Young player helps turn trauma into action on concussions

By Matt Rybaltowski
Special to CBSSports.com
Feb. 14, 2010

Remarkably, Zackery Lystedt is still a football fan. He is still a fan despite a concussion in a middle-school game that was not properly evaluated, resulting in his return later in the game. The hit and premature return left him in a coma for 30 days, on a feeding tube for 20 months and unable to speak for three quarters of a year. Three years and four months later, Lystedt still manages a perpetual smile, though he has very little feeling and movement on his right side and remains dependent on a wheelchair.

On Oct. 21, 2006, Zackery, then 13, writhed on the ground after his full-out, cross-field sprint and lunge toward a running back nearly prevented a second-quarter touchdown. Although the Tahoma (Wash.) Junior High outside linebacker was taken out for the final three plays of the half, he returned at the start of the third quarter. With the game in the balance and just seconds remaining, Lystedt exacted a measure of revenge by stripping the same running back that had scored earlier near the goal line. Swarmed by his teammates, Lystedt took pride in preserving the victory for his team.

Houston Texans offensive lineman Chester Pitts promises to find a less violent sport for his 3-year-old son, Champ. (US Presswire)

Less than a minute later, after the teams exchanged handshakes, Lystedt turned to his father Victor and said, "Dad, my head hurts." Then, "Dad, I can't see."

As his brain swelled severely and his optic nerve became impinged, Lystedt let out a blood-curdling scream and collapsed. Emergency personnel arrived immediately and airlifted Lystedt to the Trauma 1 center at Harborview Medical Center in Seattle for life-saving brain surgery. If the law that now bears his name were in place, Lystedt might still be playing football like thousands of high schoolers nationwide. Instead, he may help save the lives of many more.

"Zackery is a very inspiring young man," said Richard H. Adler, Lystedt's Seattle attorney.

As president of the Brain Injury Association of Washington, Adler was the chief architect of writing the Lystedt legislation and building the coalition of community, business and sports organizations that led to the unanimous passage of the law in both the House and Senate in Washington.

"He wants to see football made safer, he wants to make sure not another child has what he has," Adler said. "I do not know if there is another student-athlete that could do what Zackery has done to call our attention to the well-known adage that a concussion is a brain injury and brain injuries are serious."

Last spring, legislators in the state of Washington passed the Zackery Lystedt Law, which contains the most stringent return-to-play protocols of any state in the country. The law requires athletes under the age of 18 to be removed from a game immediately if suspected of sustaining a concussion. The athlete is not allowed to return to the field of play until he receives "written medical clearance from a licensed health-care provider" that specializes in the evaluation and treatment of concussions. In addition, all athletes and their parents must sign an information sheet alerting them of the dangers presented by concussions before the start of the season.

The Lystedt Law was discussed prominently in Houston on Feb. 1 at a U.S. House Judiciary Committee Forum on Head Injuries in Football. It was the third conference the committee has held on concussion prevention since last fall and the first aimed specifically at reducing concussion rates among youth players. Two days later, the Zackery Lystedt Brain Project, a measure aimed at spreading the Lystedt Law to all 50 states, was launched in Miami at the Super Bowl. Proponents of the project say it provides a glimmer of hope in providing a safer climate for amateur football.

"This is an effort to try to get each state to use the Lystedt Law as a blueprint," said Dr. Stanley Herring, Seahawks team physician and co-director of the Seattle Sports Concussion Program, during his testimony at the forum. "It is revenue neutral; it doesn't require any extra revenue. If it's a rule, not a suggestion that an athlete comes out, it's going to make us all better. When in doubt, sit them out."

Although the frequency of catastrophic football-related injuries resulting in major cognitive impairment, paralysis or even death has declined drastically over the past several decades, concussions in youth football still remain a serious concern. As players become bigger and the game has become faster, coaches on the whole still lack the requisite education to properly deal with a concussed athlete. At the same time, a dearth of on-site certified athletic trainers and poor funding in youth football has helped create an environment so violent that Houston Texans tackle Chester Pitts promises to find a less harmful sport for his three-year-old son Champ.

Each year, there are approximately 3.8 million concussions in sports and recreation throughout the country, according to statistics compiled by the Centers for Disease Control and Prevention. On the high-school level, there were more than 500,000 football-related injuries during the 2008-2009 school year, 12.9 percent of which, approximately 68,000, were from concussions. The figures were amassed by the National High School Sports Related Injury Surveillance Study, which currently provides the most comprehensive data on injuries in high school sports nationwide.

