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This Jan. 5, 2011, file photo shows Pittsburgh Penguins' Sidney Crosby playing against the Tampa Bay Lightning in the first period of an NHL hockey game, in Pittsburgh. Crosby's agent said there's no timetable for the Penguins star to return from a concussion, the clearest indication yet that he may not be ready when the NHL season begins in October. (AP Photo/Gene J. Puskar, File) (Gene J. Puskar/AP)
This Jan. 5, 2011, file photo shows Pittsburgh Penguins' Sidney Crosby playing against the Tampa Bay Lightning in the first period of an NHL hockey game, in Pittsburgh. Crosby's agent said there's no timetable for the Penguins star to return from a concussion, the clearest indication yet that he may not be ready when the NHL season begins in October. (AP Photo/Gene J. Puskar, File) (Gene J. Puskar/AP)

MATTHEW SEKERES AND DAVE MCGINN

After eight months of setbacks, has Sidney Crosby returned to square one? Add to ...

Sidney Crosby faces a long road back to the National Hockey League, medical experts say, after the Pittsburgh Penguins captain experienced post-concussion symptoms when he tried to exert himself.

Mr. Crosby’s agent surfaced late Wednesday night to say his client’s symptoms resurfaced at the 90-per-cent exertion level, which was an important clue to the status of his recovery for doctors who specialize in treating concussions. According to experts interviewed Thursday, Mr. Crosby’s inability to exercise symptom-free at the 90-per-cent exertion level could mean that he will have to start his comeback from square one, but it most certainly means that the Penguins superstar will have to back off his recovery with training camp less than one month away.

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“With somebody with an injury and an illness this long … I think how long he might take off between events might be even longer,” said Dr. Gary Joubert, chair of emergency medicine at the University of Western Ontario’s Schulich School of Medicine and Dentistry. “I think it’s going to be a long time before Mr. Crosby, in my humble opinion, is back to full activity.”

Mr. Crosby has not played a game since early January, when he suffered two hits to the head, and at least one concussion, in less than one week. Twice this month, reports surfaced that Canada’s 2010 Olympic hero would not be ready for camp on Sept. 17, and could miss the regular-season opener at Vancouver’s Rogers Arena on Oct. 6.

Pat Brisson, the player’s agent, failed to specify what in Mr. Crosby’s recovery program was adjusted after the symptoms returned recently, but members of the medical community understood that to mean a significant scaling back of the superstar’s physical activity.

Dr. Paul Echlin, a sports medicine physician from Burlington, Ont., said that when his patients experience symptoms after long periods of rest and recovery, he usually calls a meeting and tells them: “maybe you need a significant period of time without symptoms.”

In November, 2008, a consensus statement emerged from the International Symposium on Concussion in Sport, a meeting of sports doctors in Zurich. The paper included a “graduated return to play protocol,” which called for athletes experiencing symptoms at the 90-per-cent exertion level to go back to the first rehabilitation stage, defined as “complete physical and cognitive rest.”

Dr. Mark Aubry, an Ottawa-Gatineau physician and one of the authors of the Zurich paper, said that the recommendation is slightly dated, and that doctors are now suggesting that such cases attempt “light activity.” But Dr. Aubry, also the chief medical office of the International Ice Hockey Federation, was quick to point out that the activity should not be strenuous, and that the recommendation is more a psychological tool so that the recovering athlete “can feel good about themselves.”

Dr. Echlin said he loathes the idea of forcing athletes to return to resting in dark rooms if they are capable of more, or if it will promote depression or stress. He advises his patients to “go back to a level that doesn’t promote the symptoms … if you can’t walk a block without symptoms, than walk half a block.”

Dr. Karen Johnston, one of Canada’s foremost concussion experts and another author of the Zurich paper, said that Mr. Crosby’s recovery isn’t only hampered by physical issues, but mental ones as well.

“Stuff going on in your brain can be from other things, like technology and stress and fatigue,” said the Toronto-based neurosurgeon and former chair of the Concussion in Sport Group. Indeed, people recovering from concussions are advised to avoid anything that might require more than minimal mental exertion, whether it’s watching television, doing puzzles or stressful situations.

Is Mr. Crosby feeling stressed?

Well, he isn’t speaking publicly, and Mr. Brisson allowed that he had recently visited specialists in Michigan and Georgia, seeking secondary opinions and the best possible care. The agent was clear to note that no timetable accompanies Mr. Crosby’s return, and that he won’t play until he is symptom-free.

“I cannot imagine that having the world’s attention focused on you, at least the sporting world’s, is a non-stressful event,” Dr. Joubert said.

For professional athletes, returning from brain injuries is frustrating enough, but it’s particularly difficult when you get to the 90-per-cent exertion level – on the cusp of a return, or so the athlete thinks – and experience a setback.

“That’s exactly what happened to me,” said former NHL player Geoff Courtnall, who still suffers post-concussion symptoms despite retiring 11 years ago. “That’s the problem. They say you can’t train, you can’t work out until the symptoms are completely gone. And they’re gone for a certain amount of time and then you start to work out again and you feel good, and then all of a sudden, bang, one day and one workout.”

Former NHL forward Keith Primeau, who heads the “Play it Cool” program designed to educate the public about concussions in sports, said that athletes are accustomed to returning from other injuries and playing at less than 90-per-cent health, which makes a rollback in the recovery process for a concussion all the more difficult to accept. Some athletes won’t even report symptoms at that level of recovery, because a clean medical bill is seemingly so close.

“The disappointment of getting to 90 per cent and experiencing symptoms … it’s one of the most frustrating things you can ever imagine,” said Mr. Primeau, who retired in 2006 after a concussion. “But I’m just so thankful that Sid’s recognizing and admitting the trouble he is having.”

With a report from Beverley Smith

Follow us on Twitter: @Dave_McGinn, @mattsekeres

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