ORIG. / Andy Tullis/ The BulletinLisa Dickinson, left, looks at her sixteen-year-old daughter, Rylee Dickinson as they share a moment at their home in Bend Friday afternoon 10-2-15.

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Rylee Dickinson’s last memory of competing in soccer is fuzzy.

The teen and her Mountain View High School teammates were on Bend High’s turf. The rival team had a corner kick, and Dickinson stood in the goal box, ready to head the ball out.

The ball came flying. Dickinson jumped up, but a Bend High player was already behind it, ready to drive it in. Both girls got their heads on the ball, but Dickinson absorbed her opponent’s momentum.

{%pl-4434799%} She doesn’t remember where the ball went next, or much else about the next 15 minutes she made herself play.

“I would be running and I would black out while I was running,” Dickinson, now 16, said. “Then I would wake up out of it, and I was like, ‘What am I doing? Where am I?’”

Dickinson was experiencing her second concussion in three weeks.

She had headaches. She took at least a month away from schoolwork. Regaining her short-term memory took several more months.

Seeing Rylee struggle almost a year later, Lisa Dickinson wishes her daughter had taken a longer break after her first concussion during the 2014 soccer season.

A doctor at The Center Orthopedic & Neurosurgical Care & Research in Bend had cleared her to play after about a week. What parents may or may not understand is that cleared to play is not the same as risk-free.

Concussion symptoms, such as headaches or trouble concentrating at school, can appear even after the athlete seems to have recovered. They’re easy for parents to overlook and for hard-charging athletes to brush off or hide, but they are a sign the brain hasn’t recovered, leaving the athlete at risk for second-impact syndrome, which can be deadly.

Parents who are alarmed by concussion horror stories might assume medical research would reinforce their decision to keep kids away from contact sports. Yet leading researchers think the benefits of participation outweigh the risk of head trauma, and they’re looking for ways to help young athletes who struggle with prolonged concussion symptoms get back to playing. That’s despite the fact that doctors still can’t tell parents how many blows to the head a kid can take and still avoid permanent neurological damage, or whether staying concussion-free for a given window of time will keep a kid safe.

All that leaves parents weighing the unquantified risk of multiple concussions against the more concrete and immediate repercussions of holding a kid back from a sport that’s so tied to his or her identity, as well as the family dynamic.

“I think each parent has different levels of risk assessment they make in their own mind and how much they want to let the kid play, and how important it is to the kid,” said Dr. Viviane Ugalde, a concussion specialist at The Center who saw Rylee after her second concussion of that 2014 soccer season.

{%qr-I think each parent has different levels of risk assessment they make in their own mind and how much they want to let the kid play, and how important it is to the kid. %em Dr. Viviane Ugalde, concussion specialist%}

Ugalde offers families a range of options. The most conservative route, the best chance for a full recovery of the brain, is to take a year away from activities in which collision is likely, she said. The middle path is taking a few months away from the sport, just to make sure symptoms don’t pop up again. The last is to return to play immediately. “So that really puts the onus on the parents, which is horrible, right?” Ugalde said.

Ugalde did not clear Rylee to play in August, 10 months after the concussion she received Oct. 23, 2014, during the game against Bend High.

With practice about to start and knowing that she’d be missing her friends, Mountain View coach Don Emerson invited Rylee to come out as an assistant coach.

Later she began participating during noncontact drills. Rylee held out hope for a senior-year comeback, but her mom wasn’t so sure.

“If I had it my way, neither one of my girls would even consider it again,” Lisa Dickinson said. “To me, it’s just not worth it.”

At the same time, she sees the benefits of sports. “Especially as adolescent girls, keeping busy and feeling good about yourself, and feeling strong and having that sense of accomplishment is important.”

A matter of luck?

Doctors know that with each concussion, the odds of subsequent concussions increase. And with multiple concussions, there’s a greater chance of symptoms lasting longer than four weeks.

