When Is It Safe to Return to Play After a Concussion?

Zackery Lystedt loved sports. And the then 13-year-old Seattle-area middle schooler excelled in them, especially football. Then, during an October 2006 football match, Zackery made a goal-line tackle and landed hard on his helmet. An official time out was called and he walked off the field with his coach. Zackery never lost consciousness from that play. He sat on the bench for three plays just before half-time, but was returned to the game at the start of the third quarter. School coaches let him go back in the game without obtaining a medical evaluation. There were no healthcare professionals on the sidelines to assess Zackery. Before the game was over, Zackery collapsed.

Zackery was rushed to the hospital where he underwent emergency brain surgery. The surgery saved his life. Although the tenacious young man has made incredible progress during the last few years — from relearning how to swallow to regaining his ability talk, though in a measured and slow way — he remains dependent on a wheelchair and 24/7 supervision for his needs.

His parents say he should never have been allowed to return to play.

In May 2009, Washington State passed the Zackery Lystedt Law, the nation’s toughest return-to-play law aiding young athletes concussion recovery. It requires medical clearance of youth athletes under the age of 18 suspected of sustaining a concussion before they can be sent back into a game, practice, or training.

“Some people call it the toughest return-to-play law. Others call it the most enlightened return-to-play law. We think it’s both,” says Richard H. Adler, president of the Brain Injury Association of Washington (BIA of WA) and the lawyer representing Zackery and his parents for his brain injury.

The new law — House Bill 1824 — prohibits youth athletes suspected of sustaining a concussion from returning to play without a complete evaluation by a licensed healthcare professional trained in the evaluation and management of concussions. This means that athletes who sustain a concussion — or who are suspected of having sustained a concussion — are not allowed to return to play without written consent from the healthcare provider who performed the evaluation. Coaches cannot give this evaluation or go-ahead to return to play. They must wait until the athlete has been evaluated by a licensed healthcare provider, such as a doctor or athletic trainer on the sidelines, and returns with a written go-ahead. If there is no licensed healthcare provider on the sidelines, then the athlete cannot return to the game. They will need to obtain clearance later on. It is not until then that the athlete can again take the field.

Spearheaded by coalition of community partners (Seattle Seahawks, Centers for Disease Control and Prevention, Washington State Youth Soccer Association, Washington State Athletic Trainers Association, Seattle Children’s Hospital, Harborview Medical Center, Risk Managers, and Washington Interscholastic Activities Association) that Mr. Adler brought together under the banner of BIA of WA, the new law also provides an important lesson to young athletes, parents, and coaches that a person does not have to fall unconscious for a concussion — or mild traumatic brain injury — to be serious. It requires each of the state's school districts to work with the Washington Interscholastic Activities Association to develop a standard for educating coaches, players, and parents on the dangers of concussions. In addition, a concussion and brain injury information sheet must be signed by the athletes and their parents or guardians before the athletes can play or practice. “Zackery’s injuries could and should have been avoided. This is a common sense law that makes youth sports safer and prevents preventable brain injuries,” says Adler.

“It would be great if concussions in youth sports did not exist, but they do. The question is what to do about them. That’s what this law is all about,” says Adler. “We owe a great debt of thanks to Zack and his parents who have stood up and stood strong. They are amazing people who have committed themselves to ensuring that this does not happen again. They have gone through so much because of Zack’s brain injury and they will continue to go through so much during their lifetime, yet they continue to inspire those they meet to take action.”

The bill, which goes into effect July 26, 2009, has already started to make ripples in other states. Oregon recently signed a similar bill. California is poised to do the same. And so far, more than 10 other states are taking Washington’s lead by introducing similar legislation in the upcoming year. And unbeknownst to BIA of WA, the American College of Sports Medicine (ACSM) has been tracking the progress of the Zackery Lystedt Law. “We recently learned that the executive board of ACSM has signed a resolution for a National Call to Action to get all states to pass a similar law,” says Adler.

“The Zackery Lystedt Law is a massive step toward ensuring the safety of youth athletes across the country. Every year young lives are destroyed or diminished by returning to play too soon after concussion in sports, and often these tragedies could have been prevented if a medical professional had been consulted,” says Chris Nowinski, founder and president, Sports Legacy Institute. “Not only will this law protect athletes from preventable acute brain injury, but I anticipate we will discover it produces measurable results in reducing chronic brain injury down the road. Zackery’s Law sends a loud and clear message to those who have yet to appreciate the scope of the sports concussion crisis that the culture has changed, and that the bar for proper care of concussion has been permanently raised. I hope this law inspires similar changes across the country. Congratulations to all that made it happen.”