Incidence of Concussion in Youth Ice Hockey Players

Comparing frequency and maximum principal strain of head impacts for U15 ice hockey leagues with standard and modified body contact rules

Brain trauma in bodychecking ice hockey is of concern for youth participants, as it presents unique risks compared to the non-bodychecking version of the sport. This study compared head impact frequency and magnitude between two ice hockey leagues with different body contact rules in the U15 age division: AAA (standard bodychecking) and M15 Minor (modified body contact rules). Video analysis of 16 games per league revealed no significant overall diference in impact frequency. M15 Minor players sustained significantly more head-to-head (14 to 2) impacts and AAA players sustained significantly more head-to-glass (18 to 7) and punch impacts (4 to 0). Laboratory reconstructions and finite element modeling were used to determine impact magnitude as maximum principal strain (MPS) and categorized from very low to very high. Higher impact frequency of very low MPS head impact events were observed for M15 Minor (61 to 51). The findings from this study highlight that this method of modifying body contact rules in U15 hockey did not result in lower levels of brain trauma, rather it presented unique brain trauma mechanisms compared to bodychecking.

Can Referees Assess Head Contact Penalties Correctly in Canadian Youth Ice Hockey? A Video Analysis Study

OBJECTIVE

To help address the high concussion burden in Canadian youth ice hockey, our primary objective was to examine the concurrent validity of youth ice hockey referees' ability to assess head contacts (HCs) and associated penalties using video analysis methods after implementation of the "zero tolerance for HC" policy by Hockey Canada.

STUDY DESIGN

Cross-sectional study.

PARTICIPANTS

Certified Level II-III referees in Alberta, Canada.

INTERVENTION

A secured online survey with 60 videos (10 to 15 seconds) containing a player-to-player physical contact with or without a HC from elite U15 (ages 13 to 14) youth ice hockey games.

OUTCOME MEASURES

Survey questions were completed by all referees for each video, including (1). 'Did you see a player-to-player contact?', (2). 'Should a penalty be assessed?', and if yes, (3). 'Which player, penalty type, and penalty intensity?' Referee assessments were compared with a consensus agreement from 2 national and member (top level) gold standard referees for concurrent validity through percent agreement and sensitivity/specificity measures.

RESULTS

Complete-case analysis of 100 referees (131 recruited) showed an overall median agreement of 83.5% (sensitivity = 0.74; specificity = 0.69) with the gold standard. Agreement with the gold standard was highest for HC infractions [85.1% (sensitivity = 0.80; specificity = 0.69)], followed by HC penalty type (81.5%) and penalty intensity (53.7%).

CONCLUSIONS

Concurrent validity through percent agreement was high (>80%) compared with the gold standard for identifying both HC and other infractions; however, it was moderate for penalty intensity. Although knowledge of identifying HCs and penalties in this survey was acceptable, this study suggests in-game factors (eg, game management and positioning) may be a primary limitation for HC enforcement.

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.

Agreement between parent reported and child self-reported sport-related concussion history: A brief report

This cross sectional investigation measured the agreement between parent report of their 8-14 year old child's sport-related concussion (SRC) history and their child's self-report of their own SRC history. Parent-child dyads (n = 405) within a youth contact sports (e.g., football, ice hockey, lacrosse, soccer) setting participated in the study. Parents (6.2%) and 8.6% of children self-reported a history of at least one diagnosed SRC. We observed substantial agreement between the number of parent-reported and child self-reported SRCs (κ = 0.613, p ≤ .001). Partial agreement regarding the number of SRCs reported by both groups was also substantial (weighted κ = 0.693, p ≤ .001). Removing dyads where neither the parent nor the child reported a diagnosed SRC, sensitivity analyses revealed only fair agreement in parent-child SRC recall. These results indicate that parents and youth athletes overall accounts of their diagnosed SRC history correspond. However determining specifics (e.g., total concussion counts) may benefit from concurrent parent reports, or documented events in medical histories.

A video analysis examination of the frequency and type of head impacts for player positions in youth ice hockey and FE estimation of their impact severity

This research employed head impact frequency and frequency of estimated strain to analyse the influence of player position on brain trauma in U15 and U18 youth ice hockey. The methods involved a video analysis of 30 U15 and 30 U18 games where frequency, type of head impact event, and player position during impact was recorded. These impacts were then simulated in the laboratory using physical reconstructions and finite element modelling to determine the brain strains for each impact category. U15 forwards experienced significantly higher head impact frequencies (139) when compared to defenceman (50), with goalies showing the lowest frequency (6) (p < 0.05). U18 forwards experienced significantly higher head impact frequencies (220) when compared to defenceman (92), with goalies having the least frequent head impacts (4) (p < 0.05). The U15 forwards had a significantly higher frequency of head impacts at the very low and med strains and the U18s had higher frequency of head impacts for the very low and low level strains (p < 0.05). Game rule changes and equipment innovation may be considered to mitigate the increased risk faced by forwards compared to other positions in U15 and U18 youth ice hockey.

