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Why helmets can't solve concussions

A better helmet would not have stopped the internal action in Sidney Crosby's skull that caused his concussion. (Jeanine Leech/Icon SMI)

By Stu Hackel

Last month, we spoke with Hockey Hall of Famer Ken Dryden, who has been publicly discussing his concerns about concussions and traumatic brain injuries in hockey. Nearly every time this subject comes up, emails arrive and comments are posted here wondering why the sport does not merely improve the helmet, which should go a long way toward solving the problem.

So it was worth a phone call to Minnesota to discuss that question and some other concussion-related topics in hockey with  the Mayo Clinic's Dr. Michael Stuart, that institution's  Vice-Chair of Orthopedic Surgery and the co-director of its Sports Medicine Center. Dr. Stuart is also the Chief Medical Officer of USA Hockey and a hockey dad -- he has three sons who have played in the NHL: Mike, who played briefly with the Blues; Mark, with the Bruins and now with the Jets; and Colin, with the Thrashers and Sabres. Colin is currently captain of Buffalo's Rochester AHL team.

Dr. Stuart is certainly a good person to evaluate the helmet issue, even as manufacturers claim their new designs will help limit concussions. He, along with his colleague at the Mayo Clinic, Dr. Aynsley Smith, created the first Ice Hockey Summit: Action on Concussions  in Oct. 2010, to specifically address this rising problem in the sport. They plan a second such summit in the Fall of 2013.

"One of the conclusions of the group, and also the prioritized action items of this summit, was to look at hockey helmets," Dr. Stuart told Red Light. "I’m not giving up on them. I think we need to continue to look at materials, designs and novel technologies. But the bottom line is the hockey helmet does what it was designed to do, which is to prevent skull fractures and intracranial bleeding.

"There is no scientific evidence to prove that the hockey helmet reduces the risk of concussion. Now maybe it does, but we don’t have sound scientific evidence. Helmets can’t prevent this axonal injury to the brain which occurs from lineal or rotational acceleration. In large part that’s due to the mechanism of injury, the mechanism of concussion in ice hockey. Often times it’s a blow to the head; we know that."

Here's what happens inside the skull that causes a concussion, and you can see from the animation that a covering on the head won't likely prevent the action of the brain moving inside the skull:

That's why Dr. Stuart says, "It’s imperative we try to reduce blows to the head because we know that’s certainly the mechanism."

He adds that concussions can also result from blows that are not directly to the head, so even a theoretical helmet that could reduce the likelihood would be of no use. "We know concussions occur to other parts of the body. For example, the unanticipated open ice hit. You’ve seen it many times. The player, with his head down or unsuspecting, is hit in the shoulder or somewhere else and they are not prepared, and force transmission through the body, the neck and to the head causes the brain to move inside the skull.

"So it’s very clear that a helmet wouldn’t necessarily have any benefit if the concussion mechanism doesn’t involve a blow to the head."

That is not to say, of course, that helmets have no role in preventing injury. A big part of the Summit and of what Dr. Stuart advocates in USA Hockey, is for players to have a helmet that fits well. Some of the worst injuries he's seen come when helmets are dislodged or even come off during the course of play.

"The problem is magnified when there’s no facemask," he says. "If you don’t have a chin cup or a face mask, the helmet is secured to the head by the fit to the head, but also by a strap that goes under the chin and that strap is often quite loose because players don’t want to tighten a strap that presses on their neck."

Dr. Stuart and others have been working with equipment manufacturers to improve helmet fit to alleviate that problem. He's also been able to help persuade AHL team owners that visors should be mandatory for the players in that league.

Here's Dr. Stuart making a presentation to Minnesota hockey officials on some of the findings of he Concussion Summit.

Among the main priorities coming out of the Summit were to get the governing bodies of youth hockey in North America -- USA Hockey and Hockey Canada -- to approve stronger rules on hits to the head, both intentional and unintentional. At the Summit's urging, these bodies also adopted educational programs that are now mandatory for all certified coaches to help them recognize and deal with concussions among their players. The Summit also worked, and continues to work, on getting youth hockey organizations to teach body control, contact and checking skills in a practice environment starting at a young age so that physical play is not randomized but done in what many call a "head-smart" way. USA Hockey also followed the Summit's recommendation to delay legal bodychecking in games until age 13 in order to allow for greater maturity in the players' psychological and physical maturation.

Because it identified fighting as an activity that can cause concussions in hockey, the Summit also called for it elimination in junior leagues. That goal has not yet been realized, but Dr. Stuart says it's something he continues to advocate in his role with USA Hockey. While the leagues of players aged 16 to 20 have not followed that recommendation, he still believes progress has been made.

Dr. Stuart does not believe that a player with NHL potential will be at a disadvantage if he plays in a league that does not allow fighting or that the league will be harmed in its ability to attract top talent. "At the USA Hockey Winter Meetings, we heard from NHL scouts who publicly stated, 'We don’t scout junior players for fighters. We scout skill and potential,'" he says.  "If I were a player, a parent, an agent or a general manager, I would want my elite prospect to be in a league where they can develop their skill, where they are not putting their brain at risk on a nightly and weekly basis. We see all the time careers ended or at least put on hold because of concussions. So I would prefer -- especially with a young promising athlete -- to put them in a situation to get to the NHL, which would be a junior league that promotes skill and does not allow fighting. But everybody is entitled to their opinion."

While the NHL was not a sponsor of the first Concussion Summit, Dr. Stuart said the league was supportive and he applauds the steps it has taken to reduce concussions. "Their concussion program has been proactive, although certainly more can be done, and they’re working on that," he says. "but the interpretation of existing rules, the current push to reduce the number of head hits, their evaluation program, have all come a long way." He recognizes that the NHL is a different entity than youth hockey, that it is in the entertainment business, and attacking the concussion problem at that level of the game requires a different understanding.

(Perhaps the NHL will be moved to strengthen its anti-concussion efforts as a result of actions being contemplated in the insurance industry. Rick Westhead of The Toronto Star reported earlier this week that insurance companies that pay the salaries of injured NHL players are more closely scrutinizing their coverage of those who suffer concussions.)

Ken Dryden has been advocating the creation of a summit very similar to the one Dr. Stuart and Dr. Smith organized at the Mayo Clinic, and Dr. Stuart said that while he has not been in contact with Dryden, it is something he would welcome. It's one thing to have a summit and quite another to affect changes coming out of it. That is something that Dr. Stuart has been able to do. "I support (what Dryden is doing) very, very much and I’d love to help any way I can," he says.

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