When Hockey Canada held a concussion seminar last month in Montreal, the participants received a packet that included a brief welcome letter from Ken Dryden – Hall of Fame goaltender, Member of Parliament in Canada.
Dryden wrote about how we think back on the past and wonder why we could have been so wrong about things. He mentioned slavery, the absence of rights for women and smoking. Then he went to sports. Why did football and hockey players go so long without wearing helmets? Why did hockey goalies go so long without wearing masks?
Then he wondered what people will think of us 50 years from now, and he mentioned head injuries in sports – their short- and long-term effects.
“Knowing what they know then, some hints of which we know now, these people of the future will wonder, ‘What could they have been thinking? Why didn’t they do more?’ ” Dryden wrote.
That someone of such stature would make such strong comparisons underscores the seriousness of the concussion issue. At the same time, that someone of such stature wrote such a letter at all, that it was part of a concussion seminar, that it was part of a packet of educational materials, illustrates just how seriously the people of the present are starting to take it.
The NHL actually has been a leader on concussions for a long time – from instituting baseline testing and a return-to-play protocol in 1997, to outlawing blindside hits to the head this year, both ahead of similar initiatives by the NFL. Doctors know more about concussions. Awareness is higher than it has ever been before. Attitudes are changing.
But concussions always will be an occupational hazard in hockey, and they continue to challenge everyone involved in the game.
Two players returned to action this week after missing extended time because of concussions – the Minnesota Wild’s Pierre-Marc Bouchard(notes) and the Boston Bruins’ Marc Savard(notes). But Paul Kariya(notes), for one, remains out after deciding to stay on the sidelines this season in the hopes of recovering from post-concussion syndrome. And many players have been forced to end their careers because of concussions, including the likes of Pat Lafontaine and Eric Lindros.
Listen to any of their stories, and you can appreciate the toll concussions can take, see some of the progress that has been made and understand how much more needs to be done. More education. More awareness. More research. More debate.
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Consider the case of Cam Stewart. He suffered eight documented concussions in a career that included 202 NHL games with the Boston Bruins, Florida Panthers and Minnesota Wild. The last three times, he was knocked unconscious. Once, he went into convulsions. But many smaller incidents went undocumented, and the cumulative effect of his brain trauma began haunting him at the end of his career.
Stewart said he would see stars four times a game. Everything would go blurry after a hit. He would hear a buzzing sound. He would forget what team he was playing. Maybe while backchecking, maybe while squirting himself with water on the bench, it would click in, like, “OK, yep, playing Colorado.”
The last time Stewart played anyone was in a 2001 preseason game against the Edmonton Oilers. Skating through the neutral zone, looking back for a pass, he took a shoulder to the chin from the Oilers’ Scott Ferguson. “Great hit,” he said. “The kind I made a living doing.” He blacked out on the ice. He broke down in the dressing room.
And that was just the beginning.
When he tried to spin his legs on a stationary bike in the days and weeks afterward, Stewart would last three or four minutes before vomiting. He would talk to his parents for 45 minutes, then call them five minutes later and ask how they were doing. Just to get out and walk around, he would go to the Mall of America in suburban Minneapolis, only to come out and have no idea where he parked his car. “It was horrible,” he said.
He battled depression. To cheer himself up – first in Minnesota, then in Houston, where he coached in the minors after he retired because of his concussions – he went to children’s hospitals to work with sick kids. “Selfishly almost,” he said. “It was therapy for me.”
To this day, he keeps sunglasses with him at all times because sunlight gives him headaches. He gets migraines two or three times a month. He opens his desk drawer, and you can hear the rattle of a bottle of Extra Strength Tylenol. He said he still could not pass a baseline test.
Stewart has followed the study of chronic traumatic encephalopathy (CTE), a neurodegenerative disease diagnosed in deceased athletes – including one former NHL player, Reggie Fleming – who donated their brains to researchers at Boston University. The late Bob Probert donated his brain. Other former NHL players have pledged theirs, including Keith Primeau, whose career was cut short due to repeated concussions. CTE is associated with cognitive and behavioral problems.
“When I go down to these conferences and learn about it, I’ve got every symptom that comes with it, which is scary,” Stewart said. “But at the same time, we could teach a lot of people – just light hits to the head, how they can affect you for your life.”
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It wasn’t that long ago that team doctors didn’t know much about concussions themselves. Players whose symptoms lasted for 15 minutes or less were returned to the game. It wasn’t yet clear that symptoms could show up later. “Certainly there was that attitude that once a player felt fine, ‘I guess he’s OK,’ ” said Mark Aubry, the chief medical officer of the International Ice Hockey Federation and a team physician for the Ottawa Senators. “It’s really been a progression of research.”
As recently as the 1990s, doctors had a cookbook approach to concussions, and no one wanted to follow the recipe. “It used to be three concussions and you’re out,” said Jamie Kissick, head team physician of the Senators from 1992-2002. “Nobody wanted to report a concussion, because three is a pretty minimal number.”