Does Increasing the Severity of Penalties Assessed in Association With the "Zero Tolerance for Head Contact" Policy Translate to a Reduction in Head Impact Rates in Youth Ice Hockey?

OBJECTIVE

The risk of concussion is high in Canadian youth ice hockey. Aiming to reduce this burden, in 2011, Hockey Canada implemented a national "zero tolerance for head contact (HC)" policy mandating the penalization of any player HC. In 2018 to 2020, Hockey Canada further amended this HC policy including stricter enforcement of severe HCs. This study aimed to compare HC rates, head impact location, and HC enforcement prepolicy, postpolicy, and after policy amendments in elite U15 Canadian youth ice hockey.

DESIGN

This is a prospective cohort study.

SETTING

A collection of events with the video camera located at the highest point near center ice in public ice hockey arenas in Calgary, Alberta.

PARTICIPANTS

A convenience sample of 10 AA U15 games prepolicy (2008-2009), 8 games postpolicy (2013-2014), and 10 games after policy amendments (2020-2021).

INDEPENDENT VARIABLES

An analysis of 3 cohort years regarding the HC-policy implementation and amendments.

MAIN OUTCOME MEASURES

Using Dartfish video-analysis software, all player contacts and HCs [direct (HC1), indirect (eg, boards, ice) (HC2)] were tagged using validated criteria. Univariate Poisson regression clustering by team-game offset by game length (minutes) was used to estimate incidence rates (IR) and incidence rate ratios (IRR) between cohorts.

RESULTS

With additional rule modifications, a 30% reduction in HC1s emerged (IRR 2013-2020 = 0.70, 95% CI, 0.51-0.95). Since the HC-policy implementation, HC1s decreased by 24% (IRR 2008-2020 = 0.76, 95% CI, 0.58-0.99). The proportion of HC1s penalized was similar across cohorts (P 2008-2009 = 14.4%; P 2013-2014 = 15.5%; P 2020-2021 = 16.2%).

CONCLUSIONS

The HC-policy amendments have led to decreased HC1 rates. However, referee enforcement can further boost the HC-policy effectiveness. These findings can help future referee training and potential rule modifications to increase player safety nationally.

Evaluation of differences across age groups in the incidence, severity, and recovery of concussion in adolescent student-athletes from 2009 to 2019

OBJECTIVE

Concussion incidence is known to be highest in children and adolescents; however, there is conflicting evidence about the effect of age on concussion risk and recovery within the adolescent age range. The heterogeneity of results may be partially due to the use of age groupings based on convenience, making comparisons across studies difficult. This study evaluated the independent effect of age on concussion incidence, severity, and recovery in student-athletes aged 12-18 years using cluster analysis to define groupings.

METHODS

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) scores of 11,403 baseline tests and 4922 postinjury tests were used to calculate the incidence rates for adolescent student-athletes grouped into 3 age bands (12-13, 14-15, and 16-18 years of age) on the basis of clustering analysis. The recently created Severity Index was used to compare concussion severity between groups. Follow-up tests for subjects who sustained a concussion were used to evaluate recovery time. The chi-square test and 1-way ANOVA were used to compare differences in demographic characteristics and concussion incidence, severity, and recovery. Multivariable logistic and linear regressions were used to evaluate the independent effects of age on concussion incidence and severity, respectively. Multivariable Cox hazard regression was used to evaluate differences in recovery time. Further analyses were conducted to directly compare findings across studies on the basis of the age groupings used in prior studies.

RESULTS

Multivariable regression analyses demonstrated that the 14- to 15-year-old age group had a significantly higher concussion incidence than both the 12- to 13-year-old (14- to 15-year-old group vs 12- to 13-year-old group, OR 1.57, 95% CI 1.16-2.17, p = 0.005) and 16- to 18-year-old (16- to 18-year-old group vs 14- to 15-year-old group, OR 0.79, 95% CI 0.69-0.91, p = 0.0008) age groups. There was no difference in incidence between the 12- to 13-year-old and 16- to 18-year-old groups (16- to 18-year group vs 12- to 13-year group, OR 1.26, 95% CI 0.93-1.72, p = 0.15). There were also no differences in concussion severity or recovery between any groups.

CONCLUSIONS

This study found that concussion incidence was higher during mid-adolescence than early and late adolescence, suggesting a U-shaped relationship between age and concussion risk over the course of adolescence. Age had no independent effect on concussion severity or recovery in the 12- to 13-, 14- to 15-, and 16- to 18-year-old groups. Further analysis of the various age groups revealed that results may vary significantly with minor changes to groupings, which may explain the divergent results in the current literature on this topic. Thus, caution should be taken when interpreting the results of this and all similar studies, especially when groupings are based on convenience.

