SPECIAL SERIES: HEAD SHOTS
Do concussion fears stifle kids?
CALGARY • Concussion, the blockbuster movie of the holiday season, is billed as one man’s David and Goliath fight against the NFL.
Dr. Bennet Omalu, played by Will Smith, is the Nigerian neuropathologist who discovered chronic traumatic encephalopathy in football players. His discovery, and his fight to raise awareness, pitted him against the most powerful professional sports organization in the world.
The brains Omalu examines explain so many things.
Like why Pittsburgh Steelers great Mike Webster ended up sleeping in bus stations, blowing all his money after he retired — forgetting he ever had money — and using a Taser to zap himself to sleep.
Why Minnesota Vikings linebacker Fred McNeill — so smart he began law school during his last NFL season — started to lose his memory in his early 40s and eventually would be fired from multiple jobs.
Why Chicago Bears Pro Bowler Dave Duerson shot himself in the chest rather than in the head when he killed himself at 50, leaving a note that said: “I think something is seriously damaged in my brain. Please, see that my brain is given to the NFL’s brain bank.”
The potential reaction to the film scares Dr. Pierre Fremont, chairman of the Canadian Concussion Collaborative, an umbrella organization that includes the Canadian Medical Association and the Canadian Paediatric Society.
“I fear it’s going to create another huge wave of fear,” says Fremont, past president of the Canadian Academy of Sport and Exercise Medicine. “People who have kids playing football might think, ‘My kid plays football and had two concussions in three years that were properly managed, so he’s going to die after going crazy in 20 years.’ ”
He worries panicked moms and dads will pull their kids out of sports such as hockey, football and soccer to save them from the ravages of CTE — and that this, in turn, will lead to a generation of inactive, overweight children.
When concussions are properly managed, Fremont says, there is usually no cause for long-term concern. CTE is a late complication of multiple improperly managed concussions. But given a 2014 poll released by the collaborative suggests 59 per cent of sports organizations in the country don’t have a concussion protocol in place, fear is understandable.
Fremont sees the film as a warning to Canada, a message that it’s on the clock to ensure every sports organization in the country — from AAA midget hockey in Quebec to the local skiing club offering lessons on a bunny hill in Edmonton — has a mandatory concussion protocol that is reviewed annually. This needs to be done quickly and correctly, he says, learning from jurisdictions like the United States.
Without that, he worries not only about the kids who continue to play sports, but about those who won’t.
“We need to do something about concussions before fear destroys sport participation in kids,” he says.
“Only a minority of kids will be excited about golf or swimming laps in the pool. They want to play on sports teams; they want to compete against other kids. We want kids to be active instead of gaming or getting fat. It’s so important for their health, so they don’t develop chronic disease.”
No one would ever send their child onto a football field or hockey rink without a helmet. A concussion protocol — or a detailed plan outlining the steps to safely return to school or sport — is every bit as essential.
Studies show concussions are three to six times more likely to be detected in an environment with a protocol in place, Fremont says. An estimated 80 to 90 per cent of concussions resolve totally within seven to 10 days — sometimes longer, in the case of children and teenagers — so long as the brain is given proper time to rest, according to the 2012 Zurich Consensus Statement on Concussions.
Without protocols, concussions are more likely to be missed.
“We’re missing a huge amount of minor concussions that most of the time will, by luck, resolve without consequences,” Fremont says. “But a few of those are those kids who will get a second hit that will constitute a very bad episode of concussion that could have been prevented by early detection. That’s what needs to change.”
A mandatory concussion protocol was among the 49 recommendations of a coroner’s inquest into the death of Rowan Stringer, a 17-year-old Ottawa girl who died after back-to-back concussions sustained while playing high school rugby in 2013.
A youth concussion bill prompted by that inquest was introduced Wednesday in the Ontario legislature. The bill calls for a committee to develop an action plan based on those recommendations. They have one year to report.
In Quebec, a working group on sports-related concussions was struck in early 2014. Although the group has submitted a report to the minister of sports, education and leisure, recommendations have yet to be made public.
In B.C., Moira Stilwell introduced a private member’s bill in 2011 calling for youth concussion legislation, but it died on the table. She hopes to introduce a similar bill again.
Federally, Sport Canada has formed a working group on concussions and head injuries, with representatives from federal, provincial and territorial governments. Asked about a deadline for a report, a spokesperson said “this information will be made available in due time.”
Sport Canada also is working with the provinces and national sport organizations to create educational tools such as seminars and workshops for coaches, trainers, administrators and parents.
“The harmonization of educational initiatives and management protocol tools are the top priorities,” spokesman Roger Maalouf wrote in a statement to Postmedia. “Education and community-level awareness are vital to prevent injury on the playing field.”
Further, Prime Minister Justin Trudeau has asked Sport Minister Carla Qualtrough to work with her health counterparts on a national strategy to raise awareness for parents, coaches and athletes on concussion treatment.
In the meantime, sports organizations across the country are governed by a patchwork of policies — or none at all. In 2014, the Canadian Concussion Collaborative released a poll of 44 national and provincial organizations that represent concussionprone sports. Of those surveyed, just 41 per cent had concussion management protocols in place.
WE NEED TO DO SOMETHING ABOUT CONCUSSIONS BEFORE FEAR DESTROYS SPORT PARTICIPATION IN KIDS. ... THEY WANT TO COMPETE AGAINST OTHER KIDS. WE WANT KIDS TO BE ACTIVE INSTEAD OF GAMING OR GETTING FAT. — DR. PIERRE FREMONT
Rules vary wildly from province to province or city to city — even in the same sport.
