Category Archives: Concussions

Concussion discussion VI. Panel on sports-related concussions in youth

Today, the Institute of Medicine and National Research Council are holding meetings to discuss study on sports-related concussions in youth. The group began a 15 month study in October and will prepare a report on sports-related concussions in youth, from elementary school through young adulthood. A goal of the meeting will be to review the science on concussions, including risk factors, long-term consequences, and the effectiveness of protective devices and equipment among other topics.

Interestingly, the group will also cover potential impacts on military personnel and their dependents. specifically, there will be a focus on concussion resulting from sports and physical training at Service academies and recruit training for military personnel between the ages of 18-21

The specific list of topics to be discussed are:

-the acute, subacute, and chronic effects of single and repetitive concussive and non-concussive head impacts on the brain;
-risk factors for sports concussion, post-concussive syndrome, and chronic traumatic encephalopathy;
-the spectrum of cognitive, affective, and behavioral alterations that can occur during acute, subacute, and chronic posttraumatic phases;
-physical and biological triggers and thresholds for injury;
-the effectiveness of equipment and sports regulations for prevention of injury;
-hospital and non-hospital based diagnostic tools; and
-treatments for sports concussion.

One of the primary deliverables for the group is to provide recommendations to specific agencies and organizations (governmental and non-governmental) on factors to consider when determining the concussive status of a player.

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Concussion discussion V: NHL fighting and the elusive nature of recovery times

Fighting in hockey. They go hand in hand like, well, toothless grins and hockey. Over the years, the NHL has taken steps to reduce fighting in hockey, while still leaving enough wiggle room for the rare enforcers left in the game. Like all sports, hockey culture once considered the concussions that came with fighting merely a minor nuisance. Recent data, however, appears to support the notion that head injuries may contribute to long-term disability. For instance, enforcer Derek Boogaard, who passed in 2011, was found to have developed Chronic Traumatic Encephalopathy (CTE). Data linking CTE to fighting is scarce, but the possibility remains very real. In fact, experts at the recent Ice Hockey Summit on Concussion recommended that fighting be removed from all levels of hockey. Former enforcer Nick Kypreos gives one of the best interviews concerning the role of fighting in hockey, its cultural meaning and the challenges in the life of a fighter, VIDEO: The Code.

An unintended consequence of the loss of fighting is that it could result in liberties being taken against players, especially star players without repercussions. This trend started in the 1990’s when strategies like the “trap” or the left wing lock brought a wave of hooking, holding and interference that almost ground the NHL to halt. The idea that fighting acted as a deterrent to violence against the game’s stars goes back to the days when Wayne Gretzky had enforcers Dave Semenko or Marty McSorely to prevent teams from taking liberties with the Great One. However, the old protections were been swept away and new ones have yet to take hold. If fighting is no longer the deterrent, then referees must fill the void and protect players by strictly enforcing the rules. Whether this is even possible is the million dollar question. This year, ex-power forward Brendan Shanahan is taking the most aggressive approach concerning enforcement ever seen in the NHL. Although concussions are reportedly down this year, head injuries have claimed the likes of NHL point leader Claude Giroux and superstar Sidney Crosby. Only time will tell whether these new rules enforcements are being successful.

Overall, more concussions are being reported in recent years (559 NHL concussions between 1997 and 2004, Benson et al., 2011), due in part to our increasing awareness and abilities to detect such injuries. With all of this information, teams are now keeping their players out longer than ever before (see Fig, 1). For instance defenseman Chris Pronger has been ruled out for the remainder of the 2011-2012 season, including the playoffs. This decision was made in DECEMBER. However, even prolonged rest is not a guarantee of recovery. The hockey world now holds its collective breath as Sidney Crosby is again sidelined after just 8 games back from a year long absence. With all of our testing and protocols, we still appear to lack a reliable method of dealing with concussions.

