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New Brunswick Reds Chris Culligan (white) rolls on top of Western Mustangs Kevin Baker during second period semi-final action at the 2012 Canadian Interuniversity Sport men's hockey championships in Fredericton, New Brunswick on Saturday, March 24, 2012. A season-long medical study like no other has examined head injuries among university hockey players and determined there is “significant underreporting” of concussions in both men’s and women’s hockey.

Mike Dembeck/The Canadian Press

A season-long medical study like no other has examined head injuries among university hockey players and determined there is "significant underreporting" of concussions in both men's and women's hockey.

The Hockey Concussion Education Project (HCEP), which included advanced magnetic resonance imaging and specialists at rinks watching players and looking for signs of concussions, found the concussion rate to be three times greater in male hockey players and 5.5 times greater in female players than what researchers had recorded prior to 2009-10. A total of 11 concussions were either physician observed or self-reported in 55 regular-season games last season, "yielding an incidence rate of 11.76 concussions per 1,000 athlete exposures for men and women across the regular season and playoffs."

The study examined two teams and 45 players during the 2011-12 Canadian Interuniversity Sport hockey season. Players were clinically evaluated, given neuropsychological assessments and underwent MRI imaging both pre- and postseason as well as postinjury. The athletes were also game monitored by independent physicians who noted how players reacted after a hit, everything from their body language on the bench to being sluggish and caught out of position on the ice.

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Dr. Paul Echlin, a physician based in Burlington, Ont., who served as HCEP's primary investigator, believes the study shines an intriguing and in-depth light on the concussion issue.

"We did a previous study [one year ago] with the CIS without observers," Echlin said. "We didn't do MRI imaging and there was only one reported concussion for that season. This past season, we were full on with multiple physicians at games, home and away, and we did imaging. It really demonstrates the underreporting of medical concussions."

The HCEP data were analyzed by three Canadian universities (British Columbia, Western, Montreal) and two in the United States (Harvard, Illinois). Dr. Inga Koerte, a senior researcher at the psychiatry, neuro-imaging lab at the Brigham and Women's Hospital, Harvard Medical School, reviewed the specialized Diffusion Tensor Imaging of 25 male brains. What she discovered in conjunction with Dr. Martha Shenton, Veterans' Administration investigator and Harvard professor, was unexpected.

"What we found was that all the athletes had changes in their white matter," Koerte said, referring to the tissue that transmits signals from one region of the brain to another. "Two of the three subjects who had clinically diagnosed concussions had the most pronounced differences, but the surprise was you don't have to have a concussion to see changes in the white matter. This is surprising to us."

Having observers at games looking for signs of trouble also provided insight into why concussions are not being reported as often as they should. The observers were quoted by Echlin saying they heard from coaches who called the study "a waste of money," adding "the players didn't want to be declared as concussed since it would limit their playing time." Another observer said: "Players are scared to be seen as weak and almost always want to play. … I think coaches fail to admit the significance of the symptoms."

In one instance, a team trainer talked about how he treated a female player who was hit, then absorbed a second hit when her head struck the ice. Despite the player saying she had a small headache, the trainer admitted, "I allowed her to stay in the game without an appropriate physician evaluation."

The HCEP showed the frequency of concussions was higher among female players (14.93 per 1,000 athlete exposures) than their male counterparts (8.47). Researchers are not sure exactly why that is, although one suggestion is female players are more honest when it comes to reporting injuries.

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"Obviously at some stages, there's so much at stake for everyone involved," said Hugo Theoret, a psychology professor at the University of Montreal who helped evaluate the HCEP findings. "There's a conscious reaction [not to report and to keep playing]. Coaches think it's important to get a player back in the game. Some are consciously trying to limit the reporting of concussions to win more games. You see this in junior hockey where they're all trying to get to the next level. In the university setting … it's alarming."

Echlin insisted that as medical knowledge of concussions and brain damage continues to grow, so too must the need for education.

"It's not just about the NHL," Echlin said, "it's a public health issue. You want to look at how it impacts society. Do those [injured] kids fulfill their academic potential? Some of them don't. Can it be prevented? Absolutely, through education, through letting sports evolve. We all want kids to be healthy and fit and get the social benefits of sports."

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