EDITOR'S NOTE: This is the first of a two-day series on football-related concussions at the high school and youth levels.
In just five years, 49 states have passed laws to raise awareness about concussions and ensure proper treatment of head injuries in young athletes.
The rapid spread of "return-to-play" laws came after the revelation of long-term brain damage in several former National Football League players and alarm at the local level that young athletes needed more protection and care in dealing with concussions.
As the new laws settle into place, experts believe they are just a first step. The laws focus on education, but there are no penalties in place to ensure their effectiveness.
Meanwhile, concussions are increasing, and almost half the concussions in high school sports occur in football. But determining exactly what can and needs to be done is difficult in the shifting landscapes of sports and medical research.
Even with new laws, prevention of concussions remains elusive.
Parents and doctors are more concerned than ever about the long-term effects of contact sports on young brains. Coaches and players must adapt in football's play-through-pain culture as they are asked to appreciate the dangers of concussions, which may offer few physical signs initially and can vary greatly from person to person.
Even as the 2013 high school football season comes to a close, brain trauma cases of high-profile professional athletes comes to light, fanning the discussion on how to best protect young athletes from similar fates.
Injuries led to law
The mental deterioration of numerous former NFL players over the past decade made concussions a national topic.
Players such as Mike Webster, Dave Duerson and Junior Seau were all dead by the age of 50 after suffering the effects of repeated hits to the head.
Duerson and Seau committed suicide in 2011 and '12, respectively. Both shot themselves in the chest to preserve their brains for study. Along with Webster and other former players, they were found to suffer from chronic traumatic encephalopathy (CTE), a progressive brain damage that comes from repeated head trauma. It can only be diagnosed postmortem.
CTE was also found in 26-year-old Cincinnati Bengals wide receiver Chris Henry after his death in 2009 and 21-year-old University of Pennsylvania lineman Owen Thomas, who took his own life in 2010.
Neither Henry nor Thomas had any history of concussion, causing alarm about what the normal, sub-concussive banging of heads meant for younger football players. Multiple research projects in recent years have shown that sub-concussive hits take a toll on the brain, but the long-term extent of these hits is unclear.
Dr. Richard C. Cantu is a neurosurgery professor at the Boston University School of Medicine and medical director of the Sports Legacy Institute, an organization that strives to advance the study, treatment and prevention of brain trauma.
"What we know is scary as hell," he said about research on the cumulative damage of sub-concussive hits. "That's probably the best way to phrase it."
Since August 2011, more than 4,000 former players have filed lawsuits accusing the NFL of withholding information on the dangers of concussions.
Zackery Lystedt brought the focus on brain damage to the high school level in 2006.
A 13-year-old football player in the state of Washington, Lystedt suffered permanent brain damage when he continued to play in a junior high game after suffering a concussion. His ordeal led to what became known as the Lystedt Law.
The law requires a youth athlete suspected of a concussion or head injury to be immediately removed from play and that a physician provides written clearance before the athlete returns.
Washington's governor signed the law in May 2009, and it became the model for variations of the law passed in 48 other states. Only Mississippi has no form of concussion law.
As attention increased on the issue, so have the number of reported concussions.
Dr. R. Dawn Comstock maintains the High School Reporting Information Online injury surveillance system, a database that collects injury information on prep sports across the country. According to Comstock's data, the estimated number of concussions in high school football jumped from 55,007 in 2005-06 to 140,057 in 2011-12.
Most experts believe this means that fewer concussions are being missed, rather than more athletes getting concussions. Some estimate that 50 percent of concussions still go undiagnosed, down from the estimated 80 percent in the 1990s.
Dr. Joseph Congeni is the director of sports medicine for Akron Children's Hospital in Ohio.
"I think the biggest part of (concussion laws) is education," he said, "so that people can deal with it, be aware of it and know where the resources are for the best people on the medical team to care for those with brain injuries so we're not returning people to play too soon."
The intention of the laws is to make sure another Zackery Lystedt does not happen.
