In the small northeast Ohio town of Massillon, a few miles from the National Football Hall of Fame, some 20,000 fans pack into a high school stadium, drowning out the roar of a real tiger mascot on the sidelines.
Football is akin to religion in Massillon and, like a religion, it can be resistant to change. For decades jolts to the head were written off as "getting your bell rung" and considered part of the game. Now, concerns about serious brain injuries have penetrated American football culture and high schools are taking action.
After an off-season with suicides by two former National Football League players, publicity over a lawsuit against the league by NFL players and new studies adding to the growing body of research, nearly every state entered the fall season with some type of legislation protecting young athletes.
Jamey Palma, the assistant principal of Washington High School in Massillon, knows the pressure players feel to play through concussions. A high school and college player, he said he suffered four concussions, including one during a game in high school when he stayed in until the end.
The concussion was discovered afterward, when he failed to remember what happened on the field.
"Back in those days, we'd play through it," said Palma, 36.
Now many coaches and players know "seeing stars" might very well be a concussion and a concussion is a brain injury that needs time to heal.
The Ohio High School Athletic Association has devised rules to immediately remove a player and provide him medical attention upon showing signs of a concussion, said Hank Zaborniak, the association's assistant commissioner.
Between 2009 and 2011, 33 states plus the District of Columbia passed laws aimed at preventing concussions in youth sports, and another 15 states have introduced legislation this year, according to the National Conference of State Legislatures. Only Montana and Arkansas have yet to act.
Many were inspired by the case of Zackery Lystedt, who suffered a life-threatening brain injury and permanent disability when at age 13 in 2006 he was sent back into the second half of a game after suffering a concussion.
With Zackery recovering enough to tell his story, a Washington state coalition of medical professionals, later backed by the NFL and the American College of Sports Medicine, helped pass "Lystedt Laws," first in Washington and then around the country.
"This is a brave young man who put a face on traumatic brain injury," said Dr. Stanley Herring of the University of Washington School of Medicine and a Lystedt Law advocate.
IMPROVED RULES, EQUIPMENT
In the meantime, experts explore improvements in helmet design and advanced mouth guards. Some coaches mandate neck strengthening as prevention. Since 2010, the National Federation of State High Schools rule book requires removing a player from a game when he shows signs of a concussion.
With rule changes and better equipment, death has become increasingly rare. Of 1.1 million high school football players, two died of brain injury in 2011, when a rate of 0.86 per 100,000 players suffered permanent brain damage, according to an annual study by a University of North Carolina researcher.
A 2011 study by researchers from the Perelman School of Medicine at the University of Pennsylvania found that survivors of a single traumatic brain injury in young adults can show changes in their brains years later, possibly leading to neurodegenerative disease similar to Alzheimer's.
In Ohio, where 715 high schools play football, the rules removed 102 high school football players from games last year. Thirteen of them returned to the game after being checked out by medical professionals but most were held out for the remainder of the game and many for several games.
The Ohio House has passed a bill that would require youth sports coaches and officials to do what Zaborniak's group now requires in high schools - remove a player from a game or practice if the player is exhibiting symptoms or behavior consistent with concussions. The Ohio Senate has yet to approve the legislation.
Alabama is developing a concussion data bank. A California law approved in August requires trainers to understand the signs and symptoms of concussions and know the appropriate responses. Texas, with a reputation as football-mad state, established a protocol for player safety that athletic directors say is among the most stringent in the country.
Pop Warner, the largest youth football organization in the United States, in June imposed rules to reduce contact in practice.
Throughout the country, teenage players are taking cognitive function tests before the season to establish a baseline that can later be used as a comparison for those suspected of suffering concussions.
Sometimes it is the players who take a leading role.
"When I get out of the huddle and I go to the line of scrimmage, I'm looking at the defense, I'm looking at where my teammates are, but now I'm also looking out to make sure everybody is alert and responding, especially if they've just been in a big collision," said Presley Miller, the senior starting quarterback at Clark High School in San Antonio, Texas.
FOOTBALL IS SAVED
In the late 19th century, when American football was an improvised version of rugby, numerous players were badly injured and dozens died playing the game, leading Harvard University President Charles W. Eliot to campaign to ban the sport, according to John J. Miller's 2011 book "The Big Scrum: How Teddy Roosevelt Saved Football."
As president, Roosevelt called the coaches of Harvard, Yale and Princeton universities to the White House in 1905 to promote reforms that would save the sport and ultimately transform it into an industry that generates $9 billion a year for the NFL.
"At a certain level, it's just a re-run of what happened a little more than a century ago," Miller said. "The big difference is that back then players were dying. In 1905 alone, 18 players died from big-time college to the sandlot."
Direct football deaths at all levels peaked at 36 in 1968 and have been reduced to single digits in all but one year since 1978, according to Frederick Mueller, the University of North Carolina expert who publishes an annual survey of catastrophic football injuries.
Since 1984 there have been 164 football brain injuries with "incomplete recovery," which can mean the patients suffer disabilities the rest of their lives, Mueller said. In 2011, there were 13 such brain injuries at the high school level and one at the youth level.
Robert Cantu, a neurosurgeon and Mueller's co-author on the annual injury report, advocates that players under 14 not play tackle football.
THE MEDICINE OF PREVENTION
Watching his son's peewee football team play five years ago, Joe Ackerson was shocked to see young players suffer concussions without the brain injuries being identified.
Instead the boys were allowed to re-enter the game.
"Here were these young kids, ages 10 and 11, getting concussions and it not being recognized as such," said Ackerson, a neuropsychologist who treats brain-injury patients in Birmingham, Alabama. "There was a severe knowledge deficit."
Since then, with the guidance of a task force that Ackerson led, the effort to combat concussions in youth and high school sports has gained prominence in Alabama.
Ackerson also worked with educators and coaches at the Birmingham area's Hoover High School, where his now 16-year-old son plays defensive end, to develop a program for managing concussions and reducing their likelihood.
Hoover, a perennial power, has vowed to stop athletes from concealing their symptoms, no matter if it is a star who stands to lead the team to yet another state championship.
"Even if they're lying through their teeth, we've got a good line on it," said Brandon Sheppard, the school's head athletic trainer.
In Texas, 2011 legislation and increased public awareness have chipped away at old attitudes about concussions, but there are concerns about enforcement.
"I know a lot of coaches who won't go along with it," said Dave Burton, an athletic trainer in Dallas who has worked in pro sports and public schools. "They would rather have a key player at 75 percent than a backup at 100 percent."
(Additional reporting by Tom Bassing in Alabama, Jim Forsyth and Marice Richter in Texas and Marty Graham in California; Writing by Daniel Trotta; Editing by Claudia Parsons and Bill Trott)