Concussions? Hawaii has response figured out
By Amanda Waldroupe
HONOLULU — When the Roosevelt Rough Riders hosted the PAC-5 Wolfpack in the opening round of the Hawaii High School Athletic Association state football playoffs in November, Scott Yano was, as usual, pacing the sidelines.
Yano, a key member of the Rough Riders didn't line up for a single snap or mark up an offensive play on the sidelines. But everyone knew he was there for them, one of two athletic trainers employed by the Honolulu school, ready if any student suffered an injury.
You'll see athletic trainers at some high school events in many states, including Oregon. But Hawaii is the only state in the country to ensure that at least two trainers are working at every public high school.
These certified health professionals specialize in sports medicine and work to prevent student athletes from becoming injured and, if they do, overseeing their treatment, rehabilitation and return to the field.
In Hawaii, the presence of athletic trainers is a given — they are considered an essential part of any school's athletic program and play a key role in preventing concussions and helping those student athletes who do suffer concussions recover and return to both the playing field and the classroom.
The state earmarks $4.28 million annually in the public school budget for the 74 positions. Yano was one of five athletic trainers observing the November football game, which is typical in Hawaii.
Research increasingly links the presence of an athletic trainer in high school sports programs to lower rates of injury, as well as better management and treatment of student athletes — including those who suffer concussions.
In Oregon, a recent analysis shows that Oregon high schools that have athletic trainers are much more likely to identify and treat concussions than schools without them.
That finding, which was based on a review of more than 2,000 public records, mirrored findings of a joint research project by the University of Wisconsin, the University of Michigan and San Diego State University. The study evaluated the varying degrees of access that 2,459 Wisconsin high school athletes had to trainers. Their results, published in the November 2018 Journal of Athletic Training, found that the availability of trainers "positively influenced" reporting concussions, as well as post-concussion management.
In Hawaii, where athleticism is valued and recreational opportunities abound, the role of an athletic trainer is viewed not as a matter of improving athletes' performances, but, rather, protecting their health and safety.
"When I first started, my athletic director basically told me that you're here for the kids, the health and safety of the kids," said Troy Furutani, a former high school athletic trainer who now works as director of the Hawaii Concussion Management Awareness Program (H-CAMP).
"Just the fact that you had a person that was designated to take care of children playing sports has been the key," said Glenn Beachy, who was the second athletic trainer to ever work in Hawaii, working as the athletic trainer for Punahou School, the largest private school in Hawaii, for much of his 50-year career before retiring in 2017.
Athletic trainers, Beachy said, "have made a big difference for the athletes, there's no question. You see kids that are much better conditioned and understand the treatment and the importance of doing rehab."
A culture of caring
Many sources interviewed for this story say having an athletic trainer at every school is a no-brainer given the value Hawaiian culture places on community and children.
"It's a very familial-oriented culture," said Nathan Murata, dean of the University of Hawaii - Manoa's College of Education, which oversees H-CAMP. Murata added that it is natural for Hawaiians "to take care of each other, to look out for each other, to support each other."
Athletic trainers in Hawaii teach athletes how to safely warm up, cool down and train, as well as emphasize the importance of sleep, nutrition and hydration. And, of course, how to safely play the student's sport of choice — from how to fall and land properly in judo to how to avoid tackling with their head in football.
"Their main role is making sure that there's a health and safety factor" in sports and practice, Furutani said. "If somebody is injured, they're able to manage it appropriately. If it's a potentially catastrophic type of situation, with a neck injury or a head injury, that they're able to manage it on the field."
And their word on matters of health and treatment is final. "Whatever the athletic trainer decides, that's the way it's going to go," Furutani said. "If the kid's out (from playing), the kid's out. If he needs to see a doctor, he needs to see a doctor."
In Hawaii, the athletic trainers attend every practice and every home game of all the sports teams at their school. They also travel to all away games with the varsity football team and, at times, other high-injury sports, such as basketball or soccer, to provide emergency care to injured athletes.
