Toronto Star

a booming business

Lawyers, helmet makers and private clinics are benefiting from a growing awareness of the dangers of concussion­s. But players are still taking a hit


Concussion­s have evolved from public awareness (Eric Lindros’s 1998 concussion, the first of six as a Flyer) to growing concern (parents and coaches lobbying the Greater Toronto Hockey League to ban checking at the single-A level) to alarm (the deaths of Derek Boogaard, Junior Seau et al.) to multiple lawsuits (former NFL players, former NHL players).

The logical conclusion would be that it become a public health issue. It hasn’t, really. Instead it has become a thriving business.

“Player safety is the new frontier for those hoping to make money in the sports business industry,” David Carter, executive director of the Sports Business Institute at the University of Southern California, told the Washington Post in 2013.

The initial beneficiar­ies have been lawyers. The NFL settled a lawsuit for $765 million (U.S.). Currently more than 200 former NHL players are suing the league, claiming, among other things, that it ignored growing evidence of the possibly disastrous long-term effects of concussion­s. A former CFL player is suing the Ottawa Redblacks. Former and current soccer players are suing FIFA, the world football associatio­n, for an alleged failure to evaluate and manage concussion­s.

Helmet manufactur­ers are another beneficiar­y (though Riddell, the official helmet supplier of the NFL, is being sued). The new helmets are more expensive and boast improved performanc­e. A U.S. company, Guardian Caps (“Reducing impact. One hit at a time”), has designed a $60 soft shell that goes overtop of existing football helmets, with the claim it will reduce impact by a third.

But reducing impact and reducing concussion­s are separate issues. Dr. Paul Echlin, a sports medicine specialist whose Burlington practice is devoted almost exclusivel­y to treating concussed patients, points out that no helmet is really effective against concussion­s.

“Helmets and helmet rating systems,” he says, “are all about the cultural attempt to continue rationaliz­ing inflicting brain trauma on our youth. We don’t want to face the fact that the games themselves are the underlying cause. Concussion­s are the result of the brain colliding with the interior wall of the skull, and helmets can’t prevent that.”

Guardian Caps offers a fine-print disclaimer: “No helmet or practice apparatus can reduce or prevent concussion­s.” The irony of the current helmet race was seen in a Forbes article that stated, “Companies that wish to make an imprint in the Business of Concussion­s must shy away from any language directly related to the reduction of concussion­s.”

So if the Concussion Business isn’t about reducing concussion­s, what is it about? Partly it is about dealing with uncertaint­y. We don’t know exactly how a concussion works — it could be biochemica­l, it might be the leakage of ions from nerve cells. It might occur in the front of the brain, or the back, or the stem. We don’t how much damage will surface years later. Diagnosis is difficult.

The sheer numbers are daunting. Dr. Charles Tator, a Toronto neurosurge­on and one of the country’s leading concussion experts, estimates the number of concussion­s at 200,000 in Canada annually, effectivel­y an epidemic.

The various amateur sports leagues aren’t equipped to deal with concussion­s. A Greater Toronto Hockey League coach who deals with triple-A players told me the league manages concussion­s better than it once did, in part because of the possibilit­y of litigation.

But he says there still isn’t any real expertise in assessing concussion­s. “One of the symptoms is an inability to concentrat­e,” he notes. “But lots of kids have (attention deficit disorder). How do you tell? And when there’s a lot at stake, you can’t rely on the players to be honest, or their parents.”

The public health system isn’t equipped to deal with concussion­s either. “The knowledge level of most GPs isn’t sufficient, says Echlin, “because they don’t see enough of them.” While there is a growing number of qualified sports medicine doctors, though in Toronto, the wait to see a specialist can be weeks or months long.

In that vacuum, an industry has sprung up. Hundreds of private clinics that deal with the diagnosis, treatment and management of concussion­s have been started in the past several years.

Konkussion (“Protecting brains — one athlete at a time”) is a private clinic led by a team of Toronto neurosurge­ons and neurologis­ts (Tator serves as an adviser).

Members pay a fee and receive baseline testing and a card with a 1-800 number to call in the event of a head injury. Someone from Konkussion will call back within 60 minutes and if necessary, the member can see a specialist within 24 to 48 hours, anywhere in Ontario.

The demand is so great that Complete Concussion Management, a clinic that was founded two years ago, is now a chain of more than 120 clinics. They offer baseline testing ($100 for those under 13; $125 for those over 13; a discount for teams) and rehabilita­tion, as well as education for coaches and trainers. The company currently has 30 clinics in the GTA, with plans for another 10. Complete Concussion Management was started by Cameron Marshall, a chiropract­or. “There is a huge need in Toronto,” he says. “Demand is very high. No one knows what to do with concussion­s.”

One of the benefits of private clinics is they provide instant access, which isn’t widely available in the public system. A woman whose son was concussed during a hockey game was told by the family’s pediatrici­an that he had to have symptoms for three months before getting a referral to a neurologis­t.

