Derek Boogard - chronic traumatic encephalopathy

When news broke of Boogard's autopsy results of chronic traumatic encephalopathy, I thought of writing a post. Since then, I read an excellent article in the New York Times about this matter and more. It's exceptionally written and it details Boogard's last few years before he died. Really sobering.

It is a must-read. You'll never see fighting in hockey the same way again.

He's back.

As per TSN.ca, Sidney Crosby will be in the lineup to face the New York Islanders on Monday.

I'm sure everyone is happy the best player in hockey is returning. Too often are careers (and lives) cut short by repeated concussions.

He's not out of the woods quite yet though. Everyone will be holding their collective breath when he gets hit for the first time tomorrow.

If ever he gets another concussion though...

James Reimer - "headaches"

Hey folks. Just thought I'd write a quick note on James Reimer, goaltender for the Toronto Maple Leafs (a.k.a. guy with one of the most badass nicknames in sports... with the exception of Calvin "Megatron" Johnson).

As you know, he was involved in a collision in a game against the Canadiens' last Saturday primarily involving his head. There has been no official statement released if he has had a concussion, post-concussion symptoms, etc.

Apparently today he developed headaches while at practice which worsened as it continued. Obviously with a combination of impact to the head + headache a few days later makes everyone jump to a concern of concussion but it's really only speculation at this point. When it comes to concussions, it involves a full clinical history (especially the day of injury at the time of the collision and hours after) and likely a number of symptoms rather than just relying on headaches alone.

If there was no evidence of a concussion last Saturday AND if he only had an isolated bout of headaches today, it makes it very difficult to claim that a concussion is the most likely diagnosis. With that said, if he had a concussion on Saturday and he's developing symptoms with activity today, there obviously has to be concern they're related. Confused yet?

So either the Maple Leafs are trying to keep a concussion out of the spotlight, or Reimer just got some unrelated headaches today. Either way, they're playing it safe which is a very very good idea.

I'll write more if/when more details become available.

Taylor Fedun - complex femoral fracture

I feel awful for Taylor Fedun. This player was a guy is 23, an undrafted free agent, and was not supposed to come close to making the Edmonton Oilers starting line-up. This preseason, he was giving management something to really chew on given his strong play.

... then this happened. The view isn't great but you don't want to a clear view of someone fracturing their femur. Trust me, it's not pretty. Now, Fedun's entire playing career is in jeopardy not just because he will have to fight hard to make a team again, but also because of how catastrophic a femur fracture can be and the loooong (but very important) road through rehab. Unfortunately, it's not an unheard of injury. People in the hockey community know what happened to Kurtis Foster almost three years ago and how long it took for him to recover. Those who watch football may remember Vikings' E.J. Henderson's injury in 2009 and his slow but eventual return.

Photo source: myhealth.alberta.ca

Picture source: Wikipedia

The femur is the longest and strongest long bone in the body. It is the only bone that runs through your thigh and forms joints at the hip and the knee. In healthy people, it is very difficult to break and these fractures are usually seen either in high velocity motor vehicle accidents or falls from a height.


Surrounding the femur are three muscle compartments - anterior (to extend the knee and flex the hip), medial (to adduct the hip), and posterior (to flex the knee and extend the hip). The strong pull of all these muscles can actually lead to a greater angle of the fracture and separation of the fragments. Also, it has a very rich blood supply which can be disrupted from the fracture and cause a lot of bleeding. Fortunately, there is often enough supply from the blood vessels in the bone itself that can provide nutrients to help with healing.

Definitive treatment involves orthopaedic surgery where a nail is inserted to help the union of the two fragments and enable strong fixation. It is associated with 98-99% union rate.

The Oilers have already revealed these following details via twitter:

Fractures can be classified (via the Orthopedic Trauma Association) as simple, wedge, or complex. Complex fractures occur when there is no contact between the main fragments, and there is usually (not always) more than two fragments broken off. A fracture is usually classified in many other ways including the angle of the proximal and distal fragments, if the bone broken through the skin (which would require immediate IV antibiotic therapy), etc. These details were not disclosed though, and understandably so because it is not useful public information.

Also, it's good to hear he went through surgery successfully. Early surgery in this case is usually associated with better outcome.