While state laws vary in language, they all revolve around three key components:
The law emphasizes what medical experts say are the best ways to prevent serious brain injury: recognition and assessment of symptoms, followed by rest and treatment.
From the medical community to the policy makers, experts agree that the laws have been successful in grassroots education. But whether the laws provide significant protection for young athletes is unclear.
The laws do not include penalties for failure to comply with the new regulations. They do not require a minimum or standard level of medical resources at games or practices. They do not have provisions to ensure the effectiveness of the required brain injury education.
"You might consider these laws to be a low-cost, partial solution to a large public health problem," said Hosea H. Harvey, a professor of law at Temple University, referring to traumatic brain injuries in youth sports.
Cantu believes there needs to be more checking into the qualifications of physicians who decide when a player returns to action. He also believes some form of testing or other evaluation is needed to confirm that those who watch brain injury training are actually learning the material. Sitting through an on-line video typically is all the laws require.
"The laws are good, but the laws need to be funded so they can be carried out in a meaningful way," Cantu said.
Seeking more protections
Medical and sports officials close to high school football have a number of suggestions for better protection of players. Whether they are implemented is likely a function of politics and money.
One idea is that every high school sports program should have an athletic trainer. Research shows that the presence of athletic trainers in a school sports program means more concussions are diagnosed than in schools without them.
Jim Thornton, president of the National Athletic Trainers Association, estimates that slightly more than half of U.S. high schools have access to an athletic trainer.
"The excuse is budget, but it's frustrating," Thornton said. "We're relying on coaches during the heat of battle, who may have ulterior motives for leaving a kid in a game, making decisions about their healthcare."
Cantu is one of many experts hoping for a clear diagnostic tool to detect concussion.
"What we desperately need is a financially feasible marker of brain injury, an imaging study that's not a research tool, ... and see whether or not we can pick up these injuries even in asymptomatic people," he said.
Such a tool would remove much of the guesswork involved with diagnosing concussions. Diagnosis often requires honest answers from players who have been brought up in a culture of playing through pain.
A recent survey of 120 high school football players in the Cincinnati area revealed that 53 percent of them would "always or sometimes continue to play with a headache sustained from an injury" despite knowing the risks that come with concussions.
"Extremity injuries we can live with a little bit. Shoulders and knees, we can fix a lot of those," said Congeni at Akron Children's Hospital. "Significant injuries to the brain you can't fix."
The best potential area for prevention is limiting exposure to head trauma. Players absorb roughly 2,000 hits to the head in practices and games during a season. Several organizations, from the NFL to Pop Warner, have limited full-contact practices.
Rule changes will continue to be considered, with much attention likely paid to the kickoff since the highest incidence of severe injuries occurs then.
No equipment prevents concussions as of now.
Dr. Henry Feuer is co-director for the Indiana Sports Concussion Network and a neurosurgeon who has worked the sidelines for Indiana University and the Indianapolis Colts.
"There is no helmet that stops that shaking of the brain," Feuer said. "Your brain is like a little hardened Jell-O inside your skull, and when you get hit it bounces around."
Several researchers have used accelerometers in helmets to measure the force and number of impacts players absorb. This could lead to individual "hit" counts being tracked, similar to pitch counts in baseball. As of now, that technology is simply too expensive for widespread use.
More protections uncertain
The wave of new concussion laws clearly helped raise awareness of the dangers of concussions in high school football.
But whether parents, school districts and those who govern high school sports will take more steps to require certain levels of care, new rules or different equipment remains to be seen.
Some high school coaches feel that concussion laws are an overreaction to a problem primarily at the professional level. Research about the cumulative impact of hits to the head for youth athletes is mounting but still inconclusive.
That leaves parents in a difficult position. They want to protect their children. They also value the character and confidence-building experience of the country's most popular sport on their children.
Professor Harvey at Temple University does not expect more immediate action.
"If you were to look out there in the law landscape for what's coming next, as far as I can tell right now, zero," Harvey said. "Because all the other things you would do have complicated constituencies standing behind them, and we do not have universal agreement."