the law — nearly 40 states around the country have similar laws in place now — concussion protocol for youth athletics has changed.

“Part of the Zackery Lystedt Law is training which is required annually for coaches, parents and athletes,” Lutes said. “We had to put in some procedures and protocols so there is good awareness of what a concussion looks like, how to diagnose it and how to treat it.”

Athletic registration procedures now include concussion information such as pamphlets from the Center for Disease Control which can be found here: http://www.cdc.gov/concussion/HeadsUp/youth.html.

Lutes said the district has negotiated a contract with Apple Physical Therapy so there is a certified athletic trainer who specializes in concussion diagnosis and treatment covering sports where there is enough physical contact that athletes have an increased likelihood of concussions.

In addition, there is a sports medicine specialist at every varsity football, Dr. Jason Brayley from MultiCare. There is also dedicated EMT service at varsity football games in case an athlete needs to be taken to the hospital straight from the field.

“We’ve also changed some policies,” Lutes said. “We’ve changed the return to play policy where (previously) a doctor had to provide a note for return to play. We’ve now separated it from a common injury. There’s a five-step protocol.”

That five-step return to play clearance process is offered by Apple Physical Therapy at no cost to students, Lutes said. Once a student has completed that process then a doctor can sign off on return to play.

Caitlin Gallup, a certified athletic trainer who works at the Kent office for APT, said the main goal in the partnership with KSD is provide emergency coverage at varsity, JV and freshman football games as well as home games for varsity volleyball and soccer.

“We’re on the sidelines and keep an eye out for kids who are displaying signs of concussions, especially in football after a hard hit, we want to make sure they’re OK before they go back in,” Gallup said. “A lot of it, too, is just education, coach education and parent education. There’s still a lot of education with athletes. And it doesn’t have to be a blow to the head, it can be a blow to the body that makes your neck snap, so it’s just a list of symptoms that they need to look for.”

About half the time, coaches will go to Gallup and tell her a player was hit pretty hard then requests an evaluation, other times other athletes will tell her to get a teammate off the field because he’s not right. On occasion a player will ask to be checked out.

Gallup said it’s also important to be proactive on the sidelines and check a kid out after a hard hit.

Most concussion symptoms show up within 48 hours, Gallup said, but it varies from kid to kid.

“The first thing that we do when they come in and have a concussion, we have a whole packet of information flyers for the parents,” Gallup said. “We say, once they are symptom free, then we have them com back to the clinic.”

From there is a 20-minute stress test. If any symptoms come up while an athlete is doing the stress test on a stationary bicycle then they should stop. The athlete goes through a symptom check list before and after the ride to make sure nothing has changed.

That’s the first day of the five-day return to play protocol.

On the second day, Gallup explained, an athlete comes back and does a more intense test typically mimicking drills he would go through in practice. The same before and after symptom check list is used.

Once the athlete passes that, he can return to practice, however it would be no pads, no live drills no contact in football and in soccer no live drills, no heading.

After that, Gallup said, if he feels fine then the athlete can return to full practice. If after that he still feels fine then an athlete can be cleared for practice.

Still, there is a balance test that needs to be cleared in order to return to competition.

Sometimes students will try and fake their way through the tests, or, they feel fine but aren’t totally healed yet.

“We see that all the time, that’s where establishing the relationships with coaches and students is really important,” Gallup said. “That’s why those standardized tests are really important. If you can’t stand up and balance with your eyes closed, I know you’re still having some issues.”

Smith teaches his students, who come from Kentlake and Kentwood, a unit on head injuries where all kids learn about concussions by going through the same tests trainers run athletes through on the sidelines as well as after a getting concussed.

This fall, Smith has baseline tested all of the football players and when he spoke to the Reporter Aug. 31 he had nearly finished baseline testing all of the girls soccer players.

There is a neurocognitive impact test athletes can do at the start of practices to provide a baseline then there is a pencil-and-paper sideline test that is nearly identical to what trainers use in the NFL and MLS.

None of the tests stand alone, Smith said, they all come together to provide a complete picture of a student’s cognitive functioning before and after suffering a concussion in order to ensure an athlete has fully recovered prior to returning to competition.