The Saskatchewan Soccer Association, for example, introduced a detailed concussion policy in 2013. One province over, the Manitoba Soccer Association said in October that it is still hammering one out. In B.C., the provincial association says it’s finalizing a formal concussion protocol, but warns that even when it’s adopted, enforcement will trickle down to youth districts and, ultimately, coaches, parents and officials. There’s just no way for an organization based in Vancouver to police concussion management in soccer leagues from Fort St. John to Cranbrook to Tofino.
“It’s trying to work with our membership to create something they can then monitor,” said spokesman Peter Lonergan. “With the province being so big, that is our challenge ... We’d be lying if we said we could be at every game, every weekend.”
The U.S. is far ahead of Canada when it comes to concussion protocols. All 50 states have enacted concussion laws outlining the steps that must be taken when a young athlete suffers a head injury. The legislation protects the respective governments from massive lawsuits — common south of the border — should a young athlete die from repeated concussions.
But is legislation the way to go? Should Canada be following the American lead?
Proponents of Rowan’s Law say such legislation will protect all young athletes by forcing sports federations, leagues and teams to enact formal concussion protocols that educate participants and mandate the steps to return to play. But Fremont isn’t so sure. In terms of protecting children, he says the results are muddy. No one is policing sports teams to ensure athletes and parents are educated about the dangers of concussions. No one is inspecting the files to ensure every concussed participant presents a doctor’s note before returning to game action.
“In every state, the literature is starting to show that it’s very nice to have that (law) — it’s been useful to increase the awareness by coaches — but not so much athletes and parents,” Fremont says. “The bottom line is they have no way to implement it.
“Before we too rapidly decide to implement similar laws in Canada, we should at least ask the question, carefully look at the literature from the American experience, and decide if we want to duplicate or innovate.”
Fremont prefers a distinctly Canadian approach.
Provincial education ministries could enact policies to cover concussions suffered at school. Currently, Ontario is the only province in the country to have such a law. Enacted in 2015 following Rowan Stringer’s death, it applies only to students injured while playing for a school team.
National sports organizations could introduce similar rules and require all their members to follow them. The respective governments could make approved concussion management protocols a condition of funding.
All sides agree: Education is essential to prevent another tragedy.
“It’s time to go back to the earliest level of sport, grassroots, where daddy is the coach on Saturday morning,” Fremont says. “That’s where it starts.”
The main goal of every concussion policy should be to educate kids, parents, coaches and teachers about the signs, symptoms and potential severity of concussions and leave the decisionmaking to physicians, preferably those with training in traumatic brain injury, says Dr. Michael Ellis, medical director of Winnipeg’s Pan Am Concussion Centre.
In Manitoba, Ellis is a vocal advocate of standardized concussion protocols in and out of school to protect young athletes across the province, regardless of what sport they play.
“I don’t think parents or coaches should ever feel like they have to be doctors,” he says. “Parents, teachers, coaches — this is not a responsibility that should be put on their shoulders. The only thing they should be expected to do is if they worry about or suspect a concussion, they have to pull the trigger on getting the kid out of the game, and hopefully the concussion protocol will take care of the rest.”
Without firm policies, emotions can override reason. Just as youths often choose to keep playing, coaches can feel conflicted when their star player goes down in a big game. Parents can urge their children to play through an injury for a chance at a championship or individual glory.
“I’ve had parents come into the clinic who have confidence in what we tell them and ensure that their child takes all the necessary steps to return to their sport safely,” says Siobhan Karam, a physiotherapist at Toronto’s Sports Medicine Specialists clinic who has experience in concussion therapy.
“But I’ve also treated athletes with complex and repeat concussions, with very visible symptoms, and their parents will insist that their child is just fine. Even the worst concussions possible, and it’s the kid’s seventh concussion, and the parent is like, ‘Oh no, he’s fine.’ And the kid is about to throw up, and his eye function is completely off.”
Ellis says any concussion protocol must include mandatory medical clearance before young athletes can return to sport.
Until Canada reaches a point where all sports have concussion protocols, Dr. Charles Tator advises parents to be cautious.
“There are still lots of positives to be taken from team sport,” says Tator, a neurosurgeon at the Krembil Neuroscience Centre of Toronto Western Hospital. “I’m not in favour of parents withdrawing, but I do encourage parents to be very vigilant. You can’t drop off your kid and leave, and you can’t allow the coach to preach violence and aggression. That is up to the parents to prevent. Parents have to be vocal, they have to be there, they have to be watchful, and they have to realize their kids’ safety is in the hands of the coach.”
As much as Fremont would hate to see parents pull their kids out of contact sports after watching the movie Concussion, he says they should walk away from any league without a protocol in place.
“They should ask, ‘Did you establish a good understanding of concussion within your organization? Can I trust if my kid has a concussion that it will be detected early and managed properly? Do you have a protocol?’
“If they don’t, parents should not have their kids involved in an environment with a high risk of concussion and no plan. Kids should not play contact football on a football team that does not have a concussion management protocol. It makes no sense.”
I DO ENCOURAGE PARENTS TO BE VERY VIGILANT. PARENTS HAVE TO BE VOCAL, THEY HAVE TO BE THERE, THEY HAVE TO BE WATCHFUL, AND THEY HAVE TO REALIZE THEIR KIDS’ SAFETY IS IN THE HANDS OF THE COACH. — DR. CHARLES TATOR