The wheels are moving across Canada, as researchers and doctors are collaborating in labs trying to better understand an injury that at times can appear to be invisible.
Illustration by Ralph Damman/VICE
Concussions keep popping up in sport. CTE is not going away, either, as it continues to be found posthumously in athletes ranging from soccer and wrestling to hockey and football. Lawsuits, like the one against the NHL consisting of over 100 plaintiffs who allege the league was neglectful and deceitful regarding head trauma, are ongoing. The seriousness regarding head injuries in sports, and its potential drastic long-term ramifications on athletes, is at an all-time-high in the public eye. Pressure to better understand an injury that's struggled to be taken as seriously as it should be has never been more magnified. Athletes get it, too, and understand this issue is just in its infant stages, with many—from ex-NFLers to former NHL star Marc Savard to soccer great Amy Wambach—stating that they'd donate their brains to science for CTE and concussion research.
Though there's still much work to be done to reduce concussions and find a remedy for treatment, doctors, leagues, researchers, and advocates across Canada are helping in the fight. When we think of sports that have the greatest chance of causing head trauma, football is probably the first to come to mind for many. The physical nature of the sport allows for both short- and long-term injury, but the football landscape in Canada is slowly shifting in terms of how head-related trauma is perceived and treated.
This past season saw the addition of CFL injury spotters given the same powers as NHL spotters where they can pull a player from the field if they deem that he's showing concussion-like symptoms. The CFL also expanded the use of the K-D Test, with player information sent to McGill University researchers to analyze and more effectively understand the diagnosis and treatment of concussions.
Kevin McDonald, the CFL's vice president of football operations and player safety, wrote in an email to VICE Sports that there were 40 concussions in 2016 resulting in 3.8 percent of all injuries, down from 50 concussions in 2015. Five years prior, there were also 50 reported concussions; of them, 44.8 percent of players reported having a concussion or concussion-like symptoms, 16.9 percent had confirmed that they had a concussion, and 69.6 percent of all players who suffered from concussions that year experienced more than one. The CFL hopes the decrease in concussions, however slight it may be, is the result of a combination of rule changes, supplemental discipline for dangerous play, and ongoing education among the league's athletes.
"We are encouraged by the reduction in the number of concussions," McDonald said. "But we cannot assume it's a trend, nor can we pinpoint any one cause. We need to continue to monitor the situation over a longer period of time."
What McDonald couldn't answer via email was if the game itself would see modified tackling or rule amendments in the future. For now, spotters and the K-Test remain a priority.
The introduction of CFL spotters last season was largely deployed to assist medical teams and training units in identifying and assessing potential injuries by sharing video clips of plays where actions and behaviour indicate an injury may have occurred. Spotters shared hundreds of video clips with team medical staffs this year and McDonald said there were rare occasions where a CFL spotter intervened a game in progress due to a player that was under duress from a blow to the head.
The league has recently partnered with the NFL in a pilot program that tests a new concussion tool that will diagnose and assess head trauma using an eye exam. Most of the CFL's concussion blueprint revolves around education on tackling techniques, following the latest scientific protocols, and condemning reckless behaviour. But like every other sport league grappling with how to curb and implement a gold standard to prevent concussions altogether, the CFL is left waiting for some kind of scientific breakthrough where diagnosing a concussion will become an instant prognosis.
If you ask Robyn Wishart—a defence lawyer from British Columbia who has represented former CFL players on a number of concussion-related issues—she will tell you bluntly the horde of maladies her clients have suffered from: aggression, paranoia, depression, anxiety, and suicidal thoughts. She said paranoia is quite frequent, and that it's not uncommon for those affected to draw the curtains closed in the middle of the day because they fear they're being watched.
If they make it through the early onset period, they progress into neuromuscular degenerative issues, loss of strength and mobility, and will often mimic Parkinson's-like symptoms. These are all symptoms people suffering from CTE, a progressive degenerative disease that causes brain damage, can exhibit.
