There was nothing particularly surprising to be found in those internal National Hockey League e-mails on concussion that were released by a Minnesota court this past week. A bit of denial, a touch of concession – and a lot of confusion about the short- and long-term effects of head trauma.
As was to be expected. I didn't even mind the little shot NHL vice-president of hockey operations Kris King took at "the Charles Tators of the world." That comes with the territory if you're going to engage on serious issues.
What delighted me, however, was the mention that the league had been working with two corporate sponsors on a concussion-education video for youth hockey players, their families and coaches. That would have to be our video here at the Parachute Canada National Injury Prevention Program that we did with the financial support of CCM Reebok and Scotiabank (still available at parachutecanada.org).
Perhaps we are not as far apart as it sometimes seems.
What is clear in reading through those reports from TSN and the New York Times is that in 2011 the NHL was indeed acutely aware of the issue. It is equally clear that it has chosen to deal with it only partly. You might rightly take painkillers for a broken leg, but painkillers cannot set the bone.
The league has obviously been aware of the growing concerns over head injuries, particularly repetitive trauma to the head. The proof is in the pudding that it did some limited injury protection in that fighting has demonstrably gone down in the NHL. That's a good thing. If the concussion issue had not come along, then I think fighting may even have gone up, as the trend to have assigned pugilists in the lineup had become a virtual given.
So it is fair and proper to say that some good has come from this ongoing discussion. There has been some attention paid to the issue by the league. We Charles Tators of the world would just like to see more.
First aim, obviously, is to reduce the number of actual concussions, what we call primary prevention. Then we need to practise good secondary prevention, which means once a concussion has happened take the steps to treat that concussed person correctly. That means management according to best principles that have been tested over time. This would include removal of the player from the game or practice where the concussion occurred. It would include waiting until the symptoms have gone for a certain time. And then it would involve the reintroduction of physical and mental activity, gradually, leading to a return to the sport.
This is all part of proper management in 2016. But remember, this is an evolving story. In the concussion field we are still playing catch-up, because it was ignored for so long. We are all still learning, whether you are a youth player, a professional player, a coach or even a medical practitioner.
As we learn more, we have to alter our management principles. Come October, I will be attending the next International Consensus Conference on Sports Concussions in Berlin. We will all be learning more. We will talk about what is truth and what is not truth in this "moving target" of a critical health issue. We all have to keep up.
As for the NHL, so important to the sport of hockey as a key focal point, those who run the league have the power to do more than they have done. What we've learned with concussions is that for every sport, the strategies have to be sport specific. What works in football isn't going to work in hockey. Similarly, rugby has another set of circumstances that have to be dealt with. The people in the sport who know that sport best are the best ones to make those changes. We need the NHL onside and we need the NHL to take a leading role.
One obvious step would be to address the ongoing issue of shoulder pads and elbow pads. That's been on the NHL's agenda for a long time, but I don't see much movement there despite years of talk and intention. There is just no reason for some equipment to be like metal sledgehammers that knock people out. They should be protective for the person wearing them and not be offensive to the person who gets clobbered with it. There's no reason for them to be the way they are. It seems to me the hockey world has known about this for a long time, but there's only so much inertia when it comes to effecting real and necessary change.
I would also like to see greater attention paid to the person who is the repetitive perpetrator of concussions. Hitting someone in the head can be just circumstances, of course, and not every hit to the head is intentional. There is a certain element of chance and risk in the game and we are all in favour of a physical game within the appropriate rules.
That said, deliberate hits to the head should be dealt with more severely, in my view. Repeat offenders need to be identified and appropriately punished. That includes, certainly at the NHL level, a monetary fine. And the offender should be out of action for a meaningful period of time. That could be a whole season or even a whole career for continual offence. Such measures would be dealing with the issue severely, but severe measures are required in my view in that a concussion can involve permanent symptoms. It isn't something to be dealt with lightly.
Scientists at Boston University and at the Toronto Western Hospital know that repeated blows to the head can lead to a brain condition called chronic traumatic encephalopathy (CTE), which is a progressive degenerative disease found in people who have suffered such injuries. At the Canadian Concussion Centre, we have had 21 brains donated for postmortem study. One affected player, Steve Montador, was only 35 years old when he died, and his brain showed extensive CTE.
Recently, we approached the family of a well-known Hockey Hall of Famer who died following years of dementia, but the family decided not to donate the brain for further study. We have to respect such wishes and do, but we also encourage more former athletes and their families to consider helping science understand better this unfortunate, and largely preventable, condition.
Some have argued that fighting causes a minority of concussions and that is absolutely true, perhaps 5 or 10 per cent. But it is important to acknowledge that in today's hockey culture, those who make up that percentage tend to engage in many fights and, therefore, obviously suffer repeated blows. We have too many examples of hockey "enforcers" suffering from post-concussion symptoms that can lead to psychological disorder, depression and, sadly, even suicide.
We could end that overnight with a clear ban on fighting in all levels of hockey. The suggestion that the enforcers prevent other transgressions is without proof and we need to come down hard on those who give that as a valid reason for keeping fighting in the game. Very few people buy that spurious argument any longer.
We not only have to deal with the realities of concussion, we need to deal with the mythologies of concussion. Just as the "necessary safety valve" argument is one of the mythologies of fighting, concussion has its own list of non-truths. Some still say a concussion is just a "ding." Others say helmets can prevent concussions. Still others will say you have to be unconscious before you can be said to have suffered a concussion.
None of these are true. What is true is that we have learned much of late and have much to learn on the medical side of head trauma. But it is not just the medical side that needs more education, it is the players themselves. We have to educate players that they are going to actually prolong their careers, rather than shorten them, if they reveal that they've been concussed or may have been concussed. The culture of denial that they're having symptoms must be replaced by truthfulness if they hope to continue playing longer. If they hide their symptoms they are shortening their careers.
We know that in most people the toll of concussions escalates dramatically as the number of concussions goes up. And when the concussions occur and there hasn't been full recovery from the previous concussion, the results are again magnified.
The brain remembers when there have been previous concussions.
What we can do – as players, coaches, managers at all levels in the game we all love so dearly – is work together to ensure there are fewer future concussions.
I hope I don't see any Saturday night when I attend the Leafs versus Red Wings game with my daughter at the ACC. We love the game when it's played well and safely.
Dr. Charles Tator is a Toronto-based neurosurgeon and founder of the Canadian Sports Concussion Project at the University Health Network's Krembil Neuroscience Centre.