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The concussion conundrum

Awareness is improving, but exactly how the brain is damaged remains a medical mystery

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Dr. Charles Tator: 'After all of this time, no one can point which part of the brain is affected by a concussion and no one can say exactly what the mechanism is.'

KEITH BEATY / TORONTO STAR Enlarge Image

Dr. Charles Tator: 'After all of this time, no one can point which part of the brain is affected by a concussion and no one can say exactly what the mechanism is.'

Imagine for a second an alternate reality. It's March 15, 2012, and instead of returning to action against the New York Rangers after an arduous battle with multiple concussions, Sidney Crosby calls a press conference and tearfully announces his retirement from the game of hockey.

News-media outlets across Canada and North America are shocked, falling all over themselves sounding alarm bells about the dangers of head contact. One of North America's most bankable stars has been unapologetically snuffed out in the prime of his career, succumbing to the lingering effects of successive concussions.

We all remember the coverage; it started at the 2011 Winter Classic in Pittsburgh. Crosby sustained the first of two hits to his head in the span of five days. He then sat out the rest of the season and the playoffs. He would make his first attempt at a return on Nov. 11, playing seven games, and although his on-ice contributions appeared normal (12 points in eight games), he would again return to the press box until that fateful day in March when his comeback would appear solidified.

Say what you want about Crosby's recent playoff performances, or lack thereof, Sid the Kid is still the face of the NHL and one of the most famous Canadians we have. And while concussions were on the forefront of every news-media outlet in 2011 with the game's greatest name and the word 'retirement' whispered in the same breath, the injury has now returned to the dark corner of our minds, both literally and figuratively.

Retirement due to multiple head injuries has been the sobering reality for many of Crosby's colleagues: Eric Lindros, Marc Savard, Chris Pronger, Pat LaFontaine, Scott Stevens, Matthew Barnaby, Nick Kypreos and Eric's younger brother, Brett, who only played 51 games in the NHL before post-concussion symptoms forced him to call it a career.

But this is just hockey. And Canada's most popular game isn't even the biggest victim when it comes to concussions. The National Football League has been plagued by the injury that's culminated in a $765-million settlement with former players that alleges the league has been denying a link between playing football and traumatic brain injuries for decades. However, a federal judge recently declined to approve the settlement, deeming the figure too small and saying it will not go far enough to cover the players affected. A group of NHL players has also launched a similar lawsuit, and it's safe to say while Crosby is back, concussions aren't going anywhere, and they're not only costing careers, they're costing lives.

The suicide of former NFL linebacker Junior Seau in 2012 and subsequent autopsy that revealed he suffered from chronic traumatic encephalopathy (a degenerative brain disease caused by multiple head injuries), shook the American sporting world. Yet the game continued, and it's as violent as ever. The Seattle Seahawks recently won their first Super Bowl using a punishing style of defence where players bring about a hit parade on every ball carrier.

Last August, Seahawks defensive superstar Richard Sherman wrote a piece for Sports Illustrated in which he recounted playing two full quarters of football half-blind because he didn't want to jeopardize his chance at a starting spot on the roster. He ended his column with a chilling sentence about his stance on the issue, and the violent nature of football:

"If you don't like it, stop watching."

Many doctors have been studying the long-term effects of concussions for years, and are trying to grab the attention of major sports organizers. The Canadian Medical Association Journal published a wide-ranging study in 2011, which looked at concussions in NHL players from 1997-2004, outlining the severity of the problem. The NHL responded with educational-awareness campaigns, new rules and even Brendan Shanahan as a high-profile disciplinarian. But concussion rates have not dropped; in fact, they have risen since the league started monitoring them in 2008.

One could argue the rise can be attributed to increased awareness of symptoms, however, that does nothing to fix the underlying problem.

"It's almost incomprehensible that the (NHL) has allowed its resources to be damaged in this way," says Dr. Charles Tator, the project co-ordinator for the Canadian Sports Concussion Project at the Krembil Neuroscience Centre at Toronto Western Hospital. The CSCP is conducting several research studies on concussion disorders. Tator published an article last August in the CMAJ titled Concussions and Their Consequences: Current Diagnosis, Management and Prevention.

Tator calls for a three-pronged approach to prevention of concussions in collision sports: primary, secondary and tertiary. This includes reducing head-to-head contact, proper diagnosis through best practices and recommending retirement in selected cases after repeated concussions.

The third point, and probably the most important, is going to be the toughest to enforce or implement into professional leagues where players' careers depend on the ability to play.

"The NHL owners for example, why haven't they done more about it?" Tator says. "And why haven't the current NHL players, like the NHLPA, why haven't they done more? What they've done so far hasn't been enough."

Tator believes while the owners are now more cognizant of the problem, this just means they're consciously turning their backs on it.

