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Pittsburgh Penguins' Sidney Crosby, left, and general manager Ray Shero listen during an NHL hockey news conference to discuss his recovery from a concussion he suffered in January 2011 during an NHL hockey news conference in Pittsburgh on Wednesday, Sept. 7, 2011. (AP Photo/Gene J. Puskar)

Gene J. Puskar

Concussion is referred to as "the hidden" injury because its not as visible as a gashed arm or broken bone. But it has an even more sinister aspect, a Toronto psychiatrist says.

Concussion has the potential to leave the sufferer with symptoms of mental illness, and the heavy stigma of that can result in hiding the injury even deeper, Dr. Shree Bhalerao told an audience of about 200 at the Outcomes following Concussion in Hockey seminar at St. Michael's Hospital Saturday.

"I've spent 12 years doing this stuff in an acute setting, but what I haven't seen is articles from the psychiatric point of view," Dr. Bhalerao told the conference, organized by Dr. Michael Cusimano, St. Michael's neurosurgeon and pioneer in brain injury management. There will be between 15,000 and 20,000 concussive brain injuries across Canada this year, Dr. Cusimano said.

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The psychiatrist said what he sees in concussion patients is depression - 30 per cent of patients exhibit it - and diminished motivation. They're withdrawn, they have impaired sleep, anxiety and unfounded fears.

"They don't want to return to the ice. They have a feeling of panic ... the elements of an acute stress disorder," he said. Patients also exhibit personality changes. They are irritable, they have increased impulsivity and can lapse into substance abuse.

"Eighty-seven per cent have cognitive changes in short-term memory and problems in what have become known as executive functions: problems in sequencing organization, attention and planning," said Dr. Bhaleroa.

"There's still an attitude out there that brain injury is like a broken arm," said Dr. Cusimano. "You can't take your brain for granted."

In the seminar, Dr. Michael Hutchison, a post-doctoral fellow in injury prevention at St. Mike's, said a videotape study of almost 200 concussions in the NHL from 2007 to 2010 showed most are caused by head shots initiated by shoulder, elbow or gloves. Only about one in 10 were the result of fights, he said.

He found more concussions happen in the first period, when players are stoked on Adrenaline and by coaching pep talks about "owning" the rink; a high energy level and a big crowd -- contrary to the belief that injuries occur late in games when athletes are tired and let down their guard down.

Hutchison, assistant coach for the University of Toronto men's hockey team said when referees weren't strict in penalty calling, "there weren't any repercussions on the ice at the time for actions resulting in concussion."

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The seminar also heard from Karolina Urban, captain of the University of Toronto's women's Varsity Blues hockey team, who has had three concussions while playing -- the first one from a direct hit to the head, although women's hockey is supposed to have no body checking -- and two more which have not been direct head hits. In none of the cases was a penalty called, she said. Toronto's Varsity women's team had 11 concussions last winter.

Repeat concussions can happen if a player comes back when not fully healed from an initial concussion, said Toronto neurosurgeon Dr. Charles Tator. Second impact syndrome is rare, but that's a combination of bad news with good. Dr. Tator said that sometimes players die because of second concussions or are severely disabled by them.

Education of coaches and trainers of what to look for in possible cases of concussion is the key, he said. About half the states in the U.S. have legislated more education of concussion symptoms for coaches and trainers. "For some reason, we're still thinking this through in Canada," he said. He said coaches and trainers because they are on the spot at hockey games, should be trained as the first line of defence against serious brain injury.

Dr. Cusimano said part of the problem has been the macho culture of hockey. A few years ago, he said, researchers tried to take the message to hockey coaches "and some of them wouldn't be part of it," he said, fearful that they might be urged to take a softer approach to a macho game.

Rob Zamuner, who played 13 years in the NHL and is now a divisional representative for the NHL Players' Association, said NHL hockey was still making spots for enforcers -- "who have five years to do it, make the money that is supposed to support the family for their whole lives." Some decide to make that difficult deal, fearing for their jobs and suffering injury along the way, because its what they've grown up to do and do it well, he said. People are more aware of the situation now, he said.

Dr. Cusimano said about one in 4,000 hockey players has a pro career "but about 70 per cent of young mothers are thinking they don't want their young athletes playing hockey. "There's an urgency to do something now, not 10 years from now," he said.

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The incidence of concussion is serious, he said, noting research shows the occurrence of concussion is seven times as common as breast cancer and 30 times as common as HIV.

"What's happening is, it's now possible to talk about TBI (traumatic brain injury) and it becomes more possible to talk about mental illness from injury in the brain," Dr. Bhalerao said. Some may have grown up being rewarded for tough behaviour, but some may have learned it.

"It would be interesting to talk to players and see their developmental histories and to see ... are their certain enforcers or certain types of players who have a certain background? Do they have aggressive role models or have they had multiple head injuries that have made them that way even before they got to the NHL?

"Did the NHL create more of that problem?"

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Sports reporter

James Christie written sports for the Globe on staff since 1974, covering almost all beats and interviewed the big names from Joe DiMaggio, to Muhammad Ali, to Jim Brown to Wayne Gretzky. Also covered the 10 worst years in Toronto Maple Leafs hockey history. More

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