Then, in 1997, the NHL became the first league to introduce baseline neuropsychological testing. Players would take computerized tests when healthy – memory, reaction – and take them again as a comparison if a concussion was suspected or diagnosed. A player would have to be symptom-free before returning to play.
“We didn’t know what to do with them really to start, because there hadn’t been a lot of research,” Kissick said. “But in a way, it was kind of pioneering. The NHL does get slammed a lot for sometimes the reactions to head hits and that sort of thing. But from the standpoint of looking at concussions, they were in there pretty early.”
Doctors began to understand that concussion symptoms were not only physical, but cognitive. Three hundred concussions were diagnosed from 1997 until the 2004-05 NHL lockout, and in 30 percent of the cases, players thought they had recovered but still had symptoms, CBC reported. The NHL has averaged 75 concussion diagnoses per season since the lockout, down from a high of 109 in 2000-01.
Ruben Echemedia, one of the doctors who developed the baseline testing for the NHL, told CBC he wants the number to increase in the short term, because that would indicate more awareness. But while some NHL officials jumped on board immediately as the concussion issue evolved, others did not.
“I had one GM in Ottawa come in while I was checking a guy,” Kissick recalled. “ ‘Is it a concussion?’ I said, ‘Yeah.’ He said, ‘Figure out what it takes and double it.’ They were concerned about this, and management was getting concerned.
“I happen to know there’s another team where a colleague of mine said, ‘Well, we don’t have concussions, because the coach doesn’t believe in them.’ It depends on who your staff is.”
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Jason Botterill was glad to be part of the Buffalo Sabres organization. The Sabres had gone through concussion issues with Lafontaine and Tim Connolly(notes), so when Botterill suffered through his, they were patient with him. “I was very fortunate to be in an environment where I wasn’t being pushed back into duty before I had to,” Botterill said.
Botterill, a three-time gold medalist with Team Canada at the World Junior Championship and the 20th overall pick in the 1994 entry draft, played 88 NHL games for the Dallas Stars, Atlanta Thrashers, Calgary Flames and Sabres. Three times in his career, he suffered a concussion, didn’t remember the hit and needed to be helped off the ice. The last time he suffered a concussion, though, he didn’t think it was that big of a deal.
It was during the 2004-05 NHL lockout. He was playing for the AHL’s Rochester Americans. An opponent stepped up on Botterill in the neutral zone and popped him with a hit he wasn’t expecting. He was rattled, but he didn’t lose consciousness. He finished the game. But once the adrenaline wore off, his head pounded, he felt drowsy, his stomach sickened. “I knew something was wrong,” he said.
Botterill figured he would take about a week off and return with no lingering effects, as he always had before. But this time, whenever he got on a stationary bike, whenever he got on the ice, whenever he got his heart rate up, the headaches returned. The room spun. He took a couple of weeks off and tried again; same thing. He took a couple of months off and tried again; same thing.
Frustration set in. Concussions are invisible injuries – no stitches, no casts. The problem is at a cellular level. Doctors can’t give specific timetables.
“You hurt your shoulder, you go see a specialist, and he can tell you exactly how many weeks you’re going to be out and how many weeks of rehab you need to do, and he can guarantee you’re going to be 100-percent full strength if you follow this routine,” Botterill said. “You go see a concussion specialist, they can give you parameters and what the norm is, but every scenario seems to be a little different, and they can’t really give you a straight answer.”
Players ache to return to action. They got to the NHL by working hard. Now they are being told to rest, and they don’t know what to tell concerned coaches and teammates. Some return too early, like Savard did last season, causing them even more problems.
“If you’re doing a shoulder rehab, you can say, ‘Oh, today was a great day. I went up in my light weights from five pounds to 7½ pounds. I feel I’m getting stronger,’ ” Botterill said. “When you’re having a concussion, what do you tell your coach? ‘Oh, I’m five percent less foggy today? I’m having 10 percent less headaches today than I did yesterday?’ There’s not that ability to quantify that I’m getting better. It’s just, you feel very helpless.”
Eventually, doctors told Botterill their concern was that his last concussion was caused by a simple hit – a hit that likely would happen again. “They felt that my ability to sustain the hit had deteriorated,” Botterill said. “They felt that eventually I would recover from this concussion, but what they explained a lot to me was, it’s taken you longer to recover from these concussions. What is the next hit going to do?”
Botterill retired. For about three years, he still couldn’t exercise without his symptoms returning. He couldn’t shovel snow on his driveway. But he was otherwise OK in his daily life, able to go back to school and earn an MBA from the University of Michigan.
He is now the assistant general manager of the Pittsburgh Penguins, and he sees progress – medical personnel informing players, players starting to listen. Echemedia told CBC that the NHL has seen fewer symptom burdens, because concussions are being evaluated better and the symptoms don’t last as long. Man-games lost to concussions have dropped steadily over the past four seasons – from 615 to 548 to 487 to 407.
