News

Minor hockey, major injury

A growing number of young hockey players are suffering concussions. Can anything be done to stop the trend?

What is a concussion? Can concussions be prevented? Concussion statistics How to recognize a concussion What to do if someone suffers a concussion About the Pan Am Clinic

BY SUSIE STRACHAN
Winnipeg Health Region
Wave, January / February 2010

It was a mere five minutes into the second period of a game last fall between the Central Plains AA Midget Girls hockey team and Pembina Valley Hawks Female AA Midget team.

Jillene Rodgers was battling for the puck with an opponent behind the Hawks' net. Up in the stands, her parents, Ron and Carol Rodgers, cheered their daughter on. Jillene won the battle and passed the puck to her teammate.

And then it happened - the opposing player slammed Jillene to the ice. She fell backwards, hitting her shoulder first and then her head. There was no penalty called on the play. The arena went quiet as the referee skated over to check on Jillene.

Shaken but still conscious, the 16-year-old girl got up and made her way to the bench. By that time, Ron was there waiting to check on her. "My parents and coaches knew something was wrong. I didn't really remember what was going on," says Jillene, recalling the incident. Twenty minutes later, she still had no recollection of what had happened.

The coaches told Jillene to head for the dressing room to change. But even that relatively simple task proved too difficult for her. Carol went to help and found her sitting there, confused about what had happened.

Her parents drove Jillene to the hospital in Portage la Prairie, where she was diagnosed with a concussion, before taking her to the Winnipeg Health Region's Pan Am Clinic for further diagnosis and treatment.

Today, Jillene has no memory of the incident that occurred last fall. "I do remember the first period. I got a good break-away but couldn't get a good shot. In the second period, the other girl hooked my stick. I woke up after the game. I can't remember the end of the second period at all," says the Grade 11 McGregor Collegiate student.

The visit to the Pan Am Clinic was not the first for Ron. Just last June, he had taken his son Kienan to the clinic after the 14-year-old suffered a concussion while playing hockey in the AAA Subway Manitoba Classic for the Manitoba Express.

Having gone through the drill with his son, Ron knew what to expect. A concussion can be defined as stress to the brain, usually

the result of the brain bumping up against the skull. This type of injury can result in memory loss, dizziness and headaches. Repeated concussions can cause permanent memory loss, loss of brain function and personality change.

"A concussion has some of the same symptoms of a brain dysfunction like a stroke or not being sober," says Stan Szumlak, an athletic therapist at the Pan Am Clinic who helps treat people with concussions. "You may see a player get knocked silly on the ice, and their fight or flight instincts will kick in. If asked, they often want to get right back into the game. They may even lie about their symptoms, if they feel the game is important. But once back in the game, the player more often than not is confused as to what they are supposed to do."

Concussions, particularly among athletes, have often been dismissed as a health issue. Getting your "bell rung" was simply a part of the game, and getting back into the play after suffering a devastating hit was considered a sign of toughness and courage. This past season, for example, controversy arose when Pittsburgh Steelers quarterback Ben Roethlisberger missed a game because of post-concussion syndrome. One teammate suggested that perhaps the quarterback should have played despite the concussion, noting that some players would lie about their health in order to get into a game. Kurt Warner, who plays quarterback for the Arizona Cardinals and has a history of concussion problems, took himself out of a game earlier this season because of lingering concussion symptoms. He told reporters that he felt his teammates and coaches were disappointed in him for doing so.

But that attitude is slowly changing. In Canada, awareness about concussions started to grow with news of the problems experienced by National Hockey League players. For example, star forward Eric Lindros, who retired in 2007, suffered numerous concussions during his career, beginning in 1998. His brother Brett, meanwhile, retired in 1996 because of problems with concussions after playing less than a year in the league.

Today, concussions among young athletes, particularly those who play hockey, are on the rise, according to sports health experts. Part of the reason is better education and detection, but much of the increase can also be attributed to the fact that players are bigger, stronger, faster and can hit harder.

Statistics show that more concussions occur in leagues that allow contact play. Teenage boys between the ages of 13 and 15 vary in size and physical ability, when some of the kids can be as much as 50 kg heavier and 55 cm taller than other players. Body checking - the attempt to separate your opponent from the puck by using shoulders or hips to contact the other player - makes for fast-paced and exciting hockey games, but it's also associated with high rates of injury.

