Hockey Players Are the Next Frontier in Head Trauma Research

With head hits taking center stage during these Stanley Cup playoffs, the calls are growing louder for the NHL to adopt a zero-tolerance policy.

BOSTON — The storage facility is tucked down a side staircase that feeds into an alley loading dock, past nondescript dumpster bins and bicycle racks, hidden behind an unmarked door requiring special entry access. It is out of the way on purpose. Security is a big deal with brains.

A sharp breeze ushers Dr. Ann McKee inside on this snowy March morning. Setting down her handbag, she slips into a lab coat and enters a windowless room ringed with industrial-sized freezers. Whenever new brains arrive here at the VA-BU-CLF Brain Bank, delivered via private courier, the specimens are promptly photographed, weighed, and cleaved in half, down the sagittal plane. One side is sealed and stored inside those freezers, dialed to minus-80 degrees Celsius for long-term preservation. The other is fixed in formalin solution to halt posthumous decay, then refrigerated to stay fresh before McKee and her team conduct their examination.

They are looking for signs of chronic traumatic encephalopathy, otherwise known as CTE, the degenerative disease linked to repetitive head trauma. Most often, they succeed. Last July, an article published in the Journal of the American Medical Association revealed that 110 out of 111 former NFLers examined at the VA Boston Healthcare System, where McKee works as the chief neuropathologist, had been diagnosed with CTE. It was groundbreaking research. Though the rate of pathology was less severe among lower levels of American football—91% of college players for instance, and 87% overall—the results stunned and sobered nonetheless.

In the 10 months since that study was released, McKee says, “the rate of acquisition has skyrocketed.” At last count, the Brain Bank had collected 560 brains of deceased athletes and military veterans, including 177 former NFL players and nine former NHL players, roughly one new submission every day and a half. (On top of that, McKee estimates that her office gets around five calls from families of potential donors each day.) “It’s hard to keep up,” she says. “We’ve finally gotten to the point where people recognize that we can’t just ignore this and it’ll go away. Which was basically the first nine years of my work, just trying to convince people this is actually a problem.”

No such study has been conducted among hockey players; the sample of available brains just isn’t large enough yet. And even then McKee is quick to point out that much more comprehensive trials—in which patients are tracked across multiple years, containing control groups and such—are needed before any sort of true consensus can be reached. But she is leading the scientific charge at a critical time for the sport. With head hits taking center stage during these 2018 Stanley Cup playoffs—see: Washington’s Tom Wilson on Pittsburgh’s Zach Aston-Reese—the calls are growing louder for the NHL to adopt a zero-tolerance policy, rather than issue discipline based on ambiguous terms such as “intent” and “main point of contact.”

The league meanwhile remains ensnared in a class-action lawsuit filed by more than 100 former players, who allege that teams failed to properly warn them about the consequences of head trauma, to say nothing of how commissioner Gary Bettman has approached the topic. As he wrote to U.S. Senator Richard Blumenthal (D-Conn.) in July 2016, “The science, including on the asserted ‘link’ to concussions that you reference, remains nascent, particularly with respect to what causes CTE and whether it can be diagnosed by specific clinical symptoms.”

As part of their full-throated defense in U.S. District Court that same year, NHL lawyers attempted to subpoena every available medical record, photograph and micrograph from the bank’s then-approximately 400 brains. “It was very intrusive,” says McKee, who fired back with multiple affidavits and eventually scored salvation from a recordkeeping nightmare that she estimated would’ve taken until 2030 to complete. Fortunately for science, that decision freed McKee to pursue the primary foci of her career’s work: CTE diagnosis among living people, treatment for suffering patients and, maybe, just maybe, an eventual cure. “I know people debate it,” she says. “But for me, the brain is the truth. I know what I see.”

Putting on eyeglasses and medical gloves, McKee opens a small plastic container that looks as though it might have once been filled with cotton candy and sold at sporting events. Out of the soupy formalin she gently lifts the brain of a deceased 30-year-old, wholly intact and weighing 1,490 grams. She places it atop a blue dissection pad, which rests on a steel morgue table. The room is quiet, save for a roaring fume hood to mask the wretched formalin stench. Grabbing a long, thin knife no wider than a thumbnail, McKee sets its blade against the brain’s atrophied surface.

With a steady, practiced stroke, she presses down and starts to cut.

Earlier that morning, McKee sat inside her cramped 12th-story office at the VA hospital in Jamaica Plain, five miles away from the Bruins’ home rink at TD Garden, across the alley and up the staircase from all the brains. The desk was cluttered with stacks of glass microscope slides, potted plants strewn across the sun-splashed windowsill. A realist portrait of a teapot hung from the tiled wall, which McKee had painted herself. Art exercises the creative muscles in her brain after a long day of searching for the truth.