From Benson et al., 2011. A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program

So how long should players be kept out? Speaking only from my own experience having had two hockey related concussions in one month (and possibly a third), it took two years to recover from my symptoms. After 1 year I was seemingly back to normal without headaches, nausea or memory loss. The only time that I could tell that my head was still not right was any time I was on a boat, even in calm waters, where I was overcome by nausea and felt like I was going to throw up. I’m not sure what exactly was wrong, but some ability to balance was still missing. I thought my head would forever be “fragile” in this sense, but with another year, the symptoms faded. I’ve never heard of any studies on the recovery 1,2 or 3 years after a head injury. It’s a long time for typical research studies to track and for professional teams, it is an extremely long time to wait for a player. But could this be the future of hockey? Take steps to prevent concussions or wait 2+ seasons to get players back on the ice? How often can professional players not named Mario Lemieux make it back after two years away from the game? If true, we won’t just be talking about rule enforcement, we’ll be talking about serious litigation. These are the hard questions that face the NHL.

Chris Pronger out for the year.

Read “The Wayne Gretzky Analysis”.

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Concussion discussion IV.

The concept of concussion can been found woven throughout the history of human societies since antiquity. The image of David knocking Goliath unconscious with a stone to the head is but one early example. A formal definition of cerebral concussion emerged in 1787 when Benjamin Bell, a British surgeon, who  described it as,

“every affection of the head attended with stupefaction, when it appears as the immediate consequence of external violence, and when no mark or injury is discovered, is in general supposed to proceed from commotion or concussion of the brain, by which is meant such a derangement of this organ as obstructs its natural and usual functions, without producing such obvious effects on it as to render it capable of having its real nature ascertained by dissection.” (Shaw 2002)

That definition accurately describes the essence of the concussion as we know it today. In high school sports, there are an estimated 136 000 concussions every year in the US. The majority (53%) are a result of contact to the head and in most cases (83%) the symptoms subside within a week. Girls appear to be at higher risk than boys and generally experience different types of symptoms (see Concussion discussion II: differences between girls and boys). A small number of students (5%) lost consciousness during their injury and 1.5% experience symptoms that last beyond 1 month. A review of high school athletes determined 16 year old students reported the highest number of concussions (see Fig.1; Meehan et al., 2011)

High school concussions
Figure 1. High school concussions in 2008 (Based on data from Meehan et al, 2011)
In a study of high school football players, dizziness at the time of injury was a significant predictor of a prolonged recovery. Loss of consciousness and vomiting were possibly related to longer recoveries, whereas other symptoms like headaches, amnesia and visual problems were not (Lau et al., 2011).

Literature Cited

Lau B,A Kontos, M Collins, A Mucha and M Lovell. 2011. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? American Journal of Sports Medicine 39(11): 2311-2318 .

Meehan W, P d’Hemecourt, C Collins and R Comstock. 2011 Assessment and management of sport-related concussions in United States high schools. American Journal of Sports Medicine 39(11): 2304-2310.

Shaw, N. 2002. The neurophysiology of concussion. Progress in Neurobiology 67(4): 281-344.

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Concussion discussion III: The “Impact Indicator” for hockey players

Many recent high-profile cases of post-concussion syndrome have demonstrated that athletes from a wide variety of sports are vulnerable to injury. If superstars such as Sidney Crosby, Justin Morneau and Chris Paul can be sidelined with head injuries, any of us can. Indeed, important questions remain about the risks at the minor league level and the best way to protect young athletes. One recent effort is called the “Impact Indicator”. When embedded into a hockey helmet, the indicator flashes when an athlete has been hit with enough force to potentially cause a concussion. When a threshold is crosses, a green light changes to red.

Q. While the idea makes some sense, one wonders if players will be out to “light” other players up rather than focusing on just finishing a check.

UPDATE: Here is a response from the company, BattleSmart concerning the above question.

“This is a very positive question and addresses a long time concern in the sport.

Unfortunately that behaviour is already going on today and has been for a long time and is often encouraged by coaches and players – only it often cannot be determined who is doing this intentional and aggressive hitting

We need to address that behaviour and encourage all officials and coaches and players that this kind of behaviour and play will not be permitted or tolerated.

