SPOKANE — It wasn’t long ago that football pros gained cheers for delivering — or receiving — repeated, head-rattling tackles.
But by 2011, health concerns about concussions in sports moved to the forefront alongside medical research, news coverage and player lawsuits.
It led to return-to-play rules now standard — from the National Football League to kids’ sports. A national “Heads Up” campaign advocates removing any athlete with suspected concussion from play, and medical experts warn about the danger of a second blow before recovery.
The NFL adopted a comprehensive game-day concussion diagnosis and management protocol in 2011. The league just added rules on ataxia, or poor motor skills, following a hit regardless of other possible causes after Miami Dolphins quarterback Tua Tagovailoa in 2022 got two hard hits — the second requiring him to be carted off the field.
School districts in Washington follow Washington Interscholastic Activities Association guidelines for concussions and return to play. Those are fueled by the 2009 Zackery Lystedt Law that requires any youth showing signs of a concussion to be examined and cleared by a licensed health care provider before a student can return to play.
Idaho has a similar law and guidelines for schools and sport programs.
“There is a lot of misinformation about concussions still,” said Breann Booher, Mt. Spokane High School athletic trainer. “A lot of individuals believe that a concussion is a bruise on the brain or bleeding on the brain. That is simply not true.”
Concussions are traumatic brain injuries caused from a bump, blow or some kind of jolt to the head. This sudden movement can cause the brain to bounce around or twist in the skull, creating chemical changes in the brain and sometimes stretching and damaging brain cells, according to the Centers for Disease Control and Prevention.
The CDC estimates that between 1.6 million and 3.8 million sports and recreation-related concussions occur each year in the United States. About 1 in 10 contact sport athletes, such as those playing football and soccer, sustain concussions yearly.
Booher said sports concussion follow-up drastically differs from 15 years ago, which called for rest in a dark room and no stimulus until symptom-free. Athletes now are encouraged to do light aerobic activity 24 to 48 hours post-injury. They’re then gradually returned to a sport.
“With football, it’s usually noncontact for a few of those days, then they’ll gradually work back into full contact,” Booher said.
Some schools still test athletes using concussion management software as a baseline, measuring such things as reaction time and memory. However, there’s typically more reliance now on athletic trainers’ expertise in recognition and treatment of concussions.
High school football teams often have an athletic trainer at games. In Washington, those trainers can pull players for suspected head injury after a concussion examination that looks for symptoms.
“We’re typically going to look at pupil response, (and) some kind of memory examination, so that can include words, time, place, orientation,” Booher said. “We’ll go through testing looking at vestibular motor control, which is looking more at central brain function and balance.”
A team doctor might watch or run separate tests.
“At that point, depending on how tests go, we either remove them from play for the remainder of the game, or we at times have them wait maybe 20 or 30 minutes, and see how symptoms do.”
During the school year, those trainers educate players and coaches about concussion risks.
“It’s better to miss this game, maybe the next game, versus 30, 40 years down the road we’ve got some significant brain trauma,” Booher said. “When they’re 35, I want to make sure they know where they parked at the grocery store and are able to play with their kids.”
Research also has shown that people who experience a concussion are more likely to have a future concussion. More is known about chronic traumatic encephalopathy — a neurodegenerative disease found after autopsies in the brains, often of former athletes, military veterans and others with a history of repetitive brain trauma.
In this region, specific stories and tragedies have heightened awareness:
- In September 2009, high school junior Drew Swank, as a Valley Christian football defensive back, was concussed in a game and returned to play the next week. After receiving a blow to his head in Washtucna, he staggered off the field and collapsed. Airlifted to Providence Sacred Heart Medical Center, he died of his injury two days later.
- In January 2018, Washington State quarterback Tyler Hilinski took his own life. His parents later revealed in interviews that Hilinski was found to have first-stage CTE.
- In 2018, Spokane’s Mark Rypien, as a former NFL quarterback and Super Bowl XXVI MVP, went public about his years of struggling with depression, mental health and mood swings he attributes to traumatic brain injury from playing football. The Shadle Park High School graduate also played as a Washington State University quarterback.
The Zackery Lystedt Law arose out of an injury in 2006, when Lystedt, playing in a middle school game for a school in the Tahoma School District southeast of Seattle, took a blow to his head. He returned to the game and was hit again, suffering a catastrophic brain injury that had him on life support for a week. He required intense physical therapy. It was nine months before he could speak and two years before doctors could remove his feeding tube.
Avoiding second-hit syndrome continues to be the focus, Booher said.
“That can be from a minor blow to the brain. It will cause the brain to uncontrollably swell, and once that begins, it’s very hard to reverse the effects of it.”
If a school doesn’t have a trainer, she said officials or coaches will pull a player with a suspected concussion. Health professionals who can do concussion evaluations are athletic trainers, medical doctors, osteopathic medicine doctors, nurse practitioners and physician assistants.
A regional concussion form lists a youth’s return-to-learn classroom requirements post-injury, and a second page covers return-to-play protocols, Booher said. A doctor or trainer monitors that player’s progress and often checks symptoms prior to return.
Nine years ago when she started, Booher said more athletes tried to “shrug it off” with concussions. But it’s less common now.
“Education has gone a long way with the kids. I think it helps seeing the NFL on TV starting to take concussions as seriously as they have.”