NHL has unique off-ice concussion foe
The Enemy Within
ESPN.com's report on the NHL and its battle against concussions.
Marc Savard's road back from a concussion was a physical battle, but his off-ice demons proved to be the bigger fight. Burnside »
You might be surprised to learn what one doctor says has been one of the most interesting hurdles in dealing with head injuries: a player's passport. LeBrun »
We talk to the NHL's Kris King about new shoulder pads and how they can help fight off concussions. Watch
ESPN The Magazine examines whether concussion tests are currently stringent enough. Peter Keating »
You might be surprised to learn what one doctor says has been one of the most interesting hurdles in his research in dealing with head injuries.
A player's passport.
Football and hockey face a serious battle when it comes to head injuries, but the NHL has an added wrinkle the NFL doesn't have to worry about: the communication barrier. Take a league that had 879 players from 25 countries in 2009-10, and communicating what ails you or understanding what a doctor and/or trainer's diagnosis becomes that much more complicated.
"It's interesting because different cultures have different views on concussions and different views on identifying concussions, or even what the symptoms are that may suggest concussion," Dr. Ruben Echemendia, the NHL's neuropsychologist, recently told reporters. "So, we know from our research, for example, that the reporting of symptoms varies by language of origin.
"We also know from our data that certain tests will be more sensitive within one language group as opposed to another language group. So, it allows us to more carefully hone in on an individual basis to be able to identify what is happening with the player."
The NHL has been proactive in fighting concussions and their physical effects since 1997. But what can the league do to make more progress in dealing with the language/cultural element of reporting concussions?
"Very specifically, what we've been doing is that all the tests that we give have now been normed for each of the language groups," Echemendia told ESPN.com on Tuesday. "For example, we know exactly how much different the Czechs are than the Russians or French-speaking players, right across the board. We know what to expect from each of the groups."
Echemendia's group has determined that players from different nationalities and cultural backgrounds report concussions in different manners.
"We know what is the typical symptom pattern for the typical NHL player by their language of origin," Echemendia said. "So, for example, if you have one group of individuals who tend not to report a lot of symptoms and all of sudden there's a player from that group who has reported a lot of symptoms, that's something you better stand up and take knowledge of and pay attention to. Because that player is really trying to tell you that something's wrong here."
Different cultures also put more or less importance around different symptoms, Echemendia explained. One culture may not consider a headache to be important and won't report it, but they will report dizziness. Meanwhile, headaches can be one of the indicators for post-concussion syndrome.
Head shots and resulting concussions have been a hot topic in the NHL for years, especially in recent seasons. Head injuries suffered by the likes of Patrice Bergeron, Pierre-Marc Bouchard and Marc Savard have raised awareness to new heights, so much so that the NHL instituted a new rule this season (Rule 48) banning blindside hits to the head.
The Road Ahead?
While the NHL has been proactive in educating and testing players in its own league, a recent study reinforced the need for it to continue to pass down its findings to minor and junior leagues.
The study performed in Ontario observed two teams of fourth-tier junior hockey players (16-21 years old) during one season. The findings from the study were released in the Journal of Neurosurgery on Nov. 1. Some of its findings:
• Twenty-one concussions were physician observed or self-reported and subsequently diagnosed by a physician in 52 physician-observed regular-season games. A concussion was diagnosed in 19 (36.5 percent) of 52 observed games. The data from the study demonstrated a general trend of decreasing severity and normalization of the objective measures toward the injured player's baseline levels over time.
• The forward position suffered the most diagnosed concussions (12 of 17 patients, 71 percent), while defensemen were diagnosed with 29 percent of the concussions. No goalies suffered a concussion. Fifty-seven percent (12 of 21 patients) of diagnosed concussions occurred in the third period, 29 percent (6 of 21) in the second period and 14 percent (3 of 21) in the opening frame.
• There were two players who demonstrated an observable period of loss of consciousness (10-15 seconds). One individual required the physician to come on the ice and initiate emergency assessment and cervical stabilization. The player did not require an activation of the 911 system. A careful review of the files showed that seven other players recalled a possible momentary loss of consciousness as a result of the diagnosed concussion.
• Two players were not allowed to return to play for their teams for the remainder of the regular season and playoffs due to persistent concussion symptoms. One of these two players continues to remain clinically symptomatic, while the other declined further follow-up.
• Twenty-four percent (5 of 21) of the concussions occurred in players who were directly involved in a fight immediately prior to their diagnosis. Three of the four players who sustained a concussion as a result of their involvement in a fight refused follow-up with the primary investigator and were taken out of the study.
