Since setting concussion precedent with Lystedt Law, Washington getting left behind
Dr. Stanley Herring saw a boy in a wheelchair on the sideline at a Seattle Seahawks practice. That boy turned out to be Herring’s hero.
Herring introduced himself to Zackery Lystedt, who from his wheelchair looked into the doctor’s brown eyes and said in labored speech, “I’m here to help people.”
“I was in right then,” said Herring, a clinical professor in the Departments of Rehabilitation Medicine, Orthopedics and Sports Medicine and Neurological Surgery at the University of Washington.
Since meeting Lystedt, who nearly died as a 13-year-old after continuing to play in a youth football game in 2006 following an undiagnosed concussion, Herring has worked with Lystedt’s family to push Washington state to the forefront of the concussion discussion. The 2009 Lystedt Law was the first of its kind, increasing awareness and education about concussions in youth sports.
According to the law, athletes and parents are required to sign concussion information sheets each year. The current concussion information sheet for Seattle Public Schools lists the symptoms of concussions in a two-column bulleted list: headaches, neck pain, nausea or vomiting, amnesia, sadness. Underneath, there is another list of signs that can be observed by parents, teammates and coaches: forgets plays, vacant facial expression, answers questions slowly.
The last time it was updated was 2009, the same year the Lystedt Law was signed.
Since then, the other 49 states and the District of Columbia have adopted similar laws and many have amended their original laws, leaving Washington, which was the leader in concussion legislation, on the backburner. California adopted its concussion law in 2011 and has updated it three times since. The most recent amendment reflects research about the effects of full-contact football practices and more specifically defines who can clear athletes to return to the field.
In Washington, education has been effective in teaching people about concussions, Herring said. But he is hoping the state can take the next step as well.
“We don’t yet know the best tool to educate athletes, coaches and parents,” the doctor said. “What’s the most effective way to get to a high-school or middle-school athlete and get them to change their behavior?”
Like ‘half-set Jell-O’
In a room filled with the smell of chemicals and medical students preparing for a neuroanatomy exam, Kate Mulligan, a principal lecturer in neuroanatomy in the UW School of Medicine (UWSOM) Department of Biological Structure, carefully lifts a human skull out of a box. The off-white bone is smooth on the outside, but rough with jagged edges inside where the brain makes its home.
When the head rapidly changes direction, whether through a big collision or severe whiplash, the brain can run into the inside of the skull. The impact injures the brain, which has the texture of “half-set Jell-O,” Mulligan said.
Concussions damage the communication highways, called axons, between brain cells, stretching the connections and impairing the ability of cells to receive and send messages.
“It’s like running a slower version of software,” said Herring, who is also the medical director of Sports, Spine and Orthopedic Health for UW Medicine.
Because the effects of a concussion are difficult to see to the naked eye, concussions are classified as minor traumatic brain injuries. According to a study led by Dr. Ann McKee at Boston University in 2009, 1.6 to 3.8 million concussions occur in sport-related activities per year. But research has yet to link youth sports concussions with long-term consequences, said Herring, who stressed that most concussions get better within seven to 10 days.
Concussion is common and can be harmless at first, but health care professionals are most concerned with second-hit syndrome, a rare but potentially fatal condition. Returning to play too soon, especially in the same game, and sustaining another concussion before fully recovering from the first can result in severe swelling. Severe swelling in the brain can affect the brain stem and impair breathing and heart rate.
Shaking off a big collision can have big repercussions on the fragile brain.
“You can be tough,” Herring said. “But no one has a tough brain.”
‘We cannot be so naive’
It was a cold day when Annie Lorelai Hoffman got her concussion. She was playing in the Washington state quarterfinals with her high-school soccer team. When the she went up for a header, she was hit in the back of the head by another player and fell forward, slamming her head on the frozen field.
Hoffman, a star soccer player for Issaquah High School who is heading to Boise State on scholarship next fall, said she didn’t go to school for about a week after her one reported concussion, which she sustained as a sophomore. She sometimes forgot where she sat in class. On a vocabulary quiz, she blanked on all the words. For about a month after the injury, she took tests in separate rooms with extra time.
“It was pretty odd and scary having that,” Hoffman said.
As she prepares to enter the Division I ranks, Hoffman has no lingering effects from her concussion from two years ago, even though she continued the game after the hit, which she admits she can’t remember.
The 5-foot-6 midfielder who is touted for her ability to conduct her team’s offense said there is more focus on concussions with her high school team than with her club, Crossfire Premier. At her school, she and her teammates have a mandatory concussion lecture and trainers are “much more protective,” she said.
In the two academic years following the institution of the Lystedt Law, Seattle Children’s Hospital’s Orthopedics and Sports Medicine Center found that reported concussions increased more than two-fold in Seattle public high schools. Seattle Public Schools contracts with Seattle Children’s for high-school athletic trainers.
Concussions in Seattle Public Schools before and after the Lystedt Law (Source: Seattle Children’s Hospital’s Orthopedics and Sports Medicine)
In addition to the increased reporting, which, “may be attributed to heightened awareness and closer monitoring,” according to a study based on the data, the amount of time that athletes were kept out of play or practice increased by seven days from 14.7 to 21.6 in the year after the law. For female athletes, the number from the year before nearly tripled, from 9.6 days to 26.7.
