This article is part of Next, The Globe's five-day series examining the people, places, things and ideas that will shape 2013.
As a volunteer trainer for her 14-year-old daughter's rep hockey team, Beth Fleming has submerged herself in the ever-expanding pool of concussion research and head injury management protocols, and tried to spread the word.
Last year, she felt her efforts to increase concussion awareness were shrugged off by some parents, and even ignored by a coach when she advised a player be benched after showing concussion symptoms. But after a spate of grim news about head injuries in sport in 2012, Fleming is now detecting a growing sense of dread at the rink.
"I know parents are getting nervous," say Fleming, a mother of three who lives in Georgetown, Ont.
From the recent release of the world's largest study on the long-term effects of multiple hits to the head, to a divisive debate in Calgary over whether to allow bodychecking in peewee hockey, it's been an unsettling year with regard to head injuries in sports.
The stories have included the high-profile suicides of NFL linebackers Junior Seau and Jovan Belcher, who murdered his girlfriend before taking his own life. Those deaths were quickly viewed through the lens of concussions and head injuries.
Next year promises to bring further developments as researchers work to advance the field concussion science. Those findings are sure to influence what happens on the playing field, as parents, coaches and sport administrators struggle to make sports safer.
"We need to figure out more about how and why brain injuries happen, so we can protect our youth who are playing sports. And we want to make sure that they continue to play safely," says Anne McKee, a researcher at Boston University who has led much of the research into the long-term consequences of repetitive hits to the head in sports.
In professional sport, the tide is turning toward litigation. Thousands of former professional football players are seeking to sue the NFL, arguing that the league should be found liable for the long-term health matters caused by the head trauma suffered on the field; the league has asked U.S. federal court to refer the issue to arbitration. The outcome could potentially cripple the NFL financially, and have a trickle-down effect as schools, universities and youth sport leagues calculate the burden of similar lawsuits.
As it is, a small but growing number of schools boards are taking steps in concussion management by attempting to implement programs that help student athletes return to the classroom after suffering head injuries.
Researchers say that while there is much work to be done in the area of head injuries, parents should not despair.
"There's no brain trauma that's good brain trauma. But let's not get paranoid about it, we're all going to take some," said Robert Cantu, a leading researcher at Boston University program that is studying the long-term effects of concussion.
Parents should not be left with the conclusion that the best thing to do is rip their kids out of sport, says Lauren Sergio, a researcher at York University.
"When I give a talk to parents, my final message is, please don't take this as a message to pull your kid from sport, because the benefit of sport is so much greater than the small chance [of getting a serious head injury]," Sergio said. "The most important thing is: we've got awareness now."
DEVELOPMENTS TO EXPECT IN 20131. New consensus statement on concussion in sports
The most up-to-date consensus paper on what the world's leading researchers currently know about concussions in sport is set to be released this spring.
The basis for the statement happened in November, when the world's leading concussion researchers gathered in Zurich, Switzerland, to present and discuss the latest research on concussion prevention, management and treatment. Based on those findings, a consensus statement will update the guidelines which were published after the last International Conference on Concussion in Sport in Zurich four years ago.
The newest statement will act as a foundation for doctors, researchers, trainers and coaches from the grassroots level to the pros. Written for laymen as well as experts, the wide-ranging document looks at what is currently known about the condition, as well as areas in need of attention in the future. Brian Benson, a University of Calgary researcher who attended the conference, said some of the big issues to be tackled at the 2012 conference were fundamental ones: What is the best way to diagnose a concussion? How do you know if a player has healed? How does returning to the classroom affect a student athlete's recovery? Does gender play a role in risk of injury and recovery outcomes?
The document will also likely include the third iteration of a step-by-step tool used by medical professionals to assess concussions incurred on the playing field. The current version, called SCAT2, uses a questionnaire-based format applicable to any sport for athletes ages 10 and older. Researchers say it can be improved by adapting questions to specific sports, such as hockey.
2. Chronic traumatic encephalopathy (CTE) and the long-term consequences of repetitive head injuries
In recent years, researchers have gained critical new insights into how concussions affect athletes' brains in the days and weeks after a hit. Next is to assess whether and how repetitive hits to the head affect athletes long after their retirement.
A team of researchers at Boston University has dominated the news on this subject, most recently with a blockbuster study published in early December that showed that of the 85 brains of dead athletes in their study, 68 were found to have chronic traumatic encephalopathy, a disease brought on by repetitive hits to the head and linked to depression, memory loss, aggression and dementia. Half of those 68 were former professional football players; 16 more played football as their primary sport.