"It's disheartening to see that the modern awareness of concussions hasn't penetrated significantly into professional levels yet. In fact, they have almost disregarded it in terms of altering the culture of the game to conform to new knowledge. They really haven't responded appropriately at the professional level."

Dr. Paul van Donkelaar is a professor and researcher at the University of British Columbia Okanagan and the director of the university's School of Health and Exercise Sciences. He received his PhD in clinical neuroscience in 1994 and set up a Sports Concussion Lab last year partially funded by the Canadian Foundation for Innovation. His wide-ranging scientific research focuses partly on sensorimotor (how the brain tells the body what to do), plus cognitive and attentional deficits following concussions.

He says while the awareness of this epidemic is apparent within the medical community, scientists, researchers and doctors are still slugging away with the mystery surrounding the injury itself. This makes bringing forth concrete, consensual opinions tough. While blood biomarkers, proteins identified in the blood that are released from the brain that may spike after a concussion, appear to be one of the medical community's latest discoveries, all the evidence is still widely speculative at this stage.

"The basic science aimed at understanding potential biomarkers for concussion is in its infancy," he says.

Dr. Tator agrees. When it comes to concussion, we just simply haven't a clue what goes on in the brain after such forceful impact.

"That is the main problem right now -- is we don't really know. After all of this time, no one can point (to) which part of the brain is affected by a concussion, and no one can say exactly what the mechanism is. So both the anatomy and the pathology of concussion are still unknown."

The consensual opinion right now is when someone is concussed, the brain jiggles inside the skull, which leads to a myriad of problems. Dr. Michael Ellis, a neurosurgeon with the recently formed Pan Am Concussion Program in Winnipeg, says there's one thing the medical community can agree on, which is they don't know a whole lot yet.

"It's true that we still have a very rudimentary understanding of what's going on inside the brain when somebody sustains a concussion."

Outside of his work with the Winnipeg Regional Health Authority, Dr. Ellis is a concussion consultant for the NHL's Winnipeg Jets. He says while the medical community has learned a lot in the past five years or so, there is still a long way to go.

"From a physician's perspective it's enormously frustrating to not be able to give a clear understanding of what's going on that underlies people's symptoms. I think that we're starting to learn that the symptoms themselves may form certain clusters and that those clusters may be mediated by physiological processes or impairments in certain neurological subsystems."

While this information may be valuable to the medical community, for an average person who's sustained a substantial blow to the head, it can be quite overwhelming, and downright confusing.

I'm what you'd call a lifelong recreational athlete. While I've never really played any sport at an elite or professional level, the games I love have made up a massive part of my life and my personal identity.

In March of this year I took a nasty spill playing recreational hockey, landing on my chin. While I finished the game and felt OK, the following few days I started to show all the requisite signs of a concussion: headaches, dizziness, fogginess and trouble focusing. I did what any normal person would do -- I took a break from the two sports I've played regularly since high school (soccer and hockey), and then when the symptoms subsided, I was back in action.

However, after I started playing again, I found myself suffering from terrible dizzy spells that almost felt like panic attacks, which landed me at the University of British Columbia's Urgent Care Facility where an emergency room doctor would formally diagnose a concussion. Sent home with a single piece of paper that listed a four-step process for returning to physical activity, I felt not only scared, but dismayed that the best medical advice I'd received was to "take it easy" for a few weeks. I returned the following day for a CT scan and an X-ray on my neck to check for overarching damage to my body, but when I finally got the results, there was no 'radiological evidence' indicating a TBI (traumatic brain injury). So I was sent home again with nothing more than some basic advice: avoid loud noises, bright lights, cease from drinking alcohol and stop exercising for a while.

From Day 1, my symptoms were all over the map. I documented them, taking notes as best I could, avoiding medication to fully comprehend what was going on. I quickly found there was literally no pattern, reasoning or real precursor in terms of rehabilitation. My concussion was like an improvisational jazz performance -- I had no idea where it was going, or when it was going to end.

The frenetic and inconsistent nature of it left me feeling powerless and as if I was simply praying for symptoms to subside. For most days in the first few weeks, I was plagued by what I dubbed peripheral headaches. Not normal migraines that envelop the entire skull, but spotty pain that would start around one temple, make its way down my neck as the day progressed and end up in another part by the time I was ready for bed.

The other half of my initial recovery was what I called "the fog." Tough to pinpoint, it's a sensation I'd liken to when you sleep in too long and feel groggy for most of the day. Think of a mild hangover, sprinkled liberally with a feeling like you're underwater and your ears need to pop, or that you're in a plane changing altitude all the time, from morning to night.

Not only did these symptoms make concentration tough, but my speech suffered. I was so distracted by the fog and headaches I found it tough to focus on everyday conversations. Whatever eloquence I had, it was long gone.