Staff at hospitals and clinics throughout the Winnipeg Health Region see concussions in adolescents from a variety of sports, including hockey, football, lacrosse, rugby, judo and soccer. Winter sports such as downhill skiing and snowboarding are another source of concussions. Kids also come in after falling off the play structure or colliding with a tree on the tobogganing hill.

Concussions can be extremely difficult to diagnose, according to Dr. Wayne Hildahl, founder and Chief Operating Officer of the Pan Am Clinic. He says some patients who arrive at a hospital emergency room suspected of having suffered a concussion will have a CT or MRI to rule out acute life-threatening conditions, such as bleeding in or on the brain, which requires emergency treatment by neurosurgical specialists. But it is important to remember that an MRI does not rule out a concussion. "Too often we hear of an athlete, a coach, or a parent ask for an MRI so they can know whether the athlete can play," says Hildahl. The MRI does not give us this answer."

Szumlak is a former trainer with the Regina Pats of the Western Hockey League, and used to track concussions in junior hockey for Hockey Canada.

Although the Pan Am Clinic has no formal concussion treatment program, Szumlak says sees about one or two patients under the age of 18 every week.

Upon arrival at the Pan Am Clinic for their respective appointments, Kienan and Jillene were examined by one of the clinic doctors, and then turned over to the care of Szumlak, who put them through the SCAT 2, which is the standard test for checking a patient for concussion.

"We went five days after my concussion and met with Stan and Dr. Norm Silver," says Kienan. "Stan explained that a concussion is like a bruise to the brain. He did tests for memory and balance. And then he told me to keep taking it easy, and only gradually add activities and stop if they bothered me."

The SCAT 2 works for people age 10 and up, as younger children respond differently to concussion. SCAT 2 gives the team coaches, trainers and paramedics a formal list of tests they can perform, including whether the injured player can open their eyes, make correct verbal responses, respond to pain from a pinch, and assesses their short-term memory.

"A concussion damages the electrical impulses and signals that your brain functions with. Your normal brain signals are disrupted," says Szumlak. "For example, there are 12 pairs of major cranial nerves that are affected by a concussion. These nerves connect your brain to your eyes and vision, your nose and sense of smell, your mouth and sense of taste and swallowing, your ears and hearing."

The symptoms of a concussion often include headache, dizziness, and vomiting. There can be changes to the memory, reasoning and cognitive skills, and to personality. Teenagers can have relatively non-communicative personalities to start with, so it can be hard to measure if there is any difference. "The kid might complain of a headache, that they need to shake off the cobwebs. But you will quickly notice they cannot focus, and often start to feel sick within an hour or two of the hit," says Szumlak.

Like her brother before her, Jillene's SCAT 2 test showed that she did not suffer a major brain injury, but that she had been shaken up. Kienan had more memory loss, but not a headache, like Jillene had suffered. They both followed the same recovery plan.

Kienan's injury occurred when he was playing summer hockey in Winnipeg last June. He suffered a freakish hit, where he was caught off guard and spun into the boards. He didn't lose consciousness, but was very wobbly when they took him to the dressing room. Ron knew his son was in trouble. "Kienan asked me about 15 times in a row why his shoulder and back hurt.

At that point, we packed him up and went to the Children's Hospital, where they confirmed it was a concussion, and Kienan was given a referral to the Pan Am Clinic."

Szumlak says the treatment for a concussion is complete physical and mental rest, including lots of sleep, staying home from school, and staying away from computers, MP3 players, TV, video games and text messaging. Headaches caused by sunlight, computer screens, white boards and harsh lighting are all problems encountered by people who suffer concussions.

The return to play follows a graduated path of rehabilitation. Following the period of complete rest and recovery, the player can commence light aerobic exercise, such as swimming or stationary cycling. This light exercise must not result in headaches or dizziness.

Concussions can be diagnosed and treated by physicians in any hospital emergency department, and a family doctor can monitor patients who are recovering from one. Nonetheless, treatment and rehabilitation from concussion is becoming increasingly specialized as health care providers across the spectrum learn more about the condition.

Meanwhile, staff at the Pan Am Clinic, who have been working with athletes like Jillene and her brother, are in the process of trying to determine what would be involved in creating a formal concussion treatment program. "The idea for a program is still in its infancy," says Hildahl. "There are enough resources in the community to deal with this issue right now, says Hildahl "But we need to identify which physiotherapists, athletic therapists and other clinicians have an interest in this issue, and develop a coordinated approach. This is what we at the Pan Am Clinic want to work on."