• Sixty-nine percent of the observers' reports (29 of 42) documented the point of contact of the majority of hits that caused a concussion was the head. Eighty percent of the reports (33 of 41) also showed the hit causing the concussion was purposeful versus incidental.
One can debate whether Rule 48 has been applied well enough or goes far enough, but it remains a step in the right direction.
"When they implemented the more stringent guidelines regarding blows to the heads, blindside hits, I think that's potentially an important breakthrough," Dr. Mark R. Lovell, one of the world's leading sports concussion experts and founding director of the University of Pittsburgh Medical Center Sports Medicine Concussion Program, told ESPN.com on Monday.
The league has averaged about 75 concussions a season for the past four seasons and found that about half of them were caused by blindside hits. Hence the new rule. At a recent GMs meeting, the league showed video examples of players laying off the type of blindside hits that were legal before this season, the kind that caused head injuries. The message of Rule 48 may be sinking in to players, but has it had the desired effect when it comes to preventing concussions?
Echemendia said it's too early to tell.
"We need to very carefully follow the concussions this year and next year and see to what extent the rule change has had or not had on change in behavior," he said. "We do not know what is causing the concussions to be at the level where they [are] at this time. It could be an awareness issue, and if it's an awareness issue, then the blindside hits to the head rule would not come into play there."
According to the NHL, there were 33 concussions in regular-season games through Dec. 1 of this season, the exact number of concussions the league had at the same point through the 2009-10 campaign.
"But there is an uptick for the same time frame from 2008-09, and it's interestingly a drop from the year prior," said Echemendia. "So there is a lot of variability from year to year. It could be that we are making inroads in terms of our ability to communicate to players that they need to report their symptoms, that this is a serious injury, and that there is increased awareness and identification of the injury.
"It could also be that more concussions are caused because players are bigger and faster. It's hard to determine why there is an uptick."
The NHL was criticized in some circles for waiting too long to finally adopt a new rule for head shots. Some would like to see the league ban all head shots, period. But Lovell said the NHL deserves credit for being proactive when it comes to dealing with concussions.
"People don't recognize that the NHL was really the first league to sanction the use of concussion evaluation programs, neuropsychological testing, etc.," said Lovell, one of the co-founders of the league's concussion program 13 years ago. "That goes back to the mid-'90s. That was a good idea, one that needed time to evolve. It started out more as a research project. It needed time to figure out how it was best to monitor the injuries. That was a good step."
In 1997, the NHL formed the Concussion Working Group, a program which began neuropsychological testing for all players at baseline and post-injury. The program also began documenting concussions, giving the league a basis for historical data moving forward. The NHL and NHL Players' Association were even recognized in 2008 by the National Academy of Neuropsychology with an award for their joint leadership in implementing testing and promoting brain injury awareness.
But no matter how far the science has come, the players themselves hold the key to dealing with concussions and breaking through the cultural barriers that may keep them from reporting symptoms to their trainers and doctors.
"We need to put the onus on the players in terms of being honest in terms of their symptom reporting," said Echemendia. "No matter how many tests we give, we're never going to be able to proceed with 100 percent clarity what's going on with the player unless the player can tell us what's going on with them, honestly. So, we have to rely on the player to honestly report their symptoms."
Echemendia said that while some players will say they're symptom-free, neuropsych testing has picked up concussions in players who were not ready to return to action.
Lovell said it's a concern at all levels, not just the NHL.
"Even 8-year-olds will lie to me about whether they're having headaches or not because they know if they tell us they're having a headache, they're not going to play," he said. "The most important thing for them is to go out there and play again, even if it's not in their best interests. I'd have to say that's one of the most significant problems that we have in terms of dealing with concussions."
Still, there are signs that the trend is changing, for the better.
"What we've noticed is there have been changes in terms of player culture with respect to this injury and with respect to understanding how important this injury can be or how serious the consequences can be," said Echemendia. "Along those lines, I think players begin to understand that hitting is an important part of the game, but it is also one of the causes of concussion."
Compared to 10 years ago, Echemendia said the players' attitude is night and day.
"Ten years ago, there were a lot of misconceptions toward this injury and I think it's beginning to change now," he said. "I think people are starting to recognize how truly complex this injury can be and it really doesn't show up the same in two people.
"If I could just wave a magic wand, I would wave the wand so that players would understand that they absolutely have to be honest about their symptoms," Echemendia added. "The earlier they tell us what is going on with them, the less time lost and the better off they're going to be down the road."
Pierre LeBrun covers the NHL for ESPN.com.