For someone who's played sports and been active their entire life, injuries are simple: assess, rehabilitate and get back to playing. After a few days of feeling good, I went for a run and felt fine. However, a few days later I woke up, and out of the blue my right ear felt as if it needed to pop, and this persisted for the better part of two days. Once that subsided and my overall state improved, I tried running again but this time it brought about a nasty headache that had me bedridden with an ice pack for the rest of the night.

Dr. Tator, who's worked with countless patients over the years, listening to them describe a laundry list of symptoms, says once again, the world of concussions is both disheartening and confusing.

"We have no idea where fogginess comes from. We have no idea what is the exact location in the brain where headaches come from. Nor do we know exactly where the visual symptoms come from."

While a knee or a shoulder injury is relatively easy to monitor through various MRI, CT or X-ray scans, concussions are hidden within the brain, which itself is still mostly a mystery to humans. I documented many symptoms, such as bouts of light-headedness, memory loss, random ringing sensations in one ear and blurred vision. But whether or not this was the concussion, or the product of being human and living on planet Earth, is anyone's guess. Dr. Ellis agrees, it's tough to corner an injury that never really shows itself in an easily quantifiable way such as swelling, mobility issues and/or joint pain.

In terms of rehabilitation, Dr. Ellis adds that for the vast majority of patients he sees, resting until symptoms subside usually does the trick.

"That recommendation is probably going to lead to successful recovery from a concussion, but there's generally about 30 per cent of patients who will have symptoms that will last longer than the expected time of recovery. So for an adult, that's probably within two to three weeks. So for that population who doesn't recover quickly, they can begin to feel pretty frustrated and hopeless."

The mystery surrounding this injury laces recovery with a sense of hopelessness and desperation, leading to a thought pattern of doubt and inexplicability. The only symptom I could verifiably pinpoint was eye concentration. Staring at my phone or computer screen instantly brought about a feeling of dizziness, forcing me to take constant breaks from basic tasks such as emails or reading, much easier said than done for a writer, and tough for any human in today's technologically driven age.

After I realized my summer of playing hockey and soccer were definitely shot, the idea of retirement from those sports was something I was going to have to seriously consider. I started to suffer from mild depression. Not being able to lace up the skates anymore, or kick a ball around with the guys had me lost in an identity crisis. Having played both of these sports for over 20 years and loving every minute of it, now what the heck am I going to do for regular exercise? What new social outlets am I going to have to create in place of recreational sports?

In early 2012, I took a puck to the lip playing recreational hockey that forced me to lose vision for about 15 seconds. I received a boatload of stitches and a nose job, plus was formally diagnosed with my first concussion.

Now after my second concussion, I'm facing one of the toughest decisions of my life. If and when my symptoms do subside, do I continue playing hockey and soccer? The games I've played since I was a little kid, the games I've loved, the games that have helped me identify who I am as a person?

If Dr. Scott Delaney, the team physician for the CFL's Montreal Alouettes, Major League Soccer's Montreal Impact, various McGill sports teams and Cirque du Soleil, were my physician, the answer would be quite simple.

"All I can tell you with the more concussions you have, especially more than three, you're at a higher risk 10 to 20 years down the road of having memory problems, concentration problems and a higher risk of depression."

Suffering from Alzheimer's or Parkinson's disease through the twilight of my life is a heavy deterrent and does make retirement a bit easier to stomach in retrospect. But try telling that to someone whose day job is actually playing the game they love, said Delaney.

"Obviously the risk-reward comes in. It's dealing with pro athletes who will say, 'Look I hear what you're saying, Doc, but this is my livelihood and this is my chance to put away some money for the family,' versus someone who's just playing recreational hockey Tuesdays and Thursdays and now can't concentrate and go to work at IBM."

A quick Google search and the general public can overload on concussion information. However, with the Internet comes the underlying issue of credibility. Miracle-cure therapies are something in which specialists such as Dr. Tator and Dr. Ellis are seeing an alarming rise. Websites offering alternative treatments with anecdotal evidence from patients who were cured and are now happily back playing the sports they love.

"There are things being offered by many practitioners, which don't have evidence to support that they are effective," says Dr. Tator, whose expertise as a scientist, neurosurgeon, professor and administrator had him inducted into the Canadian Medical Hall of Fame in 2009. "They're generally effective for bringing in money, but in terms of providing solid relief from concussion symptoms, there's no evidence that they work."

Dr. Ellis, who did his neurosurgeon's residency at the University of Toronto and fellowship training under Dr. Tator, says the floodgates are open for these clinical entrepreneurs. The patients, often young kids with caring parents, are willing to go to great personal and financial lengths to end the suffering.