Epidemiology of female youth ice hockey injuries presenting to United States emergency departments from 2002 to 2019

BACKGROUND

This study documented injury types, rates and mechanisms for female youth ice hockey players reporting to US emergency departments to inform safety measures and sideline medical preparedness.

METHODS

The National Electronic Injury Surveillance System (NEISS) database was queried for ice hockey injuries (product code 1279) from 1 January 2002 to 31 December 2019. Incidence rate ratios (IRR) were calculated using OpenEpi and compared between age divisions. Spearman's rank correlation was utilized to evaluate the correlation between age and injury incidence. USA Hockey membership statistics were used to establish the population at risk and calculate incidence rates (IR).

RESULTS

An estimated 20,384 ice hockey injuries presented to participating United States emergency departments. The number of female youth ice hockey players increased significantly from 36,258 in 2002 to 65,072 in 2019 (p < 0.01). The most commonly injured body parts were the head (n = 5,519, IR = 62.1 [95%CI 54.3-70.0 per 10,000 athletes), trunk (n = 2,364, IR = 26.6 [95%CI 21.2-32.0] per 10,000 athletes), and wrist (n = 1,824, IR = 20.5 [95%CI 15.7-25.4] per 10,000 athletes). The most commonly reported mechanisms of injury were player-to-player collision (n = 4,746, IR = 53.4 [95%CI 46.4-60.5] per 10,000 athletes) and falls (n = 4,585, IR = 51.6 [95%CI 44.1-59.1] per 10,000 athletes). The most common diagnoses were traumatic brain injury (n = 5,333, IR = 60.0 [95%CI 52.3-67.8] per 10,000 athletes), contusion (n = 4,204, IR = 47.3 [95%CI 40.3-54.4] per 10,000 athletes) and strain/sprain (n = 3,601, IR = 40.5 [95%CI 34.1-47.0] per 10,000 athletes). A positive correlation was found between age and injury incidence, as well as increasing age and injuries from player-to-player collision and TBI's.

CONCLUSIONS

Though body checking is illegal at all levels of women's ice hockey, player-to-player collision prevailed as the leading mechanism on injury. Hopefully this study informs players, parents, coaches, trainers and clinicians about the impact of player-to-player collisions on overall injury burden in the older age divisions of youth female hockey.

Sports-Related Concussions in Adults Presenting to Canadian Emergency Departments

OBJECTIVE

To document the occurrence and recovery outcomes of sports-related concussions (SRCs) presenting to the Emergency Department (ED) in a community-based sample.

DESIGN

A prospective observational cohort study was conducted in 3 Canadian hospitals.

SETTING

Emergency Department.

PATIENTS

Adults (≥17 years) presenting with a concussion to participating EDs with a Glasgow Coma Scale score ≥13 were recruited.

INTERVENTIONS

Patient demographics (eg, age and sex), clinical characteristics (eg, history of depression or anxiety), injury characteristics (eg, injury mechanisms and loss of consciousness and duration), and ED management and outcomes (eg, imaging, consultations, and ED length of stay) were collected.

MAIN OUTCOME MEASURES

Patients' self-reported persistent concussion symptoms, return to physical activity status, and health-related quality of life at 30 and 90 days after ED discharge.

RESULTS

Overall, 248 patients were enrolled, and 25% had a SRC. Patients with SRCs were younger and reported more physical activity before the event. Although most of the patients with SRCs returned to their normal physical activities at 30 days, postconcussive symptoms persisted in 40% at 90 days of follow-up. After adjustment, there was no significant association between SRCs and persistent symptoms; however, patients with concussion from motor vehicle collisions were more likely to have persistent symptoms.

CONCLUSION

Although physically active individuals may recover faster after a concussion, patients returning to their physical activities before full resolution of symptoms are at higher risk of persistent symptoms and further injury. Patient-clinician communications and tailored recommendations should be encouraged to guide appropriate acute management of concussions.

Validity Indices of the King-Devick Concussion Test in Hockey Players

OBJECTIVE

To compare the validity indices of the King-Devick (KD) test in hockey players using any increase in test time over baseline to a 6-second increase as a positive concussion test. We hypothesized the KD test using the 6-second change would yield greater validity indices.

DESIGN

Prospective observational cohort study.

SETTING

Sports complex.

PARTICIPANTS

Sixty-five male hockey players aged 13 to 20 years.

INDEPENDENT VARIABLE

Concussion diagnosis.

MAIN OUTCOME MEASURES

Time to complete the KD test. Sensitivity (SN), specificity (SP), and the positive likelihood ratios (LRs+) were calculated using 2 thresholds for a positive test: (1) any increase in time and (2) an increase of 6 seconds or greater.

