Brain Trust: How B.C.'s sports organizations are facing the concussion epidemic

With traumatic brain injuries and the long-term fallout of degenerative brain disease permeating the broader sporting culture, B.C.'s sports organizations are under pressure to modernize their concussion protocols while educating players, coaches and officials about the dangers involved.

Every year in B.C., approximately 14,500 people visit emergency rooms because of concussions.

Numbers out of Ontario and the United States show concussions occur at a rate of about 1,100 per 100,000 people.

Hockey has been at the centre of many of the debates about concussions and their effects. Deceased players like Steve Montador, Derek Boogard, Todd Ewen and Stan Mikita were diagnosed with the degenerative brain disease chronic traumatic encephalopathy (CTE) through brain autopsies after their death.

In 2018, the National Hockey League (NHL) settled a lawsuit with more than 300 former players for $18.9 million. The players alleged the league knew about concussions and CTE and failed to protect them. The NHL denied wrongdoing and did not acknowledge liability for the players' claims in the settlement.

B.C. Hockey estimates more than 54,000 people play the sport in this province. It has taken a number of steps to better prepare participants to deal with concussions.

A B.C.-made concussion tool

B.C. Hockey says many of its associations use concussion return-to-play software for injured players and medical records software to track brain injuries.It also requires all coaches and trainers to complete training using the Concussion Awareness Training Tool (CATT).

Dr. Shelina Babul designed the tool with funding from the provincial government and other organizations. She is the associate director and sports injury specialist at B.C. Children's Hospital and sits on the board of directors for B.C. Hockey.

"I think at the very grassroots level ... immediate recognition is really the key to understand that a concussion is in fact a brain injury," Babul said. "Remove the individual from the game immediately followed by 48 hours of physical and cognitive rest and then slow, active integration back to activity as tolerated and follow the guidelines."

The CATT provides short and specific training courses for players, coaches, parents, medical professionals and school professionals. Each course features a number of video modules and follow-up questions. The courses take30 to40 minutes to complete.

And while the CATT provides valuable information about brain injuries in a short amount of time, it doesn't mention degenerative brain diseases like CTE. Babul says that was done intentionally.

"There's so many unknowns related to chronic degenerative diseases like CTE and dementia that we don't want to scare the population," she said. "As more information comes to light around CTE, and I suspect in the next five years we'll know a lot more, then we'll supplement those pieces on the site as well."

A significant portion of the CATT is based upon the 2016 International Consensus Statement on Concussion in Sport. That statement has been criticized for calling the link between repeated concussions and CTE "unknown," despite hundreds of published cases of CTE in which the only known common factor among the subjects is receiving repeated blows to the head.

The consensus statement has also been criticized for being sponsored and organized by big sports organizations including the International Olympic Committee (IOC) and the world soccer body FIFA. Thirty-two of the 36 authors of the statement have affiliations with big sports organizations including the NHL, National Football League (NFL), National Collegiate Athletic Association (NCAA), the International Olympic Committee (IOC) and others. Those relationships include employment, consultancy work, research grants and expert witness testimony. Many of the links existed at the time the statement was written. Others developed in the years following the consensusconference, while others pre-date it. The CBC was able to ascertain most of the dates for author affiliations, but some dates were not included in the resumes posted.

The CBC reached out to all 36 panellists from the latest consensus statement. Twenty-five did not respond. Most of those who did pointed to a statement from Dr. Jiri Dvorak, a Swiss neurologist and co-chair of the last conference.

Dvorak wrote that "the expert panel that authors the Consensus Statements includes people from varied clinical and scientific disciplines, including long-term degenerative diseases/processes, many of whom are not involved in organized sport."

The CBC reached out to all of the sports organizations that sponsor and organize the event as well as those that are strongly represented on the author's panel. The NFL provided a written statement, while the IOC forwarded Dr. Dvorak's response. The NHL, Hockey Canada, FIFA and the International Ice Hockey Federation did not respond.

In a written statement to the CBC on behalf of the NFL, Dr. Allen Sills, a consensus author and the league's chief medical officer said, "Important research advancements have been made over the last several years around traumatic brain injury, exposure variables, neuropathological findings and CTE. It is clear there can be long-term health risks associated with repetitive head injuries, particularly if they are not treated properly researchers and clinicians continue to work together to answer important questions about CTE, including how and why the disease manifests itself, who is at risk, and why."

What are the other B.C. organizations doing?

Football

• Tackle football is available for children starting at the age of eight, however, Football Canada will ban full, 12-a-side tackle football for children under ages 13 and under starting in 2022. Other versions of tackle will still be available. The B.C. Community Football Association (BCCFA) says it will follow suit. The BCCFA requires its coaches to complete online concussion training. It restricts the number of games players can compete in. Parents and players receive concussion education materials and parents must sign a concussion awareness form at the beginning of each season. Valder Belgrave, vice-president of the association, says registration numbers for tackle football are way down, while registration for flag football is way up.

"The significant growth that we've seen in flag football just reflects a lot of the concern that parents have with the risks associated with tackle football," he said.

The BCCFA has nothing specifically in place pertaining to CTE, but Belgrave said there is discussion on the topic.

Rugby

• B.C. Rugby's Code of Conduct requires all individuals to "understand the symptoms of concussion, and support the disclosure of those symptoms." It also requires coaches, officials and medical personnel to maintain a World Rugby concussion management certification, and adhere to the "if in doubt, sit them out"' protocol. It also follows the World Rugby Return to Play protocol. CTE is not mentioned anywhere on the B.C. Rugby website.

Boxing

• Boxing B.C. requires athletes to complete an annual medical assessment signed by a physician in order to compete. The provincial association has a new concussion subcommittee starting this year. Physicians must be present at all competitive fights and athletes must see the doctor before and after the bout.

Ryan O'Shea, president of Boxing B.C., said that safety at the grassroots level comes down to coaches understanding concussions.

"It's very, very challenging for us to be in every club, every night when there's sparring going on," he said. "I don't think athletes, three nights a week, should be in the gym going all out sparring, we know that that's not good long-term."

Soccer

• B.C. Soccer requires that all member associations have an active concussion management plan that includes concussion education for players, and parents, the removal of players exhibiting concussion symptoms, and medical clearance for return to play. B.C. Soccer also has its own two-page concussion guideline that includes the "when in doubt, keep them out" concept. Those guidelines cite the International Consensus Statement on Concussion in Sport three times.

While players in the United Kingdom under the age of 12 have been banned from heading the ball in practice, no such ban is in place in B.C. or Canada. However, Canada Soccer has restrictions on heading for players under the age of 12 including the use of lighter balls. CTE is not mentioned in any B.C. Soccer materials.

High School Sports

• B.C. School Sports is the governing body for high school sports. It has 2,577 athletes in football, 4,386 in rugby and 12,314 in soccer. Jordan Abney, the executive director, says each school district is supposed to have its own concussion protocol. B.C. School Sports has mandatory education (using the CATT) for all coaches in football and rugby. It has a motion going forward for mandatory coach training for all coaches that could be in place by fall of this year.

When asked if the public school system is implicitly supporting sports dangerous to students' brain health football and rugby Abney responded, "At this point there hasn't been any push or desire from our membership, which are the schools themselves, to look at removing either of those sports. They continue to be pretty healthy in terms of participation and interest."

Abney says B.C. School Sports is adding Rugby 7s as a demonstration sport this year. It's under consideration to become a full sport next year.

Brain Trust is a CBC Vancouver series that investigates the world of concussions, CTE and the medical research that informs their treatment.