It's been called hockey's silent epidemic.
But the number of players being concussed playing in hockey -- a recent study in junior hockey detailed in the Journal of Neurosurgery put the rate at 25% -- is shocking and should get people talking.
Silence can no longer be the status quo.
As the body of research grows, it's becoming clear the long-term ramifications of repeated concussions are devastating. They can lead to a condition called chronic traumatic encephalopathy (CTE) -- a study at Boston University in conjunction with The Sports Legacy Institute linked repeated concussions with Alzheimer-like symptoms -- for which there is no cure.
The best remedy? Don't get a concussion in the first place.
"Prevention is probably number one because some players are very badly off. Can we catch it early? Is there a drug that could be effective or a particular exercise therapy? So far, we have nothing to treat this. We can treat a concussion in the acute stages. You have to follow a strict protocol for both physical and what we call cognitive rest, mental rest," said Dr. Charles Tator, one of Canada's top experts on concussions and the founder of ThinkFirst Canada (thinkfirst.ca), a national brain and spinal cord injury foundation whose mission is to reduce the incidence of these catastrophic injuries in Canadian sport.
"But we have nothing to treat (CTE). Let's say you have have had 10 concussions and still have a lot of symptoms, you are still disabled. There is virtually no treatment for that. You can look it up on the Internet and find herbs and exercises and this and that, but there is no scientifically proven way to treat these symptoms."
Tator has helped launch a study at the Krembil Neuroscience Centre at Toronto Western Hospital which will examine donated brains from deceased athletes who have sustained concussions to try and understand what happens to the concussed brain and what causes CTE. Finding what causes it could lead to a treatment.
There are some interesting developments.
One area Tator said the Toronto Western study will examine is the buildup of protein in the brains of concussed athletes.
"We're really keen to see if we can get drug to get the protein out of the brain once it gets deposited. It seems to be deposited as a secondary effect. We don't know for sure. It seems to rush into damaged tissue and the question is whether its presence causes further damage. I suspect its presence is causing further damage," Tator said.
He said researchers are hopeful that ultimately there could be a blood test or a sampling of spinal fluid to determine whether the brain has sustained significant damage.
"We call these biomarkers and we're all hoping that one day there could be a reliable test that we could use to advise players how bad the injury is and when they can return to play."
Another question that needs to be answered is if there is a possible genetic link between concussions, their severity and long-term effects. Brothers Eric and Brett Lindros both had their NHL careers ended by repeated concussions.
"There may be certain families who are more susceptible to getting a concussion and more susceptible to their long term-effects," said Tator. "We have not been able to nail that down."
Of course, the best way to deal with concussions is not to get one in the first place.
Hockey is a collision sport and as such, players assume a certain amount of risk.
But that study of two junior hockey teams in Ontario, spearheaded by London's Dr. Paul Echlin, found that 80% of the diagnosed concussions were the result of intentional blows to the head.
A change in player mentality is needed.
The NHL was the first of the major professional leagues to form a concussion study group, introduce baseline testing and have a protocol for return to play for concussed players.
The league introduced Rule 48 to make illegal blindside hits where the principle contact was with the head after analyzing the 75 concussions averaged sustained by its players over the last few seasons. The research showed half of those were on blindside hits.
"We're talking about players getting Alzheimer-like symptoms before they're 50," Senators forward Ryan Shannon said. "We've got to respect what concussions can do, but it's tough with the way the game is structured. We're encouraged to be ruthless, to be savage and annihilate the competition. That's our culture. It's bred in us. It's tough to turn that off through penalties, but I do see the initiative with the blindside hit penalty as a big step."
According to the NHL, there were 33 concussions in regular-season games through Dec. 1 of this season, the exact number of concussions the league had at the same point through the 2009-10 campaign.
"We need to very carefully follow the concussions this year and next year and see to what extent the rule change has had or not had on change in behavior," said Dr. Reuben Echemendia, the NHL's neuropsychologist. "We do not know what is causing the concussions to be at the level they are at this time. It could be an awareness issue, and if it's an awareness issue, then the blindside hits to the head rule would not come into play there.
"But there is an uptick for the same time frame from 2008-09, and it's interestingly a drop from the year prior," he said. "So there is a lot of variability from year to year. It could be that we are making inroads in terms of our ability to communicate to players that they need to report their symptoms, that this is a serious injury, and that there is increased awareness and identification of the injury.
"It could also be that more concussions are caused because players are bigger and faster. It's hard to determine why there is an uptick."
"We have been analyzing the 200 most recent concussions, categorizing them by looking at video and trying to understand how and why they happened," NHL commissioner Gary Bettman told QMI Agency.
Bettman said the NHL will continue to analyze and monitor concussions and their causes and introduce more rules, if they are deemed necessary, to address player safety.
But when asked if the game had become too fast and dangerous, the commissioner said the league needed to proceed slowly with more rule changes.
"You can't take a sledgehammer to the game," he said. "You've got to do it with the precision of a scalpel."
"The importance is on preventing injuries because there is no effective treatment for them," Tator said. "There are players you have to tell they should never return to play."