Bodychecking experience and rates of injury among ice hockey players aged 15-17 years

Safe2Play in youth ice hockey: injury profile and risk factors in a 5-year Canadian longitudinal cohort study

INTRODUCTION

Ice hockey is a popular global sport with growing participation for boys and girls yet remains a high-risk sport for injury. While the evidence for some risk factors, such as bodychecking policy is well established, other risk factors such as player sex have been understudied. The objectives of this study were to examine factors associated with rates of game-related injury, game-related injury resulting in >7 days of time-loss, and practice-related injury in youth ice hockey.

MATERIALS AND METHODS

Safe2Play was a five-year prospective cohort study (2013-2018). All injuries were identified using validated injury surveillance methodology. Multilevel Poisson regression (adjusting for cluster by team and including multiple imputation of missing covariates) was used to estimate incidence rate ratios (IRRs) for player sex, age group, bodychecking policy, year of play, level of play, weight, previous injury within last 12 months, previous lifetime concussion history, and position.

RESULTS

A total of 4418 male and female ice hockey players (representing 6584 player-seasons) participating in under-13 (ages 11-12), under-15 (ages 13-14) and under-18 (ages 15-17) age groups were recruited. There were 1184 game-related and 182 practice-related injuries. Factors associated with game-related injury included female sex (IRR = 1.57; 95% CI: 1.18-2.08), previous injury (IRR = 1.46; 95% CI: 1.26-1.70) and lifetime concussion history (IRR = 1.41; 95% CI: 1.23-1.62). Goaltenders had a lower rate of injury (IRR = 0.54; 95% CI: 0.40-0.72) relative to forwards, as did players exposed to policy disallowing bodychecking in games (IRR = 0.44; 95% CI: 0.35-0.55). Female sex (IRR = 1.90; 95% CI: 1.10-3.28) and lifetime concussion history were also significantly associated with practice-related injury (IRR = 1.53; 95% CI: 1.08-2.18).

CONCLUSIONS

Based on data from a large 5-year Canadian youth ice hockey longitudinal cohort, several factors associated with injury were identified. Future injury prevention strategies should consider age, sex, previous concussion and injury history, and body checking leagues. Future research in female youth ice hockey including female-only leagues should be a priority to inform prevention strategies in this understudied population.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Injury Incidence, Outcomes, and Return to Competition Times after Sports-Related Concussions during One Professional Ice Hockey Season: A Prospective Cohort Study

OBJECTIVE

The objective of this study was to analyze the incidence and characteristics of sports-related concussions (SRCs) for a professional ice hockey team during one regular season in the International Central European Hockey League.

BACKGROUND

Repeated concussions are a common cause of long periods of absence in team contact sports, with a wide range of potential short- and long-term consequences for the affected athlete. Questions mainly regarding early diagnosis and ideal follow-up treatment remain unanswered, especially regarding the timing of return to sports (RTS).

METHOD

A prospective data analysis for a professional ice hockey team during a regular season was conducted. Firstly, concussions per 1000 athlete exposure (AE) and average time loss due to SRC were calculated. Secondly, the data from ImPACT Applications were analyzed for those players who were diagnosed with an SRC.

RESULTS

Five SRCs were evaluated during the regular season, which resulted in 1.35 concussions/1000 AEs, a maximum of 17 missed games, and a median of three games per SRC. The average symptom count was 9.6, with the most common symptoms being headache, sensitivity to light, and dizziness.

CONCLUSIONS

SRCs sustained in professional ice hockey are a common in-competition injury, while practices play a subsidiary role. The duration of RTS is highly individual and can be associated with symptoms lasting days to months.

Associations between the circumstances and severity of head impacts in men's university ice hockey

Improved evidence on the most common and severe types of head impacts in ice hockey can guide efforts to preserve brain health through improvements in protective gear, rink design, player training, and rules of play. In this observational cohort study of men's university hockey, we compared video evidence on the circumstances of 234 head impacts to measures of head impact severity (peak linear accelerations and rotational velocities) from helmet-mounted sensors (GForceTracker). Videos were analyzed with a validated questionnaire, and paired with helmet sensor data. Shoulder-to-head impacts were more common than hand- or elbow-, but there were no differences in head impact severity between upper limb contact sites (p ≥ 0.2). Head-to-glass impacts were nearly four times more common, and just as severe as head-to-board impacts (p ≥ 0.4). Head impacts resulting in major penalties (versus no penalty), or visible signs of concussion (versus no signs), involved greater head rotational velocities (p = 0.038 and 0.049, respectively). Head impacts occurred most often to the side of the head, along the boards to players in their offensive zone without puck possession. Head impact severity did not differ between cases where the head was (versus was not) the primary site of contact (p ≥ 0.6). Furthermore, penalties were called in only 4% of cases where the head was the initial point of contact. Accordingly, rules that focus on primary targeting of the head, while important and in need of improved enforcement, offer a limited solution.

Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey

OBJECTIVES

To examine factors associated with rates of game and practice-related concussion in youth ice hockey.

DESIGN

Five-year prospective cohort (Safe2Play).

SETTING

Community arenas (2013-2018).

PARTICIPANTS

Four thousand eighteen male and 405 female ice hockey players (6584 player-seasons) participating in Under-13 (ages 11-12), Under-15 (ages 13-14), and Under-18 (ages 15-17) age groups.

ASSESSMENT OF RISK FACTORS

Bodychecking policy, age group, year of play, level of play, previous injury in the previous year, lifetime concussion history, sex, player weight, and playing position.

MAIN OUTCOME MEASUREMENTS

All game-related concussions were identified using validated injury surveillance methodology. Players with a suspected concussion were referred to a study sport medicine physician for diagnosis and management. Multilevel Poisson regression analysis including multiple imputation of missing covariates estimated incidence rate ratios (IRRs).

MAIN RESULTS

A total of 554 game and 63 practice-related concussions were sustained over the 5 years. Female players (IRR Female/Male = 1.79; 95% CI: 1.26-2.53), playing in lower levels of play (IRR = 1.40; 95% CI: 1.10-1.77), and those with a previous injury (IRR = 1.46; 95% CI: 1.13, 1.88) or lifetime concussion history (IRR = 1.64; 95% CI: 1.34-2.00) had higher rates of game-related concussion. Policy disallowing bodychecking in games (IRR = 0.54; 95% CI: 0.40-0.72) and being a goaltender (IRR Goaltenders/Forwards = 0.57; 95% CI: 0.38-0.87) were protective against game-related concussion. Female sex was also associated with a higher practice-related concussion rate (IRR Female/Male = 2.63; 95% CI: 1.24-5.59).

CONCLUSIONS

In the largest Canadian youth ice hockey longitudinal cohort to date, female players (despite policy disallowing bodychecking), players participating in lower levels of play, and those with an injury or concussion history had higher rates of concussion. Goalies and players in leagues that disallowed bodychecking had lower rates. Policy prohibiting bodychecking remains an effective concussion prevention strategy in youth ice hockey.

Persisting Concussion Symptoms from Bodychecking: Unrecognized Toll in Boys' Ice Hockey

OBJECTIVES

Youth hockey is a high-impact sport and can cause concussions with lasting effects. We hypothesized that important injury prevention information would accrue from longitudinal tracking of concussed players with persisting concussion symptoms (PCS).

METHODS

This case series comprised 87 consecutive concussed ice hockey players aged 10-18 including 66 males and 21 females referred to our Concussion Clinic from 1997 to 2017 and followed longitudinally by clinic visits and questionnaires.

RESULTS

PCS occurred in 70 (80.4%) of 87 concussed players and lasted 1-168 months in males and 3-26 months in females. Bodychecking was the most common concussion mechanism in 34 (39.1%) players and caused PCS in 24 (70.6%) with symptom duration 4.00 [2.75, 14.50] months (median [IQR]). The remaining 53 players had other concussion mechanisms with PCS in 86.8% (p = 0.113) with similar duration (p = 0.848).

CONCLUSIONS

This is the first longitudinal study of concussion with PCS in youth hockey and showed that symptoms can last for several years. Bodychecking was the commonest mechanism of prolonged disability from concussion in boys and girls' hockey with average PCS duration of 12.3 months but several years in some players. The injury prevention message is to raise the age of permitted bodychecking to 18 in boys' hockey from age 13 to 14 where it is currently. In this case series, this change could have prevented the majority of the bodycheck concussions and several years of suffering from PCS and is strong evidence for raising the permitted age for bodychecking in boys' ice hockey to age 18.

Prevention strategies and modifiable risk factors for sport-related concussions and head impacts: a systematic review and meta-analysis

OBJECTIVES

To evaluate prevention strategies, their unintended consequences and modifiable risk factors for sport-related concussion (SRC) and/or head impact risk.