RESULTS

Eighteen players (27.7%) were diagnosed with a concussion. Using any increase in time as a positive test yielded the following: SN 72.2%, SP 78.7%, LR+ 3.4, and LR- 0.4. Using the 6-second threshold yielded the following: SN 44.4%, SP 93.6%, LR+ 7.0, and LR- 0.6. A receiver operator curve analysis confirmed 6.40 seconds or greater maximized the LR+.

CONCLUSIONS

A 6-second or greater increase in the KD test performance provides greater validity in diagnosing concussion as compared with any increase in performance time.

Male Youth Ice Hockey Concussion Incidence in a USA Hockey Membership-Adjusted Population: A Peak in 2011 and the Impact of Major Rule Changes

OBJECTIVE

To investigate the incidence of youth ice hockey-related concussions preceding and following the implementation of new body-checking and head contact rules by USA hockey in 2011. We hypothesized a decrease in concussions after the rule change.

DESIGN

Retrospective analysis.

SETTING

United States emergency department (ED) data queried in the National Electronic InjurySurveillance System (NEISS).

PATIENTS

National Electronic Injury Surveillance System reported male youth (≤18 years) ice hockey concussion cases from January 1, 2002, to December 31, 2016. In total, 848 players were diagnosed with concussion, representing a national estimate of 17 374 cases.

INDEPENDENT VARIABLES

Time, specifically years.

MAIN OUTCOME MEASURES

Incidences and incidence rates (measured per 10 000 person-years) of male youth ice hockey concussions. Annual trends were analyzed using descriptive and linear or polynomial regression analysis.

RESULTS

The national estimate of youth ice hockey-related concussions seen in US emergency departments (EDs) increased significantly from 656 in 2007 to 2042 in 2011 (P < 0.01). During the same period, their respective incidence increased significantly from 21.8 to 66.8 per 10 000, before dropping through 2016 (P < 0.05). After 2011, concussions decreased from 1965 in 2012 to 1292 in 2016 (P = 0.055). The gap in concussion incidence between the 11 to 12 and 13 to 14 divisions widened after 2011 (before 2011: 41 vs 49 per 10 000 person-years [P = 0.80]; after 2011: 45 and 89, respectively [P < 0.01]).

CONCLUSIONS

US EDs experienced a significant increase in youth ice hockey concussion visits from 2007 to 2011. After the 2011 rule changes, concussion visits decreased significantly from 2012 to 2016.

Helmet Fit Assessment and Concussion Risk in Youth Ice Hockey Players: A Nested Case-Control Study

CONTEXT

Injury surveillance has shown that concussions are the most common injury in youth ice hockey. Research examining the criteria for ensuring the correct fit of protective equipment and its potential relationship with concussion risk is very limited.

OBJECTIVE

To evaluate the association between helmet fit and the odds of experiencing a concussion among youth ice hockey players.

DESIGN

Nested case-control within a cohort study.

SETTING

Calgary, Alberta, Canada.

PATIENTS OR OTHER PARTICIPANTS

Data were collected for 72 concussed, 41 nonconcussion-injured, and 62 uninjured ice hockey players aged 11 to 18 years.

MAIN OUTCOME MEASURE(S)

Helmet-fit assessments were conducted across players and encompassed helmet specifications, condition, certification, and criteria measuring helmet fit. Using a validated injury-surveillance system, we identified participants as players with suspected concussions or physician-diagnosed concussions or both. One control group comprised players who sustained nonconcussion injuries, and a second control group comprised uninjured players. Helmet-fit criteria (maximum score = 16) were assessed for the concussed players and compared with each of the 2 control groups. The primary outcome was dichotomous (>1 helmet-fit criteria missing versus 0 or 1 criterion missing). Logistic and conditional logistic regression were used to investigate the effect of helmet fit on the odds of concussion.

RESULTS

The primary analysis (54 pairs matched for age, sex, and level of play) suggested that inadequate helmet fit (>1 criterion missing) resulted in greater odds of sustaining a concussion when comparing concussed and uninjured players (odds ratio [OR] = 2.67 [95% CI = 1.04, 6.81], P = .040). However, a secondary unmatched analysis involving all participants indicated no significant association between helmet fit and the odds of sustaining a concussion when we compared concussed players with nonconcussion-injured players (OR = 0.98 [0.43, 2.24], P = .961) or uninjured players (OR = 1.66 [0.90, 3.05], P = .103).

CONCLUSIONS

Inadequate helmet fit may affect the odds of sustaining a concussion in youth ice hockey players. Future investigators should continue to evaluate this relationship in larger samples to inform helmet-fit recommendations.

Sex-based differences in outcomes for adult patients presenting to the emergency department with a concussion

OBJECTIVE

Patients with concussion frequently present to the emergency department (ED). Studies of athletes and children indicate that concussion symptoms are often more severe and prolonged in females compared with males. Given infrequent study of concussion symptoms in the general adult population, the authors conducted a sex-based comparison of patients with concussion.

