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<p>“Oh no –&nbsp;are you OK?”</p>



<p>That’s the hurried, anxious question I receive from any friends and family nearby whenever my accident-prone brain is put in peril, whether I’ve slipped on some ice, hit my head on a light fixture, stood up too quickly on an airplane or bonked noggins with an overly friendly dog. Every set of eyes shifts to me. They know about the post-concussion complications that have afflicted me for roughly half my 39 years.</p>



<p>And my answer to their question is always the same:</p>



<p>“I don’t know yet.”</p>



<p>That’s the thing about concussions, right? They don’t play by any particular set of rules. They don’t even produce the same symptoms person to person. And in some cases, like mine, the symptoms don’t immediately manifest. I can be fine and, poof, the next morning, or days later, the first time I try to exercise, it feels like someone is inflating balloons for a birthday party inside my skull.</p><div class="injected-ad injected-video" data-nn-ad-tech-injection-count="0" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="170"></div>



<p>Despite the advancements we’ve made in the neurological understanding of concussions in the past several decades, particularly in the context of taking them more seriously in sports, we still know alarmingly little about them. Even when it seems on the surface like everything is OK, it isn’t always the case.</p>



<p>And maybe that’s why the NHL’s concussion protocol system failed Cale Makar over the past couple weeks, despite its best efforts to protect the Colorado Avalanche superstar defenseman.</p>



<p>First off – how does the system work? The protocol and concussion spotters may feel like nebulous concepts the league keeps locked away only for team medical professionals to understand, but that’s not the case. The protocol is available for public consumption – and, I must admit, it’s far more thorough than I remembered. <a href="https://www.nhl.com/news/nhl-concussion-evaluation-and-management-protocol-for-2022-23-season/c-335002568">You can read it here</a>.</p><div class="injected-ad" data-nn-ad-tech-injection-count="1" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="137"></div>



<p>It outlines the education process every player undergoes before a season starts. It explains Baseline Testing in detail. It breaks down the steps and visible warning signs in evaluating a possible concussion. It lists symptoms to watch in the days following a concussion. It has a fairly exhaustive breakdown of the in-game responsibilities in handling possible concussions and of how an acute evaluation works after a player is pulled from a game following a blow to the head.</p>



<p>The protocol does a decent job accounting for everything we can <em>see</em>. And the spotters are more diligent than they sometimes get credit for. At a Feb. 1 game I attended between the Leafs and Boston Bruins, after A.J. Greer fought Wayne Simmonds and was “punched by an ungloved bare fist,” per the protocol, Greer was pulled from the penalty box and sent off the ice to be looked at.</p><div class="injected-ad" data-nn-ad-tech-injection-count="2" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="148"></div>



<p>But where the protocol sometimes fails players like Makar is in how little it respects what we <em>can’t </em>see, what we don’t understand about concussions – the problems that only time can heal. Makar passed the existing, official evaluation in time to return to the Feb. 7 game against the Pittsburgh Penguins. Yet the following day, he woke up symptomatic. He was ruled unfit to play and missed the Avs’ next four games. You’d think that would be enough of a red flag for the league, seeing a player <em>pass </em>the in-game evaluation and then end up <em>not OK </em>the next day, but the delayed-symptom injury literally happened again, to the same player, in his first game back from his concussion-related absence.</p>



<p>As Avs coach Jared Bednar worded it during his Tuesday radio appearance with Altitude Sports Radio: <a href="https://publish.dailyfaceoff.com/colorado-avalanches-cale-makar-in-concussion-protocol/">Makar is back in protocol because of “delayed” symptoms</a> as a result of a blow to the nose he took in a Feb. 18 collision with the St. Louis Blues’ Alexei Toropchenko. Just like Makar ended up in protocol with delayed symptoms after the hit from the Penguins’ Jeff Carter 11 days earlier. And Makar had fully passed protocol and was medically cleared to play in the Feb. 18 game, <a href="https://twitter.com/Peter_Baugh/status/1628118090847293460?s=20">Bedar told reporters Tuesday</a>.</p><div class="injected-ad" data-nn-ad-tech-injection-count="3" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="212"></div>



<p>One school of thought here is to shrug one’s shoulders and say, “Hey, this is a tough break, Makar passed all his tests and seemed fine.”</p>



<p>The other is to recognize Makar’s plight as something that could be the NHL’s Tua Tagovailoa moment and mobilize the league and NHL Players’ Association to re-evaluate the protocol.</p>