DESIGN

This systematic review and meta-analysis was registered on PROSPERO (CRD42019152982) and conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES

Eight databases (MEDLINE, CINAHL, APA PsycINFO, Cochrane (Systematic Review and Controlled Trails Registry), SPORTDiscus, EMBASE, ERIC0 were searched in October 2019 and updated in March 2022, and references searched from any identified systematic review.

ELIGIBILITY CRITERIA

Study inclusion criteria were as follows: (1) original data human research studies, (2) investigated SRC or head impacts, (3) evaluated an SRC prevention intervention, unintended consequence or modifiable risk factor, (4) participants competing in any sport, (5) analytic study design, (6) systematic reviews and meta-analyses were included to identify original data manuscripts in reference search and (7) peer-reviewed. Exclusion criteria were as follows: (1) review articles, pre-experimental, ecological, case series or case studies and (2) not written in English.

RESULTS

In total, 220 studies were eligible for inclusion and 192 studies were included in the results based on methodological criteria as assessed through the Scottish Intercollegiate Guidelines Network high ('++') or acceptable ('+') quality. Evidence was available examining protective gear (eg, helmets, headgear, mouthguards) (n=39), policy and rule changes (n=38), training strategies (n=34), SRC management strategies (n=12), unintended consequences (n=5) and modifiable risk factors (n=64). Meta-analyses demonstrated a protective effect of mouthguards in collision sports (incidence rate ratio, IRR 0.74; 95% CI 0.64 to 0.89). Policy disallowing bodychecking in child and adolescent ice hockey was associated with a 58% lower concussion rate compared with bodychecking leagues (IRR 0.42; 95% CI 0.33 to 0.53), and evidence supports no unintended injury consequences of policy disallowing bodychecking. In American football, strategies limiting contact in practices were associated with a 64% lower practice-related concussion rate (IRR 0.36; 95% CI 0.16 to 0.80). Some evidence also supports up to 60% lower concussion rates with implementation of a neuromuscular training warm-up programme in rugby. More research examining potentially modifiable risk factors (eg, neck strength, optimal tackle technique) are needed to inform concussion prevention strategies.

CONCLUSIONS

Policy and rule modifications, personal protective equipment, and neuromuscular training strategies may help to prevent SRC.

PROSPERO REGISTRATION NUMBER

CRD42019152982.

Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport-Amsterdam, October 2022

For over two decades, the Concussion in Sport Group has held meetings and developed five international statements on concussion in sport. This 6th statement summarises the processes and outcomes of the 6th International Conference on Concussion in Sport held in Amsterdam on 27-30 October 2022 and should be read in conjunction with the (1) methodology paper that outlines the consensus process in detail and (2) 10 systematic reviews that informed the conference outcomes. Over 3½ years, author groups conducted systematic reviews of predetermined priority topics relevant to concussion in sport. The format of the conference, expert panel meetings and workshops to revise or develop new clinical assessment tools, as described in the methodology paper, evolved from previous consensus meetings with several new components. Apart from this consensus statement, the conference process yielded revised tools including the Concussion Recognition Tool-6 (CRT6) and Sport Concussion Assessment Tool-6 (SCAT6, Child SCAT6), as well as a new tool, the Sport Concussion Office Assessment Tool-6 (SCOAT6, Child SCOAT6). This consensus process also integrated new features including a focus on the para athlete, the athlete's perspective, concussion-specific medical ethics and matters related to both athlete retirement and the potential long-term effects of SRC, including neurodegenerative disease. This statement summarises evidence-informed principles of concussion prevention, assessment and management, and emphasises those areas requiring more research.

Compulsory collisions and corporate interests in school rugby: challenging distortions in the framing of childhood injury

This article examines how 'framing' is used to resist a proposal to remove rugby tackling from UK schools. It focuses on rugby tackling for UK school children, which is often a compulsory part of many schools' curricula. Specifically, we explore the importance of framing in how the problem is described in various academic publications, how ideas about risk are articulated and how advocates themselves are represented. We show how the corporate interests of rugby governing bodies can become entangled with distortions about injury prevention. These distortions (or framing practices) include omitting arguments, conflating arguments, changing the argument, misrepresenting advocacy positions and skewing advocate identities. Next, the article demonstrates how a combination of recent advocacy, political interventions, research and cultural shifts appears to be changing perceptions about the risks associated with rugby tackling for children in school settings. In conclusion, we argue that while framing can be a useful strategy for policy advocates, there is value in paying attention to how framing is used by different stakeholder groups.