The Impact indicator will actually serve to help identify the players / teams who do this.”

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Concussion discussion II: differences between girls and boys

There is a rising tide of awareness when it comes to concussions in sports (see “the concussion discussion”). A recent study demonstrated that from 1997-1998 to 2007-2008, concussions rates in high school athletes increased 4.2-fold. Rates rose in all 12 sports monitored, so it is likely an improvement in diagnosing, rather than some trend in biology or athletics. However, the most disturbing part of this study was that females were twice as likely to experience concussions as their male counterparts. There is now evidence that there exist quantifiable differences in outcomes between the sexes after concussions:

“Female athletes had significantly greater declines in simple and complex reaction times relative to preseason baseline levels, and they reported more postconcussion symptoms compared with males. As a group, females were cognitively impaired approximately 1.7 times more frequently than males following concussions”. So why are females more susceptible to concussions? This video explores possible explanations including differences in anatomy (namely neck strength) and self reporting between boys and girls.

Another study followed NCAA athletes over 3 years and found that 3.6% of females athletes reported concussions in practice and 9.3% in games. In contrast, male athletes reported concussions more often after practices (5.2%) and less often after games (6.4%) than girls. A recent 2011 paper reports that both girls and boys report headaches as the major symptom of a concussion. However, differences are apparent in the secondary symptoms reported by the two groups. Whereas boys report confusion and disorientation, girls most often report sensitivity to sound and drowsiness.

And then there is the case of women’s lacrosse, which has the highest concussion rate among all women’s sports. A major factor can be found in the rules, where girls are not allowed to lay with helmets. With swinging sticks and balls flying at high speeds, concussions seem like an inevitability. Check out this video on the controversy surrounding the high rate of concussions in lacrosse:

MSNBC ran a piece questioning the utility of concussion-reducing headbands being sold to girls for soccer.

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See “Concussion discussion V: NHL fighting and the elusive nature of recovery times”.

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The concussion discussion and the NHL (part I)

I don’t remember much, but I know that it happened fast. I was playing a little extra hockey in a rec league. It was full contact, and like so many others, I got caught letting my guard down near some guy who was taking things a little too seriously. Our team was winning, so we put our forwards back on defense and our D-men up on forward. I was playing wing and my D-man made a slow pass up to me and the other the opponent stepped up and made a completely clean hit on me. After being erased, I immediately popped up on my feet. Years of training had drilled into my head not to show any weakness. I made it to the bench, and felt remarkably fine. No coaches or trainers in rec league, so it was really up to me to decide if I was OK. Yup, I’m OK. I played the rest of the game and the only strange thing was that I could not find my upper gear as far as skating. My body felt “loose” and I couldn’t accelerate the way I usually did. Still, I played the rest of the way not really helping or hurting my team in any meaningful way. It wasn’t until the end of the game that I realized the severity of the hit. I was the last one off the ice and lost track of the next last player. I got a few steps away from the ice and realized that I didn’t know which dressing room we were in. In fact, I didn’t know where ANY of the dressing rooms were! I turned back and asked some friends who came to watch which way to go. They showed me the way and made sure I didn’t pass out on the way.

Back on my competitive team, I got my bell rung from a routine hit during the next game. I got up immediately and neither the trainer nor the coaches ever suspected anything was wrong. Inside my helmet though, I was seeing stars. A few games later, I made a big hit and had that funny feeling in my head again. I contemplated whether I should take a break from playing if I couldn’t even throw a good hit, but it was the playoffs and we were eliminated that game. I never had to decide whether I should keep playing or not because I never played competitive hockey again. I estimate that it took some 18-24 months for my head to completely clear. That summer I got motion-sick on completely calm waters about 5 feet from the dock! Something in my head was clearly broken. Time healed me, but I always wonder about these players that play a week after a concussion.