"It's very much like cigarette smoking. You could smoke for 50 years and not have lung cancer. But we wouldn't say cigarette smoking doesn't cause lung cancer," she told VICE Sports. "The answer seems to be that some people are affected by one hit as badly as others are affected by 50."
Aaron Geisler played semi-pro football for a total of 11 years in Southern Ontario and the United States and said he's seen a drastic shift in the education and science of concussion research. For the past year he's been Football Canada's manager of program development, and was the technical director for three years before that.
"You either passed out or had very clear signs of concussion. Loss of consciousness was the biggest indicator of a potential concussion," he said of his playing days. "Concussion wasn't something that was discussed in the way that it is now."
Since 2009, Football Canada has tweaked and made careful alterations to how the game is being played. The biggest change came when the league implemented the Safe Contact initiative for all coaches, which went from a two-hour module to a 10-hour workshop. The now-mandated workshop educates coaches on concussion protocols and new tackling progressions, which teaches players to tackle with the front, chest and shoulder.
There are currently around 8,900 mandated coaches, and this year every coach that operates under Football Canada will be recognized under the Safe Contact program. On top of that, Football Canada also uses the Standardized Concussion Assessment Tool and offers an e-learning guide on the basics of concussions.
The organization also tweaked some rules for safer play. In 2014, it instituted the defensive posture rule where if a player was deemed to be in a defensive pose, he was considered off limits from hitting. Quarterbacks also had the same leniency. Penalties were awarded against you if you led with the crown of the helmet in blocking or tackling. And last June, at their annual general meeting, they mandated 21 new strategies, mostly structural and safety changes, beginning in 2018.
"Right now we have processes in place to reduce instances and frequency of contact. You might not get a concussion, but if you're taking repetitive hits that's an issue for us," Geisler said.
"Although prevention is a big side of concussion, the reality is, concussions will occur no matter [what] we do in sport and in real life. It's about changing the culture. You're not here to be tough and hide injuries. You're here to play and play safely."
In Zurich in 2012, at the International Consensus Conference on Concussion—considered the gold standard when it comes to research on concussions—a report found that the majority of concussions (80-90 percent) are resolved within 10 days, but may take longer in children and teens. Football Canada has adopted the Zurich guidelines, a six-step approach to ensure that you return to the field without any symptoms. Advancing through each step requires the person affected to have no symptoms and a final medical clearance. One issue with the process is that it requires two people for an accurate diagnosis: a truthful athlete and a knowledgeable doctor up to speed on current concussion policies.
To help combat athletes giving false symptoms to avoid missing field time, a Children's Hospital of Eastern Ontario study that was published in the Journal of the American Medical Association—using more than 3,000 youths between the ages of 5 and 18 years old—has created a prediction score to anticipate how long a child or teen will experience post-concussion symptoms. This means that doctors can be less reliant on a person's cooperativeness, taking the onus away from the player in order to accurately diagnose a concussion.
This is another important step in helping reduce long-term concussion effects by making it more difficult for athletes to get back to playing when they shouldn't be in order to avoid potentially fatal tragedies, like the devastating 2013 incident that took the life of Ontario high school rugby player Rowan Stringer.
Nearly four years ago, Stringer, the 17-year-old co-captain of John McCrae Secondary School, received a pass from a teammate, ran a few yards and was then swing tackled to the ground, with her head taking full brunt of the impact. She laid there, tried to get up, and was then taken to hospital where she died four days later.
A few days prior to her final match on May 8, Stringer sent text messages to her best friend, writing how she got kicked in the head that week and how she had headaches and might have a concussion, according to the Ottawa Citizen. When her best friend asked her if she was going to play the next game, Stringer, eerily, replied with, "Yeah. Nothing can stop me. Unless I'm dead."
