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The Globe and Mail

Ken Dryden’s heads up: The need to know more about concussions

No NHL games have been played this year but tens of thousands of minor hockey games have been played across the country. This is now Christmas tournament season. Days are about to be spent in arenas instead of in offices or schools, days filled with pizza, Tim Hortons coffee, motel rooms and hockey bags. For the kids, it will be days of bonding and trouble. For the parents, days of bonding and fear of trouble.

The season is half over. This is a moment for parents and coaches to talk and catch up. The NHL lockout seems to be hockey's biggest issue but, of course, it isn't. It will be resolved, soon, or for next year. The game, not untarnished or unaffected by it, goes on. And if parents are talking about anything other than how much ice time their kid is getting or the cost of their child's "family" experience in terms of money and time, it is about concussions. No NHL players have suffered concussions this year but hundreds of kids have. Parents think about this and worry. Coaches and minor hockey officials do too. Everybody knows a little about concussions. About their prevention and treatment, nobody knows a lot. Everybody is looking for guidance.

The 4 th International Consensus Conference on Concussion in Sport was held recently in Zurich. Most of the world experts – 180 doctors and researchers from 20 countries – were there. It was called a "consensus" conference because without scientific proof on so many matters relating to concussions, a consensus of the world experts represents the most definitive word available on concussions, and will remain so until the next conference four years from now.

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For a lot of these experts, their life's work has been dedicated to the brain and brain injury. A few attended the first conference 11 years ago in Vienna and have been at every conference since. They have seen what concussions can do to a career, to a childhood passion, to a life.

Awareness about concussions is undeniably better than it was. It's become mainstream today for fans to cringe not just whoop at a big hit; for parents to wonder if their young son or daughter, with lots of choices available to them, should play hockey or football at all; and for obituaries of former players to mention that, at a younger age than seems usual, the player suffered from dementia, and that the readers understand – right or wrong – that the dementia was the result of severe and repeated blows to the head from playing his sport.

In today's world, punch-drunk boxers aren't funny anymore.

That's progress, but if the public knows concussions are bad, it doesn't know how bad the short-term or long-term effects may be, because for the most part scientists don't know either. That was also clear at the Zurich conference.

To help the tens of thousands of volunteer coaches and trainers without medical training make medically-difficult, competitively-difficult in-game decisions – does an injured player come out, or stay in? – the Zurich conference agreed to a clear, certain message: "When in doubt, sit them out."

The problem is that players don't want to sit out. Players want to play. So wrapped up in a game, they're often the last ones to notice what others can see. The fog will go away after a hit to the head – they're sure of it. They'll be okay. They're trained to see past obstacles, to ignore pain to the point where they often don't feel pain at all, and to focus on what, to them, is truly important – the game, the season, the championship to be won. They need someone around them whose interest is only them. A trainer, or coach or parent may not be ideal, but could be the best they've got. If the player sits out the rest of the game, the player gains time to see what symptoms persist and develop, time to see a doctor; time until the next game, time to give everyone a better chance of being right.

Every medical non-professional and professional needs the confidence to make that in-game decision. They can't know if they are right. They need to know: the mistake of not allowing someone to play when they're okay, is better than the mistake of allowing someone to play when they're not.

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Some day trainers and coaches might even get, if not assistance, at least not resistance, from an injured player's teammates. Because teammates matter so much to each other and don't want to let each other down, because they're 17 years old and immortal, the natural, normal, adolescent pressure to keep playing is almost irresistible. Not long ago a slogan was introduced about drinking and driving that reflected, and helped to create, a powerful new attitude – "Friends don't let friends drive drunk" – and a culture that seemed impossible to change has been transformed. Some day, why not a similarly powerful slogan between teammates – "Friends don't let friends play concussed."


Each new piece of information raised at the conference seemed only to highlight more things we don't know. New imaging devices can see abnormalities in the brain that couldn't be seen before. What caused these abnormalities? Do they relate to concussions? What effect do they have on the player? And crucially, with these abnormalities what should a player do? Better imaging ahead will only mean more questions without answers. Should the player continue to play? What about an NHL star whose whole future seems tied to the fame and fortune he can achieve from a few short years of play?

There's a mystique about athletes. They ask their bodies to do the unimaginable, and often their bodies deliver. When it seems their bodies will break, they don't break. The athletes' doctors adapt to them as they adapt to the special qualities of their other patients. But sometimes it's more than that. Coaches, trainers everywhere; media; thousands of fans in the stadium or arena, millions more at home: this is no simple doctor-patient relationship, or so it seems. This is another world, where another world's rules may apply.

Some doctors become unsettled, if not star-struck, around athletes. As fans, too, some of them hope too hard and want too much for injured players to be fine and to play. A lot rides on what the doctors say – a game, a season, a championship for everyone; happiness or despair for many; and (often an unfair accusation too easily made) a lucrative practice, a sports injury clinic, a little stardom for themselves. They have seen players do and overcome almost anything. By seeing them and treating them as almost super-human, they sometimes treat them as almost sub-human. Maybe players' shoulders and knees can overcome almost anything. Maybe brains are different.