The findings, though, only provide a small fraction of the actual number of concussions that occur in a given year. In 2004, a study in the Clinical Journal of Sports Medicine found that only 47 percent of all concussions in high school football were being reported. Dr. Dawn Comstock, an associate professor at The Center For Injury Research and Policy at Ohio State University's Nationwide Children's Hospital and an administer of the surveillance study, said other studies place the figure of unreported concussions at closer to "60 percent." On the youth level, John Butler, executive director of Pop Warner Football, said there have only been 11 reported concussions among the nation's largest youth football organization. It's a figure he takes "with a grain of salt," since there are more than 375,000 Pop Warner players each year in the United States.

"When an athlete injures an ankle it will usually be pretty apparent because he will be limping," Comstock said. "There are outward visual signs and symptoms that are easy to spot by an observer. With a concussion unfortunately, many of the signs and symptoms aren't outwardly apparent to an observer -- things like a headache, dizziness [and] nausea. When you look at those symptoms, many of them we don't know of unless a student-athlete tells somebody."

Comstock said the misreporting of concussions is a two-pronged issue that she attributes to the lack of awareness among some parents, coaches and athletes in combination with the culture of machismo prevalent among teenagers in the sport for decades. With potential college scholarships on the line and pride at stake, often the last thing a youth football player wants to do is leave a game. It might explain why Comstock's research found that 15.8 percent of high school players returned to a game last season after experiencing a concussion that resulted in a loss of consciousness.

A greater focus on identifying head injuries in youth football is of paramount importance considering that neuroscientists believe teenagers take longer to recover from a concussion than athletes in college or the professional ranks. A concussion that could take an NFL player "five to seven days" to recover completely might take a youth player "10 to 14," Herring said. While experts have yet to determine a definitive explanation, Herring added that there are several theories, including the water content of the brain, the geometry of the skull and alternative pathways in the brains of adults that "can accommodate with other parts of the brain," when concussed.

Dr. Bennet Omalu, an associate clinical professor of pathology at the University California-Davis, agrees. "The young brain is more vulnerable," Omalu said. "They have a larger concentration of cells, a larger blood supply and the receptors are still not mature. It's completely different."

Though teenagers take longer to recover, Comstock said more than 40 percent of youth football players return to play too soon.

Omalu said that as early as one to three hours after a concussion, certain proteins begin to accumulate noticeably in the brain such as Amyloid Precursor Protein (APP). Even when concussion symptoms appear to subside, Omalu said it takes approximately three months for APP to disappear. This figure remains constant among all age groups.

Omalu became so impassioned during his testimony in Houston that at times he nearly leapt out of his seat while pleading for additional funding for research. The forensic pathologist is known best for performing an autopsy on former Pittsburgh Steelers center Mike Webster in 2002 and his subsequent discovery of Chronic Traumatic Encephalopathy (CTE) in the Hall of Famer. He has also found large traces of CTE in former Eagles safety Andre Waters and pro wrestler Chris Benoit.

CTE is a degenerative disease of the brain that can result from multiple concussions over an extended period or "even one major episode of blunt trauma to the head," Omalu said. Patients who suffer from CTE can experience problems with memory, confusion, depression and irritability. As in the case of Webster, CTE can be responsible for causing full-blown dementia. In December, a spokesman from the NFL acknowledged that "concussions could lead to long-term problems," in a report by the New York Times.

In Houston, Omalu told the committee he believes he has discovered a cocktail of "two to three drugs" that will lead to the cure of CTE. Though Omalu would not reveal the identity of the drugs, he said all three are currently on the market. The drugs, he said, would inhibit the accumulation of abnormal proteins in the brain called "tau" by binding to "RNA receptors in the brain," and preventing "the up-regulation of genes, which follows concussions."

If his study is approved, Omalu said it will take him roughly "three months to a year," to develop a cure. He is hamstrung by a lack of funding, though, and needs $1 million to complete the study. He envisions a scenario where players could be taking a pill on the sideline minutes after experiencing a major hit.

Andre Waters committed suicide, reportedly induced by brain damage brought on by concussions. (Getty Images)

"A player could take the drugs on a routine basis like we take aspirin to prevent heart attacks, or take the drugs immediately after sustaining a concussion for a couple of months," Omalu said. "Players who are already manifesting the symptoms of CTE may take the drugs, as well to cure them by removing tau, which has accumulated in their brains. My focus is on active players."

Chris Nowinski is the president of the Sports Legacy Institute, a research center founded in 2007 to "solve the sports concussion crisis," according to its website. Four years earlier, Nowinski was forced to retire from the WWE after experiencing post-concussion syndrome. Like Omalu, he has worked tirelessly at developing a connection between multiple concussions and long-term neurological disorders. Nowinski is skeptical of a cure for CTE.

"It's nice to think Dr. Omalu figured out how to get rid of tau in three months, something the entire pharmaceutical and Alzheimer's industry has been trying to do for 50 years," Nowinski said in an e-mail. "As a likely [CTE] sufferer, I hope it's true, but as a drug industry consultant, I am pretty sure it's not."

