Concussions: Tackling the hockey problem head-on

Everything a hockey parent needs to know about kids’ concussions and playing it safe.

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One moment, you’re cheering on your kid and then—smack—he’s down. The whistle blows; play stops. A child is lying on the ice. The trainer’s steps echo as he walks out. Please, please, not his head, is the silent prayer. Then movement, sticks bang the boards in applause, and we sigh. The game goes on.

I became a hockey mom when my son Aaron joined a league at the age of five. (My two older kids had no interest in hockey.) After a few months, a niggling fear appeared in the back of my mind and in my heart: Kids get hurt. No matter how tough your child is, injury is a reality of contact sports. But in hockey, a game that increases in violence and speed as kids grow older, players can break bones, or worse—sustain a concussion, a mild traumatic brain injury.

According to a survey commissioned by Hockey Canada during the 2011-12 season, three out of 10 parents said they had a player who had suffered a concussion. Of every 1,000 Canadian children, between three and five will suffer a concussion each year.

The conversation about hockey head injuries—why they happen and what to do about it—escalated after Sidney Crosby, hockey hero to so many kids, struggled with concussion symptoms after two hits in 2011. Hockey Canada put out a concussion-awareness app, endorsed by Crosby, as a resource for kids and adults. In 2013, the government launched a multi-million-dollar initiative funded by the Canadian Institutes of Health Research to study the impact concussions have on the paediatric brain. We’re beginning to understand how damaging this common type of head trauma is.

Primary care sports medicine specialist Paul Echlin, who works at the Elliott Sports Medicine Clinic in Burlington, Ont., also worked for 10 years as a junior hockey team physician. He believes there is a concussion epidemic in hockey. “Eighty per cent of my patients are between nine and 18, and they’re out of school because they can’t function after a concussion. You start to think, ‘What are we doing to our kids?’ It’s almost criminal, and no one talks about it enough. It’s time parents and players face the often devastating effects.”

In July, 16-year-old Winnipegger Ethan Williams, a prospect for the Moose Jaw Warriors in the Western Hockey League, committed suicide after suffering eight diagnosed concussions. (That’s a lot for such a young player.) Concussions have been linked to a higher risk of suicide, anxiety and depression, and such emotional and cognitive symptoms as disturbed sleep, difficulty concentrating, frustration and forgetfulness. Repeated head injuries can change a player’s personality and lead to learning disabilities or other mental health problems. It’s believed that the potential for cumulative brain damage increases with each one (the majority of which go undiagnosed).

Concussions—and bodychecking—have become hot-button issues. The American Academy of Pediatrics would like to see the bodychecking age raised from 13 to 15, while the Canadian Paediatric Society recommends competitive leagues delay bodychecking until the bantam level (ages 13 and 14), and that non-competitive recreational leagues ban it for boys of all ages. (There is no bodychecking allowed in girls-only or women’s hockey.) In 2013, Hockey Canada made a controversial change when it raised the minimum age for bodychecking from age 11 to 13, nationwide. The Greater Toronto Hockey League recently voted against a proposed bodychecking ban for A-level players of all ages, and the Newfoundland Hockey League voted down a proposed ban for bantam (under 15) and midget (under 18) players. Meanwhile, minor league hockey enrolment has flatlined across Canada.

I didn’t know much about concussions when my son started playing. But hockey has become a way of life for our family. From early morning practices to evening games and weekend tournaments, you’ll find us in rinks almost every day. I figured there’s an injury risk in every sport—soccer, gymnastics, even bike-riding—and that hockey was no different. As Aaron nears the bodychecking age of 13, however, more concussions are happening around him. Last year, he may have suffered a mild one during practice. He recovered within a week, and the doctors couldn’t determine for sure whether it was a concussion. But another head injury could mean rethinking his participation in the sport he loves and losing its many rewards, including exercise, healthy competition and friendships.

So, short of dropping out of the sport once it gets too rough, how can we make sure our children are safe—or at least safer—on the ice?

Not just “part of the game”
The first step, says Echlin, is that we have to stop thinking of concussions as “just headaches” that are part of the game and start taking them seriously. Some hockey fans have characterized the concussion risk as hype, but Echlin disagrees. “The fear of kids getting concussions is not hype. It’s a public health issue. Despite the clear evidence that concussions are dangerous to children’s brains and can ruin lives, there’s a huge resistance to accept that fact. ” He cites the concussed professional players who are now suing the NHL for not doing enough to protect them from the dangers.

“We now know that concussions are most dangerous for adolescents,” says Toronto neurosurgeon Charles Tator, founder of the Canadian Sports Concussion Project. “In adolescence, the brain—especially those areas that control emotion and learning—is undergoing enormous development, so that’s when it’s most at risk.” A 2002 study at the Université de Montreal showed that the teenaged brain is not only more sensitive, but it also can suffer cognitive deficits for as long as six months after a trauma. He’d like to see bodychecking delayed for all players until age 16, when the brain is more mature. “There will still be injuries, but we can reduce them,” Tator says.

Paediatrician Roger Zemek, director of paediatric emergency research at Children’s Hospital of Eastern Ontario in Ottawa, has found that kids take longer to recover from concussions than adults—about 30 percent have symptoms that persist for a month or more—and some are sent back to sports and school too early. That’s particularly scary knowing that even if the first head injury seems minor, concussion risks rise dramatically with repeated injury.

