CATHY WURZER: Say, before we start this next segment, I do want to mention that this conversation is going to have mentions of suicide. So if that is going to be upsetting to you, you might want to turn away for just a few minutes.

Former Minnesota Wild player Chris Simon died of suicide last week. Perhaps you heard about that. And it’s renewing the conversation about a degenerative brain disease called Chronic Traumatic Encephalopathy, what’s known as CTE. It’s a disease that affects people who have had repeated head injuries.

Simon’s family believes he suffered from the disease. But there’s no confirmation because CTE can only be diagnosed after death, with the brain autopsied. When victims are alive, CTE can cause symptoms of memory loss, confusion, impaired judgment, impulse control problems, aggression, depression, anxiety, and can cause suicide.

In the state of hockey, we wanted to learn more about the risk of CTE in hockey. So joining us right now is Dr. Michael Stuart, a recently retired orthopedic surgeon at Mayo Clinic and the chief medical officer at USA Hockey. Doctor, it’s a pleasure. Thank you for joining us.

MICHAEL STUART: Thank you for having me.

CATHY WURZER: CTE, as you know, has been found in the brains of people who played in the NFL. Some of our listeners may remember former Minnesota Wild player Derek Boogaard, who died of an accidental drug and alcohol overdose back in 2011. He was just 28 years old, and he was found to have CTE. What do we know about the prevalence of CTE among hockey players?

MICHAEL STUART: Well, unfortunately, we don’t know. As you mentioned, CTE is actually a diagnosis that can only be made after a brain biopsy at the time of an autopsy. So it’s not actually a clinical diagnosis.

There is a diagnosis called traumatic encephalopathy syndrome, which is currently being studied. But this is a diagnosis of exclusion in contact athletes, which means their symptoms cannot be attributed to other neurodegenerative diseases, psychiatric conditions, metabolic syndromes, vitamin deficiencies, et cetera. So I also share the concerns that repetitive brain injury may contribute to these neurodegenerative problems, including CTE. But there’s not yet a definite cause-effect relationship between concussion or repetitive subconcussive brain injury in contact sports with CTE.

CATHY WURZER: Hmm. It is a bit of a– as you say, it’s an issue that folks are looking at. And I’m wondering, in NHL hockey, Chris was known as an enforcer. So was Derek Boogaard. And that’s a term– for folks who don’t know, it’s a term used to describe players who fight on the ice.

There was a study from Columbia that found enforcers die younger. Of the 21 enforcers they looked at, 11 died because of causes often linked to CTE. And I don’t know what you’re going to say about this. But is there any rule that fighting– again, concussive head injuries may be associated with fighting– could play in the risk of getting brain injuries?

MICHAEL STUART: Well, certainly, that’s an excellent question. And I was actually a coauthor on that study. I just want to make the point that fighting is not tolerated throughout the world in the sport of ice hockey except in the NHL and some other professional and Junior A leagues. A fight in a hockey game is an ejection penalty in youth, high school, college, and all of international hockey, just like other sports. But people naturally associate hockey with fighting because of the NHL visibility on TV and other media platforms.

I personally have been opposed to fighting in hockey for many years because I truly believe it increases the risk of injury, including concussion, and therefore feel that fighting, even in the National Hockey League, should be a game ejection penalty. So the bottom line, I think, is even though we can’t prove that fighting results in CTE, I think it’s very clear that repetitive brain injury is not a healthy thing. And so whatever we can do in sports, including ice hockey, to reduce concussion and traumatic brain injury is a very noble goal.

CATHY WURZER: I was going through some research before I started to talk to you here. The NFL was hesitant to talk about CTE. The NHL seems like it is too. Why do you think the league is so hesitant to acknowledge CTE?

MICHAEL STUART: Well, I think they rely oftentimes on medical expertise. And if you look critically at the peer review literature or the available research, there is not a direct cause-effect relationship. However, there clearly is increased risk with repetitive traumatic brain injury and subsequent neurologic problems.

So even though they’re hesitant maybe to implicate certain activities, such as concussion or hitting your head against an opposing linemen or something, they are trying very hard now to reduce the risk and severity of concussion in sport.

CATHY WURZER: And let’s talk about that. I was watching the state boys high school hockey tournament and the girls, for that matter, because I love high school hockey, to be honest with you. And they seem to be so much more well protected now with their helmets and other protective gear that they’re wearing. Has head and brain safety evolved? It seems like it has evolved in the sport of hockey.

MICHAEL STUART: It certainly has. And our goals at USA Hockey and through our Mayo Clinic Hockey and Concussion Research Group are to reduce the risk and severity of concussion, but it’s actually a multifaceted approach. And helmets are actually designed to prevent skull fracture. They don’t necessarily reduce the risk of concussion.

But there’s education. There’s coaching techniques, promoting sportsmanship with mutual respect. There’s rule enforcement and some recent rule changes, such as penalizing all head hits and delaying body checking in games until age 13, which I think are making a difference. So there is definite priority by USA Hockey, Minnesota hockey parents and players and coaches to reduce the risk of concussion.

CATHY WURZER: Say, as a physician, and you’ve done research, what questions as a researcher do you want to have answered when it comes to CTE and other brain injuries for athletes? What’s missing out there?

MICHAEL STUART: Well, I think it all starts with prevention. And then we also have to be able to better identify and validate objective diagnostic tests for concussion. Right now, it’s very difficult as a health care provider, an athletic trainer, a physician to make the diagnosis because there isn’t a blood test or an X-ray at this juncture. We have to go by symptoms and signs. So if we are able to better identify those athletes, we could remove them from play.

And also, treatment strategies. It may be not only are there ways to prevent concussion but ways to act promptly if someone does have a traumatic brain injury to reduce some of these long-term consequences. And that’s why we’re currently doing research not only on neck strengthening to prevent concussion but also the use of a multi-ingredient dietary supplement, which may mitigate some of the effects of a traumatic brain injury, allow for a quicker recovery, and maybe prevent some of the long-term consequences.

CATHY WURZER: Wow. Now, that’s interesting. I don’t think I’ve ever heard of that.

MICHAEL STUART: Yeah. We’re in our third year of research. We’ve already done some prospective randomized clinical trials on Junior A players here in Minnesota and also on high school players, both male and female high school ice hockey players. And we are currently analyzing the data. And we’re hoping that maybe something like this will play a role.

CATHY WURZER: Well, doctor, I appreciate your time and your expertise and your thoughts on this. Thank you so much.

MICHAEL STUART: It’s my pleasure. Thank you.

CATHY WURZER: Dr. Michael Stuart is a recently retired orthopedic surgeon based at Mayo, chief medical officer at USA Hockey. By the way, because we mentioned suicide, if you or someone you know is struggling with depression or thoughts of suicide, they can call or text 988. That’s the National Suicide and Crisis Lifeline.