Others hope that initiatives such as the Lystedt Law can limit concussions years before the onset of CTE. One advantage of the Lystedt Law for coaches is that it frees them of all responsibilities regarding the decision of when a player can return. Recently, the American College of Sports Medicine partnered with the Sarah Jane Brain Foundation (an organization focused on helping children with Pediatric Acquired Brain Injures) in efforts to enact the Zackery Lystedt Law in other states. Patrick Donohue, the foundation's founder, hopes to raise awareness during a presentation at the National Governors Association meeting later this month.

"The bill adopted in Washington state is literally nothing short of brilliant. I don't recall a law in my political life of something so impactful," Donohue said. "Every state is going to adopt this. I can't promise by September they're all going to have them adopted, but we already have coalitions in just about every state."

Close to 20 states now have concussion legislation pending and 25 others have formed coalitions aimed at advancing the Lystedt Law, while Oregon governor Ted Kulongoski signed a similar bill -- "Max's Law," last summer. Just six states -- Alaska, Delaware, Louisiana, Nevada, North Dakota and Wyoming -- have yet to form coalitions. Dan Henkel, senior director of communications and advocacy at the American College of Sports Medicine, said the issue of concussions in sports has reached "a tipping point."

"People in every sector understand that we need to address this: athletes, teams, leagues, the media, policy makers, the public and the medical community," Henkel said. "The attention that the NFL is properly focusing on concussions has drawn additional attention to concussion issues in youth and college athletics. It's very gratifying to see so much momentum toward thoughtful, effective solutions."

There are other initiatives that intend on increasing awareness of concussion prevention. In April USA Football, the sport's governing body on the youth and amateur levels, has plans on adding several chapters to an online coaching course, including a section on concussions. More than 26,000 youth coaches completed the course in the past two years and executive director Scott Hallenbeck said the organization frequently holds clinics on proper tackling technique.

Herring, an advisor to USA Football and Adler, the chief architect of the Lystedt Law, will attempt to further broaden their message at a concussion summit later this month in Indianapolis in front of national youth associations in several sports, including football. Adler will also appear on a national conference call sponsored by the CDC several days later, in front of a wide audience of organizations interested in pushing the law in their states.

"It is our intention to conclude the conference with a reaffirmation of a mandate and call to action for all youth sports organizations, schools, parents, student athletes, coaches, health care professionals to protect our youth, prevent preventable brain injuries and make sports safer," Adler said.

In Texas, meanwhile, the state legislature passed Will's Bill in 2007, a measure that requires every school employee involved in athletics to complete head injury training. An official from the University Interscholastic League (UIL), which oversees high school athletics in Texas, said the organization has not received any reports of failure of compliance. The UIL also did not immediately have records of the number of concussions statewide since the passage.

The law was named in honor of Will Benson, a quarterback from St. Stevens Episcopal School in Austin, who died following a head injury suffered five years earlier. Will's father Dick said the hit that forced his son to be carted from the field was so insignificant that no one even witnessed it. The shot still managed to open a subdural hematoma, or small tear, in Benson's brain from a hit two weeks before. Benson's brain cavity became flooded with blood, causing him to experience multiple seizures.

During the forum, the emotional testimony of Benson's father included a detailed account of how it took emergency personnel close to an hour to transport his son from the field to the hospital via helicopter. A team doctor on the field initially misdiagnosed Will Benson's condition as an adverse reaction to a muscle relaxer, his father said in a hallway outside the forum at the Prairie View A&M College of Nursing. Because of this, personnel downgraded Benson's emergency from a Category 1 (life-threatening) to Category 3 (mild) response.

Wayne Chrebet is among the many NFL players whose careers were cut short by concussions. (US Presswire)

"If they had made the right 911 call and wasted no time, the helicopter would have come out [earlier]," Dick Benson said. "With a subdural hematoma, an hour might have saved his life."

For Benson, his son's case illustrates how a preventable tragedy can still occur if the medical professionals in charge of treating players with head injuries lack proper training. Shockingly, most high school games take place without a certified trainer on the field. Just 42 percent of schools nationwide have athletic trainers present to provide services for their athletes, according to the National Athletic Trainers Association.

"We know that having an athletic trainer available means a lot of things -- in one school it may actually mean having a full-time athletic trainer on staff," said Comstock, the administer of National High School Sports Related Injury Surveillance Study. "At other schools, it may mean somebody who is only there during football competitions. In some cities [even], four or five schools may have the services of [just] one trainer because of budget cuts."

Benson is also advocating major rule changes on all levels of football on spearing or helmet-to-helmet hits. His son was a victim of spearing during his initial concussion when a fullback from St. Michaels, a rival of St. Stevens, led with his helmet while making a block. Though spearing is illegal, Benson believes the penalty should be stricter.