Athletes are vulnerable, athletes at every age and level. Absorbed in what they're doing and surrounded by hope, mystique and (for a few) dollar signs, they often need others to see for them. The knowns about them are so big and obvious – money, fame, the championship to win – that at the crunch moment, to play or not to play, their unknowns – their health now and in the future – can seem less consequential. Yet an athlete is a patient, not also a patient. Theirs is a doctor– patient , not doctor– player relationship.

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In Zurich, highly professional doctors wrestled with these apparently complicated questions: Is an athlete different from a non-athlete, a young athlete from an adult athlete, an amateur from a professional? Should one be treated differently from another? After two or more concussions, should one be advised differently about his or her future? The doctors asked these questions to help them find answers, and to help them find explanations, perhaps justifications, for what they felt.

It's easy for a doctor not to understand an athlete. It's also easy for a doctor to try to understand him or her too well. It's not up to a doctor to be the athlete, to imagine the athlete's choices and make those choices for him. It's up to the doctor to pass on what he or she knows as a doctor. It's up to the athlete – youth-adult; amateur-pro – as a patient, a human being, to decide. If strong-minded, capable doctors can't stop themselves from being distracted by the trappings of sports, if their distraction is all so inherently human it may never go away, how do we protect the athlete?

ONE MORE BIG QUESTIONChronic traumatic encephalopathy (CTE) has been found in the brains of many former football and hockey players including Bob Probert, Rick Martin and Derek Boogaard. It is a degenerative condition in which there is loss of brain tissue, and an abnormal buildup of deposits in nerve cells of a protein called tau. CTE's sporting trail goes back to a study of boxers in the 1920s and a condition then called dementia pugilistica, "punch drunkenness." CTE, it seemed, was triggered by repeated non-concussive and concussive blows. That's now less clear. Research today makes the possible link between CTE and other progressive degenerative diseases such as Parkinson's and ALS. Yet fewer than 100 cases of CTE have ever been confirmed. Confirmation requires an autopsy, and an autopsy requires a reason to conduct an autopsy. Until recently, there was rarely a reason.

More brains are now being donated for study. The Center for the Study of Traumatic Encephalopathy at Boston University holds the largest collection of these brains. CTE destroys brains and destroys meaningful life beforehand. But we don't know if there is a connection between hits to the head in football and hockey, between non-concussive and concussive blows, and CTE. But if there is a connection ...? What do we do until we know?

CTE looms. If repeated non-concussive and concussive blows in boxing can cause CTE, why can't repeated non-concussive and concussive blows, the kind that happen play after play in football, moment after moment in hockey, cause CTE in football and hockey players too? To a parent, to an interested citizen, to the media, it only makes sense. To a scientist, not yet; maybe not ever.

But if there is a connection, what does that mean for the future of football and hockey? It's a question decision-makers can't not ask themselves. But we don't know the implications of CTE and we're not going to know, not for five or 10 years, not for one generation of player or more.

At the opening of the conference, Mark Aubry, chief medical officer for the IIHF and a team doctor for the Ottawa Senators, described the current state of our scientific understanding and treatment of concussions this way: "We're at the end of the beginning," he said. Through the auditorium, there were murmurs of agreement. Aubry's words suggested to those present that, about concussions, we know so much and know so little; that we've come a long way and have a long way to go.


The conference itself suggested something else. As players, coaches, parents and league officials we want concussions not to be a problem. We want that their apparent effects are exaggerated. We want that concussions can be prevented by better helmets and mouth guards. We want that anything else can be resolved by better medical treatment. But concussions are a problem. Their effects, even only those we see – players out of the lineup for a few weeks or months – not including CTE and other things we don't know, are not exaggerated. Helmets and mouth guards, according to every study, at most are a small part of the answer. For better medical treatment it's the same. It will be years at best before science can offer significant new approaches. In the meantime as it does, games are being played, concussions are being suffered.

The answer to the concussion problem is not in science – for a non-scientist it can take a gathering of the world's foremost experts to make this clear. The answer is in how we play. There are many things we don't know. But what we do know, with absolute certainty, is that a hit to the head is a bad thing; and a hard hit to the head is a very bad thing. And this, as a basis for the rules of our games and the enforcement of those rules, for our strategies and techniques of play, for the culture of our games, where head safety is central and not an afterthought, where we don't have to wait for the science, where information doesn't have to pass to the smallest village – where we just know – this is a good place to start.

And now at this Christmas tournament, surrounded as you are by players, coaches, parents, on-ice and off-ice officials, by many of the people who decide the way we play, in the endless time between games and in the endless hours before the next day's games, over Timbits and coffee, with a half a season yet to go, this is a good time to begin our game-changing conversation.

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