METHODS

Adults (≥ 17 years of age) presenting with concussion to one of three urban Canadian EDs were recruited. Discharged patients were contacted by telephone 30 and 90 days later to capture the extent of persistent postconcussion symptoms using the Rivermead Post Concussion Symptoms Questionnaire (RPQ). A multivariate logistic regression model for persistent symptoms that included biological sex was developed.

RESULTS

Overall, 250 patients were included; 131 (52%) were women, and the median age of women was significantly higher than that of men (40 vs 32 years). Women had higher RPQ scores at baseline (p < 0.001) and the 30-day follow-up (p = 0.001); this difference resolved by 90 days. The multivariate logistic regression identified that women, patients having a history of sleep disorder, and those presenting to the ED with concussions after a motor vehicle collision were more likely to experience persistent symptoms.

CONCLUSIONS

In a community concussion sample, inconsequential demographic differences existed between adult women and men on ED presentation. Based on self-reported and objective outcomes, work and daily activities may be more affected by concussion and persistent postconcussion symptoms for women than men. Further analysis of these differences is required to identify different treatment options and ensure adequate care and management of injury.

Proceedings From the Ice Hockey Summit III: Action on Concussion

OBJECTIVES

The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these 5 objectives: (1) describe sport related concussion (SRC) epidemiology; (2) classify prevention strategies; (3) define objective, diagnostic tests; (4) identify treatment; and (5) integrate science and clinical care into prioritized action plans and policy.

METHODS

Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches, and officials) voted to prioritize these action items in the final Summit session.

RESULTS

To (1) establish a national and international hockey database for SRCs at all levels; (2) eliminate body checking in Bantam youth hockey games; (3) expand a behavior modification program (Fair Play) to all youth hockey levels; (4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues; (5) establish objective tests to diagnose concussion at point of care; and (6) mandate baseline testing to improve concussion diagnosis for all age groups.

CONCLUSIONS

Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity, and consequences of concussion in the sport of ice hockey.

Factors associated with concussion-symptom knowledge and attitudes toward concussion care seeking in a national survey of parents of middle-school children in the US

BACKGROUND

Developing appropriate concussion prevention and management paradigms in middle school (MS) settings requires understanding parents' general levels of concussion-related knowledge and attitudes. This study examined factors associated with concussion-symptom knowledge and care-seeking attitudes among parents of MS children (aged 10-15 years).

METHODS

A panel of 1224 randomly selected U.S. residents, aged ≥ 18 years and identifying as parents of MS children, completed an online questionnaire capturing parental and child characteristics. The parents' concussion-symptom knowledge was measured using 25 questions, with possible answers being "yes", "maybe", and "no". Correct answers earned 2 points, "maybe" answers earned 1 point, and incorrect answers earned 0 point (range: 0-50; higher scores = better knowledge). Concussion care-seeking attitudes were also collected using five 7-point scale items (range: 5-35; higher scores = more positive attitudes). Multivariable ordinal logistic regression models identified predictors of higher scores. Models met proportional odds assumptions. Adjusted odds ratios (aORs) with 95% confidence intervals (95%CIs) (excluding 1.00) were deemed statistically significant.

RESULTS

Median scores were 39 (interquartile range: 32-44) for symptom knowledge and 32 (interquartile range: 28-35) for care-seeking attitude. In multivariable models, odds of better symptom knowledge were higher in women vs. men (aOR = 2.28; 95%CI: 1.71-3.05), white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.88; 95%CI: 1.42-2.49), higher parental age (10-year-increase aOR = 1.47; 95%CI: 1.26-1.71), and greater competitiveness (10%-scale-increase aOR = 1.24; 95%CI: 1.13-1.36). Odds of more positive care-seeking attitudes were higher in white/non-Hispanics vs. other racial or ethnic groups (aOR = 1.45; 95%CI: 1.06-1.99) and in older parental age (10-year-increase aOR = 1.24; 95%CI: 1.05-1.47).

CONCLUSION

Characteristics of middle school children's parents (e.g., sex, race or ethnicity, age) are associated with their concussion-symptom knowledge and care-seeking attitudes. Parents' variations in concussion knowledge and attitudes warrant tailored concussion education and prevention.

Epidemiology of Concussions in High School Boys' Ice Hockey, 2008/09 to 2016/17 School Years

OBJECTIVE

This study examined the epidemiology of concussions in high school boys' ice hockey during the 2008/09 to 2016/17 school years.

DESIGN

Prospective cohort study. Athletic trainers from an average 33 high schools annually reported boys' ice hockey concussion and athlete-exposure (AE) data for the High School Reporting Information Online system.

SETTING

Convenience sample of high school boys' ice hockey programs during the 2008/09 to 2016/17 school years.

PATIENTS OR OTHER PARTICIPANTS

High school boys' ice hockey players (aged ∼14-18 years).

INDEPENDENT VARIABLES

Concussion data on event type, injury mechanism, symptom resolution time, and time loss were obtained.

