Arlene Karika-Thompson was walking away from the baseball diamond when the sound of a metal bat rang throughout the complex. 

Thinking one of the baseball teams just recorded a hit, Karika-Thompson retrieved a lawn chair from her car and hurried back. When she settled into her chair, she noticed her 10-year-old son on the bench. Moments later, he returned to the game and was hit by a runner. Visibly shaken, her son was removed. 

Not thinking anything was out of the ordinary, she drove her son home and promptly put him to bed since it was a late-night game. The next morning, things took a turn for the worse. 

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“He was rubbing his eyes and then said, ‘I can’t see,'” Karika-Thompson said. 

She rushed him to the hospital, where she learned he had a skull fracture.

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She soon pieced together that her son had been hit in the head with a metal bat while warming up to go into the game as a pitcher. The force of the strike had not only knocked her son unconscious, but also resulted in a traumatic brain injury, affecting his brain function.

“My son lost everything — memory, vision, taste, smell,” Karika-Thompson said. “I had three doctors tell me I was lucky that he survived the night. It was a long journey.”

With the injury taking place in 1995, there was a lack of research and resources for treating traumatic brain injuries, commonly referred to as TBIs. Additionally, there weren’t many concussion protocols for kids playing youth sports. 

Her son eventually succumbed to his traumatic brain injury in 2019, nearly 25 years after the accident. 

Karika-Thompson, who left her career as a teacher to become a re-entry specialist at the Brain Injury Association of Colorado, wonders whether her son’s outcome would have been different if the injury took place today.

“Nobody told me what had happened, and there was no protocol,” Karika-Thompson said.

The changing landscape of concussion protocols 

A lot has changed since Karika-Thompson’s son died.

Over the past two decades, the medical community has grasped a better understanding of brain injuries, leading to expansive research on the topic. The advancement in knowledge has led the sports industry — including major sports organizations, like the NFL and NHL — to look at head injuries through a new lens. 

The NFL started to place an emphasis on brain injuries when Mike Webster became the first player to be diagnosed with chronic traumatic encephalopathy, also called CTE, a neurodegenerative disease caused by repeated head injuries. A Boston University study examined the brains of 376 deceased former NFL players. Out of the nearly 400 former athletes, 345 had CTE (92%). 

The staggering statistic led the NFL to alter kickoffs in an attempt to reduce the amount of full-speed tackles. It also now issues penalties if a player lowers their helmet while tackling, a change made in 2022 to help reduce concussions. 

The NHL has made similar changes, such as implementing “Rule 48,” which prohibits direct hits to the lateral side of the head. Like the NFL, the NHL has also bolstered its concussion protocol standards by requiring mandatory evaluations when players hit their heads and the removal of players if an athlete shows symptoms of a concussion. 

Changes are trickling down to youth sports and other recreational sports to help reduce TBI incident rates. 

Vail-Summit Physical Therapy certified brain injury specialist Melissa Volkert said experts in the field of TBIs periodically release a statement on the best practices regarding concussion protocols once they reach a consensus.

“We have modeled our return-to-sport and our return-to-play guidelines on this most recent research in 2022,” Volkert said. 

One of the biggest deviations from the previous concussion protocols are the guidelines on activity. Although most of the general public believes the best way to heal from a concussion is to sleep, limit screen time and have no physical activity, current research encourages light activity within 24-48 hours of the injury.

“We are actually encouraging early return to physical activity,” Volkert said. “… Around 24-48 hours after your injury, you can do 15-20 minutes of light aerobic exercise, which this article says is about 55% of your max heart rate.”

These changes in concussion protocols have had an overall positive effect on the mental health of brain injury patients. CommonSpirit pediatric Dr. Dana Barnett said the old guidelines often did damage to the psyche of patients, especially in younger patients. 

“With the guidelines changing, it has been nicer because I think it allows somebody to feel like they are making more progress than being more isolated than they previously used to be,” Barnett said. “They can start progressing back to learning and activities of daily living and even physical activity.”

The exercise shouldn’t be taxing to the patient. Light activity allows blood to circulate through the body and jumpstart the healing process. Volkert points out that there is a fine line between light physical activity and pushing it too much.

“We do not want people to go too hard,” Volkert said. “We are not asking people to sprint right away or jog. This is like light walking.”

The process of going through the return-to-activity protocols looks different for everyone, but there is a heavy emphasis on backing off when symptoms arise both mentally and physically. 

For example, if a student is trying to complete a school assignment on the computer, but they can only go 15 minutes before getting a headache, Barnett would recommend the patient complete the assignment in chunks.

Once a brain injury patient is able to withstand regular activities and light aerobic exercise, they can begin moderate sport-specific exercises. This might look like doing walk-through drills for a football player or skating lightly for a hockey player. 

If symptoms are not triggered by the increase in stress and activity, athletes can then move to heavy, noncontact activity, such as sprinting or regular weight-lifting routines. Once athletes make their way through that checkpoint, they will be cleared by a doctor for full-contact practice. If all continues to go well, health care workers will then clear the athlete for competition. 

According to the Centers for Disease Control and Prevention, each step in the return-to-sport guidelines typically takes a minimum of 24 hours to complete, meaning that most concussed individuals will be sidelined for at least a week. The vast majority of athletes with head injuries are sitting on the sidelines longer than in previous years. According to an analysis published by the British Journal of Sports Medicine, high school and college football players in the late ’90s and early 2000s were returning to play just three days, on average, after getting a concussion. 