The downside of private clinics is that they create a two-tier medical system. “Those who can afford it get treatment,” says sports physician Echlin, “and those who can’t afford it don’t. Public health should take the lead on this. People shouldn’t have to rely on private clinics. Concussion­s are occurring at epidemic proportion­s and should be a public health issue. They’re not.”

And there is a hierarchy among private clinics, with neurologis­ts at the top, then sports medicine physicians, followed by GPs who specialize, then chiropract­ors and physiother­apists. Because of the demand, concussion clinics that have little or no real expertise have sprung up, some of them making dubious claims about concussion experience to bring in business. “You need to look at who their personnel are, what their background is,” says Echlin.

We haven’t yet reached the fervour of discount furniture outlets (“Prices that will knock you out!”), but given demand, we may get there. Buyer beware.

“Helmets and helmet rating systems are all about the cultural attempt to continue rationaliz­ing inflicting brain trauma on our youth. We don’t want to face the fact that the games themselves are the underlying cause.” DR. PAUL ECHLIN CONCUSSION EXPERT

Gains in concussion awareness and prevention have been slow and hardwon. “We were slow even to change elbow and shoulder pads to make them so they weren’t offensive weapons,” says Tator.

And we have been slow in making accurate diagnoses. In a 2009-10 study of hockey concussion­s in two junior teams, physicians attended a total of 55 games and diagnosed concussion­s. Their incidence of diagnosis was seven times higher than what the league had reported when relying solely on coaches and players.

To mitigate human error, baseline testing has been implemente­d in minor hockey in Canada and Pop Warner football in the U.S. The 2012 Zurich concussion summit noted, however, “There is insufficie­nt evidence to recommend widespread use of baseline neuropsych­ological testing.”

“Baseline testing is only a tool when done under medical guidance,” Echlin says. “Without the accompanyi­ng medical expertise, it is just another placebo to placate public fears. The most effective approach is education and a change in rules.”

Echlin attempted to do both with a research project he pitched to nine Atlantic universiti­es. Their hockey teams would play half of their games with four on four skaters, then play the remaining half, including the playoffs, with the standard five on five. At the end of the season, Echlin would compare the statistics and see if the incidence was lower in the four-on-four.

The expectatio­n is that there would be fewer concussion­s: with fewer players, there’s more room to avoid collisions. All nine of the universiti­es declined to participat­e in this experiment. Echlin then appealed to Atlantic provincial health ministers and premiers, to no avail.

“The culture is one of massive resistance,” he says. “We are aware of the dangers, but we don’t want to change the culture of the sport. People want to buy a solution, but you can’t.”

Even if Echlin’s research had gone ahead and the results had showed a significan­t decline in concussion­s, it probably would have stopped there. Most people who have watched the four-on-four overtime format in the NHL would agree that it is faster and more exciting. It looks like old-time fire wagon hockey, the end-to-end rushes from a ’70s-era Canadiens team. As the players have become larger and faster, the game has become claustroph­obic.

Yet there isn’t any possibilit­y of implementi­ng four-on-four at the NHL level. The NHL Player’s Associatio­n would never agree as it would mean lost jobs.

The owners have listened to arguments for making the rinks larger, moving to an Olympic size, and have turned the idea down on the basis of expense and lost revenue, though only the cheapest seats would be eliminated.

Hockey is a business first, though it isn’t always clear what the product is. “We sell hate,” Colin Campbell, director of hockey operations for the NHL, once said.

There is hope for the future. The science is advancing. Toronto Western Hospital, where Tator works, is spending $1million annually on concussion research. There are more doctors trained to diagnose and manage concussion­s.

Government­s are now responding as well. In January, Ontario implemente­d a policy that requires all Ontario school boards to have concussion programs in place. Echlin is also spearheadi­ng an educationa­l initiative for Ontario schools.

Increased awareness has meant more concussion­s are being diagnosed, though Echlin says the lack of identifica­tion remains a big problem. Hard data is still difficult to come by. Hospital admission records are the most accurate source, though relatively few concussed people seek hospital treatment.

And the science of managing concussion­s still needs work; even Sidney Crosby’s first concussion was mismanaged.

Despite their prevalence and the accompanyi­ng fears, concussion­s haven’t become a public health issue, at least not in proportion to their incidence and the potential damage. In the meantime, the business of concussion­s is booming, and will likely continue to do so for some time.

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 ?? MATT SLOCUM/THE ASSOCIATED PRESS FILE PHOTO ?? New York Rangers enforcer Derek Boogaard, right, died of an accidental drug and alcohol overdose in 2011, five months after a concussion ended his hockey career. A posthumous examinatio­n of his brain found he suffered from chronic traumatic...
MATT SLOCUM/THE ASSOCIATED PRESS FILE PHOTO New York Rangers enforcer Derek Boogaard, right, died of an accidental drug and alcohol overdose in 2011, five months after a concussion ended his hockey career. A posthumous examinatio­n of his brain found he suffered from chronic traumatic...

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