"We don't have very good guidelines about what constitutes a concussion expert. It's probably one of the worst terms that's out there because it can be very misleading, largely because you don't need to have any training or experience to call yourself a concussion expert. You can be a chiropractor, a psychologist, a homeopathic doctor or a neurosurgeon and open a practice where you are independently managing patients with concussions. Obviously these people have very different levels of training and experience in terms of managing patients with acute traumatic brain injuries. And it's unfortunate because it confuses the public who often cannot discriminate between these professionals when they all call themselves concussion experts."

And beyond the shady alternative-medicine cures, there's also a growing industry offering products such as helmet sensors that send a message to a parent's phone when a child's equipment is shaken violently.

This is much of the same, Dr. Tator says.

"We get approached very frequently by researchers and small companies that think they have made a discovery and will assist in the diagnosis of concussions. We're always looking for something that will help, so we haven't really discouraged those engineers and other professionals from trying to improve the diagnosis of concussions, but so far I think the jury is out in determining what role the sensors have."

So what is the end result? Both Dr. Tator and Dr. Ellis say a specified 'concussion' doctor is the answer, much like an oncologist whose area of expertise is a specific type of cancer, or an ophthalmologist, who specializes on one part of the body (the eye).

"I think we're heading in that direction but we're just at the beginning of that process, and not even the medical professionals have got this sorted out," Dr. Tator says. "Gradually we're getting there and organizing care, it will take another few years for society and the health-care professionals to get this sorted out, but now at least it's on the discussion table."

In Manitoba, Dr. Ellis is one of the founders of the Pan Am Concussion Program in Winnipeg, a provincially funded, multi-disciplinary program devoted to the care of children and adolescents with concussions and TBIs. Ellis' aim is to elevate the standard of care in Manitoba that ultimately brings together trained experts in the various aspects of TBI under one roof and one set of guidelines.

In late May, U.S. President Barack Obama held the first-ever White House Healthy Kids & Safe Sports Concussion Summit. In his speech, Obama himself admitted to experiencing concussion-like symptoms as a kid while playing football. He further talked about washing away the "suck-it-up" mentality.

Along with the summit came the announcement of a $30-million joint research effort by the NCAA and the Department of Defense, and an NFL commitment of $25 million over the next three years to promote youth-sports safety. While the $765-million NFL settlement works its way through the legal system, another shocking revelation has brought soccer into the discussions as well: Patrick Grange, a former semi-professional player who died at 29 due to ALS. Grange was found to have the same degenerative brain disease as Junior Seau from repeatedly heading the ball throughout his bid to make it to a Major League Soccer team.

Here in Canada, the facts concerning Sidney Crosby's concussion history are no mystery. He's had two so far, which puts him at a higher risk for another down the road. No one wants to see the Golden Boy retire, and even mentioning the potential of Crosby hanging up the skates any time soon seems sacrilegious. But if he does succumb to the injury, you can be sure there will be plenty 'I told you so' from various medical experts who think the NHL's product is inherently violent and dangerous at its core.

A major part of the allure of sports such as hockey and football is its physicality. Hockey just wouldn't be hockey without punishing bodychecks, fighting and players like Ryan Getzlaf, the Anaheim Ducks captain who played through an ugly facial laceration that required multiple stitches during the Stanley Cup playoffs. And football wouldn't be football without players such as Sherman, who hunt down ball-carriers like ravenous predators tracking prey.

"It's hard for anyone to say to get rid of the contact because that's the nature of these sports. It's hard to take contact out of sports, which are contact sports," says Dr. Peter Crocker, a sports psychology researcher who teaches at UBC's School of Kinesiology.

Dr. Crocker works with various athletes on a regular basis at UBC and is primarily a researcher in the field of coping and emotion related to sports. He says the problem with something such as a concussion is it can be easy to hide at times, and in our society, grit is rewarded, not shunned.

"There is some value in our culture attached to playing injured because of some sense of toughness, you're commitment to the sport, which I think in most instances is pretty stupid. But it's something that is highly valued and is very difficult to get out of sports, especially if you look at hockey."

Dr. Crocker says the culture is changing around concussions; however, a tipping point, or full-blown mentality shift, has yet to take place. During my interviews for this piece, Dr. Delaney, who's been treating concussed pro athletes from a wide variety of sports for years, noted NHL player Bill Masterton died on the ice as the result of a head injury caused by a hit.

"You hope it's not going to be the case where someone dies for things to really change," he says.

However, it would be 11 years after Masterton's death before the NHL would make helmets mandatory.

My symptoms have not subsided after three arduous months, and in all likelihood I will retire from all contact sports at the ripe age of 31. The cost-benefit analysis is just too high for someone like myself who simply plays for fun and uses their brain to pay the bills. And there will be no teary press conference, or public outcry for me. Just another name added to the list of people who can no longer play the sports they love.


Patrick Blennerhassett is a freelance writer/editor based in Vancouver. He is the author of two fiction novels and a Jack Webster Fellowship Award winner.

Republished from the Winnipeg Free Press print edition July 5, 2014 D7

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