It’s not often that scientific studies are a dramatic plot point on the big screen. But this year’s Concussion biopic is the exception, highlighting the effects of chronic traumatic encephalopathy (CTE), the degenerative brain disease caused by repeated hits to the head.
Though the movie focuses on the NFL, CTE isn’t limited to football. In fact, similar effects were first discovered in boxers, and have since been found in hockey players and soccer stars. The discovery has changed how fans view their beloved sports – and what parents see when they’re cheering on their kids. There’s a wave of worry on the sidelines: Could those repeated knocks to the head be causing long-term damage? Are those kids too young to appreciate the risks? And how many concussions is too many?
They’re not wrong to be concerned, according to Charles Tator, a neurosurgeon and one of Canada’s top concussion experts. “Those are healthy fears,” he says. “Parents should be aware of the potential ravages of concussion.” But weighing the benefits of sports against the possibility of long-term damage is difficult, and the science in this field is still relatively new. Here’s what we know.
The anatomy of a concussion
Karolina Urban suffered multiple concussions while playing hockey for the University of Toronto. The first time, she was checked by another player. “I don’t remember it happening,” she says. “I just remember being on the bench, and my teammate saying, ‘Are you okay?’ I’m like, ‘Yeah, I’m fine,’ and I went back out.” That night, she called her mom, who asked if she was drunk, because she was slurring her words. But it took falling during skating drills the next day to convince her to see the doctor. “That first concussion, I had the attitude of many athletes: no pain, no gain,” she explains.
Concussions are the result of “the jiggle of the brain inside the skull,” explains Tator but it’s not clear exactly what happens as a result of that movement. That’s because the damage can’t be seen with imaging machines like CTs and MRIs – in fact, part of the definition of a concussion is that you can’t see it on a brain scan. And animals’ brains are so different than humans’ that studying the effects of concussions on them isn’t very useful.
Instead, concussions are diagnosed by their symptoms, including headaches, confusion and difficulty concentrating. The severity of concussions is seen on a spectrum, ranging from the degenerative damage of CTE to mild concussions, which will often resolve in 7-10 days with proper treatment for adults (it may take longer for children and adolescents). Post-concussion syndrome, which affects 10% to 15% of people with concussions, is between those two extremes: it’s where symptoms persist, most often for less than three months, but sometimes for longer than a year or permanently.
Slightly less than 1% of boys younger than 18 and just under 0.5% of girls are treated for concussions in Canada every year, most often from hockey or skating. Many experts suspect they’re underreported. Paul Echlin, a primary care sports medicine specialist in Burlington, Ont., whose specializes in concussions, is one of them. He’s lead studies on concussions in Junior and university hockey players, and found that concussions happened in 36.5% and 20% of the games they observed, respectively. “That’s epidemic proportions,” he says. “It’s unacceptable.”
Echlin points to a Virginia Tech study that put instruments on the helmets of young football players to track hits, and found that [kids 9 to 12] averaged 240 impacts a season. “Why are we doing this to our children?” he asks. “Would you hit your child 240 times?”
Most sports fans are aware of some of the horror stories of former athletes stricken with CTE: NFL player Mike Webster tasing himself to get to sleep; Derek Boogaard, who died from an overdose of drugs and alcohol at 28 while still playing as an enforcer for a NHL team, and whose young brain was found to have CTE already; Chicago Bears star Dave Duerson, who shot himself in the chest, leaving behind a suicide note that read, “Please, see that my brain is given to the NFL’s brain bank.”
It’s difficult to know how many professional – or amateur – players get CTE from their hits, because it can only be diagnosed after death, by looking for an abnormal buildup of tau, the same protein found in people with Alzheimer’s. (Doctors can’t diagnose CTE based on people’s symptoms, because they’re not specific and resemble other diseases.)
Researchers at Boston University have analyzed the brains of 91 professional football players and found that 95% of them had CTE. They also found it in 131 out of 165 people who played football at lower levels. But it’s important to keep in mind that these brains were donated for examination because the disease was suspected – they’re not representative of all professional athletes, and even less so of amateurs. “There’s a huge bias in the way we’re looking at this,” says Lili-Naz Hazrati, a neuropathologist at the Hospital for Sick Children who works with a similar brain bank.
There have also been some surprises: The University of Toronto has not found it in some pro athletes, including a hockey enforcer. There seems to be significant individual variation in which people will get post-concussion syndrome as well. “We recently looked at our data at the Canadian Concussion Centre and found that a significant number of people have post-concussion syndrome after even a single concussion, and others don’t get it until they’ve had 10,” says Tator. Researchers don’t know why this is, but they suspect it may include a genetic component – Tator even asks patients how siblings have reacted to concussions. For the same reason, it’s very difficult to tell how many concussions is too many. “We don’t know what the magic number is,” says Tator.