While Boston University claims 600 athletes have already pledged their brains to research after they die, other researchers have thrown their hats into the ring. The brain of Junior Seau, NFL linebacker who died of suicide in 2012, will be studied at the National Institutes of Health. In Canada, a team led by Dr. Charles Tator is also collecting brains. It has already studied the brains of six former CFL players, and the results should be published in the next year.
Currently, the data sample is wildly skewed toward finding the disease. That's because CTE can only be diagnosed after an athlete dies, and families often donate the brain of a loved one who is already showing symptoms. That means scientists are still working to answer one very basic question – how common is CTE? – as well as a number of other questions, such as how many hits, at what severity over what period of time, are required to trigger the disease? Some clues suggest there may be a genetic or environmental component that stops the advance of the disease in some people, suggesting there may be hope for a cure.
3. Legal action
If it is true that violent contact sports have lifelong, debilitating consequences for athletes, should sports organizations be on the hook for damages?
That issue will continue to play out in the courts this year, as the NFL stares down a monster lawsuit brought by thousands of retired football players touched by head injuries during their careers. At the heart of the players' claims is the charge that the league hid what it knew about the link between hits to the head and long-term brain damage. As The New York Times reported in December 2012, another new frontier could emerge if insurance companies balk at paying for the league's mounting legal bill and the hundreds of millions of dollars in potential damages that might stem from the cases brought by the retired players.
The NFL's legal woes are sure to be watched by other professional sports leagues, specifically the NHL. But it also has the potential to affect sports at the lower level. Because as information about the link between head trauma and long-term injuries grows, coaches, athletic directors and others will have a harder time claiming that they were unaware of the dangers.
As a result, colleges, high schools and club teams may be forced to consider severe measures in the face of liability issues, like raising fees to offset higher premiums, and requiring players to sign away their right to sue coaches and schools. Some experts are projecting even more severe measures: that schools and leagues may even shut down teams because the expense and legal risks are too high.
4. Unravelling possible gender effects
For years, scientists have noted that girls seemed to be suffering concussions at rates higher than boys. But they have yet to determine why that is.
Now scientists are beginning to turn their focus to a possible gender effect in concussions, even though the dearth of literature on gender differences was highlighted four years ago as an area in need of more attention at the International Conference on Concussion in Sport.
"We're still just ramping up. Science is really slow. It just takes us so long to get a protocol together, get it past the ethics boards, and find subjects," said York University researcher Lauren Sergio. "Something that highlighted as a problem in 2008 isn't something that shows up in the literature until now."
Scientists are looking at plenty of possible culprits. Some believe that the reason is anatomical, and the way girls' brains and skulls are shaped makes them more susceptible. Sergio said the reason could be biomechanical: girls' necks and shoulders simply aren't as capable of sustaining hits as boys'. Sociological reasons may be at play, too, she said. For example, boys are often encouraged to roughhouse and wrestle at a young age, so by the time they join organized sports, they may be used to falling properly.
Some concerned parents say the issue is in the refereeing. Even though bodychecking is banned in women's hockey, hits do occur. A bodycheck can result in a major penalty, which means major consequences, such as a two-game suspension. They say some referees hesitate to call major penalties, because they don't want to be too heavy-handed, for fear of retribution from parents.
5. New football helmet standards
According to a Canadian researcher who has worked in conjunction with the NFL to improve helmet safety, football helmets will soon be better equipped to mitigate the type of hits that result in concussion.
"More sophisticated standards are going to be developed within the coming year or two," says Blaine Hoshisaki, a researcher at the University of Ottawa who is working with a non-profit corporation that certifies helmets in the United States to improve the way football helmets are tested.
Head injuries in football most commonly happen in two ways, Hoshisaki said. The first is a direct impact, when a player flies through the air and lands on their head. The second, more common way for head injuries to occur is from head-to-head impact, when two players' heads collide. Football helmets are tested for the linear force that results from a direct impact, but are not tested for their ability to mitigate the rotational force generated by head to head hits, Hoshisaki said. The new, tougher standards will require football helmets do be tested for both linear and rotational forces.
Currently, hockey helmets aren't tested for rotational forces, even though in hockey concussions most often result because of the rotational forces generated when a player's head comes into contact with another player's shoulder, elbow, or fist.
It's possible that the CSA, which certifies all hockey helmets legally sold in Canada, will follow the lead of the National Operating Committee on Standards for Athletic Equipment (NOCSAE), a non-profit corporation that funds research and develops performance standards for protective equipment used in a variety of sports in the United States, said Dr. Hoshisaki, who is working with NOCSEA to develop the new football helmet standards.
"Once we deliver one standard … then typically what happens that people then take that information and then begin developing similar types of protocols for other standards. And I think that's what's going to happen," Hoshizaki said of the CSA.