Below are reasons why this injury is concerning:

1. It can be life-threatening if not addressed promptly. The rich blood supply of the femur means that a fracture can result in a lot of bleeding. You can lose up to 3 L of blood, although the average is closer to 1 L. FYI, we generally have a total of 5 L of blood in our bodies at any given time. Maintaining adequate volume early (via IV fluids) in the injury is a very high priority. The femoral artery (largest artery in the lower body) and the sciatic nerve (largest nerve in the entire body) run nearby, but because they are surrounded by muscles, they are usually protected from injury.

2. It is a long road through rehabilitation. Early physical therapy is important, like for many orthopaedic injuries. Of course, each case is different, and activity depends largely on how well the fragments are fixated. Actual healing of the fracture itself takes anywhere from 3-6 months, and then muscle rehabilitation begins. Baseline function and strength can return anywhere from six months (esp in young patients with aggressive physical therapy) to two years (older patients). Athletes usually take a solid year to return to sports.

Fortunately, prognosis is usually excellent. Complication rates are relatively low. These complications include infection (~1%), malunion (healing at the wrong angle) and/or nonunion (no sign of healing at 3 months) of the bone (3-5%) and neurovascular injury.

It's a long road.

I remember thinking when I was younger that I loved touch-icing because of the odd time the offense beat the icing call and generated an exciting scoring change. Now, I agree with the NHLPA and I can see the likelihood for these serious injuries outweigh the potential for 'entertainment'.



Sources: UpToDate

Recent articles on injuries/health and sport

Decided I'll sneak this in every once in a while once I find a couple good reads on some deeper talk on injuries and health related to sports today.

ESPN: "NFL - No more pain-tolerance talk"
Battling the age-old, and likely outdated, philosophy that athletes should battle through pain.

Football365: "Ignorance to mental illness not bliss" tweeted from @alimsomji
Talks about a few cases of depression of soccer players in Europe.

OilersNation: "More important than Stanley: Parenthood"
Great article by Jason Gregor on an NHL player's struggle in trying to become a parent

Sidney Crosby and postconcussion syndrome

One of the biggest stories heading into the start of the NHL season: When will Sydney Crosby play again? Unfortunately, it seems that not even Crosby knows at this point. A growing number of people are starting to wonder if that day will ever happen...

The topic that I'll look at here will revolve around postconcussion syndrome (PCS) and general information about the prognosis of it.

• Symptoms and disability are usually greatest between 7-10 days after the concussion.
• Most recover from PCS by three months, with 10-15% still experiencing symptoms after one year (the article quotes possible biased reporting in the study which means the prevalence may actually be lower).
• In a small study of 79 patients who presented with concussions to the Emergency Department, 28% had one or more complaints after 6 months.
  

In the quick review I did of some studies, the risk factors for a prolonged recovery time usually included...

• older age
• increased number of symptoms immediately after the concussion (i.e. headache, dizziness, nausea, decreased level of consciousness) - one study these symptoms doubled the risk of PCS
• longer post-traumatic amnesia
• abnormalities seen on MRI or CT immediately after the concussion
• more disability when admitted to rehabilitation
  
• preinjury unemployment, substance abuse (you'd like to think that these last two aren't relevant to Crosby's case)

In a nutshell, it looks like the majority of factors that are correlated with long-term disability lie more in the acute injury itself rather than the length of recovery time itself. (Does that make sense?)

One stat that made me think of Marc Savard: In a prospective cohort (I know, not the best evidence) of 2995 people, disability 1 year after a traumatic head injury was also often associated with disability 5-7 years after the injury. However, this was also highly dependent on the severity (i.e. initial level of consciousness) of the injury.

Interestingly, some of what I was reading started to go into complications of repeated traumatic head injuries. Lo and behold, common complications of the repeated injuries include increased risk for depression and chronic pain. Ring a bell?

Here's hoping the NHL takes these head injuries as seriously as trying to keep the Coyotes in Phoenix...


Sources: UpToDate and DynaMed

Depression

Trying to talk about depression in sports, or just depression for that matter is like saying I want to discuss "apples". Where would I begin?

Given the news of Rick Rypien's passing, and arguably that of Derek Boogard, mental illness has been in the NHL newswire a lot more recently than I can remember.

And rightfully so.

I think the most important conclusion I want to draw in this post is that depression is a medical disease. It may seem like a simple and obvious statement to some, but maybe a bit harder to accept for others. I'm not going to get into how it's diagnosed, treatment, etc. Today's post is just focusing on my argument that for most people it's not something trivial or an excuse.