Nearby, a pair of framed Sports Illustrated covers are displayed. The first shows Vince Lombardi, hoisted onto the shoulders of Packers players following his final game as Green Bay’s coach. The other depicts a crushing tackle from an NFL game in 2010, accompanied by an ominously blurry headline:

CONCUSSIONS

THE HITS THAT ARE CHANGING THE GAME …

… AND THE HITS NO ONE IS NOTICING

McKee was raised as a cheesehead in Appleton, Wisc., five blocks from the hotel where visiting NFL teams stayed during road trips to Lambeau Field. Before her late mother passed away, she fondly recalls visiting an assisted living home and seeing not only nurses wearing green and yellow gear, but elderly patients too. Whereas every Sunday was once reserved for watching Packers games, McKee, now in her 60s, cannot stand to see so much as a quarterback sack without contemplating what might become of that young signal-caller’s brain. “You look and you think, ‘well, I wonder how well he’ll do,’” she says. “It’s almost not if, but when.”

Fishing around her desk, McKee locates a wooden board with six slides, each containing a 50-micron sliver of brain, stained and set between two pieces of thin mounting glass. “This is actually Aaron Hernandez’s brain,” she says, referring to the former Patriots tight end who committed suicide in a jail cell at 27 years old, incarcerated on charges of multiple homicide. “To see this amount of damage in a young person,” says McKee, “it’s never stopped shocking me because it’s just unheard of.”

Imagine a construction site. The workers are the brain cells, bustling and building. The scaffolding itself is known as tau, a protein that binds those cells together and helps molecules move between them. Now imagine the gelatinous brain itself, tethered inside the skull. Each hit, each bump, each collision stretches the internal elements of the brain, rattling that scaffolding loose. The worker cells can always repair the damage—it is their job, after all—but too much tau buildup can prove toxic. Among other diseases, this is a hallmark sign of Alzheimer’s and CTE.

“See how brown that is?” McKee says, gesturing at one of the Hernandez slides. Because tau cannot be seen with the naked eye, her lab infuses each brain with a dark brown dye that stains the protein, like a lightbulb revealing a secret message written in invisible ink. “And you see how they’re all at the crevices?” she says. That is the frontal lobe, the biggest part of the brain, the part that controls decision-making and judgment and “our higher-order self,” McKee says. The part that makes us human. Hernandez’s frontal lobe is covered in dark brown spots.

According to McKee, the scientific community has already established an age-related progression with CTE. The disease worsens over time, spreading throughout the brain and infecting other functions. But there has to be a trauma-related trigger, too. “We’re trying to establish what that is,” she says. The big, concussion-causing hits are obvious candidates, but McKee points elsewhere. “On some level, that big impact is safer because you’re going to rest your brain,” she says. “The small ones you don’t even recognize you have, you’re going to rush back in and re-injure. Twenty percent of CTE cases never had concussions. Our work is really pointing to these repetitive small hits that occur, practically every play in football, but a lot in hockey too, especially if they’re an enforcer or a rough player going into the boards a lot.”

Behind the door to her office, a chalkboard lists several pending tasks in neat handwriting. The second item reads: NHL CASES. For McKee and her colleagues, that is the next frontier. She cannot divulge specific findings until the data is finalized and published, but she estimates that between 60% and 70% of hockey players whose brains have been donated to the BU bank, a relatively small group compared to their football brethren, were discovered to have CTE. That group includes ex-NHLers Derek Boogaard, Reggie Fleming, Bob Probert, Larry Zeidel and most recently Jeff Parker, as well as four former junior hockey players—all of whom committed suicide before their 30th birthday. It does not include defenseman Steve Montador, whose brain was autopsied at Toronto Western Hospital and diagnosed with CTE just the same.

“We’re trying to understand if there’s a difference in the pathology of a hockey player versus a football player, if there’s a different region of the brain that’s more vulnerable, if the hits result in a different susceptibility,” McKee says. “It’s my impression that hockey doesn’t have the same number of sub-concussive hits. It wouldn’t surprise me overall if hockey had less damage, but regardless of whether or not it’s as severe, it’s equally devastating.

“All you have to do is look at what’s happened to a lot of players. They talk about their symptoms, the symptoms are the same, the impulse control, aggression, volatility, suicidality, depression … all of those are the same.”

Back inside the lab, McKee opens a second bucket and cradles a cross-section in her hand. It is smaller than the first one, shrunken from damage and atrophy. Dried blood is pooled at spots of contusion. “Do you know how old 343 is?” she asks Audrey Hilderbrandt, a research assistant at the Brain Bank. Each bucket is marked with an identifying number, no name.