Watching the aftermath of the Aaron Rome hit on Nathan Horton in game 3 of the Stanley Cup finals was stomach-wrenching. Defensemen have a responsibility to be physical along the blueline, but this particular hit was clearly across the line. Although the contact could not have been avoided entirely, Rome certainly should have pulled up and not finished his check so strongly. The puck had been passed off well in advance, so Horton was vulnerable and not expecting a full bodycheck. A blindside check on an unsuspecting player is not only uncalled for, but potentially career-ending. In an interview with the Toronto Star, former NHLer Keith Primeau indicated that, “the hit reflected the lack of respect among players”.

The incident played out against a larger backdrop of concussion injuries in the NHL, and indeed sports in general. Like football, boxing and even professional wrestling, hockey is coming to terms with the fact that concussions can have profound and long-term effects on athletes. Recent advances in both science and awareness have slowly brought the issue out of the shadows. Several flashpoint events occurred this year in the NHL with the loss of Sidney Crosby and Horton to severe concussions.

Preventing players from getting back on the ice too soon has been a major evolution in the NHL, even in the last 10 years. As recently as 2000, Eric Lindros attempted to come back from a series of concussions only to succumb to further injury from a vicious Scott Stevens hit. At the time, there was much controversy about the role the Philidelphia Flyers played in letting Lindros skate too soon after his previous concussions. In contrast, Sidney Crosby was kept out for the remainder of the 2010-2011 season by the Pittsburgh Penguins after his severe concussion. Clearly, strides have been made in our collective understanding of the significance of these types of injuries.

Just look back at the 2003 playoffs between the Anaheim Ducks and New Jersey Devils. Paul Kariya got knocked OUT COLD in game 6 and returned to score later that game. Should he have played? No. Will we ever see a similar performance? Never. And that’s a good thing. We lose amazing feats of courage from the likes of Kariya, but we also avoid losing players by putting them at undue risk. Still, it’s one of the greatest performances that has gone unappreciated because the game involved two teams with little following at a time when the NHL has almost no national audience.

Although medical treatments for concussions have improved, there remain difficult questions about how best to shape NHL rules for player protection. This season, the NHL instituted new rules concerning head shots. In essence, it bans blindside hits where the head is the principle target. In addition, referees can use the “attempt to injure” criteria to cover conduct that doesn’t fall into the previous description and the NHL commissioner can apply “supplementary discipline”. Even with the new rules, however, there are grey areas of interpretation. Hopefully, time will allow for the referees and the NHL to fine tune the application of these rules to protect player safety.

I’m no referee, but I thought I would put up some examples of plays that fall into different categories (like I said, there is a lot of grey area). Some plays are bad luck, some are questionable, some are no-doubters and some make you wonder what the heck was going through their heads. (NOTE: over the past few years, so much has changed with respect to our understanding of concussion. If I was to categorize these hits today, it would be a much different story than it was when I wrote this.)

1. ACTS OF GOD – Clint Malarchuk. Terrible outcome, but really, no rule could ever help avoid this. Some injuries are a result of a fast moving game filled with body contact. Warning, if you are squirmish about blood, don’t watch this video.

2. QUESTIONABLE. Steve Downie hit on Dean McAmmond. The puck was moved only a fraction of a second before the hit, and the elbow wasn’t up, but Downie leaves his feet. It was a preseason game and neither player was probably as sharp as they normally would be during the season.

3. BAD PLAYS – Andy Sutton hit from behind. Sutton is anticipating that Pascal will skate forward and doesn’t let up on the hit when he stops. It happens quickly, but there must be zero tolerance for hits from behind since players can be paralyzed or even killed on such plays.

4. NO ROOM IN HOCKEY FOR THIS – Headshots on Paul Kariya and Teemu Selanne. These were bad.

The safety of the players is the most important reason for stricter enforecement, but beyond that, imagine how much good hockey we have lost to these injuries. Here are some of the players that lost major time to concussions:


Selanne & Kariya
Pat Lafontaine
Eric Lindros
Keith Primeau
Sidney Crosby

See “Concussion Discussion” parts 2 to 6.

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