At least a half-dozen states are considering measures that would toughen restrictions on young athletes returning to play after head injuries, inspired by individual cases and the attention the issue has received in the NFL.
Washington state led the way last year, passing what is considered the nation's strongest return-to-play statute. Athletes under 18 who show concussion symptoms can't take the field again without a licensed health care provider's written approval. Several other states, including California and Pennsylvania, have similar bills pending.
Elsewhere, the Maine legislature passed a law last year that creates a working group on the prevention, diagnosis and treatment of concussions in young athletes. In New Jersey, there's no state law to regulate how head injuries should be handled for athletes, but the legislature has allowed a commission to look into brain injury research.
"There's no doubt that the majority of the people believed it was time and that it was extremely important to do something like this," said Mike Colbrese, executive director of the Washington Interscholastic Activities Association. "The mantra for the movement has been, 'When in doubt, sit them out.' "
These state-level efforts come as a congressional committee prepares to hold a forum in Houston on Monday looking at how high schools and colleges deal with concussions. The same House panel has held hearings on head injuries in the NFL, and the NCAA recently endorsed the idea of requiring athletes to be cleared by medical personnel before returning to competition if they show concussion symptoms.
Estimates for the number of sports- and recreation-related concussions in the United States each year go as high as 3.8 million, according to the Brain Injury Association of America.
The Washington law is named after Zackery Lystedt, who suffered a life-threatening brain injury after he returned to his middle school football game in 2006 following a concussion. Lystedt's family contacted Republican state Rep. Jay Rodne for help, and last May, Gov. Chris Gregoire signed the new legislation.
"I was honored to really be a part of it," Rodne said. "It's a testament to Zackery and his mom and dad."
Although there were some initial concerns about how the law would be enforced -- and whether schools in rural areas would have access to enough medical services to ease the burden of complying -- Colbrese says the rule has opened some eyes around the state.
He says schools have claimed their athletes are suffering more concussions than last year, but the reality is that they aren't. "You didn't know about them last year," he said.
About a month ago, Rodne's eighth-grade son, Tye, sustained a concussion while wrestling.
"It brought everything really to home, so to speak," Rodne said. "He had to sit out for a week, and he had to get checked by the doctor."
Assemblymember Mary Hayashi is hoping California will soon have a similar requirement. After learning about concussion-related health problems for retired football players, the Democrat has led a push to strengthen her state's laws.
Hayashi introduced two bills this month. One would require high school coaches to get training on potentially catastrophic injuries in addition to first aid certification already required. The other would require an athlete suspected of having a concussion to get written permission from a doctor before returning to play.
"We were on this topic way before Congress decided to launch hearings," she said. "I think that the media attention on all this, and certainly (other states) taking action, I think helps us to sort of say, 'What can we do to protect kids?"
Because younger athletes' brains are still developing, they often need longer to recover from a concussion, and the risk of a catastrophic injury is greater if they return to the field too quickly.
In Pennsylvania, state Rep. Tim Briggs has introduced a bill that also would require written clearance for an athlete to return to play. He says he hears "occasional comments that I'm going to scare parents from getting their kids into different sports" -- but that's about it as far as naysayers.
In Connecticut, Massachusetts, Missouri and Rhode Island, lawmakers are also looking into enacting return-to-play restrictions.
"We've ignored it for so long and now the baby boomer generation of athletes are coming to middle age and older adulthood and we're seeing the effects that the bodily abuse has had on them over the years," said Missouri Rep. Don Calloway, who filed legislation in his state. "You wonder what we could have done as a society or as leagues or just as citizens to perhaps have prevented some of that stuff."
Even these new laws can't prevent every tragedy. Colbrese said a high school football player in Washington died after a concussion this past fall -- he had been medically cleared to play.
Micky Collins, assistant director of the University of Pittsburgh Medical Center's Sports Medicine Concussion Program, says the measures being considered are a big step forward, but that even some medical personnel have a lot to learn about how to evaluate head injuries.
"In a perfect world, we would have an athletic trainer in every school where there's contact sports," said Collins, who also is the co-founder of ImPACT Applications, which developed a computer-based program to help measure the severity of a concussion.
The program tests, among other things, a person's memory, and the results can be compared to a baseline to show whether an athlete is ready to return to competition -- or even how much an injured student should try to take on academically.
"That's the only objective data point" within a subjective evaluation process, Collins said. He says computer-based testing is used by many colleges and in multiple pro leagues, and that it's common in high schools in some states.
In New Jersey, around 140 schools use the ImPACT program, which limits how much schools must rely on answers from an athlete who might play down the effects of an injury so he or she can return to the game.
The new proposals working their way through statehouses also would place greater responsibility on coaches and medical personnel to make the final determination on whether an athlete plays -- and they're supposed to err on the side of caution.
"Once it's a law, it becomes, I think, the next level," said Briggs, the Pennsylvania legislator. "You'll want coaches and parents and athletic trainers to take this seriously. There might be a lot of pressure on a kid to brush it off and ignore the symptoms."