PHOENIX -- Mary Shannon suffered her first concussion during North High School soccer tryouts in 2011, colliding with the goalie and hitting her head on the ground.
Under a state law signed earlier that year, she had to receive written medical clearance to return to the field. That took a month.
After a collision with an opposing player left her with a second concussion earlier this year, Shannon decided that was enough. Having learned about the dangers of concussions and with encouragement from her parents, she quit, deciding to limit her involvement to refereeing and helping the team in other ways.
"Yes it's a big part of my life, and yes, I love it, but I can still participate in it without having to put myself in the danger of getting another concussion or some other injury," she said.
In Arizona, about 7,000 high school athletes suffer concussions each year, according to research by A.T. Still University in Mesa. While football justifiably gets most of the attention, concussions are a threat in any high school sport.
A 2011 state law requires that high school athletes be removed from play if a concussion is even suspected and then receive written clearance to return from a medical professional like a physician or athletic trainer.
The law also called for concussion-education programs for coaches, students and parents. This led to the Arizona Interscholastic Association requiring every high school athlete in Arizona to complete Barrow Brainbook, interactive online training developed in part by Barrow Neurological Institute at St. Joseph's Hospital and Medical Center.
But the effort didn't end with a law. Medical professionals, advocates and others have since offered free baseline cognitive testing, known as ImPACT, that helps measure the effects of concussions and established a network of concussion experts that athletic trainers can consult via telemedicine.
Soon, a voluntary registry created by Barrow and A.T. Still will allow high schools to report concussions to researchers looking to improve the safety of athletes.
Dr. Javier Cardenas, a child neurologist at the Barrow Neurological Institute, said Arizona's approach to concussions is "really the most comprehensive program like it in the country and likely the world."
Sen. Rich Crandall, R-Mesa, who shepherded Arizona's law through the Legislature, said that in the end keeping athletes safe comes down to students, parents and coaches recognizing the symptoms and keeping athletes with concussions off the field.
"If those three are on board, we're going to be able to make a difference in Arizona," he said.
When the National Football League approached him about following a Washington state law on concussions, Crandall said the time seemed right for Arizona.
"We're a big high school football state," Crandall said. "We're not Texas, but still, it's a big deal."
In the process of creating the legislation, Crandall said, he and advocates found that parents can be a barrier to acting in the best interests of an injured student athlete. As an example, he described a scenario in which a student is being considered for an athletic scholarship.
"The coach is saying, ‘No, let's pull him out,' and the parent's saying, ‘No, you don't get it. My boy needs to perform in front of these coaches, these scouts,' " Crandall said.
Signed by Gov. Jan Brewer, the law established a protocol that goes into effect when a high school athlete suffers what's even suspected of being a concussion. The athlete is immediately removed from play by either the coach, a referee or other official, a licensed health care provider or the athlete's parent.
If the athlete is examined by a licensed health care provider and a concussion is ruled out, he or she may return to play the same day. Otherwise, the athlete cannot return before receiving written clearance from a health care provider defined by the law as a physician, a physician assistant, a nurse practitioner or an athletic trainer.
The law also requires student athletes and their parents to sign a form acknowledging they have reviewed the risks and symptoms of concussions.
It's modeled on Washington state's 2009 Zackery Lystedt Law, named after a boy who suffered a brain injury in 2006 after returning to a middle school football game following a concussion.
As of late April, 47 states and Washington, D.C., had enacted youth concussion laws, most of them based on the Lystedt Law.
Dr. John Parsons, an associate professor and director of the athletic training program at A.T. Still University, said that the narrow definition of who can clear an athlete to return to competition sets Arizona's law apart. Laws in Washington and other states refer generally to health care providers, he said.
Parsons said the most common criticism of high school concussion laws is that there are no punishments for not following them.
"It's more or less honors policy, and you hope that the law compels them to be compliant," he said.
Crandall said the law doesn't need punishments to be effective.
"The fear for a school district would be somebody filing a suit for breaking the law," he said. "You don't have to have punitive penalties when that's kind of overarching from everybody. A coach puts a kid back in with a concussion and a parent sues -- that's the last thing any school district wants."
The Arizona Interscholastic Association, an independent body that oversees high school athletics, doesn't track whether individual athletes or coaches have completed concussion training. It instead relies on schools, coaches, parents and others to report violations of its bylaws.
Chuck Schmidt, assistant executive director and chief operating officer of the AIA, said that if a complaint comes in the organization will look into it. But anything more than that just isn't feasible, he said.
"We don't have an NCAA budget in order to create that enforcement," he said. "But I think we do a fantastic job of utilizing our resources effectively and efficiently in the cases where we need to look into something and determine if it's a bylaw violation -- be it from concussion to recruiting."
Sanctions vary depending on the nature of the violation, Schmidt said.
For example, he noted, Veritas Prep Academy in Phoenix recently reported a violation involving a boys' basketball player who hadn't completed Brainbook. The AIA accepted the school's decision to forfeit games in which the player appeared and create procedures to guard against such an oversight.
Beyond the law
The day before she sustained her first concussion and pulled herself out of soccer tryouts, Mary Shannon had completed Barrow Brainbook.
"The symptoms were fresh in my mind," she said.
