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The quest to save athletes’ brains

Canadian researchers tackle what’s become a major public-health issue: concussion in sport.


At age 22, Kinesiology major Christophe Alarie was forced to choose between his health and his favourite sport, football. While he was a linebacker for the Université de Montréal Carabins, he suffered two concussions in the same week and a third just a month later. “And I had already had four others while playing football in high school and at CEGEP,” he said. “I was well cared for by the Carabins medical team, but I was obviously in bad shape.” Frequent headaches, memory problems, difficulty concentrating, extreme fatigue, anxiety and depression kept him out of school for an entire year.

But before putting his studies on hold, and right after being diagnosed with a sixth concussion, Mr. Alarie consulted Dave Ellemberg, a neuropsychologist and professor at UdeM who is studying the effects of concussion on the brain. “He helped me understand that the symptoms that persisted between concussions were part of the cumulative effects,” Mr. Alarie said. Intrigued by the dangers associated with this type of brain injury, he decided to write his master’s thesis on the subject, under the supervision of Dr. Ellemberg.

This would not have happened 15 years ago. No one was talking about concussions, also known as mild traumatic brain injuries. “Seeing stars” after a hit to the head was par for the course for both amateur and professional football players. Nor was it a matter of concern for the trainers or the parents of young athletes. Even scientists paid little attention.

“In the early 2000s, I submitted one research application after another to hospital ethics committees, Dr. Ellemberg recalled, “and the response was always that sports-related concussions were not considered a problem. And it was the same story from federal research funding agencies.”

Finally, in 2005, his laboratory became one of the first to receive funding from the Canadian Institutes of Health Research to further investigate these injuries, which in any given year affect one out of two athletes, amateur and professional alike, as well as many recreational athletes.

Experts refer to it as a silent epidemic because so many victims don’t bother to be treated. Some researchers say that 80 to 90 percent of concussions go undiagnosed because athletes don’t recognize the symptoms. Some are convinced that a brain injury can only be caused by a hit to the head that results in a loss of consciousness. In fact, a concussion can occur without direct contact to the head – a forceful blow to the lower body can trigger such violent vibrations that the brain bumps up against the inside of the skull – and without any symptoms for the first 24 to 48 hours.

Many athletes don’t realize that, if left untreated, a concussion followed by a second one within a short time can cause serious damage and even death. Nor are they familiar with the long-term risks, including anxiety, depression, impaired cognitive function, premature aging of the brain, Alzheimer’s-type dementia and occasionally even suicide, as seen in the cases of Junior Seau, Ray Easterling and Dave Duerson. The brains of these former National Football League players showed evidence of chronic traumatic encephalopathy, a neurodegenerative disease believed to be triggered by repetitive brain trauma.

Even before these tragic findings were published and before NHL star Sidney Crosby made headlines because of his concussions, Canadian researchers were already at work, concerned by the sheer number – more than 20,000 –of mild traumatic brain injuries reported each year in Canada. In the last 10 years, research groups studying sports-related concussions have been springing up across the country. Today, there are about 100 scientists working to improve the prevention, diagnosis, management and prognosis of mild traumatic brain injuries, whether sports-related or accidental.

At Toronto’s Hospital for Sick Children, Dr. Jamie Hutchison is developing blood tests that could help in the diagnosis and the prognosis of head injuries. “The results are showing huge promise,” he said. A few kilometres away, at Holland Bloorview Kids Rehabilitation Hospital, neuropsychologist Michelle Keightley is striving to promote the management of concussions and the recovery of young victims.

“About 10 to 15 percent of all kids in hockey will sustain a concussion during a season. [There are] about 240,000 kids in Ontario enrolled in hockey, so that’s about 24,000 to 36,000 concussions every year,” she said. “This doesn’t count other contact sports like soccer, football, rugby or even cheerleading, skiing, equestrian …” Dr. Keightley has discovered that even if kids say they feel better physically a short time after a concussion, their executive and metacognitive functions and their information processing speed often take longer to return to normal. The same observation was made in adults.

At the University of Calgary, Willem Meeuwisse and his colleague Carolyn Emery, a teacher and physiotherapist, are looking at how to prevent sports injuries, particularly concussions, in young hockey players. They have shown that body checking at the Pee-Wee level in Alberta nearly quadruples the number of concussions. “Removing body checking could prevent more than 400 concussions per year in our province alone,” Dr. Meeuwisse explained. Hockey Canada took the researchers at their word and banned body checking at the Pee-Wee level nationwide last fall.

For his part, Dr. Ellemberg is focusing on the changes that take place in the brain following a mild traumatic head injury, depending on the athlete’s age, sex, number of previous concussions and how long it has been since his or her last head injury. He and his team were the first to identify, in painstaking detail, the effects of concussions on the electrical activity in the brains of children and teens compared with adult brains. “A child’s brain is as afflicted as an adult’s,” he said, “however, the adolescent brain is more fragile because it is undergoing rapid development.”

