Concussion conundrum: As awareness increases, officials work to improve policies to limit brain injuries

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The human brain, for all its power, is a fragile organ.


The human brain, for all its power, is a fragile organ.

One hundred billion neurons are busy at all times of day, helping the heart beat and the lungs breathe; taking in sights, sounds and smells; planning ahead; looking back. Most of these tasks come effortlessly. It’s just what the brain does.

Concussions break up the connection.

They are essentially an earthquake of the brain. Anything that causes the head to snap back and forth quickly, from a blow to the head to an upper body hit, makes the brain shake and shudder inside the skull. Blood flow is disrupted. Cells die.

And aftershocks can be felt for weeks.

Though concussions can occur in any setting, it is on the sports field that they tend to draw the most attention. In September, for example, the Carolina Panthers and the National Football League were criticized for not following concussion protocol with star quarterback Cam Newton after he took a hit in the final minute of a game.

Concern isn’t limited to professional sports leagues. There also has been a steady increase in awareness of the effects of brain trauma on younger athletes.

During the past several years, Dr. Miki Cain, a pediatrician at the Hilo Medical Center, said he’s noticed medical schools placing more focus on concussions and recognizing symptoms.

“It seems like in the media it’s a bigger deal, too, so it’s dipping down to the pediatric side of things,” he said.

In April, a class-action lawsuit filed by more than 20,000 retired NFL players against their former employer was settled for more than $1 billion, three years after an initial decision was reached in the case. That decision was appealed; in the appellate court decision, Judge Anita Brody found that the NFL had not taken “reasonable actions to protect players from the chronic risks created by concussive and sub-concussive head injuries and (had) fraudulently concealed those risks from players.”

Repeated head injuries are linked to chronic traumatic encephalopathy, or CTE, a degenerative brain disorder.

Because their immediate symptoms are not as obvious as head injuries that lead to conditions such as amnesia, concussions are, in medical terms, referred to as mild traumatic brain injuries, or mTBI. But their prevalence — annually, concussions make up more than 75 percent of all TBIs — and their potential for cascading long-term neurological effects such as CTE has in recent years led to a national push for increased concussion education at all levels of play.

“For kids, who have very fast-growing brains and lots of blood flow, we can’t afford to have serious injury year after year after year,” said Josh Green, a Kailua-Kona emergency room doctor and state senator. He said people who have suffered one concussion are more likely to have another.

One 2006 study by University of Pittsburgh’s Brain Trauma Research Center found that more than 300,000 sports-related concussions occur annually in the United States. More than 62,000 of those occur in high school contact sports.

And the 15-19 age group has the highest rate of incidence for TBIs, according to a 2010 report published in the Journal of the American Medical Association.

During the 2014-2015 school year, there were 1,008 concussions recorded statewide in Hawaii high schools. That’s just the reported ones.

“It’s a more serious time,” Green said. “Collisions are harder and faster than they ever were before. Kids are much bigger (who are) playing varsity sports, so you’re going to have injuries that are more prevalent.”

For decades, concussions were widely considered — if they were considered at all — to be nothing more than getting your bell rung, just part of the game. But that attitude is changing.

“People are a lot more aware of what’s going on,” said Paul Bello, who coached girls soccer at Hilo High for 12 seasons before retiring last year. “I’ve seen it from when nobody cared, or you’d just go back to play.”

“There has been this history of just dismissing what they call a ‘ding,’” said Kamehameha Schools athletic trainer Zeny Eakins. “We all have those aunties or uncles, moms or dads that (say), ‘Oh, I used to play with that. I was fine the next day.’”

Part of the problem is that concussion trauma isn’t as immediately visible as, say, a broken bone.

“Sometimes you can really tell; they’re just dazed,” Bello said. “Sometimes it doesn’t show up for a while. Someone could finish playing and then come off with all of the symptoms. It’s kind of scary.”

“We can do a sideline assessment (of symptoms), but that’s about it,” said Waiakea High athletic trainer Dan Renteria. “Other stuff they do at the hospital.” CT scans are one way to confirm that an athlete has been concussed.

Green played sports through college. He suffered a concussion while a goalkeeper for Swarthmore College’s soccer team, even though he didn’t know it at the time.

He lost consciousness after his hit and came out of the game. That was it.

“This was in 1988,” Green said. “I didn’t do any testing or medical care. … I played another game the next day.”

It wasn’t until he got to medical school that he realized the concussion had likely been the cause of his damaged sense of smell, which persists to this day.

Now, Eakins said, “We are less apt to dismiss minor signs and symptoms because you just never know what a person’s reaction to a concussion will be.”

“How one presents at the moment changes over time,” said Ross Oshiro, program director for sports medicine at The Queen’s Medical Center in Honolulu.

During his tenure as athletic health care coordinator for the state Department of Education, Oshiro helped establish the Hawaii Concussions Awareness Management Program, an organization focused on providing research and resources to the medical and sports communities.

HCAMP is part of the University of Hawaii at Manoa’s Department of Kinesiology and Rehabilitation Science. Partners include the state Education and Health departments.

Hawaii’s first concussion education act was signed by Gov. Neil Abercrombie in 2012, the culmination of efforts by HCAMP to standardize post-concussion protocol for high school athletes.

“We saw the national trends coming toward us,” said state Sen. Jill Tokuda, an Oahu Democrat who introduced the first Senate concussions bill during the 2012 legislative session.

In 2012, there was a wave of similar measures passed around the country. By 2013, every state had legislation on the books requiring some form of concussion education for high school athletes and their coaches and parents.

This year, Hawaii’s bill was updated to address an even younger group of athletes — middle-schoolers.

“It’s a continuous process to make sure we’re working in the right direction, but I feel very good about where we’ve come since 2012,” Tokuda said. “When I go to these (concussion) meetings, you see coaches, you see people from the medical community, all of these people coming together to have conversations that weren’t happening before. I think that is a really positive development.”

There is still a ways to go.

“Part of it is passing legislation for actual action and the other part is a communitywide mentality,” Green said.

For a number of reasons, including what Green dubbed the “old-school mentality” of playing through injury, it’s not always easy to keep concussions at the forefront of people’s minds — particularly teenagers who think they’re indestructible.

“I think most coaches are watching for it,” Bello said. “Kids themselves are more aware … it’s being monitored a lot closer.” But they’re also “pretty good at hiding it,” he said.

Renteria said he expected raising awareness to remain challenging in the future.

“Unless it hits you, no pun intended, then you become more aware of what’s going on,” he said.

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Even though a concussion can present differently from person to person, there are still a few basic signs and symptoms that athletic trainers, coaches and parents can look for as student-athletes take the field.

“Some patients feel like if they didn’t fall unconscious, they didn’t have a concussion,” said Dr. Miki Cain, a pediatrician at the Hilo Medical Center. “There’s a wide variety of symptoms.”

The federal Centers for Disease Control and Prevention put possible symptoms into four categories: physical, emotional (mood), sleep and mental processes.



Blurred or fuzzy vision.

Nausea or vomiting.


Light and noise sensitivity.

Balance problems.

Lack of energy.

Emotional (Mood):



Nervousness or anxiety.


Sleeping more or less than usual.

Trouble falling asleep.

Mental Processes:

Difficulty thinking clearly.

Difficulty concentrating.

Feeling slowed down.


Difficulty remembering new information.

Source: CDC