At Kentlake, Smith said, serious return to play protocol began in 2005 while he began working with Dr. Brayley in 2008 on the computer-based ImPACT cognitive function test, which I would not recommend doing on an empty stomach and six hours of sleep.

I took the test Aug. 30 under those circumstances and can tell you my cognitive functioning was not good at that point. At least that’s what Smith told Brayley on the sidelines prior to the Kentlake-Thomas Jefferson football game at French Field that night.

Still, if a student has a concussion, there’s no faking it on that test which does a pretty thorough check on how the brain is working by testing ability to recall words, designs and patterns among other things.

Lutes is pleased with the partnership with APT and Dr. Brayley as well as what Smith is doing at Kentlake.

“I think we have a very comprehensive and very good concussion management program,” Lutes said. “I want to keep following the national trends on new information that comes out. We have a program that is full circle right now. We work with the prevention side of it, the diagnosis and intervention side of it, we work with rehabilitation side of it and the return to play side of it which we are strict about. We can always get better but I think we’ve got the components in place.”

ON THE SIDELINES

Brayley moved the Seattle area after serving in the military and the timing was perfect for him to connect with the Kent School District, first with Smith at Kentlake, then more broadly as the district developed its concussion management protocol.

“The timing was just right,” Brayley said. “I had really developed an interest in sports concussions. With that came this evolution regarding concussions. There’s been a lot of concerning research that has come out. If we’re not careful we may be finding information that we should’ve done things differently in the past.”

Brayley covers all the home football games at French Field to help with any injuries that may happen during contests whether they are muscular-skeletal or head injuries.

“This is something I do on a voluntary basis,” he said. “I do it as part of my sports medicine outreach for the community.”

He spends part of his time in practice at the Covington MultiCare.

When athletes are injured during games, depending on the severity of symptoms on the sidelines, Brayley said he works with the trainers and the parents of students to ensure follow up care.

“Treatment is a difficult word,” Brayley said. “These kinds of injuries are not like a broken wrist which, if it doesn’t require surgery, you put it in a cast for six weeks. With concussions, treatment really starts with recognition, starting with observation, clinical evaluation, then you’re being very stringent with physical and mental rest.”

From the perspective of Aaron Radford, who coaches boys and girls soccer at Kentwood High, wrote in an email that concussions have always been a topic of concern but it has been more frequently discussed in the past three years.

“I truly appreciate the new laws about concussions and returning to play,” Radford wrote. “It makes the decision for the coaches much easier to deal with. If we suspect there is a concussion, then the player is out and they must get checked by a licensed health profession that is certified in concussion management.”

Radford added that he believes every coach is more aware of concussions and how to handle them from the sidelines during practice or play which has improved player safety dramatically.

“No coach wants to pull a player out of games without knowing for sure if there is something wrong, but we no longer get to — or have to — make those tough decisions.  It is clear cut, the players need to be out until we are sure everything is safe. It is in the best interest of the players.”

Brayley said that the most important message regarding concussion management is a safe return to play plan. He explains to parents that he didn’t develop the guidelines, nor did his employer, but rather a group of experts from around the globe who developed them and update them regularly.

There was a time when student-athletes returned to play too soon, when there wasn’t widespread agreement at the youth level on how to help kids heal, but now everyone is on the same page.

“If your child truly has a concussion, it’s not as easy as going in and getting a clearance note,” Brayley said. “It’s a slow and graduate process when followed correctly, when the current international consensus guidelines are followed.”

CLOSE TO HOME

The Lystedt Law is particularly close to home for student-athletes in the Tahoma School District.

Lystedt was injured playing for Tahoma Junior High.

Tony Davis, the district’s athletic director and longtime football coach at the high school, said the district has followed the provisions laid out in the Lystedt Law in much the same way as the Kent School District.

It’s not an easy subject for Davis, who has coached the Bears high school football team for nearly 20 years now, to talk about.

But, it’s important. When an athlete has a head injury, he comes off the field and does not return to play until he has followed the protocol laid out by the Lystedt Law, Davis said.

