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Things to think about if you want to play hockey

Posted on December 16th, 2011 in Brain Function,Sports by Robert Miller

Derek Boogaard (from the NYT)

No doubt many of you have already read the New York Times articles on the short life of Canadian hockey enforcer Derek Boogaard who was initially drafted into the NHL by the Minnesota Wild.  In May of this year (2011) he was found dead by his brothers in his Minneapolis apartment,  after a night of consuming pain pills and alcohol.  He was 28 years old, an age at which a professional hockey player normally expects to be in the prime of his career as a player. But at the time of his death, Boogaard’s mental health had deteriorated; he showed signs of emotional instability and depression. Several months after his death, the results of his brain postmortem analysis came back: it revealed serious signs of brain degeneration with extensive deposits of “Tau” protein in many different brain regions: he was suffering from severe Chronic Traumatic Encephalopathy  (CTE).  Dr. Ann McKee, the Boston expert in CTE, who carried out the analysis of Boogaard’s brain,  informed Derek’s parents of the diagnosis and said that had he lived, he very likely would have suffered from mid-life dementia.   Thus,  it was  more than alcohol and drugs that caused Derek’s problems. Friends and family all noticed that he had gone through significant changes in personality before his death and it now seems clear that his brain had been traumatized into an emerging state of dementia.

After more than six months pursuing Derek’s past history, including extensive interviews with members of his family, doctors and NHL officials, reporter John Branch published a three part series in the New York Times on Derek Boogaard’s rise and fall as a hockey enforcer.  Derek’s role as a hockey enforcer meant that his job was to fight the other team’s enforcer. He was not drafted into the NHL for his skating skills or goal scoring. In fact during his entire NHL career he scored only three goals. He was drafted for one role only–his ability to hit others, while being hit at the same time. The National Hockey League, which claims that fighting is against the rules (after each brawl, both fighters must go to the penalty box for five minutes); they also argue that the enforcer arrangement helps keep violence on the ice minimized, because if players know they might have to face the other team’s enforcer, someone that might deliver a blow that could break a nose or a jaw, they themselves are less likely to start a fight on their own. If you have ever been to an NHL hockey game and sit close to the plastic partitions at either end of the rink, you quickly learn how violent the sport is, even without an enforcer.

Every Canadian boy who plays hockey wants to make it to the NHL as a goal-scoring standout. But for those who don’t make it that way, if you are big and tough and willing to fight, you can get to the NHL through the side door as an enforcer. Derek was drafted in 2001 by the Minnesota Wild  for his success as an enforcer while playing in the Western Hockey League for several years. Team enforcers must always be ready to assume their role: as tensions and rough play of a hockey game escalate, the likelihood that the enforcers from each team will  square off in the rink, with gloves dropped and fists flying, becomes all but inevitable, even though a fight does not take place in every game.  Once a member of an NHL team, Derek quickly fulfilled his role as an enforcer and became the single most feared player in hockey. As a result, he was one of the most popular, widely recognized players on the Minnesota Wild hockey team.

Most players and fans believe that fighting is part of an NHL hockey game and everyone who profits from the sport believes that fighting is essential to maintain fan interest and attendance.  By the time Derek died, his performance as a skater and fighter had badly deteriorated. He was addicted to pain killers and alcohol, but in addition, he was confused and depressed, as he faced an uncertain future. Though he was seemingly addicted to pain medication, he probably had no idea that his addiction and consumption of Oxycontin could not relieve him from the confusion and depression he felt as a result of  the brain damage he suffered from his life as an enforcer.

Derek had been drafted by the Minnesota Wild, not because of his skating ability, but because of his fighting skills. At 6 feet 8 inches he was an imposing opponent and quickly gained a reputation as the best enforcer in the league. His parents had sent him for additional training as a boxer to hone his fighting skills in hockey. Fans in Minnesota loved him and he always attracted a lot of attention in the bars he went to in Minneapolis.

Reporter John Branch has provided an intimate account of Derek Boogaard’s rise to prominence as a hockey enforcer and his decline in performance, at least part of which can be attributed to the brain damage he suffered from numerous fights and many concussions. No one knows with certainty how many concussions Derek suffered during his hockey career, but then too, no one knows if simply adding up the number of concussions a player has increases his risk of CTE. Does merely getting hit hard without an ensuing concussion also contribute to the development of CTE? The three parts of the published articles include Derek Boogaard: A Boy Learns to Brawl“, “Derek Boogaard: Blood on the Ice”  and  “Derek Boogaard: A Brain ‘Going Bad’“; these articles appeared on December 3-5 of this year. A video that covers Boogaard’s  life and the postmortem diagnosis is part of the supporting material associated with the publication. Numerous other links are available that reveal more about the pathology of the brain in CTE, and the likely etiology of the disorder, though the details of the disease remain poorly understood. The figure below shows the dark staining material based on immunostaining techniques that reveal the tau protein for different sections of the cerebral cortex obtained from three different individuals (A-C), while the figures below (D-F) are higher magnification microscopic sections revealing the dark neurofibrillary tangles characteristic of CTE and other degenerative disorders. These regions of the brain are associated with nerve cell destruction and glial reaction. To a pathologist, these images reflect serious brain damage and functional incapacity.