Stringer suffered three concussions between May 3 and May 8 and was not feeling well before her final match. It was during that match she sustained Second Impact Syndrome, which occurs when the brain swells rapidly after a person suffers successive concussions before symptoms from an earlier diagnosis have slackened. There were no doctor's visits during that period of feeling uneasy. There were no dizzy spells. No vomiting. Stringer kept any symptoms of malaise or discomfort to herself.
Her death led to Bill 149, which received Royal Assent, passed with all-party support and became law last June. Also known as "Rowan's Law" it will be made up of 49 recommendations focusing on treatment and education. Ontario will be the first province in Canada to implement a concussion legislation; every jurisdiction in the United States already has this in place. Leading the charge on Rowan's Law is Nepean-Carleton MPP Lisa Macleod, who says although Bill 149 will go a long way in reducing the rate of concussions in sport, Canada is still playing catch up.
"In the Commonwealth system we do not have a mechanism when there is a coroner's inquest to take those recommendations and apply them to law. What this bill does is centralize all of the relevant bodies," she told VICE Sports. "There is no universal approach to concussions in Canada. It varies from sport to sport, league to league, whether you're playing extracurricular or association level. It's our responsibility that any issues, signs of concussion are realized because if not there could be fatal consequences."
Dr. Neilank Jha, an Ontario-based brain surgeon who is among the world leaders in his field, has been chairman of Koncussion Project since 2010 and has worked with most major sports leagues and amateur sports groups as well as motor vehicle accident cases. He believes we've reached the beginning stages of understanding the effects of increased exposure to head injury and how this may impact cognitive, emotional, physical, and sleep symptoms.
"A second concussion before recovering from a first concussion can cause irreversible brain damage in some cases, and even death in exceedingly rare cases," he said, which is exactly what happened to Stringer. "In post-mortem we are starting to recognize that repetitive head trauma appears to cause neuropathological changes (brain damage) to the brain," he continued, which is consistent with the belief that repeated concussions or head injuries can lead to CTE.
"To this day we do not have a rapid, accessible and practical way to diagnose concussions."
Despite some advances and various gadgets that provide image samples of the brain, the ability to diagnose whether or not a concussion is present has been difficult. A potential breakthrough may have occurred, though, thanks to researchers at Western University in London, Ontario. They recently claimed to have developed a blood test that can diagnose a concussion with a 90-percent accuracy rate. After two years of blood profiling, researchers have determined that there's a single test that can tell whether or not a person has suffered a concussion.
This could be monumental, but some caution the findings of the study.
"This particular study was done on a very few number of people, included only male adolescents and did not factor out many variables that can affect the results such as diet, time of day, gender, etc. The authors point out the limitations of their study and correctly state that much further work is required to validate their approach," Dr. Carmela Tartaglia, a neurologist and researcher with the Canadian Concussion Centre, told the Globe and Mail.
Doctors believe it's taken at least 20 years for concussions to become part of public discourse. Researchers cite a lack of funding over the years as a primary reason why they've been behind the eight ball in treatment and prevention. The trouble with concussions is that there hasn't been a rapid and practical process to diagnose it yet, and doctors have yet to figure out why brain trauma caused by continuous head knocks are varied from person to person.
"Unfortunately we know very little about the brain but we're starting to gain more and more information with each passing year. Research dollars are starting to increase but they're nowhere near some of the levels of other issues," said former Philadelphia Flyer great Eric Lindros, an advocate of concussion research after sustaining the injury numerous times throughout his Hall of Fame career.
In 2013, the American Medical Society for Sports Medicine (AMSSM) released a position statement that estimated as many as 3.8 million concussions occur within sports annually, with up to 50 percent of concussion injuries unreported. Dr. Michael Cusimano, a neurosurgeon and researcher at St. Michael's Hospital in Toronto, has spent 25 years working with concussions as a faculty member and is the resident expert on sports-related concussions. He told me, without providing any comparative data, mind you, that he's seen a rise in concussion cases in recent times.