“How do you predict those folks that are going to have a recurrent concussion?” Ugalde said. “We don’t have a good handle on that.”

Most of the time, going right back to a contact sport has no consequences. The Center’s charitable arm, The Center Foundation, provides athletic trainers to Bend, Summit, Mountain View, La Pine and Sisters high schools, and the trainers see about 3,000 athletes a year. About 100 concussions are reported to the athletic trainers each year, Ugalde said. (The count does not include concussions that happen outside of school sports. The St. Charles Bend emergency room treated 180 pediatric concussions in 2013 and 224 in 2014.)

Ugalde said few athletes have multiple concussions. Looking at 282 concussions over two academic years, 2011-12 and 2012-13, she found that 17, or 6.4 percent, represented a second or third concussion.

“The lucky thing is that there’s hundreds of thousands of kids out there playing sports,” she said. “And they do well.”

Ugalde treated one girl, a lacrosse player, who received her first and only concussion as a senior in high school. She had persistent headaches. “Nothing worked,” Ugalde said. “All the medicines made her sicker. She had lots of side effects with them.”

The girl was still struggling as she went to college, said Ugalde, who has not treated the girl since that time. “She’s a bright girl, but she had to have accommodations at college to help her get through college.”

While there’s no way to predict who will be so unlucky, research points to some risk factors.

Pre-existing conditions, such as attention deficit hyperactivity disorder, learning disabilities and a history of migraine headaches, seem to be associated with a slow recovery from concussion, said Sondra Marshall, a clinical psychologist at St. Charles Health System who works with pediatric concussion patients. Marshall works alongside doctors at Central Oregon Pediatric Associates and on tough cases as part of a multidisciplinary team that usually includes Ugalde.

If an athlete has one concussion with an unusual course of recovery, Marshall tells the parents, “The best I can do is predict the next one is going to be atypical. And it may take longer.”

If each concussion results in more intense and long-lasting symptoms, or if it takes less and less impact to trigger symptoms, then it’s time to talk about a kid’s future.

“That is a warning sign that return to play should be very seriously considered in terms of contact sports,” Ugalde said.

{%pl-4434794%} Rylee Dickinson’s case illustrates how little one can learn from looking solely at the number of concussions in an athlete’s career. She suffered her very first in eighth grade, but she and her mom said that wasn’t much of a factor when she got her second one as a sophomore in high school. She had collided with a teammate at soccer practice and was cleared to play about a week later.

Dickinson admits that in the weeks leading up to the Oct. 23, 2014, game against Bend High, she brushed off some minor headaches because she wanted to keep playing. Dickinson and her parents think the fact that she wasn’t fully recovered from the first head injury is what made the next concussion so much worse.

So-called second-impact syndrome can be deadly, and it’s what Oregon’s laws around concussions in youth sports were designed to prevent. Sometimes, though, kids fall through the cracks. Ugalde said she has heard about kids who seem OK after a concussion, but then their grades slip. “That kid shouldn’t be doing contact sports,” she said. “They’re still struggling with cognitive recovery.”

Dickinson’s fourth concussion came last spring. She was sitting on the floor at home, watching television, when one of the family’s two Lab-Rottweiler mixes playfully barreled into her. She didn’t feel the effects right away, but later that night, she felt like she was going to throw up.

Lisa Dickinson was not surprised that Ugalde didn’t clear Rylee to compete in August. Having home-schooled Rylee and her sister, Macenzie, she noticed that Rylee still didn’t absorb reading material as effortlessly as she used to.

Rylee is at a critical junction, Ugalde said. “I think you really have to make that decision about what’s more important to you, that short-term — ‘I might be able to play a season or two before I have my next one — but then what kind of repercussions do I have at that point?’”

Brain glitch

A concussion is often described as the brain bouncing against the inside of the skull, first in the direction of impact and then against the opposite side. The proverbial rung bell.

