Concussions and depression: Yes, Virginia, there IS a connection.

Wade Belak, 1976-2011

 

It’s been a rough summer for hockey. The deaths of Derek Boogaard, Rick Rypien and Wade Belak have raised questions about the role of fighting in the NHL, and whether the NHL/NHLPA are doing enough to support players with mental health issues. I was astounded to find I was consistently finding people questioning the link between head injury and depression in the numerous news stories and blog posts on the subject.

The CBC recently published an interview with Dr. Robert Cantu, co-director of the Centre for the Study of Traumatic Encepholopathy at Boston University. Dr. Cantu (a neurosurgeon) explains that depression, anxiety and substance abuse are all common in athletes with CTE (chronic traumatic encephalopathy). He goes on to state something any rational person could have guessed – that NHL players have admitted to him that they’ve had concussive-type injuries far more frequently than they’ve actually reported to their coach or trainers.

 

In a truly spectacular show of idiocy, the CBC’s story received comments like these, questioning the head injury/depression link:

 

IMHO, hockey players kids are raised as prima donnas who are encouraged to win at atl costs. I find a lot of them to be incredibly immature. Scientists should be looking at their lifestyle first. I would think the depression came from excesses in lifestyle, and an immaturity with which they cannot cope with the stress related to that lifestyle.

- GordonRobertson

Nice try.
These tragedies likely have more to do with the moral conflict one would have to deal with after having been paid a large sum of money to inflict violence on others.
Once again nice try Dr. Cantu.
Obviously the NHL did a good shopping job. 

- Hihohum

 

Wow. So here we have the (apparently not uncommon) opinions that depression comes from lifestyle excess, immaturity, and moral conflict. No doubt GordonRobertson and Hihohum’s opinions are based on their extensive reading on traumatic brain injury.

 

Right?

 

Hell no, because they’re completely wrong. There are literally thousands of studies linking traumatic brain injury to depression, and not just in CTE (a condition so dramatic that it actually changes the gross appearance of the brain), but also in mild concussive injuries. Something that keeps coming up is the argument that correlation does not imply causation. Do the concussions actually result in depression, or do people who’ve had concussions just happen to also be depressed?

 

Yes, concussions can cause depression. 

 

Researchers at McGill’s Montreal Neurological Institute did a study using fMRI (functional MRI), a technology which looks at blood flow to specific areas of the brain as related to neural activity. Put simply, the more neural activity in an area, the more blood flow to that area. The McGill team examined athletes suffering from post-concussive syndrome both with and without depression, and compared them to athletes who had never been head injured.  None of the athletes studied had been diagnosed with depression prior to their injury.  The team found that the fMRI results on the depressed post-concussion athletes were very similar to those seen in people with major depressive disorder. Let’s make this crystal clear – after a concussion, athletes with no history of depression became depressed. Fancy brain imaging on these athletes looked like fancy brain imaging done on people with regular (non-head injury-related) depression. What’s truly scary is that the concussed athletes (both depressed and not depressed) were also found to have areas of grey matter loss in their brains. Let me say that again another way. The actual anatomy of their brains had changed.

 

Not convinced?

 

How about the 3rd International Conference on Concussion in Sport? In 2008 a group of neurologists, neurosurgeons and representatives from various hockey organizations sat down in Zurich and spent a long time discussing nothing but concussions. The idea was to produce a list of recommendations for the management of head-injured athletes that could be used by doctors, trainers, and other people involved in their care. The group encouraged evaluating head injured athletes for depression, as “Mental health issues (such as depression) have been reported as a long-term consequence of traumatic brain injury, including sports related concussion.” They also provide about 11 references for that statement, which you’re more than welcome to look up on your own.

 

The implications

 

It’s difficult to pin down an exact percentage of people with concussions who end up with depression as well. A review article published in 2001 suggests the number could be as high as 42%. Dr. Cantu’s experience, as well as that of anyone who is an athlete, who’s been around an athlete, or who’s ever spoken to an athlete tells us that a lot of concussions go unreported. The implication is also that there are a lot of athletes (in the NHL and elsewhere) who could be suffering from depression and other mental health problems.

The NHL/NHLPA Substance Abuse and Behavioural Health Program has come under fire in the wake of Boogaard, Rypien and Belak’s deaths. The suggestion is that not enough is being done to protect the well-being of NHL players and alumni. The NHL and NHLPA released a joint statement on September 1st addressing the deaths.