MAIN OUTCOME MEASURES

Concussion rates with 95% confidence intervals (CIs) and distributions were calculated.

RESULTS

Overall, 348 concussions were reported in boys' ice hockey during the 2008/09 to 2016/17 academic years, leading to a concussion rate of 0.68/1000 AEs (95% CI, 0.61-0.75). Most occurred in competitions (85.6%), particularly after the first period (72.1% of all competition concussions). Among practice concussions, most occurred after the first hour of practice (60.0%). Most concussions were due to player contact (47.7%) and boards/glass contact (31.9%). Although 69.0% of concussed athletes had symptoms resolve in less than 7 days, only 14.1% returned to activity within a week.

CONCLUSIONS

Most concussions occurred within the second and third periods. Preventive strategies that counter an increased risk of concussion due to a greater intensity of gameplay coupled with increased fatigue may be warranted. Moreover, athletes may further benefit from prevention efforts that focus on anticipating impacts during gameplay.

Exposure to brain trauma in six age divisions of minor ice hockey

Acute and chronic neurological risks associated with brain trauma sustained in professional ice hockey has generated concern for youth participants. Minor hockey is a different game when compared to elite players presenting distinctive risk factors for each age division. Objective measures of brain trauma exposure were documented for six divisions in minor ice hockey; U7, U9, U11, U13, U15, U18. Game video analysis, physical reconstruction and computational modelling was employed to capture the event conditions, frequency of impacts, frequency of high strain magnitude (>0.17) impacts, and cumulative trauma. The results showed proportional differences in the event conditions; event type, closing velocity, and head impact location, informing the improvement of age appropriate protection, testing protocols, and safety standards. Frequency of events were highest for U7 when players were learning to skate, and again in U18 as game physicality increases. No significant difference was observed in frequency of high magnitude impacts across age divisions. A peak in high magnitude impacts was empirically observed at both U7 and U15 where skill development in skating and body checking, respectively, were most prominent. Finally, a cumulative trauma metric incorporating frequency and magnitude of impacts provided a detailed analysis of trauma exposure provides for a targeted approach to managing injury risk specific to age division. Objective measures of brain trauma exposure identified in the current study are important to inform strategy, guide legislation and initiate policy for safe play in minor ice hockey.

The Effects of Anticipation and Visual and Sensory Performance on Concussion Risk in Sport: A Review

Sports-related concussions pose a significant public health concern, and preventative measures are needed to help reduce risk in sport. Vision training could be a suitable prevention strategy for sports-related concussion to help improve athletes’ abilities to scan the visual field for oncoming objects or opponents and thus anticipate head impacts. By accurately anticipating impacts, athletes can prepare for impact or attempt to avoid the collision altogether. The purpose of this review is to explore the relationships between anticipation, visual and sensorimotor performance and head accelerations, as well as to examine the efficacy of vision training programmes in reducing concussion risk in sport. Anticipation of head impacts has been shown to help reduce linear and rotational head accelerations, particularly for mild-to-moderate severity head impacts, but less so for severe head impacts. There is conflicting evidence regarding the influences visual and sensorimotor performance and oculomotor behaviour have on concussion risk. However, preliminary research indicates vision training may help reduce concussion rates in collegiate American Football players. Therefore, this promising area of research warrants further investigation, particularly the role of anticipation and visual and sensory performance on reducing concussion risk in non-helmeted contact sports.

Concussions in Ice Hockey - Moving Toward Objective Diagnoses and Point-of-care Treatment: A Review

The incidence of sport-related concussion coupled with a doubling of the participation rate in youth hockey over the past two decades provides impetus for the review of the most promising concussion treatment options. This narrative review summarizes the future treatment options for sport-related concussions in ice hockey, while acknowledging their generalizability to concussion in all sports. Symptom assessment, sign observation, as well as cognitive and balance testing, have historically been used to diagnose a concussion. These methods continue to improve, but the need for effective treatments is clear. Pharmacologic, transcranial light, and nutritional supplement treatment options for concussion warranting further investigation have been identified. Dimethyl fumarate is an immunomodulatory compound thought to trigger antioxidant gene expression. Memantine reduces apoptosis and astrogliosis by inhibiting the calcium influx into cells normally caused by glutamate's activation of N-methyl-D-aspartate receptors. Thioredoxin-mimetic peptides and transcranial photobiomodulation temper the effects of the energy crisis by acting as free radical scavengers. In addition, seven neuroprotective nutritional supplements have been identified: berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins. An estimated US $1.1 billion has been spent on unsuccessful traumatic brain injury clinical trials. As our ability to accurately diagnose concussion improves, dimethyl fumarate, memantine, thioredoxin-mimetic peptides, transcranial photobiomodulation, and nutritional supplements (berberine, creatine, curcumin, melatonin, omega-3 fatty acids, resveratrol, and vitamins) warrant further preclinical and clinical examination in advancing the treatment of sport-related concussions.