More important to medicine’s current understanding and treatment of the condition is what happens at the cellular level. The impact stretches or twists the membranes of nerve cells, touching off a metabolic cascade that depletes the neurons of energy and inhibits functioning.

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Explaining it in terms that his young patients understand, Gerard Gioia, a neuropsychologist and director of the Safe Concussion Outcome, Recovery & Education (SCORE) Program at Children’s National Health System in Washington, D.C., likens a concussion to a software glitch.

It takes time for neurons to restore their chemical balance, but medical researchers no longer believe sitting in a dark room is very helpful. Once headaches, nausea and any other acute symptoms have subsided, patients may gradually ramp up activity.

Gioia is among a group of researchers who believe doctors need to go even further with promoting an active recovery — a general therapy for concussion patients that gives credit for simple, everyday activity.

“I am literally coaching people to think about what they can handle, what they can tolerate the first day of the injury,” he said.

Kids are always doing something, Gioia said, even if it’s just walking around the house. So his idea is to give them credit for that activity, watch to see whether it causes symptoms and push to the next level.

Researchers also think that active recovery can be used with kids who can’t seem to shake the initial headaches or other symptoms.

“We’re looking at a group of kids that don’t feel better at rest,” said Nick Reed, an occupational therapist at Holland Bloorview Kids Rehabilitation Hospital in Toronto. “Because of that they’re no longer allowed to progress to that return-to-play protocol.”

Holland Bloorview is one of several teams across Canada that’s studying the effects of a specialized active recovery protocol on kids with prolonged concussion symptoms. Reed said the protocol is an intermediate step that involves exercise, visualization and sports-specific drills.

Reed doesn’t think that just because a kid struggles to recover from a concussion he or she should rethink sports.

“We take a real pro-sports approach,” Reed said. “We think there’s considerable benefit involved in participating in physical activity including sports. So we want kids participating in sports. We want them educated, and we want them doing it safely.”

Gioia, a former football and rugby player, sympathizes with the active kids who become bored and depressed when sidelined by a concussion. He thinks the popular view of concussions is too doom-and-gloom. “My view is, ‘You’re going to get better,’” he said. “I give them the pathway for what they need to do to get better.”

Knowledge

Oregon’s first law around concussions in youth sports was named for Max Conradt, a 17-year-old football player who experienced a concussion during a game in 2001. In the next game he played, he collapsed at halftime with brain bleeding. He fell into a coma and now lives in a group home in Salem.

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Max’s Law required all school districts to adopt concussion-management policies. Coaches must be trained to recognize symptoms. They must remove kids from play if they suspect a concussion. The kid must be evaluated by a professional, and he or she must have a medical release to return to play.

Jenna’s Law, passed in 2014, essentially extended the same requirements to nonschool sports. It was named for Jenna Sneva, a world-class skier from Sisters who came close to permanent disability after a career’s worth of concussions.

By now, coaches and school personnel are well versed in the return-to-play protocol, said Bob Marsh, athletic director at Pilot Butte Middle School. He thinks the next step is to train parents. “I don’t think they understand it entirely.”

Seventh-grader Mason Briley has been playing tackle football since fourth grade, but he got his first concussion in 2014 on the playground at Pilot Butte. He and his friends were doing a wide receiver play, and he hit heads with another boy, his mom, Melissa Briley, said. The concussion caused Mason to miss a couple of weeks of school.

Then last spring, toward the end of his sixth-grade year, he rolled out of a closet shelf where he and a friend were making forts. He hit his head on the toy box below. That time Mason was out of school for about three weeks. He made several trips to a pediatrician at Mosaic Medical for short-term memory and balance testing before he could go back to school, starting at part time, and engage in physical activity.

Mason’s dad, Philip Briley, said the pediatrician told him that because Mason, who is 12, is so young, his brain will become stronger. “So after one year without a concussion, it’s like he never had a concussion.” Briley’s pediatrician at Mosaic Medical could not be reached for an interview.

