Waiakea High School won its first football game of the season on Sept. 10.
Players filed off the field, jubilant after defeating Keaau High 42-6.
Michelle McBraun carried a set of shoulder pads in one hand as she waited for son, Ethan, a senior slot and defensive back for the Warriors, to come off the field. McBraun’s younger son plays for the junior varsity team.
“It’s the most exciting feeling in the world for a parent,” she said of watching her sons play.
Concussions are not something anybody really wants to think about while watching football, and McBraun said that most of the time, they’re not on her mind. Each year, she watches the concussion education video provided by the Hawaii Concussion Awareness Management Program. Concussions are part of the annual football parents’ meeting. Both McBraun sons have had their baseline testing.
There’s a lot of information out there for parents, McBraun said.
“At the high school level, I’m pretty sure there’s a high awareness of this issue,” said HCAMP co-director Ross Oshiro.
That high awareness tends to fall on football players, who experience the most concussions overall (statewide, 360 were reported in 2014-2015), but it’s not just the gridiron where student athletes can take a hit.
“With football, you’ve got hundreds and thousands of kids, so based on sheer numbers, you’re going to be higher,” said Nathan Murata, co-director of HCAMP and chair of the University of Hawaii at Manoa’s Kinesiology and Rehabilitation Science program.
Statewide the sport with the highest incident rate of concussions — the number of concussions per athletes enrolled — is girls’ judo. Its incident rate for the most recent year available, 2013-2014, was 2.85. Football, by contrast, has a 1.79 incident rate.
Incident rate refers to the number of concussions per 1,000 exposures. An exposure is defined as an athletic game or a practice.
“Everybody knows about football, but here in Hawaii it’s girls’ judo. Then you have basketball, you have soccer,” Murata said. “Those seem to round out the top five for us.”
Waiakea trainer Dan Renteria said judo is a high-risk one for concussions partially because of newcomers who are still learning to grapple.
“If you’re a longtime judo player, you learn how to fall,” he said. “That’s the first thing you learn. At the high school level they’re new, so they don’t really know how to fall.”
Soccer, which has seen considerable increases in participation at both the youth and high school level over the past decades, also has a high concussion rate.
A study published in the September issue of Pediatrics found that as injuries in youth soccer had risen 114 percent between 1990 and 2014. Concussions accounted for 7.3 percent of the injuries.
“Any time you play the ball with your head,” said retired Hilo High girls soccer coach Paul Bello. “They say there’s a regular way to do it, but you can have perfect form and still get a concussion.”
Concussions also can occur in soccer from players running into each other, as happened to one of Bello’s goalies during a game.
“The game stops for 45 minutes,” Bellow said. “There’s some scary stuff that happens.”
In the 2014-2015 school year, a total of 1,008 concussions were reported to HCAMP.
“You might think, wow, that’s a lot,” Murata said. But in the 2010-2011 school year, just 464 concussions were reported.
The rise tracks with national trends of increased reports of concussions, which researchers attribute to growing awareness of the injury.
A recent study by Blue Cross/Blue Shield using medical claims data found that concussion rates in the 10-to-19-year-old age group had risen 71 percent from 2010 to 2015, paralleling Google search trends that showed an increase in the number of people who search for “concussion” (the term is also used more in the fall, during football season).
“There is a direct correlation of (reporting) and recognition of signs and symptoms,” Murata said.
If anything, concussions remain an under-reported injury in spite of efforts to raise awareness.
“We asked the kids not to hide, because some of the kids would try to hide it; they would go to the extreme,” Bello said. “I’ve seen that side where coaches will not say anything to anybody — it’s not a good thing.”
“Coaches have been caught up, but … being aware of dangerous play has changed the game,” said Waiakea High athletic trainer Dan Renteria. “If you’ve been coaching for 15 years or 20 years, you don’t like seeing changes like that.”
Ideally, students will self-report when they experience concussion symptoms.
“There’s a push now for students to be observant of students on their team, so it’s not so much self-reporting, but being able to look out for your friends,” said Kamehameha Schools Hawaii trainer Zeny Eakins.
It’s hard to tell if that’s working, she said.
“I hope friends would take care of each other, and they know their pals, so they would notice if something was a little off,” Eakins said.
“I think we probably miss a lot of opportunities to see people because young athletes, they want to keep playing and they want to make their coaches and parents proud,” said Dr. Josh Green, an Kailua-Kona emergency room physician and state senator. “But at the same time, we want them to know that it’s better to get cleared.”
Bello once pulled a starting player from the lineup of the Big Island Interscholastic Federation championship game because she had been “dinged” in practice the day before.
“She started to warm up, and we had to get her off the field,” he said. “She just wanted to play that bad, and we just couldn’t let her. It didn’t help that we didn’t win the game.”
But “the trainer has the last say,” Bello said. “I’m not going to pester the trainer to get you cleared.”
“A lot of them (the athletes) are understanding,” said Hilo Medical Center pediatrician Dr. Miki Cain. “Sometimes it’s more the parents that are ready to have them play.”
Cain moved to Hawaii Island from Texas, and said he’s nevertheless been “pleasantly surprised” by parents here being receptive to having their children sit out for an extended recovery period.
In Texas, he said, “There’s much more pressure to clear patients to go back to school early. I see it less here.”
“I think you get that (pressure) no matter what, if it was a sprained ankle or a knee hurting, or a concussion,” Oshiro said. “There’s always that from the athlete, the coach, the parent; it’s all there.”
Because concussion symptoms can change over time, recovery plans can change, too.
Hawaii’s concussion management program includes a seven-step Return-To-Play plan. Athletes must obtain medical clearance and wait a minimum of 24 hours between each step.
The program also involves education of teachers and administrators, in an attempt to have as many people as possible informed of what symptoms look like.
“There’s a component of the child getting back in the classroom and (then) having symptoms because of the classwork,” Oshiro said. “Maybe they’re having vision problems, so maybe they cannot focus on what the teacher is writing on the board … so it’s knowing that their classroom work needs to be adjusted.
“From a parent’s perspective, if their child is concussed, this is different than any other type of injury their child may sustain. Every concussion is different.”
“I don’t think, with the kind of sports that are out there, that you can eliminate it entirely,” Murata said of concussions.
Green said that he tries not to discourage kids from from playing football or soccer.
“I try to encourage, if they’re in a higher-risk category, that they then adjust their behavior,” he said.
But if an athlete has had two significant concussions, Green said, “Then it’s time to change sports.” In that case, he’ll talk with parents and students about switching to non-contact sports entirely.
“There’s a lot more opportunities out there,” he said. “We want kids to continue to be super active and continue to have a sport that gives them positive self-esteem.”
Green has found that parents typically find the concussion recovery process to be eye-opening.
“They go through it once, and they’re worried,” he said. “They go through it a second time, and they’re hyper-aware.”
The cabinets in the athletic trainers’ office at Kamehameha Schools Hawaii are covered in bright decals from colleges across the country. Any time a student stops by for an ankle-taping, or for icing, or just to chat — the decals are there. They’re a reminder of what’s still to come.
“It’s high school sports, but we’re thinking long-term — what are they doing after high school?” Eakins said. “If they expect a collegiate career in their sport, we want to make sure we send them off in good spirits, physically and mentally.”