Lifetime prevalence of concussion among Canadian ice hockey players aged 10 to 25 years old, 2014 to 2017

BACKGROUND

The primary objective of this study was to identify the self-reported lifetime prevalence of diagnosed concussions among Canadian ice hockey players aged 10 to 25 years old.

METHOD

Medical records were identified for n=5223 athletes whom completed comprehensive baseline assessments with a Canada-wide network of private concussion management clinics. Variables extracted included: sex, age, diagnosed history of and number of prior concussions, diagnosed health condition(s), and Post-Concussion Symptom Scale scores.

RESULTS

Approximately 22% of all athletes, 21.7% of females and 21.8% of males reported that they had sustained at least one diagnosed concussion. Age was significantly associated with history of concussion as was having an additional health condition. Sex was not significantly associated with a history of concussion.

CONCLUSION

Lifetime history of concussion prevalence estimates aligned closely with estimates previously published. Future investigations should seek to establish the prevalence of concussions that occur during ice hockey games and practices alone.

Incidence and Risk of Concussions in Youth Athletes: Comparisons of Age, Sex, Concussion History, Sport, and Football Position

Objective

This study was designed to determine concussion incidence, risk, and relative risk among middle and high school athletes participating in various sports.

Method

Data were retrospectively obtained from 10,334 athletes of 12 different sports in Hawaii. In addition to determining the overall concussion incidence, comparisons of incidence, risk, and relative risk were made according to age, sex, concussion history, sport, and football position.

Results

The overall incidence of concussion among youth athletes was 1,250 (12.1%). The relative risk for a concussion was almost two times greater in 18-year olds than in 13-year-old athletes. In comparable sports, girls had a 1.5 times higher concussion risk than boys. Athletes with a prior concussion had 3-5 times greater risk to sustain a concussion than those with no history of a concussion. Among varied sports, wrestling and martial arts had the highest relative risk of a concussion, followed by cheerleading, football, and track and field. No differences in concussion risks were found among the football players in different positions.

Conclusions

Older youths, females, those with a history of concussion, and those participating in high contact sports were found to have higher risks of sustaining a concussion. The findings increase awareness of concussion patterns in young athletes and raise concerns regarding protective strategies and concussion management in youth sports.

Proceedings from the Ice Hockey Summit III: Action on Concussion

The Ice Hockey Summit III provided updated scientific evidence on concussions in hockey to inform these five objectives: 1) describe sport-related concussion (SRC) epidemiology, 2) classify prevention strategies, 3) define objective, diagnostic tests, 4) identify treatment, and 5) integrate science and clinical care into prioritized action plans and policy. Our action plan evolved from 40 scientific presentations. The 155 attendees (physicians, athletic trainers, physical therapists, nurses, neuropsychologists, scientists, engineers, coaches, and officials) voted to prioritize these action items in the final Summit session. 1) Establish a national and international hockey data base for SRC at all levels, 2) eliminate body checking in Bantam youth hockey games, 3) expand a behavior modification program (Fair Play) to all youth hockey levels, 4) enforce game ejection penalties for fighting in Junior A and professional hockey leagues, 5) establish objective tests to diagnose concussion at point of care (POC), and 6) mandate baseline testing to improve concussion diagnosis for all age groups. Expedient implementation of the Summit III prioritized action items is necessary to reduce the risk, severity, and consequences of concussion in the sport of ice hockey.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Using opinion leaders to address intervention gaps in concussion prevention in youth sports: key concepts and foundational theory

Behavioral interventions to increase disclosure and proper management of concussion in youth sports have unrealized potential when it comes to preventing concussion. Interventions have focused on changing individual athlete behavior and have fallen short of the potential for sustained systemic behavioral change. One potentially critical reason for this shortfall is that other key determinants of risk behaviors at all levels of the socio-ecological model (e.g. interpersonal, community, policy) are not addressed in extant programming. There is a critical need for theory-driven interventions that address concussion prevention and education at the community level and target sustainable culture change. The Popular Opinion Leader (POL) intervention, a multi-level intervention model previously successfully employed in multiple public health contexts, is theoretically well positioned to affect such change. POL is based on the Diffusion of Innovations framework and involves identifying, recruiting, and training well-respected and trusted individuals to personally endorse prevention and risk-reduction within their social networks. Critical behavioral changes related to concussion disclosure and management have been shown to diffuse to others if enough opinion leaders endorse and support the behaviors. This article summarizes the concepts and principles of POL and describes how it could be adapted for and implemented in youth sport settings. For optimal impact, POL needs to adapt to several factors unique to youth sports settings and culture. First, adult involvement may be important, given their direct involvement in the athlete's medical care. However, parents and coaches' opinions on injury care-seeking, competition, and safety may affect their perceptions of POL. Second, youth sports are structured settings both physically and socioculturally. Games and practices may provide opportunities for the informal interactions that are critical to the success of POL. However, youth sport setting membership is transient as players get older and move to other sport settings; POL approaches need to be self-sustaining despite this turnover. Moreover, stakeholder value placed on athlete development and competition, alongside safety, must be considered. Formative research is needed to ensure that POL principles are translated into the youth sport setting while maintaining fidelity to the concepts and principles that have made POL successful for other health outcomes.