 

 

While the circumstances of each case are unique, these tragic events cannot be ignored. We are committed to examining, in detail, the factors that may have contributed to these events, and to determining whether concrete steps can be taken to enhance player welfare and minimize the likelihood of such events taking place. Our organizations are committed to a thorough evaluation of our existing assistance programs and practices and will make immediate modifications and improvements to the extent they are deemed warranted.

It is important to ensure that every reasonable step and precaution is taken to make NHL Players, and all members of the NHL family, aware of the vast resources available to them when they are in need of assistance. We want individuals to feel comfortable seeking help when they need help.

 

Obviously NHL players are either not “aware of the vast resources” or not “comfortable seeking help”. Whatever is currently being done can’t be enough if three players have (directly or indirectly, intentionally or not) killed themselves in under 5 months. Were Rypien and Belak’s depression issues linked to head injuries? Does it matter? Whether their depression was pre-existing or the result of an injury, it was real, and it killed them.

Having said that, knowing that depression is found in as many as 42% of people suffering head injuries, it behooves the NHL to find a way to reduce those injuries. Fighting has been named as a culprit, as has contact with the head, hits from behind, and I’d add poorly fitted helmets to the list. The NHL has made efforts to reduce injury with Rule 43 (checking from behind), but remains miles behind other hockey organizations. One of the few sane commenters on the CBC article noted that the most exciting hockey game they’d watched in recent memory was the 2010 USA-Canada Olympic gold medal game – a game played under IIHF rules, where hits to the head and fighting aren’t permitted.

 

Take-home points

 

Some concussions cause depression. Period. No, no, we don’t need to talk about it. The science is there.

Fighting for the sake of fighting (I’m looking at you, Matt Carkner and Colton Orr) has no place in an NHL interested in the well-being of its players. Rule changes need to be made to reduce the incidence of head injuries. Obviously the very nature of the game dictates that you can’t eliminate every injury. The point is to eliminate what you can. The IIHF, NCAA and Olympics all have more protective rules, and all have exciting hockey.

The NHL/NHLPA need to do more to ensure their players and alumni’s mental health and substance abuse needs are taken care of. Three deaths in less than five months should be an enormous wake up call – one that never should have happened.

 

The folks at puckscene are hosting the Wade Belak Memorial Charity Drive to benefit the Tourette Syndrome Clinic at Toronto Western Hospital, the charity he’d chosen to skate for on Battle of the Blades.

September 4-10 is National Suicide Prevention Week in the US. Your contribution can be as simple as educating yourself on the warning signs of depression and suicidality. Extensive resources can also be found at The Canadian Association for Suicide Prevention.

 

References: 

Jen-Kai Chen; Karen M. Johnston; Michael Petrides; Alain Ptito
Neural Substrates of Symptoms of Depression Following Concussion in Male Athletes With Persisting Postconcussion Symptoms
Arch Gen Psychiatry. 2008;65(1):81-89.

M Aubry; R Cantu; J Dvorak; K Johnston; P McCrory; W Meeuwisse; M Molloy
Consensus Statement on Concussion in Sport: the 3rd International Conference on Concussion in Sport held in Zurich, November 2008
Br J Sports Med 2009;43:i76-i84.

Eugene Gourley; Jeffrey S. Kreutzer; Ronald T. Seel
The prevalence and symptom rates of depression after traumatic brain injury: a comprehensive examination
Brain Injury 2001; 15(7):563-576.

Torn pectoral? Gross, dude.

Want to know what it takes to gross me out? This:

Gross.

That’s Scott Howson, GM of the Columbus Blue Jackets. I could easily fill a post on the subject of how kickass it is that there’s a GM on Twitter (solid PR move, Columbus), but let’s talk about the pectoralis major and what happens when you tear it (other then me getting grossed out).

Pectoralis Major (aka the pec, pec major, moobs, etc.)

Pectoralis major

Pectoralis major is the muscle that makes up the bulk of what your personal trainer calls your pec. You’ve got one on each side, and if you’ve ever benched too much, then you know exactly where they are.

The pec originates at the sternum, clavicle and aponeurosis of the external abdominal oblique, and inserts on the bicipital groove of the humerus.

Huh?

The pec is connected to the sternum, collarbone, top of the abs, and the upper arm.

That’s better.

It has several jobs, mostly involving shoulder movement (and holding your arm on), and the NCAA guide to “Ice Hockey Officials’ Signals” will illustrate them nicely:

Arm flexion

Arm flexion: In order to get your hands up in front of you to signal cross-checking, you’d first have to raise them up in front of your body. That’s arm flexion.

Arm adduction

Arm adduction: To signal kneeing, you reach across your body and slap the opposite knee. To do this you have to adduct your arm (the opposite of raising it away from your body to the side).