First off, let's clarify - sadness is part of life. Duh. We get our sad days, mad days and happy days and everything in between -- those are just emotions. We're supposed to feel them. However, a major depressive disorder is not just being sad. It comes down to a chemical imbalance in the brain that causes someone to feel hopelessness, despair, or even numbness for extended periods of time. You wouldn't say to someone with diabetes, "Hey! Stop being so tired and just correct your sugars already!". Nor would you tell someone with half a foot to try to walk properly. That would be stupid.

Pathogenesis

If you grouped all the patients in the world with depression, you'd actually have a large group of people with similar symptoms but a wide variety of different reasons for being depressed. Let's list a few key causes:

• Genetics - Single gene causes haven't been identified yet, but there is a strong pattern of heritability of depression - 42% heritability in women, and 29% in men.
• Early life adversity - exposure to severe stress and trauma as a child can cause major changes in a child's brain to stress and negative stimuli. If you want to get technical, studies have shown overactivity of corticotropin-releasing cells in the hypothalamus - that basically means the cells in the brain that stimulate stress response in the brain become overly sensitive.
• Social factors - Strangely, proximity to someone who is depressed can make you more prone to get it too. Chew on this: you're 93% more likely to become depressed if you are directly connected to someone who is depressed. Other factors include poor sibling relationships, and persistent negative and critical comments.
• Psychological factors - pessimism, neuroticism, and certain personality types are more likely to lead to depression than others.
• Secondary depression - this can arise from a number of medical conditions like heart attacks, neurologic diseases, and metabolic problems.

On top of all these causes, research has shown physical changes in the brain in patients who are depressed. I'll admit that it's tough to determine whether or not these changes are present in people who will become depressed, or occur after people are depressed (i.e. cause/effect vs correlation).

Certain neurotransmitters, or chemicals that cause signal conduction in the nerves of the brain, have shown to be imbalanced or functioning abnormally. As mentioned above, overstimulation of the corticotropin-releasing cells in the hypothalamus, resulting in abnormally increased stress responses can play a role as well. Other physical changes seen are an abnormal density of glial cells in the frontal or occipital cortex of the brain, a smaller hippocampus, or altered brain activity.

Now don't go to your family physician tomorrow and ask for an MRI of your brain to assess the size of your hippocampus, or ask for certain hormone levels to see if you're depressed. That's not the point. What I'm trying to get at here is that many people who suffer from depression should not be dismissed.

A common but often misplaced argument is: "this person has no reason to be depressed. He/she is hot/has money/lives the life." (Exhibit A: list of famous people with depression, from Wikipedia) Such a scenario is actually common with people with depression. They could have a great spouse, supportive children, a stable job, and still find sadness and disparity... that's how their brain has been wired.

Sources: UpToDate

Ryan Kesler - "labrum repair" surgery

For my first post with actual content, let's go with some fresh hockey news despite the fact that I abhor the Canucks. Never liked Ryan Kesler's antics but he carried the Canucks on his back for portions of the playoffs when others didn't show up *cough* SedinsLuongo *cough* and I can admire that.

Anyways.

As per TSN.ca, Canucks forward Ryan Kesler just underwent "hip surgery" to repair his labrum.

The labrum of the hip, or the acetabular labrum, is a ring of cartilage that surrounds the hip joint and helps with stabilization. It deepens the "socket" portion of the joint making it more difficult for the femur to slip out (coincidentally this is pretty much Wikipedia says in its article). The hip, like the shoulder, is a joint with lots of flexibility and range of motion. With these types of joints, what you gain in flexibility you often lose in stability. The labrum helps counteract this instability. (the shoulder also has a labrum)

I am GUESSING that Kesler tore his labrum at some point in the playoffs (was it the end of the Nashville series where he pulled up lame after chasing the puck?).

Many fans are probably asking why he didn't go for surgery immediately after the playoffs. With labral tears, conservative treatment (i.e. physical therapy/rehab + rest) is used first to see if symptoms of the tear abate. Only if symptoms continue despite rehab is surgery offered. Surgery involves either the repair (sewing up of the labrum) or a resection, where the torn piece is removed.

Sources:

http://orthopedics.about.com/od/hipinjuries/qt/labrum.htm

UpToDate

Wikipedia (sketch of hip)