Health care workers are especially worried about adolescent patients getting multiple concussions. With the brains of school-age children still actively developing well into early adulthood, a history of concussion poses the risk of long-term cognitive damage.

Why young brains are especially vulnerable to brain injuries

It is because of the development of children’s brains that more stringent return-to-activity guidelines have been introduced over the past decade.

“That’s why you end up with these crazy, strict protocols because they are kids and are not really looking out for themselves,” Middle Park Health trauma medical director and ER Dr. Michelle Lupica said. “And that’s normal.”

With so many student athletes often being driven and wanting to return to a full workload as soon as possible, Barnett tries to highlight the importance of taking it slow to her patients.

“The biggest one is probably second impact syndrome, where the brain is literally just not healed and then you go and injure it again,” Barnett said. “This can lead to severe or fatal neurologic outcomes. That is going to be the biggest one.”

A push to change the stigma around safety

Growing up in the early 2000s, it was common for Salomon-sponsored skier Drew Petersen to see some of his favorite snowsports athletes without a helmet as they flew off a cliff or performed a rail slide in the streets.

Whether out for a day on the slopes or in a video uploaded to YouTube, it is common to see athletes of all ages not sporting a helmet while attempting a jaw-dropping trick. While the stigma around wearing a helmet has changed in the past 10 years or so, Petersen attests there is still plenty of work to be done.

“It really doesn’t look that cool to not wear a helmet,” Petersen said. “Helmets look cool now. … I pretty adamantly believe and profess — and I think it’s the ground swell opinion — that wearing a helmet is cool.”

According to a 2012 study of national bicycle helmet use, 42% of children ages 5-17 always wore a helmet. Helmet use saw a decrease among lower-income households, non-White populations, Hispanic populations and children 10-14 years of age. Adult helmet use was also associated with an increase in child helmet use. 

A 2022 study published by the American Academy of Pediatrics reports that the most often cited reasons for not wearing a helmet include cost, discomfort and lack of belief that it is necessary to prevent an injury.

In terms of the effectiveness of helmets, five studies from different countries concluded that wearing a helmet decreased the risk of head, brain and severe injury by 63% to 85% for all ages of bicyclists. 

Petersen credits the helmet he was wearing for saving his life in both of his skiing accidents. Although the helmet failed to prevent a traumatic brain injury, Petersen does not think he would be alive today if he did not have a helmet strapped to his head.  

It is because of his accidents, and others he has witnessed in the snowsports industry, that Petersen is an outspoken advocate for helmet use. 

“I think when I was younger, I didn’t realize the influence or significance that I could have on what kids think is cool,” Petersen said. “Now I do, and I am going to use that for good and for trying to help others stay safe.”

Stephanie Zavilla, the director of sports performance at the Winter Park Competition Center, has seen a steady trend of adolescent athletes growing more serious about brain safety and wearing a helmet. 

“I think for the most part kids understand,” Zavilla said. “Of course there is going to be disappointment if they are going to have to be pulled from a competition or they do not get to train. By and large, when we explain the ‘why,’ athletes are pretty on board.” 

U.S. Ski and Snowboard and the USA Snowboard and Freeski Association have seen an advancement in helmet rules over the past decade. 

“They have taken it really seriously and made sure that helmets have to have certain specs,” Zavilla said. “I have been to a lot of competitions where they make sure the helmet is the one they recommended with the FIS label. We also did a whole education seminar with our coaches this year that highlighted the benefit of MIPS technology.”

Multidirectional Impact Protection System, or MIPS for short, is a design used by many companies to enhance the safety of helmets by reducing the risk of rotational impacts. While many of the helmets on the market today utilize the protection system, there are still helmets that continue to lack the technology.

With young athletes taking influence from a wide range of people, Petersen implores every community member to do their part in setting the standard of wearing a helmet.

“Culturally, we have to all realize that we are role models to those kids,” Petersen said. “It doesn’t have to be a professional skier. Like the guy who is ripping under the chair at A-Basin every day, kids look up to him as well as the cool people in the lift line. Those people should be wearing helmets, as well.”

Advancements bring hope for preventing dire outcomes

Although there were very few concussion protocols in place when her son was playing baseball, Karika-Thompson is encouraged to see how far the science and research has advanced.

She credits these improvements to medical professionals and to the general public for gaining a more robust understanding of TBIs. 

With a better understanding of how each brain injury can have different effects, health care providers now have the expertise and knowledge to provide a proper treatment plan that is based on the individual’s history. 

According to professor and author David K. Menon at the University of Cambridge, large international collaborations have led to an improvement of understanding and care of traumatic brain injuries over the past decade. Menon recognizes that significant problems around brain injuries still remain and calls for more collaboration in order to improve patient outcomes.

Karika-Thompson also feels like health care workers now have a firm grasp of the domino effect traumatic brain injuries can have on an individual. 

“If you have an initial injury, you are three times greater to have a second injury,” Karika-Thompson said. “If you have a second injury, you are eight times greater to have a third injury. I can tell you from experience, those injuries can be as simple as bumping your head on a cupboard or getting whiplash.”

Above all, Karika-Thompson is grateful to see the drastic improvement in concussion protocols. Not only are the newest guidelines keeping people safe, but they are keeping kids like her son from being put back into a game after a significant head injury.

“It was terribly, terribly mishandled,” Karika-Thompson said. “But today, it is much better. He is why I do what I do. I want to serve people who have brain injuries and let them know they are not alone.”

Editor’s note: Sky-Hi News reporter Emily Gutierrez contributed to this report.