It took a few small conversations to kickstart the statewide talk about concussions in high school athletes.
Until this year, Hawaii’s push for increased awareness and education paralleled that of most other states. With the passage of legislation updating the original 2012 concussion education act, Hawaii is moving to the forefront policy-wise.
Having the policy in place and implementing it successfully are separate issues, however.
Part of the problem in creating a standardized concussions protocol — when a student-athlete should come out of a game, how long an athlete should stay out after a concussion — is that there were few examples to work from until recently.
An international consensus statement defining a concussion was developed in 2001 at the 1st International Conference on Concussion in Sport, held in Vienna. The statement was updated three years later to specifically address pediatric concussions.
“Before 2004, there were at least half a dozen to a dozen different concussion protocol,” said Ross Oshiro, program coordinator for Queen’s Medical Center’s Sports Medicine program and former health care coordinator for the state Department of Education.. “And it would vary from (being) asymptomatic after 15 minutes, you can go back into the game to (being) called a concussion, you had to have loss of consciousness.”
“There was no standard of care,” agreed state Sen. Josh Green (D- Kona, Ka‘u). Green also is an emergency room physician.
“Each neurologist, of which we have few, would set their own standards,” he said.
Statewide efforts to standardize concussion protocol began around 2007, Oshiro said, and by 2009, a concussions working group was trying to establish its own state standards.
“At the time, it was just (Department of Education) that we were concerned with,” he said. “As the DOE started doing it, a lot of the private schools kind of followed suit because at the time, it was best practice nationwide.”
The Department of Health provided funding from its neurotrauma support division to establish the Hawaii Concussion Awareness Management Program (HCAMP) in 2010.
It was then that baseline testing (see adjacent story) was first formally recommended as an add-on to preseason training for contact and collision sports.
“You do tend to rely on the trainers, who are very good,” Green said.
On the Big Island, Waiakea trainer Dan Renteria started using baseline testing back in 2004, when he worked at Kamehameha Schools.
“Without them, we wouldn’t get the information,” said HCAMP co-director Nathan Murata, chair of the University of Hawaii at Manoa Kinesiology and Rehabilitation Science department. “They’re the front-line people; they’re the ones who do the lion’s share of the work.”
Education of coaches and parents also became “critically important,” Murata said. For parents, “You want them to recognize signs and symptoms when the student goes home.”
“From a parent’s perspective, if their child is concussed, this is different from any other type of injury that their child may have,” Oshiro said. “Every concussion is different, and they have to take an active role in the recovery of their child.”
Though the DOH neurotrauma support division was HCAMP’s “biggest champion” for funding, Murata said, the group knew that financial resource was not always guaranteed. They decided to seek legislation to ensure that the work could continue.
Sen. Jill Tokuda (D- Kaneohe, Kailua, Heeia, Ahuimanu) and Rep. Ryan Yamane (D- Mililani, Waipio Gentry, Waikele) each introduced a version of the bill in their respective chambers.
The stakeholders, Tokuda said, “had come together to really say, nationally and even locally they’re starting to see this trend where we’ve got to make sure we take care of our young athletes.”
That was in 2012, around the same time many other states were enacting concussion-related legislation.
The initial piece of legislation required the DOE and the Hawaii High School Athletic Association to develop a concussion education program for students ages 14-18.
It wasn’t only the students and parents who’d be taking part. Coaches and athletic trainers were required to attend annual concussion education sessions, as were sports officials, school faculty, staff administrators.
The latter requirement is different from that in other states, Oshiro said.
“I think that is probably the biggest challenge: getting everybody from principal to janitor (up to date),” he said. “There’s a component of the child getting back into the classroom and having symptoms because of the classwork…maybe having vision problems, so maybe they cannot focus on what the teacher is writing on the board.”
It’s about getting as many people in the loop as possible, said Kamehameha Schools athletic trainer Zeny Eakins.
“You have this overall health system in place that’s going to help the student get better,” she said.
“Getting the word out hasn’t been too bad,” said Chris Chun, director of the Hawaii High School Athletics Association. Most education comes from a free online course with a video component. The HHSAA also works with HCAMP to coordinate annual seminars on each island.
“Besides the signs and symptoms of a concussion and what parents and coaches should do, on Oahu we have one of our former athletes that has gone through a concussion (come talk),” Oshiro said. “It affected her life tremendously. On Maui, we have an athlete in the same situation. That helps; it makes it more real to the audience.”
Some states have run into lawsuits because they did not have appropriate concussion management policies in place. The Illinois High School Association was sued in 2014 on behalf of a former high school football player (the lawsuit was dismissed).
In 2015, the Pennsylvania Interscholastic Athletic Association faced a class-action lawsuit from two former athletes and one parent who said the association had not done enough to protect students from concussions.
As in Hawaii, Pennsylvania’s legislature passed a concussions law in 2012. Though it required concussed players to be removed and evaluated by a person trained in concussion management, but it did not mandate education, establish recovery protocol, or mention baseline testing.
This year, the 2012 legislation was updated to be still more specific about concussion policy.
For high-schoolers, the education and monitoring program already in place now requires, in addition to removal from a game, “medical clearance from licensed health care providers trained in concussion management” before an athlete can return to previous activities.
It also mandates immediate removal from a game or practice if a participant is “suspected” of having a concussion, strengthening previous language that required removal only if symptoms were observed.
Cognitive baseline testing is specifically required — not recommended — under the new program, as is continuous data collection.
And the bill provides HCAMP funding directly out of the state budget: $450,000 in all.
Funding is broken into three major areas. The first provides baseline testing licensing fees to all 67 high schools in the state. The second pays for diagnosis by neuropsychologists, who analyze the data.
“We can administer the test, but we do not do any interpretation,” Murata said.
The funding also pays for HCAMP’s three part-time personnel and its travel expenses. The organization is in the process of hiring its first full-time employee thanks to the legislative funding.
“That differentiates the state of Hawaii from all the other states in the union,” Murata said.
At a recent concussion summit in July, featuring speakers from out-of-state, the visitors were “really surprised” that state funding had been appropriated.
“I think that’s significant,” he said. “It’s a shout-out to our legislation.”
“We just want to make sure this is something that we can continue to provide at all levels for many years,” Chun said.
And the legislation now includes youth sports, defined as any athletic activity where participants are 11 years or older.
Tokuda’s two sons are in elementary school and play youth soccer. Before each season, Tokuda said, she is required to read an information packet about concussions and warning signs.
“Even at the littlest ages, they can get hurt,” she said.
Email Ivy Ashe at iashe@hawaiitribune-herald.com.