The Brileys said they heard plenty of negative feedback from relatives about their decision to let Mason play football this season. Melissa said her brother-in-law bluntly told them they were “stupid.”

She would be inclined to pull Mason out of football if he were hurt again. “With each blow to the head, it creates trauma,” she said. “Of course, now we have to worry about the next time he gets hit. What could that do? It could cause him damage. He could hemorrhage.”

{%qr-No matter what, you’re taking a risk. If that’s the risk you want to take, it’s your life, so why hold a person back from what they want to do? %em Philip Briley on his decision to let his son Mason continue playing football%}

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Philip Briley sees no reason to deprive Mason of his passion. “No matter what, you’re taking a risk,” he said. “If that’s the risk you want to take, it’s your life, so why hold a person back from what they want to do?”

Mason is wiry and fast. He plays cornerback and tailback, and in his team’s first game of the season, he scored a touchdown and racked up 175 yards running and receiving. The team lost, but the Brileys — and most of the Giants’ sideline — were thrilled by Mason’s performance.

“It was awesome watching him play out there,” Philip Briley said afterward.

If concussions are like other health issues, simply being aware of the risks isn’t enough to change behavior. Consider the fact that about half of all athletes have concussions that they don’t report.

Emily Kroshus, an assistant professor in public health at the University of Washington, became fascinated with the issue after one of her brothers, a neurobiology major at Harvard University, tried to hide a concussion he sustained playing hockey.

Clearly, a lack of knowledge wasn’t the problem.

Kroshus has found that college athletes’ perception of normal behavior, as well as pressure from fans, coaches, teammates and parents, are associated with the likelihood that they will report concussions.

More has to be done to change the culture of youth sports, Kroshus said. “I don’t think we can pat ourselves on the back and say, We handed out a fact sheet. Athletes are going to be safe.”

A self-described jock, Kroshus thinks Americans have allowed sports to become too all-encompassing. “You can still go on the field and compete hard and care a lot and not have this distorted idea of what the sport means in your life,” she said.

Athletic identity

After Rylee’s experience, Lisa Dickinson wants to see her younger daughter, Macenzie, explore all her talents. Macenzie, 12, took a spill on her scooter last summer and had a concussion with amnesia.

She’s playing volleyball in middle school, but Dickinson said she won’t be playing with a club. Besides, Macenzie has other interests, such as art, which Rylee didn’t have a chance to explore once she started playing soccer year-round at the age of 10.

Between high school and travel teams, Rylee played on a coed indoor team with her parents. Her dad had played in high school, and Rylee’s dream was to play for University of North Carolina, a top women’s program. She pushed herself by scrimmaging with boys. “I would rather go out there … and get beat up playing with them rather than just play with girls because I always felt like I got better,” she said. “They play so much faster.”

Still recovering from her concussion last spring, Rylee gave track a try. She’s found herself with time to attend her church youth group, and last summer she got a part-time job coaching 3- and 4-year-olds.

{%pl-4337329%} Maddie Martin is still trying to figure out her post-concussion life.

Starting classes at Bend High in September, Martin hoped she’d look more like the “old Maddie,” who not only played softball year-round, traveling to Portland twice a week for three-hour practices, but played cello — first chair — bowled and made As in honors classes. She still couldn’t compete in softball, but she hoped to return to the school orchestra, bowl and take a couple of college-prep courses.

Midway through the second week of the fall term, it’s obvious that her concussion recovery isn’t complete. She dropped precalculus. Bowling practice doesn’t deplete her energy, but Lava Lanes is one of those noisy environments that could overstimulate her brain or trigger a headache. She’s already realized she can’t handle orchestra. She’s practicing with a club softball team, but only if she has enough energy left after a day of school.

“I’ve never been a kid that goes 50 percent. It’s 100 percent or nothing,” Martin, 16, said. “The fact that I can’t do 100 percent, it just sucks.”

