Blake Lee, 17, suffered his first concussion without ever hitting his head.
The soccer goalie was in the middle of a game in 2011 when another player collided with him. The other player broke his femur and was immediately taken to a hospital. But Lee believed he could keep playing, despite the headache he felt after the hit.
"I didn't think anything was wrong with me," Lee said. "I thought you had to get knocked out to have a concussion. It didn't even occur to me that I could get a concussion from whiplash."
Lee said his terrible headache continued for the next few weeks. The first doctor he saw believed he had a sinus infection. It wasn't until two and a half weeks after the injury that another doctor determined Lee had suffered a concussion.
During that time, the Eastside Catholic student had been participating in soccer and lacrosse practice six days a week and played in two games. His headaches had only gotten worse.
"It was unbearable," Lee said.
The doctor advised Lee to immediately take time off of sports and school to allow his brain to rest from physical and mental exercises. It was two months before he was able to resume his schoolwork and start light physical activity again.
Even though he was in significant pain, Lee said he was initially hesitant to take his doctor's advice and give his brain some rest.
"I didn't want to be told I couldn't do anything," he said.
According to a new study from the University of Washington, Lee's desire to play through his injury is not unique.
Dr. Sara Chrisman, a University of Washington adolescent medicine specialist, led a focus group of 50 Seattle-area high-school varsity athletes in 2012 and learned that, although the students knew the symptoms of a concussion and understood the long-term effects of such an injury, they were unlikely to report head injuries on the field. Dr. Chrisman is concerned that athletes who keep playing after a concussion are at greater risk for serious injury, or even death.
The students Chrisman interviewed said they didn't want to be pulled from the game and were willing to downplay their injuries. Some athletes didn't want to look weak or be judged negatively by their peers. Chrisman said the girls in her study were even less likely than the boys to report concussion symptoms to a coach.
"Girls need to be tough to be in sports," Chrisman said. "They need to show they are able to handle it."
Another problem is that head injuries can cloud a player's judgment, Chrisman said. Athletes can be disoriented after a head injury and may not be able to identify concussion symptoms.
Dr. Richard Ellenbogen, chief neurosurgery at Seattle Children's Hospital, says concussions rarely result in serious injury, but in some cases the side effects have been lethal. Repeat concussions can result in brain swelling, permanent brain damage and even death.
Ellenbogen said doctors still don't fully understand the long-term impacts of a concussion, but they know that a child's brain takes longer to recover than adults.
In 2009 Washington State passed the Zackery Lystedt Law, which requires coaches, youth athletes, and their parents be educated on the risks of concussion and head injury. Additionally, any youth athlete suspected of having a head injury should be removed from the practice or game. The athlete may not return to play until he or she has been evaluated by a licensed health care provider and gets clearance to play.
Ellenbogen said he agrees with the law and advises that any athlete who suffers a blow to the head be taken out of play until their symptoms have subsided and they've seen a medical professional.
"Always err on side of player safety," Ellenbogen said. "It's only going to be worse the more times you [are injured] without rest to recover to your baseline."
In the past, Chrisman said physicians believed concussions were only serious if the patient lost consciousness. Now they know that is not true, she said.
"If a kid is experiencing any symptoms they should not be on the field," Chrisman said. "Activity and stress can make symptoms continue longer."
The national Centers for Disease Control and Prevention (CDC) reports that if a second concussion occurs before the brain recovers from the first the patient's recovery slows and they are more likely to have long-term effects.
Chrisman's study found coaches are crucial in keeping student athletes from returning to a game after suffering a concussion. She reports that when coaches encourage athletes to report concussive symptoms, they are more likely to do so.
"Our research suggests coaches have a larger role to play in concussive safety than they realize," Chrisman said. "It's one thing for a coach to be watching and it's another to say 'If you feel dizzy I want you to talk to me.'"
Ellenbogen argues parents are equally important when it comes to preventing further injury after a concussion.
"You can't put this all on the coach," Ellenbogen said. "Parents should be on the sidelines and advocate for the kids. If they have a hit, take them out."
Chrisman said parents can most easily recognize if their child is not acting normally after an injury.
Despite the risks, Ellenbogen said he does not believe parents need to keep their kids out of sports. His own son played football and his daughter played soccer.
"Sports are healthy," Ellenbogen said. "We know that keeping kids involved in sports activities keeps them out of trouble, and it's healthy physically. There are risks, but the idea is to minimize those risks."
Since his first concussion, Lee has learned to take head injuries more seriously. He's had two more concussions since and took himself out of play both times.
"Every time I get hit I take a minute and see how I feel and test my balance before I go back in the game," Lee said.
He's also followed his doctor's advice and allowed his brain to rest after injury, even avoiding television, music and his cell phone.
"At first I didn't believe that sitting and watching TV would hurt me, but I would watch for a couple hours and get a terrible headache and have to go to bed," Lee said. "Sitting at home not doing anything is what made the difference in my recovery."
Lee also does brain rehabilitation exercises like marching to a metronome and counting backwards. He said this kind of work has made his brain feel stronger than it did before his concussions.
Now that he knows more about head injuries, Lee said he also encourages his friends to take a break if they get hit.
"Concussions can be really serious or not at all," Lee said. "But anytime you have symptoms you need to come out of the game."