From McKee (J Neuropathol Exp Neurol, V 68, July 2009, Fig. 2)

Perhaps contributing to the rapid decline in Derek’s mental state, was the manner in which he fought [from another player about Derek’s fighting]: Derek would take two or three punches to land one good one. He wasn’t a defensive fighter. I remember he said: ‘I hate guys that hide. When I fight, I’m going to throw, and I’m going to throw hard. I don’t have an off switch.’ Anytime a fight didn’t go his way — a draw or maybe he thought he lost — that would eat at him.”  As an indication of Boogaard’s mental deterioration, at one point during Derek’s career (quote from the article), “in the fall of 2009, a team doctor asked Boogaard to name every word he could think of that began with the letter R. He could not come up with any.”

When his brain was examined in the laboratory of  Dr. Ann McKee she was shocked to see such an advanced level of CTE in a person so young. The “tau” protein has numerous functions, including  its service as an important envelope protein for microtubules, one of the main transport highway systems for moving material from the soma into the axon and back. If that system is damaged, nerve cells are at increased risk of cell death.  The “Tau” protein is also abnormally present in Alzheimer’s disease and other degenerative disease states, including some cases of Amyotrophic Lateral Sclerosis (ALS or Lou Gerhig’s Disease–the acquired not the genetic form)  that are referred to as “Tauopathies.” When Dr. McKee talked with Derek’s parents and conveyed her diagnosis, Derek’s father found it somewhat reassuring that his son’s brain deterioration was so advanced that, had he survived, he very likely would have become senile in middle age.

Ann McKee, a neuropathologist, runs the Center for the Study of Traumatic Encephalopathy at Boston University School of Medicine. Her collection of brains from athletes now includes 80 and while each of them suffered from some level of CTE, Boogaard’s brain revealed the most significant level of damage she has seen, quite shocking for someone so young. The study of traumatic brain disease first began with boxers, then moved to football players and more recently has focused on hockey players. Unfortunately, at the present time, the disease can only be diagnosed at autopsy and not during the life of the athlete. Although the Center has only four brains from deceased hockey players, each of them showed signs of tau pathology.  Initially the NFL was suspcious about the connection between brain trauma from football injuries and degenerative brain disease, but they now support studies of the Center and force players to sit out at least one game if they experience a concussion.  Currently the NHL has rejected the idea that hockey is associated with CTE, although awareness is increasingly focused on preventing players from playing after experiencing a concussion. The trouble with this rule is that every enforcer realizes their special vulnerability: if they shows signs of weakness, the will soon be traded. Boogaard was let go by the Minnesota Wild in 2010 and wound up playing a few games with the New York Rangers so pressure exists among enforcers not to reveal the depth of their injuries and to keep playing when hurt.

Vertebrate evolution, with an increasing emphasis on expansion of the brain cavity and its support for enhanced cerebral function,  developed a marvelous fluid encasement  and meningeal system for protecting the brain and preventing acute injury from violent, sudden movements. As sports were introduced and became more violent, helmets were developed to enhance the protection of the brain, but we now realize that this additional protective method does not work effectively when someone is holding the shirt of an opposing player and trying to drive their fist through his jaw. Ejection of the helmets during a fight usually happens, even though it is against the rules to play without a helmet. Both boxing and hockey celebrate and promote the contact sport of a fist from one opponent meeting the jaw of another. The emerging analysis of traumatic brain injury from such collisions means that to continue on with these sports without dramatically improving the protection for athletes engaged in them will put our culture back to the era of Rome and the coliseum events where human destruction was a sport.  Perhaps we are there already.

Minnesota, right next door to Canada, is a hockey state. When we moved to Minneapolis from St. Louis  in 1988, our two sons were 11 and 8 years of age. They were both eager to try and play hockey. So we signed them up for skating lessons during the summer. In many ways, I was relieved to see that they were so far behind their peers in terms of skating skills, such that they had very little chance of catching up, without putting in some extraordinary additional effort. Nevertheless, both played “neighborhood hockey” which was a much milder form of the game and more suitably tuned for transient interest. We had neighbors whose sons were more serious about hockey, some of whom wound up playing for the high school team. At that level, many young hockey players in Minnesota, like their Canadian counterparts, harbor a strong desire to play in the NHL and the quality of ice hockey at the high school level in Minnesota is quite impressive. But one of our neighbor’s sons experienced several concussions as a star of the high school hockey team, which seemed to permanently change his mental state to one in which he showed signs of confusion. I was grateful that neither of my sons took up hockey or football in any serious way. What outweighed any passion they had for sports, was a passion for reading and learning. I believe that my wife’s constant reading to them while they were evolving in the womb was an important element in creating their strong bond for literature and their pursuit of English Literature as a major focus in their lives. Now, if we only had a culture that was strong enough to support such interests.


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