Before getting two concussions in 2014, Martin’s life revolved around softball. At the age of 14, she was being courted by Arizona State University, her mom, Molly Ryan, said.

Trying out for a team in the Willamette Valley in August 2014, Martin took a 50 mph ball in the face. Her parents took her to an emergency room in Portland, where they were relieved that all the bones in her face were intact. She had a concussion, but then, it seemed as though every girl on the team had had one concussion, Ryan said.

Back home in Bend, Ryan took Maddie to a pediatrician, who said she needed to wait a couple of weeks after her symptoms cleared before returning to softball. “That’s what we did,” Ryan said.

But she didn’t take Maddie back to the doctor. “We should have gone back for the she-is-clear appointment,” Ryan said.

Martin ended up joining a different Portland-based travel softball team, which wasn’t aware of her August concussion. Playing at a college-exposure tournament in California that October, Martin dove into a base. She made it to home, but she felt dizzy. She saw the landscape tipping. A throbbing headache came next.

When the headaches and other symptoms persisted for three months, Ryan said Maddie’s pediatrician and Marshall changed her diagnosis from concussion, which is a mild traumatic brain injury, to a traumatic brain injury.

{%pr-4337333%} Martin was irritable because she couldn’t do everyday things like go to a grocery store, much less carry on with her usually packed schedule. Her best friend didn’t understand her bad attitude, and their friendship ended. The loss of that friendship hurts more than anything. “To not stick there by me and just wait it out,” she said, “just broke my heart.”

Concussions in themselves can trigger depression and anxiety. Kids might also need to see a therapist to deal with all of the changes brought by the injury, to help reshape their identities, Marshall said. Although complicated cases are not the norm, Ugalde said there are enough kids in Central Oregon who are dealing with chronic symptoms that she would like to set up a support group.

Chronic symptoms

Austin Crook, a former standout soccer player for Bend High, is trying to bring attention to post-concussion syndrome as he tries to heal his brain enough to withstand normal levels of physical activity. At age 23, he rides a stationary bike for exercise and avoids any jarring movement that could send him into a dark room, battling a headache for weeks on end.

Researchers find that around 10 percent of young athletes have chronic symptoms, and Crook points out, that’s 10 percent of hundreds of thousands of concussions in youth and college sports a year. “That’s a huge chunk of the youth that are going to be dealing with that this year,” he said.

There are more treatment options available now than even four years ago when Crook left Oregon State University after getting back-to-back concussions playing pickup basketball. He spent six months sitting around in dark rooms at his parents’ house in Bend. At the time, his parents didn’t understand a concussion’s impact on mental health. “We had our own family problems from that,” Crook said. His parents would ask, “Are these symptoms created in your own head?”

A middle school teacher in Arizona, Crook set up a concussion survivors Facebook group. His experience served as a warning for his younger brother, Hayden, a walk-on place-kicker at University of Oregon who dropped out in the summer of 2014 because he’d had multiple concussions and was extremely susceptible to headaches.

“My brother and I have created a bond that’s like unbreakable because of this,” said 21-year-old Hayden Crook.

The Crook brothers are working on how to relate to the rest of their still-athletic family. Their father, Brian Crook, played baseball and football in high school and college and never experienced concussions like his sons did. “I’ve had four knee surgeries, so if you tear your knee up, I can relate to that. I get that,” said Crook, who coached baseball at Bend High for about 20 years.

Crook said he understands why his sons are leading cautious lifestyles, but he’s at a loss for ways to connect with them. “What do guys do when they want to connect? They go do something,” he said. “We go play golf, we shoot hoops. You go do something. You don’t sit around and talk.”

Hayden Crook often wishes that when he was younger he’d learned a sport like tennis, something he could fall back on after a concussion. Brian Crook, principal at High Desert Middle School, has heard his sons say these things and scoffs at the notion that either one of them could have been steered toward some mild activity, like piano lessons.

“Our kids were competitive out of the womb.” •