Sunday, July 22, 2012

Two British Columbia doctors who specialize in geriatric medicine and are extremely concerned about concussions in young people had a message delivered to The Coaches Conference that was held in Burnaby this weekend.
Dr. Maria Chung is a clinical assistant professor at the University of British Columbia and the acting head of the Division of Geriatric Medicine at Vancouver General Hospital and UBC.
Dr. Amanda Hill is a clinical associate professor at UBC and the acting head of the Division of Geriatric Medicine at St. Paul’s Hospital in Vancouver.
Dr. Hill also is on the board of directors of the Alzheimer Society of B.C.

Here is the letter they co-wrote:

Dr. Maria Chung
Clinical Assistant Professor
University of British Columbia
Acting Head Division of Geriatric Medicine
Vancouver General Hospital and UBC

Dr. Amanda Hill
Clinical Associate Professor,
University of British Columbia
Acting Head Division of Geriatric Medicine,
St. Paul's Hospital

Dear Coaches:
As geriatricians who deal with the devastating consequences of dementia we feel we have to speak up about the fact that young men in junior hockey leagues throughout  this province are being exposed to risks of long-term brain injury and dementia.
In 2010-11, the Western Hockey League reported 100 concussions. A prospective study of concussions in junior hockey in Ontario (1) showed that concussions are under-reported in junior hockey, suggesting that this number is probably a lot higher. This study also found that 25 per cent of concussions were caused by fights.
In the 2011-12 season, the WHL stopped reporting concussions. It is unclear what purpose this serves, except to obfuscate important facts. In this season, the WHL witnessed 799 fights in the regular season — 1.01 per game, about nine boys fighting every night of the season. (In the same regular season, the NHL had 601 fights, an average of 0.49 fights per game.) The 'leading fighter' in the WHL experienced 26 fights in the season (one a week), with 14 players experiencing 15 or more fights. Eight of these boys were 17 or 18 years old.
Dr. Anne McKee (2) describes the entity Chronic Traumatic Encephalopathy (CTE) in 47 cases of athletes who experienced multiple minor and major head traumas. This is a disease characterized by early onset dementia, emotional disturbances, substance abuse, Parkinson's-like symptoms and frequent early and traumatic deaths.
We now have neuropathologic evidence of CTE in a number of NHL veterans and last year people were shocked by the deaths of five young 'enforcers.'
Bob Probert, 45, died of a heart attack but was found to have CTE. He also suffered from addictions. The autopsy of Derek Boogaard, 28, revealed CTE. Barry Potomski, 38, died of a heart attack. Rick Rypien, 27 and  Wade Belak, 28, died in presumed suicides after battling depression. The neuropathology is not yet available on the last three men.
The challenges these men faced with substance abuse, memory lapses and depression are typical of the clinical histories of other athletes with CTE. It is unclear whether fighting or other causes of head trauma pose the bigger risk; however, it is clear that the hockey players who have suffered most from this disease were enforcers.
The science is here. We know that young brains are immature and are more vulnerable to minor trauma. It is very evident that repeated minor traumatic brain injuries can cause CTE, and head injuries have been associated with Alzheimers disease. The brain is like Jello — if it is stressed there is a lot of internal movement. This movement causes stretch on the long part of the nerve called the axon and causes intra cellular trauma. Damaged proteins are produced that are in themselves toxic to the nerve and cause a cascade of damage that progresses long after the injury. In most cases and when there are not other injuries the cascade settles down. However, with repeat injuries and in those who are predisposed, this cascade continues in a predictable anatomical pattern through the brains for decades causing the lesions that we see in CTE. These lesions have been seen in athletes as young as 20. Sadly, when the disease expresses itself clinically it manifests as out-of-control behaviour so these  young men are written off as no good. We all know that these kids have to be very disciplined to play junior hockey — these behaviours are inconsistent but fulfill a public stereotype.
This is a preventable dementia and we need to do what is necessary to prevent it. Fighting is gratuitous and preventable, and the coaches and the referees, fans, parents and the whole junior hockey system are accountable for it.
The WHL has put in place new rules regarding hits to the head and softer shoulder and elbow pads, and that is excellent news. However, it is bizarre to put in an elaborate set of rules to prevent hits to the head and then to encourage fighting and have a record of fighting that exceeds the NHL.
There are precedents for banning fighting. The Ontario Junior Hockey League has dropped the number of fights per game from 0.6 to 0.25 with a ban on fighting. In the NCAA, a player who fights receives a game misconduct and must sit out the following game. There are increased suspensions for every additional fight in which a player becomes involved. USA Hockey is to vote on this at some point this summer, with a ban perhaps to go into effect in the 2012-13 season.
If the WHL and other junior hockey leagues in this province will not step up we need to pressure the provincial government to act to disallow adults from sending children out to fight against each other for the entertainment of a crowd. It also makes the WHL very vulnerable to a huge class action suit for failing to protect children in their care. Quite frankly, we believe this is an issue of child abuse.
Surely we need to protect these boys in the face of very real risks of long-term devastating damage.
I, Dr. Amanda Hill, am a hockey mom. I love the game, I love the kids who play it and I have loved my involvement with junior hockey. We owe it to all of our kids to ensure that they are safe when they go out on the rink.
(1) Echlin PS Neurosurg Focus. 2010 Nov;29(5) A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates.
(2) Ann C. McKee, MD, J Neuropathol Exp Neurol. 2009 July; 68(7): 709-735.  Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy following Repetitive Head Injury  

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