A state law enacted 25 years ago has helped make countless Hawaii student athletes healthier — and is also paying dividends that could someday be felt nationally or even worldwide.

Public high school athletic directors and administrators, doctors and private school athletic trainers were among those who pushed for a 1993 law that started a pilot program assigning at least one full-time certified athletic trainer to every interscholastic sports-playing Department of Education high school in Hawaii.

Since then a comprehensive collection of data from school athletic trainers has made Hawaii a resource for credible information used in research about high school sports injuries, including concussions.

Dwight Toyama was the Kaimuki athletic director in 1993. As chairman of the Oahu Interscholastic Association’s legislative committee, he led the lobbying efforts, along with OIA Executive Director Ted Fukushima and Ed Kiyuna, who was in charge of the Hawaii High School Athletic Association.

“It was definitely a big step for the health and welfare of the student athletes,” Toyama said. “This thing really had a domino effect, in a good way. One of the things Dr. (Bart) Buxton and, of course, Ross Oshiro emphasized was data, data, data. That was pounded into the trainers.”

Buxton, who was the athletic training education coordinator at the University of Hawaii, pushed for the law. Oshiro is a veteran athletic trainer who later led establishment of the Hawaii Concussion Awareness Management Program (HCAMP). Also, testimony by Interscholastic League of Honolulu athletic trainers Cindy Clivio (Kamehameha Schools) and Glenn Beachy (Punahou School) helped, Toyama said.

Athletic trainers at public schools are DOE employees. Requirements include a Bachelor of Science degree, passing a national athletic trainers board of certification exam and licensing by the state Department of Commerce and Consumer Affairs, Oshiro said. Salary range is from $4,316 to $5,053 per month.

“Hawaii is the first and still the only state so far (with a trainer at every interscholastic sports- playing high school),” said Nathan Murata, formerly HCAMP’s principal investigator and now dean of the UH-Manoa College of Education.

Since information about injuries is from athletic trainers who actually see them occur, the data are more valuable to researchers.

Dr. John Leddy is a leading concussion researcher and orthopedics professor at Buffalo State University in New York.

“They have a good program,” Leddy said. “They have a lot of good data, the only state in the country (with that much), and it’s supported well by the state. They have a lot of potential to collect some good information and get published.”

More research

Emily Kosderka is a professor of exercise science at Concordia University in Portland, Ore. She is working with Hawaii researchers on a study of the benefits of light exercise sooner than what was previously thought prudent after a concussion.

“The work that is happening there in concussion research and management is exemplary,” Kosderka said. “Through the HCAMP project and the work of Dr. (Rachel) Coel and Dr. (Jennifer) King and their colleagues, Hawaii is out in front in what we’re doing to help people get better.”

Teamwork within the community “really sets Hawaii apart,” said Coel, who regularly deals with concussion patients as director of sports medicine at The Queen’s Medical Center.

“There’s a partnership, just sort of an unspoken, unwritten rule that we all work together for the betterment of our patient care,” Coel said. “Not just with other physicians, but athletic trainers, coaches, parents, schoolteachers, opening the lines of communication. So, for example, I work at Queen’s, but I work closely with Dr. Jennifer King at Kapiolani and Chris Lynch, who is also at Kapiolani.”

Murata mentioned Ben Chun at Kaiser in addition to Coel and King as doctors always willing to assist in HCAMP’s efforts.

“Those three have been the catalyst,” he said. “And they help us at no charge.”

Hawaii has also been at the head of the pack with rule changes in high school football designed to make concussions and other injuries less likely. In 2015 it was among four states that started enforcing a blind-side blocking rule that was adopted nationally starting last season.

“It didn’t come without some blowback, people saying, ‘Hey you’re ruining the game.’ In reality it’s making it safer,” said Matt Sumstine, HHSAA coordinator of football officiating.

Also, Sumstine said he doesn’t see coaches “bringing (concussed players) back into games like before.”

Key mandates

Every high school coach in every sport is now required to either attend a concussion clinic or view one online every year. This is mandated by the HHSAA and administered by HCAMP.

“The care and management of concussed student athletes is a team approach,” reads a DOE memo from last year.

That teamwork includes the state Legislature, which has provided funding for HCAMP and made it law to expand base-line testing for younger athletes and those competing on nonschool teams.

“In 2016 we passed another measure that actually expanded it to middle school students,” state Sen. Jill Tokuda (D, Kailua- Kaneohe) said. “A lot of people don’t realize it includes youth programs.”

With that law, HCAMP now receives $450,000 annually from state general funds (HCAMP, established in 2010, was previously funded by the state Department of Health).

“I don’t think we would’ve gotten that without (Tokuda),” who was then chairwoman of the Senate Ways and Means Committee, Murata said. “She was gung-ho for it.”

Among other functions, HCAMP provides high school programs with concussion awareness clinics and base-line testing. Part of the funding is to pay for licenses for the online Immediate Post- Concussion Assessment and Cognitive Testing (ImPACT).

HCAMP is now tasked with identifying nonschool youth sports programs and serving them similarly.

State Sen. Josh Green (D, Naalehu-Kailua- Kona), who is also an emergency room physician, has introduced a bill this session that calls for $1.5 million for “research and coordination of studies and care” for children as young as 8.

“Right now it’s the tip of the iceberg with the high school (student athletes),” Green said. “I think we should get closer to when kids start to get head injuries.”

(Green and Tokuda are among six candidates running for lieutenant governor in November’s state elections.)

Wait and see

Tokuda and others want to see how the program works with middle schoolers first. She said it is not yet known how different base-line testing would be for elementary school-age children, or how much funding would be required.

“Not to say that we don’t move in that direction,” Tokuda said. “But have we even finished doing well with middle school and high school? We have to know exactly what it will fully cost and what it means for elementary-age kids. We have to be prepared for it. We’ve done it well so far and moved in a very targeted, focused direction.”

Ross Oshiro, now coordinator at Queen’s sports medicine, still works closely with HCAMP. He agrees with Tokuda.

“I think we can say we are leading the country in concussion management which encompasses the entire state’s high schools,” he said. “We can thank the legislators for supporting us to protect our youth, and high school athletic trainers and administrators for treating our student athletes. As far as what needs to be done, we are working on educating our middle schoolers. We need to gather more research on how the educational tools are working on this age group before moving down to the elementary level.”

Murata said he hopes fifth- and third-grade students will eventually be tested. And whatever is done, it will be statewide, he added.

“That funding is coming in, and that’s huge,” he said. “From Kau to Kekaha, they will all have access.”

And researchers here and beyond Hawaii’s shores will have access to even more potentially valuable data.