Despite the initial success of increased education, Herring stressed the problem hasn’t been fixed by just a law.
“We cannot be so naive to think that if you say so, it will be so,” Herring said with regards to education and legislation concerning concussions.
A study published in 2014 by Harvard University and Boston University found that for every reported concussion within Division I football players, 27 went unreported.
Wanting to hide concussions to benefit the team immediately may not even be a young athlete’s fault. Doctors say you can blame it on biology.
A brain does not reach full maturation until a person’s mid-20s, and the final part to develop is the frontal cortex, where executive functions like decision making and long-term planning are processed. The frontal cortex develops most during high-school and college years, when teenagers still walk around in blissful ignorance feeling like indestructible superheroes.
“Teenagers are not able to see far into the future, even if they’re very intelligent,” said Juliane Gust, a pediatric neurology resident at UWSOM. “High-school students focus on themselves and what’s happening in the immediate future.”
Culture change
The training room at Roosevelt High School is at the end of a narrow hallway, tucked behind a set of stairs leading to the school’s weight room. In his final year as the athletic trainer for Roosevelt, Morten Orren, currently the athletic trainer and sports medicine teacher at Liberty High School in Renton, Wash., saw a football player get forced down that hallway by his teammates into the fluorescent training room. A week before, he took a big hit on the football field and got a concussion.He continued to play and practice afterward
That night Orren saw him, he was admitted to the emergency room.
“I tell the football team before the season, ‘Don’t be afraid to rat out your teammates,’” Orren said. “You’re just going to save their life in the long run.”
Translating knowledge to safety starts with changing the culture of sports, Herring said, which promotes toughness and playing through pain.
Knowledge is one the weakest indicators of behavioral change said Cliff Robbins, the program manager of education and research at the Sports Legacy Institute (SLI). Research from Harvard School of Public Health and Boston University School of Medicine in 2013 indicated that athletes are least likely to self-report concussions if they perceive their actions will reflect poorly on their athletic performance.
The research asked male junior ice hockey players questions concerning their understanding of concussions and symptoms, their reporting behavior and attitudes about outcomes of reporting a concussion. The paper suggests that modifying education to focus less on personal effects of an injury and more on how playing with one can hurt the team could increase a behavioral change.
“People seem to have a generalized idea that, ‘OK, we get it now that a concussion is something that we need to take more seriously,’” said Lisa McHale, SLI director of family relations. “But my concern is that I don’t think that it is yet translating to the safety on the field.”
As the medical director of the Seattle Children’s Concussion Program, Herring has worked not only to implement more accessible education and clinical care for concussions, but also social changes to create a more accepting atmosphere for concussion discourse.
Herring is a Texas native who likes to joke that there are only two sports in his home state: football and spring football. At football, water was withheld during practice. It was thought that water made you sick. It made you look weak.
“Can you imagine if you went to play in any sporting event now and water was withheld from you in practice?” Herring said. “There would be an uproar. It took time for that to change socially. We’re hoping that it would be just as unacceptable to play with concussion symptoms as it would be to not have fluids during practice. We have to change the culture around this.”
Protecting athletes from themselves
Football, with its popping pads, smashing helmets and crushing hits, is a violent sport. Tom McNalley knows this. It’s the reason why the attending physician in rehabilitation medicine at Seattle Children’s Hospital and the UW Medical Center is drawn to the sport, but it’s also why he’s troubled by it.
“There are injuries in almost every game and they are putting their lines on the body for the sport,” said McNalley, also an assistant professor in rehabilitation medicine at the UW. “I find myself compelled to watch it. I can’t convince my heart to not like something when my brain says so.”
In March, Chris Borland, a 24-year-old former linebacker for the San Francisco 49ers, retired from football, citing safety concerns. When he retired, the inside linebacker who had just finished a stellar rookie season with 108 tackles, told ESPN’s “Outside the Lines” he considered the lives of former NFL greats who were diagnosed with chronic traumatic encephalopathy after their deaths in his decision. Specifically he mentioned Dave Duerson and Ray Easterling, who both committed suicide, and Mike Webster.
As discussion grows about the potential dangers of football, some parents are choosing not to allow their children to play the sport, including Orren, who has a 3-year-old son. However, not playing sports at all to avoid potential injury can result in other health related issues such as childhood obesity. So for Gust, it’s a matter of changing the system and intervening through safety measures before concussions can occur.
“We were able to change cars to make them safer and we should be able to change sports too,” the neurology resident said. “Teenagers don’t think it applies to them, so we have to change the system.”
For concussions, development of safer equipment has started, as the Seattle Sports Concussion Program worked with the UW mechanical engineering department to develop a force reducing helmet. The reduction of the force would help to prevent the brain from hitting the inside of the skull during a collision on the field.
Herring would like to continue combining work from different fields. He has long been interested in brain injury and since meeting Lystedt on the Seahawks practice field, his passion has grown.
“They love youth sports, they just want it to be played safely,” Herring said of the Lystedt family. “We’re going to get this right. I promised them personally that Zack would never be forgotten.”
Originally published here.