"Part of it is the diagnosis because we are more aware of it. We are recognizing it more frequently. I do think in certain sports there probably is a true increase in the actual incidents," he said.
"Pro sport is all about winning and money. So that's presented to children and youth in that way as well. So there are higher stakes involved. And it's been shown there's a win-at-all-costs attitude, so people are willing to take greater risk."
The University of Calgary's newly established concussion clinic has been described as a world leader when it comes to neuroscience and concussions. Since opening last fall, Dr. Katie MacGregor said she's definitely seeing a number of concussions that need acute clinical management, particularly with high-risk sports such as hockey and football. She said she found those who fell into that category weren't being properly managed. The innovative clinic offers a self-referral online questionnaire, acute concussion management, and in-house research in an effort to improve their concussion knowledge. They also aim to use their patients as part of their research.
"This really is an evolving field. There are a lot of grey areas which is why it's such a hot topic in the media," she said, adding that doctors will need to examine the issue further to discuss how to evolve research practices. "To have that link between clinical practice and research, that's the aim of the clinic."
Dr. Charles Tator, the director of the Canadian Sports Concussion Project at Toronto Western Hospital, believes that someone will develop a drug in the next five-to-ten years that will prevent the brain from being damaged during high-risk sports. He said the drug might reduce concussion symptoms, headaches, depression, and anxiety, but what sport needs and doesn't have yet is a pill that protects the player from the next big hit, to tolerate blows better.
In his Toronto lab he spends most of his time researching what happens to the brain when there has been a concussion and why certain people have consequences of concussions.
"We now know you don't have to lose consciousness to have had a concussion. You don't even have to have amnesia," he said. "Although everyone is concerned about the concussion problem no one really wants to pay for the research necessary to look into it in greater detail."
Dr. Tator said his department spent $500,000 on research in 2015, and in 2014 they were granted $1 million. In 2016, funding increased to $10 million toward the Canadian Concussion Centre and they are still looking for further investment, as test cases for concussions can become an expensive exercise. To study an athlete, costs can vary from $15,000-20,000 for neurological tests and imaging. An MRI, as an example, can cost up to $1,000. Dr. Tator said concussions compete with other serious diseases for government funding such as cancer, heart disease, and diabetes, and usually doesn't fare that well.
Lindros, a proponent of Rowan's Law, runs an annual concussion clinic, explaining to hockey players that it's OK to take time away from the sport if you don't feel right. Lindros, who reportedly suffered six concussions from 1998-2000, the most notable on a devastating hit from Scott Stevens, said it wasn't until the late 1990s that discussions about heavy hits to the head took place. He played in a different NHL than the one that exists today. While fighting remains a part of the game, it's steadily decreased in recent seasons. Fighting numbers have hovered around 0.30 per game the last three seasons, down from 0.65 during the 2001-02 campaign. And in an effort to minimize on-ice carnage from heavy head-high hits and one-on-one slugfests, the NHL has been evolving Rule 48 which bans certain hits to the head.
Sports leagues, even the ones that aren't as physically forceful as hockey or football, are starting to treat head injuries more seriously—with education, concussions spotters, and minor rule changes. The NFL has tweaked tackling laws and has also added concussion spotters. Major League Baseball introduced a seven-day disabled list for players suffering from a concussion or concussions-like symptoms. But without a clear analysis and method of concussion diagnosis that's a sure thing, it's a lot of educated guesswork. Lindros is certain that concussion-based accidents are consistently happening outside of sport, too, in schools at recess, on weekends riding bicycles, or even during activities like skateboarding.
"As much as things have come forward and improved of late, it certainly took forever to get it going and there's a pile of work to be done to get things up to speed to where things need to be," he said.
The future of how to reduce and treat concussions is still muddy. No one has all the answers, but the wheels are moving across Canada, as researchers and doctors are collaborating in labs trying to solve an injury that at times can appear to be invisible.