The scientific work begins when the brains arrive packaged in wet ice, usually shipped through FedEx. But securing them altogether is an involved process too. In 2009, McKee was contacted by Chris Fleming, son of Reggie Fleming, a former NHL defenseman who had died that July at age 73. The family was interested in sending Reggie’s brain for examination, so McKee contacted some friendly neuropathologists in Chicago and found a funeral service team to extract the brain fresh. From there it was shipped to the old VA Boston location in Bedford, where Fleming soon became the first hockey player both tested for and diagnosed with CTE.

At the time, this was a rare circumstance—relatives of a deceased athlete reaching out. Usually the burden of recruitment fell to Chris Nowinski, a Harvard-educated, former WWE wrestler-turned-Ph.D., who co-founded the non-profit Concussion Legacy Foundation. Now the word is spreading, largely thanks to a donation registry that has seen prominent athletes—including hockey players like five-time Olympic gold medalist Hayley Wickenheiser of Canada and New Jersey Devils defenseman Ben Lovejoy—pledge their brains to science.

“It’s not necessarily that I was expecting someone like Ben Lovejoy’s brain to show up anytime soon,” Nowinski says. “It’s more to raise awareness that there is this brain bank and we’re seeking players. We’re in a race against time. I don’t ever want Ben Lovejoy’s brain to come here. I want the program to have been shut down because we cured CTE.”

Indeed, while hockey still lags far behind football in terms of actual donations, the discussion has never been louder. Even better, former players are leading the charge. On several occasions McKee has met with Eric Lindros, the Hall of Fame forward whose advocacy efforts have been focused on education and legislation in his home province of Ontario. And a recent book by six-time Stanley Cup-champion goalie Ken Dryden—titled Game Change: The Life and Death of Steve Montador—was ostensibly written as a letter to Bettman, pleading for change.

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To Dryden and others, the issue starts at the top with the commissioner of the NHL. "He could use the considerable power and skills he has developed to make hockey the exciting, amazing, safer, better game it can be in the future," Dryden writes in the final chapter of Game Change. The issue again swirled around Bettman during a radio appearance on WFAN last month, when he referenced McKee and her Boston-based colleagues in saying, “They will tell you that as it relates to hockey, they don’t have enough evidence to reach any conclusions, and they have told me that directly.”

Later that week, McKee and Nowinski released a joint statement refuting that account, which took place in 2012 when only four ex-NHL players had been analyzed: “We told Mr. Bettman that with that sample, we could not conclude if the presence of CTE was most likely associated with head impact exposure from normal hockey play or fights. However, we were clear that the evidence supported the conclusion that in those four former NHL players, their CTE was due to the head impacts they received as a hockey player who participated in fights as part of the game.”

As a lawyer by trade whose company is currently getting sued by retired members of its workforce, Bettman was again turning to the same technicality that colored his 2016 missive to Blumenthal. The NHL has taken steps by altering its concussion protocol, implementing centralized spotters who watch games on television to supplement in-arena officials employed by the league, but merely focusing on the lack of an absolute, no-shred-of-a-doubt scientific consensus linking CTE and concussions skates past the larger point.

“Yes, we’re working on ways to diagnose clinically during life,” McKee says. “A lot of symptoms are nonspecific and could be seen in a variety of different disorders.” Currently there is no method for diagnosing CTE in a living human. And doctors just cannot traumatize patients for clinical trials either … obviously. “So we are as close to an indisputable level of evidence about trauma as possible. [Bettman’s] talking about concussions. It’s a buzzword, but it’s not the right buzzword. We’re talking about repetitive head impacts. Not just concussions, but those asymptomatic hits that occur over time, to a high level during a single season. He went over the wording carefully. But I think he’s avoiding things that are clearly indisputable.”

This is all put with a flat, matter-of-fact tone, as though McKee were reading results from a chart. The NHL might be on the cusp of dramatic changes—Penalize every head hit, regardless of intent? Outlaw fighting altogether? Promise lifelong medical coverage to retired players?—but McKee and her colleagues cannot concern themselves with those issues. They are consumed with finding blood tests that would allow doctors to diagnose brain trauma as easily as torn ligaments, or locating biomarkers to distinguish CTE from Alzheimer’s, or creating a way to inject dye into a living brain and tag the tau protein so it illuminates on an MRI. And what if they could modulate the brain environment that actually causes these problems, like changing its inflammatory response to impact?

“We can stop dilly-dallying and arguing about, is this a disease or is this my imagination?” she says. “There’s been a lot of blatant denial or obfuscation of the work. But now I think we’re at a point where, look, there’s a problem. We all know that. We need to work on solutions. Maybe that’s diagnosis during life, in young players especially so they can stop playing. Or we could identify how common this is in the hockey or football population.

“And if we can see it early, we have a much better chance of treating it or stopping it altogether.”

And for that, they need more brains.