On non-game days, they work with every student athlete who's been injured, providing ice and heat therapy, taping and providing rehabilitative and stretching exercises. They make referrals to physical therapy and other specialized treatment that an athletic trainer may not have time, or the expertise, to do.
"It's really hard to devote all our time to just one person," said Yano, the athletic trainer at Roosevelt, noting that he and his colleague could be working with a dozen injured athletes at a time, in addition to attending practices and games.
Trainers also are responsible for collecting injury data — including the specific injury, location of the injury on the body, how many days the athlete was taken out of practice and play, and information on specific treatment. Furutani said that data is instrumental in seeing trends in injuries, which coaches use to change how athletes play and practice.
A "significant difference'
It wasn't always this way in Hawaii.
In 1991, athletic directors, coaches and professional organizations launched a public education campaign to show parents, athletes and school administrators the importance of athletic trainers.
At the time, there were only five athletic trainers working in Hawaii high schools, and all those schools were private. "That set the standard of what people thought needed to be done for athletes," Beachy said.
Beachy remembers being the only athletic trainer at a state wrestling tournament and treating mostly athletes from opposing schools.
"I was the only one that was qualified to really help these kids," he said. "And the coaches were going, 'Wait, we need an athletic trainer.' So I think they started seeing the benefit."
At the same time, Bart Buxton, a professor at the University of Hawaii - Manoa, surveyed the health care practices and injury rates of high school sports teams.
The study, which Buxton first published in 1991, found "significant differences" between schools with athletic trainers and those without athletic trainers.
In 1993, the Hawaii Legislature responded by providing $1.16 million in funding for a two-year pilot study, which placed 10 athletic trainers in 10 public high schools. Legislators and policymakers wanted to know if the presence of athletic trainers not only reduced injury rates, but presented potential cost savings.
Furutani was one of the first athletic trainers hired.
In those early years, he worked out of a tiny office, sometimes providing care to student athletes from the back of a truck — taping ankles, icing shoulders, making sure athletes were hydrated.
He remembers covering high school state championship baseball games at the University of Hawaii - Manoa's stadium from 8 o'clock in the morning until 11 at night, until the last athlete went home. "It was fun," Furutani said. "We just did what we had to do."
Beachy compiled the injury data gathered by Furutani and the nine other athletic trainers into a report for the Legislature. It showed a significant drop in the rate of injury, as well as better health care outcomes and treatment available to student athletes with access to trainers.
"All of that (data) helped their cause to get the funding," said Ross Oshiro, the coordinator of the sports medicine program at the Queen's Medical Center in Honolulu and a former athletic trainer.
The next year, the Hawaii Legislature dedicated funding so that all 43 public high schools had an athletic trainer. Beachy, Oshiro and others say that because Hawaii's public schools are all in one school district, it was administratively easy to add funding for athletic trainers into each school. Four years later, the Legislature added funding ensuring that all but nine of the smallest high schools had two athletic trainers.
Yano said it's necessary. During the winter season, he and his colleague at Roosevelt attend the practices of four soccer teams, four basketball teams, as well as wrestling and cheerleading teams. Even with two trainers, he said, "You get stretched out a little bit. We could actually use more positions."
Research drives policy
Athletic trainers say the strong relationships with athletes may make the students more willing to report a concussion or other injury.
"When you're here every single day you build rapport with them," Yano said. "It's actually almost like a family. They have someone to go talk to. The key is trust."
Still, Oshiro said that he and his colleagues constantly battle against "that mentality of 'suck it up and get back onto the field'," as they stress to athletes, as well as their coaches and parents, the importance of reporting a possible concussion.
That effort has been aided in the past few years by the increased attention to brain injuries in youth sports. Furutani said that when he first began working as an athletic trainer, concussion monitoring was "not even discussed."