“It used to be, a guy gets knocked out in a game and comes back and scores a goal, everyone talks about, ‘This guy’s so tough. That’s great. What a great accomplishment,’ ” Botterill said. “Now, if a guy does it, well, why was he back playing? Don’t you have these standards in, the protocol in here? Why was he back on the ice or why was he back on the field?
“And to me, that’s a huge step. At least people are thinking about these things, and it’s not just the glorification of getting back out there as soon as you can put your skates on or tie up your cleats again.”
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What else can be done? What about equipment? If it were up to Stewart, every NHL player would be required to wear the best helmet, the best mouthguard, the best everything. Why not protect players as much as possible before they even take the ice?
“I agree with all the stuff that’s being said, but do something about it,” Stewart said. “Make things mandatory. Don’t give guys a choice to not do their chinstrap up. If there’s more than two fingers, you get a penalty. If you don’t have your mouthguard in, you get a penalty.”
Stewart is now vice president of Bite Tech, which develops mouthguards for Under Armour. The company says its products provide protection while improving performance, opening airways and reducing the stress hormone cortisol. Stewart said they have helped with his symptoms, cutting down on his headaches, keeping him from popping pain pills. He said he sells NHL players on the performance-enhancing aspect, while caring most about their protection on the ice and their quality of life off of it.
“No doctor will say a mouthguard prevents concussions, but they will say, ‘You know what? There is a little bit of a cushion there,’ ” Stewart said.
Doctors caution about equipment and concussions. Helmets can prevent head injuries like skull fractures and mouthguards can prevent dental injuries like broken teeth. But concussions are caused by the brain rattling around inside the skull, and that is caused not just by blunt force, but by rapid snapping or rotational force.
Dentist Paul Piccininni, a member of the IIHF medical committee, questioned the science behind the performance-enhancing aspect of mouthguards. He said there is no proof that mouthguards reduce the risk of concussions, but he left open the possibility they might help because they absorb some shock and keep the lower jaw from smacking into the upper jaw. “Absence of proof is not proof of absence, and more research and study is needed,” Piccininni said.
Neurosurgeon Charles Tator – a professor at the University of Toronto and the founder of ThinkFirst, Canada, a brain and spinal cord injury foundation – wouldn’t go even that far on mouthguards. “There is absolutely no evidence that they reduce the risk of concussion,” he said.
Tator was just as forceful about helmets that claim to help with concussions, one of which has been endorsed by Hall of Famer Mark Messier. “Regardless of what you hear, who you hear it from – whether it’s a former National Hockey League player or not – there is no such thing as a concussion helmet,” Tator said. “They just do not exist.”
“My opinion,” Tator said, “is that reducing concussion risk requires a great deal of behavioral adjustment on the part of many.”
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So how do we adjust behavior? In March, the NHL instituted Rule 48, banning lateral or blindside hits in which the head is targeted or the principle point of contact.
A working group submitted a video analysis to the league’s 30 general managers showing specifically how concussions were caused in recent years, and a devastating hit by the Philadelphia Flyers’ Mike Richards(notes) on the Florida Panthers’ David Booth(notes) last season became a catalyst for change.
Concussion experts generally feel the NHL should ban all hits to the head.
“From my perspective, I’m always going to be asking them to push further,” said Chris Nowinski, a former Harvard football player and professional wrestler, whose athletic career ended because of concussions and who co-founded the Sports Legacy Institute to explore the effects of brain trauma on athletes. “I don’t believe the costs of the concussions are worth it. You want the league to start thinking about how important it is to keep their best players on the ice and having long careers.”
But the NHL is trying to strike a balance. Violence is an inherent part of hockey and its appeal. Defenders hit not only to separate opponents from the puck, but to intimidate, to make opponents hesitate next time. Fans frankly love hitting, and they appreciate skill not only for the skill itself, but because of the context, the environment of ever-present danger. It’s one thing to make a pretty play; it’s another to make one amid the threat of being steamrolled.
The idea is to take the worst injury-causing violence out of play. (Fighting is another debate entirely.) NHL senior vice president of hockey operations Colin Campbell said blindside hits caused 50 percent of the league’s concussions. Doctors say that when a player doesn’t see a hit coming, he can’t protect himself by firing the muscles in his neck and stabilizing his head. Aubry, who was part of the working group on concussions, said: “You’ve won a good part of the battle if you can eliminate the blindside hits.”
Rule 48 has resulted in some fines and suspensions, but, more importantly, an adjustment on the ice. Campbell and other NHL officials have noted a change in players’ behavior. So has Aubry. He said a Senators player had a chance to smack an opponent with his head down one night late in a game that already had been decided, but he held off. The opponent was in a vulnerable position.
“I think what we’re seeing this year, although it may take time, is a little bit of a change in culture,” Aubry said. “In other words, I think players are a lot more careful when they go and hit someone, certainly when the player’s least expecting it. … Although we’ll never prevent the complete elimination of concussions, we’re headed in the right direction.”
We can only wonder where we’ll be in 50 years.