But we do know that the damage from concussions is cumulative, so those who have had many before have a greater chance of long-term effects. Teenagers are also at risk, because “the adolescent brain is the most vulnerable,” says Tator. That may be because the brain is making millions of connections for the first time, especially in the frontal lobes, and those new connections are particularly vulnerable. Teens also participate in riskier activities and more sports, so they’re more likely to have repeated concussions.
The prescription for recovery from specialists often centres around physical and mental rest, and then a gradual return to normal activities. The physical damage from a concussions can cause anxiety or depression, and the isolation that can result from not being able to return to everyday activities can also exacerbate it, says Ryan Todd, a resident who’s studying psychiatric illnesses caused by concussions at University of Toronto. The recovery process can be hard, agrees Echlin. “People are anxious to get back to sport, to school, to their jobs. But it’s worth it.”
Urban found that taking time off from her activities was difficult. By the time she had her third concussion during a hockey game, she knew to report it to the medical staff right away and take a break from playing. And unlike the first time, this time her symptoms – headaches, dizziness and sensitivity to light – were undeniable, and immediate. To recover, she wore sunglasses, stayed calm and rested – not being able to read, for example. Yet she sat and wrote an exam, uncharacteristically failing. “I don’t like missing things, delaying things,” says Urban, who would go on to get a masters in neuroscience and is now studying concussions as part of her PhD.
It also worsened her anxiety. “It’s hard for me to say whether the concussion was a direct cause of that,” she says. “But it’s really taken until this year for me to, with help, be able to adjust to [my anxiety] and cope with it.” She also says she has felt a bit off since that concussion. “At the end of the day, I’ve never really felt the same.”
A specialist can help players make the difficult decision of whether or not to stop playing their sport. “Cognitive decline [for example] would be a universally accepted reason for that,” says Tator. Echlin also discusses it with his patients. “When patients come in with the third concussion – or even the second, if they’ve been out for a few months and still have symptoms – I’ll ask, do you want to do this again? What’s your goal here? Is it to play sports and go to school, or is it to risk sustained impairment?”
For Urban – who ended up playing in the Canadian Women’s Hockey League, one step below her Olympic dream – the risks are worth it. “Personally if I had a kid right now I’d want them in sports, because I think the benefits are greater than the risk of having a concussion,” she says. “There’s only so much prevention we can do. Injuries are inevitable, but it’s that recovery that’s the most important piece.” While she doesn’t regret playing, she does feel that she should have taken better care of herself after her concussions.
Educating parents, coaches and players
It’s important to take the time to recover after a concussion, because going back to regular activities increases the chances of long-term symptoms and makes it take longer to recover. In rare cases, if you suffer a repeat concussion before the first concussion has healed, it can result in second impact syndrome, which can be fatal. That’s what happened to Rowan Stringer, a 17-year-old rugby player who fell into a coma during a game after she suffered her third concussion in a week. Her parents later found out she had Googled concussion symptoms and texted her friends about it – but had never told an adult. “She never found the proper information that would have given her any idea of the terrible ramifications of playing when your brain hasn’t had time to heal,” says her mother, Kathleen.
Her family is now pushing for more education in schools around concussions through a private member’s bill in Ontario called Rowan’s Law. “If you educate the kids now, they’ll grow up and it’ll be like no drunk driving, no bullying, no smoking,” says her father, Gordon. “They’ll grow up knowing that if they get a hard knock on the head and they’re not feeling right, they’ve got to give their brain time to recover. That’s how we’ll change the culture.”
Doctors like Echlin are also advocating for making sports safer, arguing this is a public health issue. “In the end, we should change the sports,” he says. He believes parents are also rightly stepping away from contact sports like football and hockey, towards things like basketball and soccer. “If I had a child right now, it would be very difficult for me to recommend a sport where there are repeated hits,” he says.
There are also many efforts to educate players, parents, coaches and trainers on the symptoms and repercussions of concussions, trying to get players to ditch the “walk it off” culture that has been standard for so long, and to embrace proper recovery protocols. “Historically, professional athletes would have a concussion a few minutes before, and they’d go back on the field while they couldn’t remember, they couldn’t see properly. Kids would do it too,” says Hazrati. “That person should not be going back out.”
Education is particularly important because spotting a concussion often relies on a player reporting symptoms. “Some kids lie about their symptoms in order to escape from being excluded [from the game],” says Tator. That’s why a lot of the current research is focused on finding an objective test for concussions and a test for CTE while people are living, using things like diffusion tensor imaging MRIs, magnetoencephalography scans (MEG), PET scans and blood tests for tau proteins. “The whole world is looking for an objective test,” says Tator.
In the meantime, parents should follow any hunch that their child has a brain injury, says Echlin. “If you suspect anything, then get that child to a specialist to be evaluated. Don’t wait or be intimidated by the sport culture or any part of the team.”