Know the signs
How can you tell if it’s a concussion? If it’s a clear case (loss of consciousness or severe headache), get medical help. If your child is conscious, stop the activity and go to the doctor. If he isn’t conscious, call 9-1-1. In the absence of obvious signs, diagnosing a concussion can be tricky—as it was in my son’s case. “You can’t see a concussion on an X-ray, MRI or CT scan. All we have are cognitive tests,” Tator says. In addition to checking vision, balance and reflexes, doctors will ask kids about symptoms and test their memory and recall. “The younger the child, the harder it is to diagnose, because they need to communicate the subtleties they feel,” Tator explains. Some kids will often report a stomach ache instead of a headache when they’re feeling nauseated, and older kids may ignore or lie about symptoms because they want to keep playing.

All too often, coaches and parents shake off the possibility in a combination of fear and commitment to the game. Since you don’t have to lose consciousness to have a concussion, spectators and players may not realize it’s even happened. And while helmets help guard against skull fractures, they aren’t concussion-proof. That’s because when there’s a blow to the head, or rapid deceleration in speed, the brain can move or bruise against the inside of the skull.

The bodychecking debate
Since it was implemented in 2013, Hockey Canada’s bodychecking ban for kids under 13 has had many fans up in arms. Hockey traditionalists such as Don Cherry consider bodychecking an integral skill that must be learned early to avoid injury; others argue that hockey without bodychecking completely waters down the game. But medical experts considered the ban a step in the right direction. York University health professor Alison Macpherson, a child-injury-prevention specialist in Toronto who supported raising the age minimum for bodychecking in minor hockey, found herself caught in the crossfire. “Online, some people accused me of trying to ruin the game,” she recalls. “But from my perspective, preventing concussions actually keeps kids involved in sports.”

Don Power, a Newfoundland-based sports columnist and president of a minor hockey association there, argues that minor hockey, and bodychecking in particular, has been unfairly targeted in the concussion scare. “The fact is, many concussions are caused by collisions and illegal hits, or by not learning to bodycheck properly. That’s the real danger. Injuries happen when some kids know what they’re doing, and others don’t,” Power says. For kids who play competitive hockey, and may move up the ranks, bodychecking skills are just as important as passing and shooting, he says. The argument: The earlier kids learn the skill safely, the better they’ll execute it during the teen years—when the size differential between players going through puberty can be greatest. And for those who want to play without checking, there are less competitive, non-contact leagues.

“Bubble-wrapping children or taking them out of a sport because you’re scared is not the answer,” Power says. “You can keep your child home, and he can trip and hit his head on the coffee table. Kids cross the street, they ride bikes. They need to learn to play safely, but you can’t prevent all injuries.”

Moving forward
Echlin says he’s not suggesting that we overprotect our youngest players. “Sports have been my life—as both a physician and an athlete. No one wants to take sports away from kids altogether. But the number one thing is the long-term health of your child. Why are we still playing sports in a way that traumatizes our kids? If they’re going to play fast contact sports that are violent, such as hockey or football, or even soccer, then let’s reduce head trauma to a minimum.” This could mean no bodychecking; switching to four-on-four hockey with less contact; choosing coaches who don’t promote violence; and creating stronger protective gear. Players, coaches, parents and health professionals must take injuries seriously and follow consistent guidelines for diagnosis and treatment.

In June, Zemek and the Ontario Neurotrauma Foundation released new guidelines for identifying and managing paediatric concussions at ONF.org. While for most kids symptoms disappear within two weeks, they can persist for three months or more (and sometimes permanently). How long to keep kids at rest varies. Introduce activity gradually, following the six-step Return to Play protocol. (Step 1: no physical activity and limited schoolwork; Step 2: light aerobic exercise such as walking; Step 3: return to the ice for light skating, but no abrupt stops or body contact; Step 4: try a few drills, but no body contact; Step 5: try drills with body contact; and Step 6: return to competition.)

“The science behind sports concussions is here,” Echlin says. “It’s unethical to ignore the evidence. Now we have to educate everyone—including our kids—so they can make better decisions. They are the next generation of coaches and parents, and they have to think about how they want to play the game.”

10 things you need to know about concussions

1. A concussion is a brain injury that can cause a variety of easy-to-miss symptoms. Doctors can’t “see” concussions using imaging. You don’t need to lose consciousness and a well-fitting helmet will not necessarily prevent one.

2. Symptoms can include headache, nausea, vomiting, light sensitivity, dizziness, confusion, slurred speech, poor balance, irritability, memory problems, blurred vision, sleepiness, sadness, anxiety or feeling in a fog. If you suspect a concussion, call the doctor.

3. If his head hurts, he’s off the ice, no questions asked. It doesn’t matter if he’s in the third period of a tied championship game.

4. Do not give Advil or Aspirin. Administered in large amounts, Advil and Aspirin can cause further bruising or internal bleeding. Tylenol is a safer bet; ask your doctor about proper dosages.

5. For the first 48 hours, be vigilant for signs of deterioration. Severe headache or persistent vomiting mean you should go to the ER.

6. Concussion risk increases with each one. The brain is more likely to get reinjured if it hasn’t properly healed the first time. A child’s brain needs both physical and mental rest to heal (no jumping, no math problems).

7. Screens exacerbate a concussion headache. That means you have to limit the three things kids are most addicted to: TV, computer and phone.

8. If he says his head hurts, and the pain won’t go away, believe him—even if, ordinarily, your kid will do anything to skip school. The boredom of staying home and off screens will drive him—and you—so batty, there’s no way he’s faking.

9. His brain needs to rest in a dim room. This means no screens, pulling the curtains and keeping sunglasses handy. Contact teachers about making up homework in stages and catching up gradually.

10. Don’t send him back to school or sports until he’s symptom-free. Even with a mild concussion, this means no school or sports for at least a week—sometimes two.

A version of this article appeared in our October 2014 issue with the headline “Head on,” pp. 35.

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