That's precisely what Dr. Javier Cardenas envisioned when he and others at Barrow helped create the online course in collaboration with the AIA, the Arizona Cardinals and A.T. Still. Since 2011, more than 150,000 students have completed it.
Cardenas said that Brainbook, which is designed to resemble a social media site, is unprecedented in the U.S.
"There is not a single state that provides athlete-specific, athlete-directed concussion education," he said. "We developed it because the CDC provides concussion education to coaches, to health care providers, to parents - but nothing directed at the athletes."
August 2012 saw the launch of the Barrow Concussion Network. One of the program's partnerships was with Dick's Sporting Goods and the ImPACT cognitive test to provided free baseline concussion testing for all AIA-member schools that don't offer the ImPACT test on their own. About 2,000 students took part this school year, a number Cardenas said was low because of late attempts at getting the word out.
The goal for next school year is 10,000 to 20,000 students, he said.
Another initiative from the Barrow Concussion Network allows athletic trainers across the state to consult via telemedicine with concussion experts in Phoenix on diagnoses and concussion management.
This fall, the network plans to launch what researchers hope turns into a detailed registry of all concussions in Arizona high school sports.
"The registry project is one that we initially came up with to really try and capture the number of concussions in Arizona and what happens to those student athletes," said Dr. Tamara McLeod, the John P. Wood, D.O., Endowed Chair for Sports Medicine and a professor in the Athletic Training Program at A.T. Still.
The purpose of the registry isn't merely tracking the number of concussions but collecting information on continuity of care and symptoms in concussion patients.
"We want to know more than the raw numbers," Cardenas said. "We want to know how people are actually being treated and how they're recovering."
The research is voluntary; although each event is reported by a particular school, if an athlete opts not to participate, the information will be wiped from the log.
If the athlete chooses to participate, he or she will provide information on their continuing care and symptoms.
Massachusetts is the only state that requires schools to report concussions. The regulations, which apply to public schools and members of the Massachusetts Interscholastic Athletic Association, require an annual accounting of head injuries and suspected concussions.
Paul Wetzel, spokesman for the MIAA, said the requirement is a research tool.
"There is not a lot of clinically gathered or anecdotally gathered data on concussions in high school sports," he said.
When Mary Shannon suffered her second concussion in January, she wasn't knocked out, stumbling around or otherwise displaying symptoms that would have made it immediately obvious that she had a concussion.
"If I hadn't have pulled myself out, nobody would have pulled me out," she said. "It was kind of like, he (the coach) said, ‘Are you OK?' and I said, ‘I don't think so.'
"But if I had said I was OK, I probably would have been in the game."
Despite the requirements to remove athletes from play at even the hint of a concussion and to only return those who have received written clearance from a health care provider, medical professionals and others say that those aren't foolproof.
Dr. Ben Bobrow, the medical director for the Arizona Department of Health Services Bureau of EMS and Trauma System, said he suspects that athletes commonly minimize concussion symptoms. While severe concussions result in symptoms such as confusion, memory problems, alack of muscle coordination known as ataxia and loss of consciousness, lesser concussions can result in minor symptoms such as headaches and dizziness that are much easier to hide.
"If you think about kids on the sideline or in a game, they want to play, they want to be in the game, they don't want to let on that they have some kind of problem," he said.
Chris White, head athletic trainer at Brophy College Preparatory in Phoenix, said that coaches play a crucial role because they can make sure athletes who may have suffered concussions don't return to play. But he said that the ultimate responsibility doesn't rest with any one group.
"It's a real team effort, and when you have a deficiency anywhere, it's a problem," White said.
Mattie Cummins, program director and former executive director of the Brain Injury Alliance of Arizona, said that the student and his or her parents can either help or hinder when an athlete has symptoms of a concussion.
"It's the parents and the kid who see behaviors or they feel behaviors after the game ends, when they go home, when they go to school," she said. "It's that parent or kid that has the control."
Many parents have been brought up to consider concussions "a bop on the head," she said, making it vital to make sure they know just how far-reaching the effects can be.
"The message that we're focusing on with parents is this concussion can affect their (the athlete's) world tomorrow," she said. "It can affect their world at 22. It can affect their world at 23, when they're out getting a job, when the sports is over. And really, it's not about today, it's about the rest of their lives."
While concussion research has made strides in recent years, including evidence linking concussions to cognitive and behavioral problems as well as depression and suicide, Bobrow with the Arizona Department of Health Services said that there is still much more that can be done.
"It's actually kind of a black box for us right now, we don't actually know how severe it is," he said. "Or, you know, we know a little about how many head injuries you can have before you have a big problem, and it's likely different for different people."
Schmidt said that the AIA updates its bylaws as often as necessary based on developments in preventing and responding to concussions.
"That's the primary goal of the AIA, to ensure the safety and health of our kids," Schmidt said.
On April 15, the AIA Executive Board approved a rule restricting the amount of time teams can practice full-contact while wearing pads. It's aimed at minimizing the risk of concussions and other injuries.
Crandall said Arizona law likely will remain as is for the foreseeable future but eventually will expand, just as the rules of football have changed over time to keep players safe.
"It's going to evolve, for sure," he said.