In just five years, 49 states have passed laws to raise awareness about concussions and ensure proper treatment of head injuries in young athletes.

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 "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 and that more should be done to prevent serious brain injuries among young athletes, especially among football players. 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. Medical experts do not completely understand what takes place in the brain when it shakes, twists or stretches inside the skull.
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.
As the 2013 high school football season begins, the discussion continues on how to best protect the brains of young athletes.

Injuries led to law
The mental deterioration of numerous former NFL players over the past decade made concussions a national topic.
High-profile players were dead by the age of 50 after suffering the effects of repeated hits to the head. Autopsies on many former players revealed chronic traumatic encephalopathy, a progressive brain damage that comes from repeated head trauma.
This type of brain damage also was found in younger players with no history of concussions, causing alarm about what the normal, sub-concussive banging of heads meant for the sport. Multiple research projects have shown that sub-concussive hits take a toll on the brain, although the long-term extent of these hits is unclear.
"What we know is scary as hell," said neurosurgeon and noted concussion expert Dr. Richard C. Cantu 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. The law also requires parents and athletes to sign a concussion information sheet and mandates the creation of concussion education materials for coaches, players and parents.
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 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 fewer concussions are being missed, rather than more concussions occurring. 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 and the team doctor for Archbishop Hoban High School's football team 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."

Legal protections
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:
- Educating coaches, parents and players on signs and symptoms of concussion;
- Removing from a game or practice any athlete who might have a concussion and not allowing the athlete to return that day;
- Requiring an injured athlete to be cleared in writing by a physician before returning to play.
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.
Anecdotal evidence suggests that the laws are making a positive impact.
From 2005-09, for example, a survey found that 16 percent of athletes who lost consciousness during a game returned to play that same day. Today, research shows that less than 2 percent of football players who suffer a concussion return the same day.
According to the National Center for Catastrophic Sports Injury Research, 2012 was the first year since 1990 in which there were no fatalities directly attributed to playing football at the youth, high school and college levels.
But experts believe the laws constitute a first step, not a final answer.
The laws do not include penalties for failure to comply with the new regulations by coaches, school officials and medical workers. 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.
Harvey questions if it was wise for all states to follow the Lystedt model without evidence the law reduced the danger of youth traumatic brain injuries.
Cantu, a neurosurgery professor at the Boston University School of Medicine, 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 online 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. "That costs dollars, and that's dollars that none of the states have put forward to those laws."

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. An athletic trainer is someone specifically trained to provide early assessment and treatment of sports injuries, including concussion.
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."
Research shows that the presence of athletic trainers in a school sports program mean more concussions are diagnosed than in schools without them. Without athletic trainers, the worry is many athletes are playing with concussions but they and their coaches don't know it.
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 gritting their teeth and playing through pain.
"A lot of people think kids aren't as tough as they used to be," said Vic Whiting, head football coach of Canal Fulton Northwest High School in Ohio. "Maybe they're playing Xbox too much and not outside enough doing things like they used to. But as far as wanting to win and when it's game time trying to stay in at all costs, these kids still do that. You can't listen to them."
To Whiting's point, 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.
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."