“If we have a head injury, then we shut it down,” Davis said. “We’ve taken very similar steps not specifically because of head injuries, overall to help our kids stay safe. What the Lystedt Law has done it taken the gray area out of it for coaches and school districts.”

In the Tahoma School District, every student who plays sports from seventh through 12th grade has to sign the athletic handbook which has general concussion information, which helps bring a level of awareness to families and gives them a quick reference to a list of signs of concussions.

This season, like players in the Kent School District, the Tahoma football squad went through the ImPACT cognitive functioning test early on in practices which provides baseline data. That was done with Dr. Brayley during two-a-day practices.

“That’s new for us,” Davis said. “We’ll see how it goes. I hope it’s something I hope we can continue. It’s interesting to see how that data is used. It’s an education for all of us. You’ve got to rely on your experts and that’s the approach we’ve taken.”

Davis said he has noticed a shift in football culture not just locally but nationally.

“One of the things that we do a good job of, and I think it’s important for all coaches, there’s an element of masculinity, of bravado in football … we want them to be comfortable telling us (if they’re hurt),” Davis said. “We’d rather have you sit out for a day or two days or the whole season if that’s what it means to keep you safe. For us, that’s always been the approach we’ve taken. The challenge is getting kids comfortable with that. There’s a relationship element to that.”

An example Davis gave about the shift in culture was during practice this season, a day after the kids were wearing pads during training, one of the players woke up with a headache. He didn’t want to say anything to the coaching staff but his friends, Davis said, were concerned and approached the coaches.

“I’m glad we have that kind of culture,” Davis said. “It’s pretty cool that kids are looking out for each other, as well.”

A MOTHER’S WARNING

Little more than a year ago, Andrea watched her then 12-year-old son collide with another player in a play at a base during a baseball game in a youth athletic league.

Initially her family was told her son was fine and they could take him home but by the time they arrived the boy was showing serious signs of a concussion. He was rushed to the hospital, where he was induced into a coma and treated to reduce the swelling in the brain.

Andrea, whose name has been changed to protect the privacy of her son, said it was a scary experience and there were times they didn’t know what to expect.

Then her son woke up.

“We were very fortunate, he didn’t have any brain damage,” she said. “The first thing he said was, ‘Did we win?’ He asked the doctors if they could move so he could watch the Mariners game. We knew mentally he was there.”

Still, it hasn’t been an easy road back for the boy, Andrea said. He will never get to play sports again. He has to be careful — he suffered a skull fracture in the collision — when doing strenuous activity. There are things he still can’t do.

Andrea said it’s vital that parents call 911 for help if they are at an athletic event where medical coverage isn’t provided if they suspect their child has suffered a concussion.

“You have to be an advocate for your child. You have to be adamant,” she said. “Even though it might be OK in the the moment, you really have to know your child and see what’s changed.”

She knew before they left the field her son wasn’t feeling right. He was nauseous in the car. He said, though Andrea described him as quite competitive, that he should not continue playing.

Andrea encourages parents of athletes, especially those who are not in high school, to learn about the signs of concussions.

“That’s the key, educating parents,” she said.

Brayley said the delayed onset of symptoms can cause concern and confusion for parents.

“There’s a misconception that you will see every last symptom right away or shortly thereafter,” the doctor said. “What any parent should be looking for is a distinct and rapid change in what is normal for their child. Even if they get checked out by their doctor once, if something isn’t right, get them checked again.”

Next week the second part will feature the stories of athletes who have suffered concussions, how they recovered from them and how it affected their lives on and off the field or court.

What is a concussion?

A concussion is an injury that changes how the cells in the brain normally work. A concussion is caused by a blow to the head or the body that causes the brain to move rapidly inside the skull. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious. Concussions can also result from a fall or from players colliding with each other or with obstacles, such as a goalpost.

The potential for concussions is greatest in athletic environments where collisions are common. Concussions can occur in any organized sport or recreational activity. As many as 3.8 million sports- and recreation-related concussions occur in the United States each year.

Source: Center for Disease Control “Heads Up Concussion In Youth Sports”