Isabelle Gagnon, a physiotherapist and researcher at the McGill University Health Centre in Montreal, is heading up an ambitious and innovative project: to create a national database on concussions in children and teens – with their parents’ consent – for use by scientists and clinicians. The database will list the profiles of children who’ve sustained brain injuries by documenting their medical history, the circumstances surrounding their injury, their symptoms and other information. Over a six-month period, researchers will study the subjects’ balance, cognitive function, academic performance and social skills. “There are currently 48 researchers, clinicians and managers involved in the project,” Ms. Gagnon said. “This type of cooperation is rare in the research community. The large sample sizes will enable us to gain a better understanding of brain recovery in children and how to promote their rehabilitation.”

Ms. Gagnon’s project received over a $1 million in funding last November, just after the federal government announced a $7.5-million investment by the CIHR and their partners into research on concussions in children and teens. Eighteen other projects benefitted from financial support. These grants are part of a CIHR initiative to better coordinate research on mild traumatic head injuries on a national scale. Similarly, the Institute of Neurosciences, Mental Health and Addiction, or INMHA (one of the 13 CIHR institutes), is taking part in an emerging international initiative on traumatic brain injuries. The aim of this initiative, which involves the U.S. National Institutes of Health and the European Commission, is to improve the outcomes of victims of head trauma and reduce the overall burden of these injuries by 2020.

The scientific director of INMHA, Anthony G. Phillips, believes that such efforts point to the critical nature of these injuries. “They are not trivial. Whenever one loses consciousness, obviously the brain is affected. And, sadly, with head injury there can be a lasting impact. What we are trying to do collectively is to find ways of intervening effectively at the very first occurrence of a traumatic brain injury.”

Canada is making its mark in the study of head injuries. “Concussion research is just in its infancy,” said world-renowned scientist and neurosurgeon Charles Tator, director of the Canadian Sports Concussion Project under way at the Krembil Neuroscience Centre at Toronto Western Hospital.

“There is, in fact, some very good research that is being done right now across the country, but is it going somewhere? It’s too soon to know if we are on the right track or not because we don’t even know the mechanism of concussion.” To help improve the prevention, diagnosis and treatment of head trauma, Dr. Tator’s institution announced in May the establishment of the Marion and Gerald Soloway Chair in Brain Injury and Concussion Research. Meanwhile, in August, Western University’s Schulich School of Medicine & Dentistry announced a partnership with the Boston-based Sports Legacy Institute, making Western the new site of the two-year-old Canadian chapter of SLI. The aim of the partnership is to help understand and mitigate the long-term effects of concussion related to sport.

Although there is still much research to be done on concussions, researchers have been able to widely disseminate their findings up to now. “The media show a keen interest in our work,” Dr. Ellemberg noted. “The buzz grew, and [brain injuries] soon became a public health issue.”

Today, most professional sports teams follow protocols to better manage concussions from the moment they occur until the athlete’s return to the sport. Universities have also joined the bandwagon.

“We are very cautious in how we manage concussions,” explained Guy Asselin, head physiotherapist for Université Laval’s Rouge et Or football team, whose victory last year marked the team’s eighth Vanier Cup championship. The players, coaches and medical team follow the guidelines of the Consensus statement on concussion in sport, established at the first international conference on concussion in sport in 2001 and reviewed every two years by an international panel of experts.

“It is unthinkable to jeopardize the health of our student athletes for a game of football. The consequences can be devastating,” said Mr. Asselin.

When it comes to prevention, there is still a lot of work to be done, according to a recent study by Scott Delaney, a McGill University Health Centre researcher and the physician for several professional and university sports teams, including the Montréal Alouettes. He found that 20 percent of football, hockey, basketball, rugby and soccer players at McGill and Concordia universities had exhibited signs of concussion, but some of them had kept their injuries a secret. Why?

“Because they think it isn’t dangerous to play with a head injury,” Dr. Delaney said. “That’s the main reason. Others say they kept quiet because they didn’t have any problems afterward. Some are afraid they won’t be allowed to play their sport or that it will affect their relationship with their coach. This indicates that young people are familiar with the symptoms of concussion, but not the risks of continuing to play in spite of them.”

A change in sports culture is needed, maintains Dr. Ellemberg. “For some, a concussion is like a battle wound. It shows that they gave their all. Asking to be treated for it, or to be taken out of action long enough to recover, would be a sign of weakness. In my opinion, concussion research should also focus on that aspect.”

So, it seems that myths surrounding concussions are hard to dispel, leading many to advocate for a legal framework on how to manage head injuries in children. Every U.S. state has adopted a law that, among other things, requires the immediate removal from play of any athlete suspected of having sustained a concussion.

All the experts agree, however, that a law or even the most compelling study won’t completely eliminate sports-related concussions. “The goal of all this is not to say that you shouldn’t be playing sports because you’re going to get a concussion,” said Dr. Keightley. “The important message is: it has to be properly identified and managed even after that first concussion, so that we don’t get those subsequent injuries.”

Marie Lambert-Chan
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