<p>In Tua’s case, after his second, gruesome concussion of the 2022 season led to an investigation by the NFLPA on his being cleared to return from his first concussion, <a href="https://www.pbs.org/newshour/nation/nfl-modifies-concussion-protocol-after-review-of-tagovailoa-injury#:~:text=As%20a%20result%20of%20the,caused%20by%20a%20neurological%20issue.%E2%80%9D">the player union and league ended up revising the protocol</a> to include the term ataxia, which refers to “abnormality of balance/stability, motor coordination or dysfunctional speech caused by a neurological issue.”</p>



<p>The point here isn’t to suggest the NHL duplicate what the NFL did, as the NHL protocol already contains a reference to ataxia. But how the NHL and NHLPA can follow suit is to consider making an immediate change to the protocol to better protect players. Makar was cleared and felt ready to return – but it turns out he wasn’t, even if it seemed like he was.</p><div class="injected-ad" data-nn-ad-tech-injection-count="4" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="183"></div>



<p>The protocol, in its current form, does acknowledge the idea that concussions don’t always clear up or show up right away. One section reads as follows:</p>



<p><em>“Concussion symptoms might develop immediately after a blow to the head or body, or they might evolve over time (hours or days). Consequently, Players diagnosed with a concussion should continue to be monitored and evaluated over time.</em></p>



<p><em>Players who are diagnosed with a concussion after the acute evaluation shall not return to play or to practice on the same day, irrespective of the resolution of all concussion symptoms.<br><br>• Specifically, Players who are diagnosed with a concussion should undergo an initial, brief period of physical and cognitive rest (e.g., 24-48 hours).<br>• Players can then become gradually and progressively more exposed to activities (a “graded return-to-play progression”) that do not provoke cognitive and physical symptoms (i.e., increased activity level should not bring on or worsen symptoms).”</em></p><div class="injected-ad" data-nn-ad-tech-injection-count="5" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="150"></div>



<p>But perhaps the current wording doesn’t allow a long enough defined period for those mysterious symptoms to surface in the first place. How else would Makar have been allowed to rejoin the Feb. 7 game in which he was injured? The protocol as currently constructed wouldn’t allow any concussed player back into a game. As NHL deputy commissioner Bill Daly put it in an email to Daily Faceoff, “There is no mandatory participation restriction other than prohibition on return to play in the same game.” So Makar obviously cleared protocol that night. Then he landed in protocol the next day. Maybe the protocol should be reworded so that any player who is pulled from a game for a suspected head injury cannot return even if he passes the testing in the moments afterward. As currently constructed, the protocol is contradictory. It states that symptoms might evolve over time yet still allows players to be cleared in the middle of games if they pass the testing. </p><div class="injected-ad" data-nn-ad-tech-injection-count="6" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="166"></div>



<p>Secondly, once players do enter protocol, what if the rules were amended so they were forced to stay there for a longer mandatory period? </p>



<p>The counterpoint might be: I’m not a doctor, and the current protocol is vetted by neuroscience professionals. And as Daly explains, “clearance is determined by meeting return to play protocols (symptom free at rest and with physical exertion and return to neurological baseline) and by a doctor’s own clinical judgment.” But given there is just so much still to learn about traumatic brain injuries and predicting how each individual recovers from them, what’s the harm in extending the grace period of recovery time, just in case? </p>



<p>Imagine if, for instance, any player entering protocol had to wait two weeks before resuming any physical activity. That alone might have been enough to keep Makar from sustaining a second injury. <a href="https://theathletic.com/4228874/2023/02/19/cale-makar-injury-update-avalanche/?source=emp_shared_article">He was never pulled by a spotter when he got hurt Feb. 18</a> – but if he was out long longer following the first injury, he wouldn’t have been in position to suffer the second. Instead, with two head injuries in 11 days, it’s hard not to think of the sad career detour Sidney Crosby took 12 seasons ago. It all happened because he took two brain blows in a span of four days. </p><div class="injected-ad" data-nn-ad-tech-injection-count="7" data-nn-ad-tech-max-gap="130" data-nn-ad-tech-current-gap="219"></div>



<p>Let’s hope Makar recovers faster than Sid did. At the same time: let’s hope Makar doesn’t rush back this time.</p>



<p><strong>UPDATE: </strong>An NHLPA spokesperson indicated to Daily Faceoff that no grievance has been filed regarding the handling of Makar’s injuries. However, the PA technically has up to 60 days to file one.</p>



<p>_____</p>



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