Now, Oshiro said, the growing body of research about concussions "is really driving the work of athletic trainers." When he started in the profession, he said, "there was no gradual return to play like the way it is now. There was no guidance as to how to communicate with coaches, with parents."
Health professionals in Hawaii say concussion prevention, monitoring and treatment have become integral to athletic trainers' jobs.
"They're the ones on the front line," Furutani said. "They're the ones assessing it on the sidelines, on treating and managing it and determining when they return to play. They're the ones communicating with everybody else, including parents, coaches, doctors and school staff. They're the key."
Hawaii, like Oregon, requires concussion awareness training in schools
HONOLULU — In addition to having athletic trainers in every school, Hawaii also has required concussion education and protocols for concussion management.
The Hawaii Concussion Awareness and Management Program, or H-CAMP, as it is known, was established in 2010 and is a collaboration between the University of Hawaii - Manoa and the state's Department of Health and Department of Education.
H-CAMP is responsible for providing training and education materials to athletic trainers, coaches, school administrator, students and parents.
The program established the protocols that dictate "how a concussed individual is managed from the start to the finish" said Troy Furutani, a former high school athletic trainer who now works as director of H-CAMP.
"Our approach is to educate as many people as we possibly can," said Nathan Murata, dean of the University of Hawaii Manoa's College of Education, which oversees H-CAMP.
H-CAMP also is responsible for carrying out key aspects of two laws passed by the Hawaii Legislature concerning concussions.
The first one, Act 197 passed in 2012, mandated annual education on concussions for coaches, school administrations, educators, student athletes and their parents.
The law also requires that concussed high school athletes are immediately removed from play, that the student must obtain written clearance from a licensed health professional before returning to school and to athletics, and establishes that Hawaii follow a return to play protocol. It's similar to Max's Law, which Oregon lawmakers passed three years earlier, one of the first in the nation to do so.
In 2016, the Hawaii Legislature passed Act 262 extending the protections of Act 197 to all children age 11 to 18.
The law also provided funds allowing H-CAMP to become a permanent program within the University of Hawaii Manoa's College of Education and high schools to conduct baseline neurocognitive testing to compare against neurocognitive testing of students post-concussion.
Since its establishment, H-CAMP has collected concussion data from all the public schools in Hawaii. That data includes the number of concussions that occurred at each school and the treatment that is provided. The data is broken down by age, gender of the athlete, sport and so on.
Oregon law has required schools to track student athletes who suffer concussions since 2010. But unlike Hawaii, Oregon has never analyzed or even collected those records.
In Hawaii, data is broken down by school league, sport, gender and other metrics. During the 2010-2011 school year, 4,683 baseline tests were taken and there were 446 total concussions.
The numbers essentially doubled in the 2011-2012 school year, to 10,113 baseline tests and 895 total concussions. The 2013-2014 school year saw the highest number of concussions — 1,370 — and the number has since dropped. During the 2015-2016 school year, the most recent data available, there were 1,092 total concussions.
Murata said the numbers have grown due to increased awareness and education about concussions, as well as the requirement to report.
The highest number of concussions are in football — in part, due to the sport having the highest number of athletes — along with girls soccer and boys and girls judo.
Murata said one challenge Hawaii continues to face is how well everyone involved in an athlete's life — their parents, their coach, athletic trainer, teachers, counselors and administrators — communicate and work together as a student heals from a concussion.
"It's still a little bit fragmented," Murata said.
H-CAMP is working to create a "return to learn" protocol that is holistic and essentially creates a care team for the athlete.
"It's not just the athlete and the physician that's involved with this kid's concussion," Oshiro said. "This injury is very different than any other injury that's out there, because it takes a team approach to manage this child.
"Everybody sees the child in a different light. So what the parent sees at home, what the teacher sees in the classroom, what the counselor sees with the kid, the athletic trainer, the coach, the physician. Everybody has a different role to play."
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