Medial rotation of the humerus

Medial rotation: Delay of game? Well, actually this isn’t really close. Imagine your arm is bent at the elbow with your hand pointed straight in front of you. Rotate your arm so that it’s across your chest (like you’ve got it in a sling). That’s medial rotation.

Deep inspiration: The NCAA can’t help me here. If you take a really deep breath, the pectoralis helps expand your chest.

Assorted scapula (shoulder blade) jobs: Flex your pec and you’ll have a better idea of what it does to the shoulder blade than I could possibly explain.

Holding your arm on: Obviously your arm is connected to the rest of your body by a lot more than your pec, but it definitely contributes. The tendon that attaches the pec to the humerus (upper arm) is about 2 inches wide – that’s not insignificant where tendons are concerned.

The Injury

Pectoralis tears aren’t exactly common, which just as well because they’re painful and take a long time to heal. The tear generally happens during the bench press, and results in sudden pain, swelling, bruising, and a dimple above the armpit (from the missing muscle). This is a gross injury on a lot of levels – there’s horrible pain, your arm stops working properly, and many patients who’ve had this injury say they actually heard their muscle tearing when it happened.

Two thirds of pec tears involve pulling the tendon off the humerus. The rest are scattered amongst pulling off one of the other attachments, or rupture of the pectoral muscle itself (which is thankfully uncommon).  Since rupture of the tendon that holds the pec to the arm is the most common, that’s what we’ll be looking at.

The Repair

The best results are achieved with a quick repair. Older or sedentary patients can be managed conservatively and non-operatively, but since the majority of these injuries occur in athletes, they’re almost always repaired surgically. The repair involves opening the shoulder, scraping what’s left of the tendon off the bone, and re-attaching the severed end of the pectoralis tendon. Traditionally the repair was done by drilling holes through the humerus and threading suture through the holes and the end of the tendon.  Recent research has shown that you can get as good a result using absorbable sutures threaded onto an anchor that’s screwed into the bone (which is a far easier surgical technique).

Anchor suture

The suture takes years to be absorbed, and maintains full strength for 5 months – plenty of time for the tendon to heal to the bone.

The Recovery

The ugly part of this injury (other than hearing your own muscle ripping) is the recovery. After surgical repair, it can take four (more likely six) months to get back to pre-injury activity:

  • The first four weeks: The patient has to stay in a sling and isn’t allowed to bear weight or move their arm in any of the ways the NCAA refs are showing us above.
  • Weeks four to six:  Simple range of motion exercises start – they’re allowed to move the arm, but not to lift it up or twist it away from the body, as these movements put too much stress on the tendon.
  • Six weeks post-op: The sling comes off and all range of motion is permitted.
  • Eight weeks post-op: Isometric training begins – no weights, just contraction of the muscles by pushing or pulling a fixed object. I’m bored just thinking about it.
  • Three months post-op: Light resistance training begins.
  • Four months: Heavy training begins.
  • Six months: Full activity resumes.

As with any major injury, it can take a long time to feel good again. The same study that looked at absorbable sutures found that at fourteen months post-op all patients were happy with their result.

What this means for Kristian Huselius

He’s in for a long, long rehab. He could be back mid-November at the earliest, more likely early January. He may not feel right or play to his fullest for a year. On the other hand, he could heal quickly and be fine. This is one of those injuries that would be a bad idea to rush back with (honestly, there’s no good injury to rush).

Things I didn’t mention, and will spend very little time discussing

Steroids: Yes, steroids can weaken tendons. No, this is no way means Huselius was using them. Tendon rupture with steroid use is frequently seen in older patients taking steroids for other reasons (like respiratory problems), and the rupture is usually atraumatic (i.e. it just happens out of nowhere). Jumping right to a steroid conclusion here would be stupid. Don’t do it.

Pectoralis minor: Pec minor is a tiny version of pec major that lives directly underneath it. It attaches to the underside of the scapula (shoulder blade) and the top few ribs. Its job is to hunch the shoulders forward. Boooooooring. That’s why I didn’t bother discussing it.

Many thanks to the NCAA refs for beautifully demonstrating the actions of pec major.

- Jo

Helmets: The NHL vs. Everyone Else (Part 1)

Part 1: Helmet Rules

Since 1979, NHL players have had to wear helmets.  Frankly, there hasn’t been much progression in their equipment policy since then.  The only thing the NHL has to say about helmets is the vaguely worded rule 9.5:

“All players of both teams shall wear a helmet of design, material and construction approved by the League at all times while participating in a game, either on the playing surface or the players’ or penalty benches.”