"Spearing just kills, period," Benson said. "My idea for it is first offense you're out of the game, second offense is you're out for the season, third offense you're out of the league."

Though tragic, football-related head injuries that have resulted in death on the high school and collegiate level such as Benson's have declined dramatically. Dr. Frederick Mueller, director of the National Center for Catastrophic Sports Injury Research, said the number of direct fatalities on the football field in recent years has been relatively low in comparison with several decades ago. In 1968, neck and head injuries were responsible for 36 direct fatalities. There were no direct fatalities in 1990 and just one in 1995, he said. The number of direct fatalities from head and neck injuries annually has been in the single digits ever since, Mueller added. He credits the reduced rates to improved medical care, better tackling fundamentals and helmet standards that did not exist before 1978.

Mike Walsh, a former fullback at the University of Maine and a coach in the Carlsbad [Calif.] Pop Warner League, believes the climate in youth football is much safer today. When Walsh played at Glastonbury [Conn.] High School in the mid-1980s, he remembers wearing suspension helmets with little padding on the inside. By contrast, Walsh said his sons Mike and Cameron used to wear the well-padded Riddell Youth Revolution helmet in youth football that contained "a rigid shell and approached the weight of an eight-pound bowling ball." Walsh said this partly explains why he would only see a handful of concussions each season while coaching Pop Warner.

"If you made a serious connection there was no doubt in my mind that the suspension did not keep your skull from hitting the shell of your helmet," Walsh said. "When I played high school ball, I saw kids vomiting and crying because of the brightness of the light [after experiencing a concussion]. I think they were considerably more affected and quite frankly I remember seeing concussions more often."

Despite technological advances in helmet design, concussion experts still have doubts that any helmet can help prevent an initial head injury. Herring responded to a question on whether advances in helmet design could assist in reducing concussion rates by saying, "If you wanted to prevent a concussion, you would need to wear one the size of this conference room [roughly 14 feet by 12 feet] and even then there is no guarantee." Each person, he added, has their own sensitivity to a hit.

One factor commonly ignored when evaluating concussion rates in football is the surface of play. Tom Bainter, the coach of Bothell High School just outside Seattle, said there were six concussions in his program in 2005, the last season before the school tore up a worn artificial turf field. The worst occurred when a freshman linebacker lowered his shoulder during a hit and slammed his head against the turf, experiencing a "double hit," as his helmet bounced back up. The linebacker missed several weeks of school and needed to be escorted through the hallways to locate his classes when he first returned. Bothell has not had a player experience a concussion since.

Don Bolinger, president of Construction Services at ATG Sports, an athletic surfacing manufacturer that has installed turf fields on the high school and collegiate level since 1980, said there is a direct relationship between concussions and the amount of sand underneath a turf field. He said most of the surfaces constructed by his company contain an all-rubber infill that unlike sand does not compact and provides a softer surface.

The company, he said, strives to create a surface safer than natural grass. Playing surfaces, he added, are given a G-Max rating that tests its softness, or the amount of shock your brain receives when it hits the ground. Artificial turf fields with high contents of sand will produce G-Max ratings in excess of 200, comparable to the amount of force your head experiences when hitting a dashboard during a car accident. While there are still hundreds of artificial fields on the high school level that contain sand underneath, surfaces with all-rubber infill are considered much safer, Bolinger said.

"When you use all rubber and maintenance it properly there is no reason why your field will ever get higher than 150," Bolinger said.

Rep. John Conyers Jr. (D, Mich.), the chairman of the House Judiciary Committee, said Congress needs to spend more time investigating the factors responsible for concussions in youth football before legislation is enacted. He has not set a timetable, but has tentative plans to hold one additional forum on concussions. Rep. Sheila Jackson-Lee (D, Texas), a senior member on the committee, would like to consider several initiatives, including requiring parents in Pee Wee football to complete a counseling session on concussion awareness and possibly holding the NFL more accountable for head injuries on the youth level.

"I understand the NFL is a private entity -- they are not here to fund public education, but I think there are opportunities they can utilize to provide some efforts that would strengthen the Pee Wee game, youth game and college game," Jackson-Lee said.

Zackery Lystedt has returned to Tahoma High School, where he is taking two classes, when not rushed between seemingly endless therapy sessions outside of school. He still can't prepare food on his own, but is able to eat with his left hand. As Lystedt strives to reach his own goal of becoming fully functional, he hopes the effects of his law can be felt across the country.

"He is a remarkable man and his parents Victor and Mercedes are remarkable, inspiring people," Herring said during his testimony. "They moved us not only to continue our work and take care of kids with concussions every day, but it also prompted us to move for legislation. For today, it's the simplest solution. Not only is it a law, it's the right thing to do."