Information for Coaches

What is Hawaii Concussion Law?

Across the United States, each state's Legislators have passed concussion laws for the purpose of protecting our student athletes' health and well-being. The goal of concussion legislation is to protect our youth from potentially devastating or catastrophic brain injuries.

Hawaii Concussion Law ACT 262

• Education of parents, athletes, school staff and administrators and sport officials
• Includes youth sports from 11 years old and above.
• Annual training of coaches and athletic trainers
• Mandatory immediate removal of the athlete when a concussion is suspected
• Need for clearance to return to play by a licensed health care provider trained in concussion management
• Return to learn and gradual return to play protocols
• Funding for high school neurocognitive testing.

Why immediate removal and what are the risks if a student athlete plays with a concussion?

Immediate removal from play is to protect the athlete from potentially long term or catastrophic brain injuries.

• A concussed athlete who continues to play is at an exponentially greater risk for long term or catastrophic brain injuries.
• A concussed athlete who continues to play will prolong his or her recovery and create a more complicated recovery.

Immediate removal will not only protect the athlete from further brain injury but also protect themselves and their teammates from other sports injuries.

• A concussed athlete who continue to play is more prone to lower extremity musculoskeletal injuries, such as a torn ACL. [1-5]
• A concussion can affect the balance and coordination parts of the brain.
• A concussed student athlete's athletic performance will decrease.
• Baseball batting average decreased, missed catches and poor decision making due to concussion symptoms
• A concussion can affect eye tracking, focusing and reaction time

What are the potential catastrophic brain injuries or long term effect of a concussion?

The adolescent brain is unique, the brain is still developing and is susceptible to Second Impact Syndrome.

Second Impact syndrome has only been reported in adolescents and young adults, ages 13- 24, with the worst outcomes in younger ages.

The cause is thought to be due to an athlete sustaining a subsequent brain injury before they have fully recovered from a previous injury to their brain, such as a concussion.

There is an increase in blood flow to the brain and an uncontrolled increase in intracranial pressure.
Loss of autoregulation of blood flow
Diffuse brain swelling or brain edema

Within a second to minutes, signs of brainstem herniation and failure

• Unconsciousness
• Pupils dilated
• Respiratory failure

While the concussed individual is recovering from a concussion, he or she may be anxious to return to his or her sport, even before they are ready to return. Coaches need to be aware that the Hawaii Concussion Law states that a high school student athlete may start a return to play protocol when he or she is cleared by a licensed health care provider who is trained in concussion management. The return to play protocol is supervised by an athletic trainer in the high school. At the youth age it is best practice to have the athlete go through a return to play play protocol prior to any contact or game activity. Youth coaches or a safety coach may be able to supervise the progression.  Included at the end of this module are examples of return to play guidelines for various sports.

Steps in return to play protocol

Before beginning physical activity in the return to play protocol, the concussed individual must first be back to school full time without any academic adjustments and be symptom free.

Before the concussed individual can proceed to the next step of the protocol, he or she must be symptom free and each step must be separated by a full 24 hours.

Step 3 - Once cleared by a licensed health care provider the concussed indiviual may start light aerobic activity such as stationary bike or walking.  
Step 4 - Running in the gym or on the field for 20 minutes, no helmet or other equipment. Example: Two ten-minute moderate pace running with a ten-minute break between
Step 5 - Non-contact training drills in full equipment. Weight training can begin.
Step 6 - Full contact practice or training
Step 7 - Full clearance to competition.

Gradual Return to Play Protocol
Step 1	Cognitive pacing	Return to life
Step 2	Academic pacing	Return to school full time without academic adjustments
Step 3	Light exercise	This step cannot begin until the concussed individual is cleared by a Medical Provider for physical activity. At this point, the concussed individual may begin walking or riding a stationary bike.
Step 4	Moderate activity	Running in the gym or on the field. No equipment or helmets.
Step 5	Sport-specific and non-contact training	Sport specific drills with equipment. Weight training can begin.
Step 6	Full contact practice or training
Step 7	Play in game
Note: Steps 3-7 are supervised by the Athletic Trainer at the high school. Each step is separated for a minimum of 24 hours.

Sport-specific Gradual Return to Play Protocol

A gradual return to play protocol should be adapted to the demands of sport the concussed individual is returning to.  The sport specific adaptation will help to determine if the concussed student athlete is ready to return to a real life competition.

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[1] Lynall, R.C., et al., Acute Lower Extremity Injury Rates Increase after Concussion in College Athletes. Med Sci Sports Exerc, 2015. 47(12): p. 2487-92.
[2] Herman, D.C., et al., Concussion May Increase the Risk of Subsequent Lower Extremity Musculoskeletal Injury in Collegiate Athletes. Sports Med, 2016.
[3] Gilbert, F.C., et al., Association Between Concussion and Lower Extremity Injuries in Collegiate Athletes. Sports Health, 2016. 8(6): p. 561-567.
[4] Dubose, D.F., et al., Lower Extremity Stiffness Changes after Concussion in Collegiate Football Players. Med Sci Sports Exerc, 2017. 49(1): p. 167-172.
[5] Brooks, M.A., et al., Concussion Increases Odds of Sustaining a Lower Extremity Musculoskeletal Injury After Return to Play Among Collegiate Athletes. Am J Sports Med, 2016. 44(3): p. 742-7.