In treating the patients who do come his way, Szumlak uses a number of techniques. Patients use exercise balls for balance, or for bumping, so they could learn to absorb an impact, and learn to see where a hit is coming from. This mock pillow fight helps a concussed player regain confidence. They also play games such as Go Fish or recite poetry, to rebuild their brain's memory skills.

The next stage introduces sport-specific exercise, such as skating drills, ensuring there are no activities that may cause a head impact. After this, the player can move on to non-contact training drills, such as pass patterns and breakaways. The final stage of recovery is to allow full-contact practice following medical clearance, in which the player can participate in normal training activities. Only then can they return to normal game play. This process may take as short as four weeks, but as long as six months.

Jillene's treatment progressed in the same way as Kienan's, except for the length of recovery. She did have a few different symptoms, but they may have been caused by a cold virus.

Initially, both athletes were displaying frustration with not being able to participate. Both athletes were modifying the intensity of activities in their teams' practices. As their symptoms resolved, they both displayed confidence in their testing and daily activities, says Szumlak.

Once back in the game, young players need to build confidence and work on skills that will keep them safer on the ice.

The risk of concussion cannot be eliminated. A helmet and mouth guard will protect against lacerations, fractures and breaks, but won't always stop concussions from happening, because of the way the brain slops back and forth inside the skull.

However, kids can reduce risk by building up their shoulder and neck muscles to absorb the force of a hit. And those who play hockey can learn how to take a hit into the boards and be more aware of players around them.

"Kids have to play smarter, to be more aware of where the other players are on the ice," says Szumlak. "They also have to learn to respect the other team, and not deliberately hit or hurt other players. It's about respect in sport. Do not skate close to the boards. Face the other player. It's so easy to be hit by another player, slam into the boards, and then crash to the ice. That's three consecutive hits, which can have dangerous cumulative effects."

Szumlak says changing the way the game is played can also reduce concussions among young hockey players. Coaches and players need to learn proper blocking and checking, goaltending and power skating, and, above all, learn to respect the players on their team and the opposing team. Parents need to set a good example, by encouraging referees to enforce the rules that are there to protect the players.

While awareness about the dangers of concussion is on the rise, Hildahl says athletes and, in some cases, parents, still need to have a better understanding of the potential long-term damage that can be caused by a concussion. "Too often, the heat of the moment or the dream of a contract in the NHL, gets in the way of good judgment," he says. "People need to realize that ignoring a concussion and returning to play before they are cleared puts them at much higher risk for a second concussion. This second concussion can occur with a blow much less severe than the first blow which caused the initial injury, but it has the potential to be catastrophic because the brain is already injured and much more susceptible to injury. This second injury can lead to life long damage, resulting in disability or even death. This is not a condition to be complacent about," says Hildahl. "Kurt Warner (the Arizona quarterback) said it right, 'This is just a game. I have the rest of my life to live and I want to be healthy to enjoy it with my family.'"

With both of his children suffering concussions, Ron Rodgers has become a bit of an expert on the subject, in that he is often consulted when a child is injured during a game he is attending. "Parents approach us now, asking our advice about what to do. In the heat of the game, it's hard to make a decision, but it's not worth sending a kid back in, when you just don't know how hard a knock they took to the head."

The injuries to their children have left both Ron and Carol a little nervous, but they remain strong supporters of Kienan and Jillene's continued play for their respective teams.

"Kienan took about 11 or 12 weeks before he went back to play, while Jillene took seven to eight weeks," says Carol. "Neither one of the kids could have prevented the hit that took them down. Both of them love to play hockey and want to continue, so for now we will accept their decision to continue playing hockey and support them. We both enjoy watching them play the game."

His dad may tease Kienan about taking up curling as an alternate ice sport, but Kienan says he enjoys hockey too much to give it up. The same goes for Jillene, who was helped along in her recovery by watching what her brother went through last summer.

Nonetheless, they are aware of the potential problems that can come with a concussion. "A lot of the kids say they want to be NHL players when they grow up, but Kienan has changed his mind about that, says Ron. "He'd rather be a psychologist or a lawyer now. He's quite concerned about the effect a concussion might have had on his brain, his ability to think and his memory."

Susie Strachan is a Winnipeg writer.

	About Wave Wave is published six times a year by the Winnipeg Health Region in cooperation with the Winnipeg Free Press. It is available at newsstands, hospitals and clinics throughout Winnipeg, as well as McNally Robinson Books. Read the January / February 2010 issue of Wave