Okay, so what exactly is a League-approved helmet?  It’s not specified in the publicly-available NHL rules.  A very scientific process involving googling pictures of NHL players has determined that it’s basically anything CSA/ASTM certified.

Dude, seriously.  Speak English.  What’s CSA/ASTM?

The CSA (Canadian Standards Association) and the ASTM (American Society for Testing and Materials) are organizations that set standards for and do testing of hockey protective gear (among several thousand other things).  The helmet standards these organizations set cover the actual construction of the helmet (ie. it can’t be leather, although that would be an interesting look), shock absorption (sorry, Wayne — the Jofa won’t cut it), penetration (can a puck or stick get through it?), retention systems (straps), field of vision, and the markings required on the helmets (the stickers on the back that prove it’s an approved helmet).

Clearly the NHL specifies that players must wear helmets that are adequately safety tested.  The kicker is that they don’t specify how the helmets must be worn, like just about every other major hockey organization does.  When a helmet flies off, it’s likely because the player wasn’t wearing it correctly.  Properly adjusted helmet straps should keep your lid in place.

Let’s Compare Head and Face Protection Rules…

For the sake of ease, I’m going to compare the NHL, the IIHF, Hockey Canada and USA Hockey.  I won’t go into goalie requirements – that’s a different animal altogether.  I also won’t discuss adult rec leagues, as some may choose to follow Hockey Canada or USA Hockey rules, and some may not.  The collection of garbage equipment that hits the ice every Sunday in my league tells you everything you need to know.

NHL:

  • Helmet: You have to wear an approved helmet while on the ice or on the bench.  No helmet required during warmups.
  • Visor:  Permitted but not mandatory.
  • Cage: Rule 9.6 actually prohibits “…pads or protectors made of metal.” but goes on to specify that “A mask or protector of a design approved by the League may be worn by a player who has sustained a facial injury”, like the visor combo Brad Stuart of the Red Wings has been wearing after suffering a broken jaw earlier this year.
  • Mouth guard: Not required, although many players wear one.  Many players also gross me (and Johan Franzen) out by chewing on them instead of wearing them properly.

IIHF:

  • Helmet: Required in the game and in warmups.  Fit is specified: “A helmet shall be worn so that the lower edge of the helmet is not more than one finger-width above the eyebrows, and there shall only be enough room between the strap and the chin to insert one finger.”
  • Visor/cage: Full face masks or visors are recommended for all players.  Women and players under 18 are required to wear a full face mask.  Players born after 1974 must wear a visor at minimum.
  • Mouth guard: Mandatory for players under age 20.

Hockey Canada:

  • Helmet: Required in the game and in warmups, with strap securely fastened.
  • Visor/cage: Under 18 and women — Full-face protection.  Over 18 — Visor.
  • Mouth guard:  Compulsory if you’re wearing a visor.

USA Hockey:

This warms my heart: “USA Hockey strongly recommends that all players and goalkeepers in all age classifications properly wear an internal mouthpiece, a HECC approved helmet and a HECC approved full facemask for all games and practices.”  FYI, HECC is another standards organization.

  • Helmet: Required in games, warmups and practices, with strap securely fastened.
  • Visor/cage: Full-face protection is required for all players below adult level.
  • Mouth guard: Required for females 19 and under, and in all players through midget level (including high school).

This is a good time to stop and point out that the IIHF, Hockey Canada and USA Hockey require that equipment be worn “…in the manner for which is is designed” (IIHF) or the player can be given a misconduct.

The wrong way to wear a helmet. (photo: Andre Ringuette)

College Hockey (bonus section):

  • The NCAA requires full face masks and mouth guards (and helmets, obviously).
  • The CIS (Canadian Interuniversity Sport) requires a helmet and at minimum a half visor.  Mouthguards are mandatory with visors.

Obviously everyone is stricter than the NHL when it comes to face protection and equipment fit.  To an extent, head and facial protection is self-policed, in the sense that the players decide if they want to wear a visor, a mouth guard, etc.  There is absolutely no question that more protection leads to fewer injuries, and plenty of excellent research to prove it.  The question is why players who grew up in systems that require facial protection and properly-fitted equipment decide to take a step back once they’ve gone pro.  There are complaints of visibility problems, discomfort, etc., but if that’s what you grew up wearing, one would think you’d be used to it.  I’ll spare you the discussion of the visibility problems and discomfort caused by a stick or skate to the eye (see: Berard, Brian).

Next time I’ll get into the medical reasoning behind a properly-fitted, properly-worn helmet, facial protection, and mouth guards.  I’ll also discuss arguments for and against them, both reasonable and stupid.

- Jo

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