Transcript
Steve McGuire: Hi, my name is Steve McGuire, and you’re listening to Hard Knock Ice. Chronic traumatic encephalopathy, or CTE, has become a growing cause of concern in the National Football League. But as the conversation continues to swell, I began to wonder how the CTE problem expands into other contact sports like hockey.
To do this, I first needed to understand what exactly CTE entails. According to the Boston University CTE Center’s website, chronic traumatic encephalopathy is “a progressive degenerative disease of the brain found in people with a history of repetitive brain trauma.” I asked Dr. Ross Zafonte, the Chief of Physical Medicine and Rehabilitation at Massachusetts General Hospital and Brigham & Women’s Hospital, to explain what happens to the brain of someone suffering from CTE.
Dr. Ross Zafonte: That’s an incredibly complex story, but just at a more basic level, the brain suggests evidence or the data suggests evidence in pathological studies abnormal Tau protein deposition, which is a type of protein that is important to neuronal function but develops an abnormal configuration and if there it’s deposited is a problem. And then there are issues around the depth of sulfide and the perivascular spaces of the brain.
SM: My previous understanding of the disease was that it was solely the result of repetitive head trauma. Dr. Zafonte explained that, while blows to the head are a significant contributor, CTE isn’t exactly that cut and dry.
RZ: The pathology and the repetitive contact are super important, that’s A. B, that we need to understand that the elite people have very different levels of exposure, they’re super important to understand, but they have different exposure than I did as a child or most people do. Number three, co-factors could be playing a role. Number four is we don’t understand all of the issues that go on with these persons and how it might make them symptomatic or not symptomatic.
SM: Dr. Zafonte also told me that it is difficult to draw clear conclusions about the disease, but that awareness of the disease and its causes is crucial at all levels of contact sports.
RZ: So I think this is an interesting and critical issue for us to understand. 1. We have higher level contact sport athletes who have been noted post mortem, after they die, in pathological specimens to have the pathology associated with CTE. 2. We cannot diagnose it yet in life. 3. We are not yet sure what the phenotype, or in other words what the direct symptoms that are directly attributable to the pathology are, although there are suspicions. 4. We’re not yet sure about what happens in early life and how it’s related, but there is some work that suggests very early exposure to contact sports is problematic.
SM: That early exposure is exactly the reason why I sought out top collegiate ice hockey programs to discuss CTE. I spoke with Bert Lenz, the director of sports medicine for olympic sports at Boston College. Bert explained that repetitive head trauma looks a lot different in ice hockey than it does in other contact sports.
Bert Lenz: I don’t know how repetitive the head trauma is because nothing is coming from a set position like in football. … Hockey, you’ve got to get yourself caught, either with your head down coming across the ice or up against the boards and then you get hit. Now, you can play the game enough if you’re a good enough player to keep yourself out of most of those positions. Though, I think the resetting doesn’t make it as repetitive in hockey as it does in football.
SM: When I asked Dr. Zafonte how severe the CTE problem is in sports outside of football, his response surprised me.
RZ: We don’t know. I don’t think we know. I think I have worries for all people who have significant long-term repetitive contact; however, we don’t know who is at highest risk. We don’t know if the pathology will show in everyone. It’s not clear that the pathology leads to symptoms in everyone. We don’t know that, yes or no, yet.
SM: According to Lenz, defensemen in hockey may have it the worst when it comes to repetitive head trauma.
BL: ... to me the defensemen are the most susceptible to not having control because they’ve got to look down, play the puck with their back to the player coming behind them so it’s gonna be hit or miss. They can make a clean play and then still get hit, or they can end up eating a puck, lose control of the puck and their feet, and then they’re getting hit regardless.
SM: At Boston College, the training staff is well aware of the dangers of head trauma and is actively working to reduce the frequency and severity of head trauma in contact sports.
BL: The City of Boston has a few mandates that we have to take certain precautions based on personnel at a hockey game or a football game. They also include men’s lacrosse in that as well.
SM: In 2014, the city of Boston passed the Gameday Safety Ordinance. This ordinance requires all D1 athletics programs in the city of Boston to provide an on-site neurotrauma consultant for football, hockey, and men’s lacrosse for the safety and treatment of the players. But according to Bert, this new law didn’t change much in terms of gameday operations for Boston College.
BL: I feel we were ahead of the curve. And a lot of that goes to us already having football and being ahead of the curve on including our physicians. We had a team already available. We didn’t have a quote-unquote neuro-specialist. But we’ve had sports medicine-trained family medicine physicians that have the extra certification, the extra qualifications that come under that ordinance that allow you to have the proper coverage at football games, and our team physicians have always had that.
SM: Boston College prizes education as a crucial part of keeping players safe.
BL: All sports, the biggest thing is education. … it’s a very important issue, concussions are real, educating the student-athletes on what the symptoms are, what the impact of them playing with symptoms becomes is one of the bigger pieces.
SM: Dr. Zafonte says that this kind of education has to be combined with real, genuine changes to the sport in order to protect athletes.
RZ: I think USA hockey changed the age of hitting for kids, early on at some time, understanding how we do that, and how we play the puck and what the optimal [unintelligible] scenarios are in limiting some elements of that early contact. And drawing up rules-based changes that accommodate for that is true.
Football is doing a lot of that now. They made some extensive efforts, as you’ve seen on rules-based changes, issues regarding everything from the kickoff and others. And there was just a study that was published about the Ivy League that talks about a decreased concussion rate because of some of the changes they’ve made.
SM: Dr. Zafonte is referencing a study published in November 2018 that focused on eight Ivy League football teams. The study indicated that concussions could be reduced in college football by making simple changes to the kickoff rules. According to Dr. Zafonte, these evidence-based rule changes are a step in the right direction for making contact sports safer for young athletes.
RZ: So, I’m not sure you can make contact sports ever completely 100% safe, but the question then becomes a) how do we maximize it and what are the risk-benefit ratios at lower levels of participation because there is a price to be paid for kids not doing anything, and a lot of kids just won’t be runners or be involved as enthusiastically in less-contact sports or in things that are a little bit slower. So, how do we maximize that safety, understand exposure risk, and understand, well, if they are exercising at a younger age and we limit certain things, what is the positive and what is the negative of that?
SM: For Hard Knock Ice, I’m Steve McGuire.