Common Ice Hockey Injuries and Treatment: A Current Concepts Review

Injuries are common in ice hockey, a contact sport where players skate at high speeds on a sheet of ice and shoot a vulcanized rubber puck in excess of one hundred miles per hour. This article reviews the diagnoses and treatment of concussions, injuries to the cervical spine, and lower and upper extremities as they pertain to hockey players. Soft tissue injury of the shoulder, acromioclavicular joint separation, glenohumeral joint dislocation, clavicle fractures, metacarpal fractures, and olecranon bursitis are discussed in the upper-extremity section of the article. Lower-extremity injuries reviewed in this article include adductor strain, athletic pubalgia, femoroacetabular impingement, sports hernia, medial collateral and anterior cruciate ligament tears, skate bite, and ankle sprains. This review is intended to aid the sports medicine physician in providing optimal sports-specific care to allow their athlete to return to their preinjury level of performance.

Understanding the psychiatric effects of concussion on constructed identity in hockey players: Implications for health professionals

OBJECTIVE

The following study was undertaken to investigate the effect of concussion and psychiatric illness on athletes and their caregivers.

METHODS

Semi-structured interviews with 20 ice hockey stakeholders (17 men and 3 women) including minor and professional players, coaches, parents, and physicians were conducted over two years (2012-2014). These interviews were analyzed using grounded theory.

RESULTS

From this analysis, a common biographical theme emerged whereby the subject's identity as a hockey player, constructed early in life over many years, was disrupted by concussion. Furthermore, some players underwent a biographical deconstruction when they experienced post-concussive mental illness, which was amplified by isolation, stigma from peers, and lack of a clear life trajectory. Many players obtained support from family and peers and were able to recover, as evidenced by the biographical reconstruction of their identity post-hockey concussion.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Understanding the process of biographical deconstruction and reconstruction has significant psychosocial treatment implications for both healthcare professionals and caregivers of this population. Specifically, the authors suggest that interpersonal psychotherapy (IPT) that focuses on role transitions may create opportunities to facilitate the process of biographical reconstruction and life transition.

Concussion Rates in U.S. Middle School Athletes, 2015-2016 School Year

INTRODUCTION

Concussion incidence estimates in middle school sports settings are limited. This study examines concussion incidence in nine U.S. middle schools during the 2015-2016 school year.

METHODS

Concussion data originated from nine public middle schools in Prince William County, Virginia, during the 2015-2016 school year. Certified athletic trainers collected concussion and athlete exposure (AE) data in school-sanctioned games and practices in boys' baseball, basketball, football, soccer, track, and wrestling; and girls' basketball, cheerleading, soccer, softball, track, and volleyball. Athletic trainers also acquired data on non-school sanctioned sport concussions. In 2017, concussion rates were calculated per 1,000 AEs. Injury rate ratios with 95% CIs compared rates between games and practices and by sex.

RESULTS

Overall, 73 concussions were reported, of which 21.9% were from non-school sanctioned sport settings. The 57 remaining game and practice concussions were reported during 76,384 AEs, for a concussion rate of 0.75/1,000 AEs. Football had the highest concussion rate (2.61/1,000 AEs). Concussion rates were higher in games versus practices (injury rate ratio=1.83, 95% CI=1.06, 3.15), and in girls versus boys in sex-comparable sports, i.e., baseball/softball, basketball, soccer, and track (injury rate ratio=3.73, 95% CI=1.24, 11.23).

CONCLUSIONS

Current findings parallel those found in high school and college sports settings in that higher concussion rates were reported in girls and competitions. However, concussion rates exceeded those recently reported in high school and youth league settings, highlighting the need for continued research in the middle school sports setting. Given that one in five concussions were from non-school sanctioned sport settings, prevention efforts in middle school sports settings should consider sport and non-sport at-risk exposure.

Short-term Outcomes Following Concussion in the NFL: A Study of Player Longevity, Performance, and Financial Loss

BACKGROUND

A short-term protocol for evaluation of National Football League (NFL) athletes incurring concussion has yet to be fully defined and framed in the context of the short-term potential team and career longevity, financial risk, and performance.

PURPOSE

To compare the short-term career outcomes for NFL players with concussions by analyzing the effect of concussions on (1) franchise release rate, (2) career length, (3) salary, and (4) performance.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

NFL player transaction records and publicly available injury reports from August 2005 to January 2016 were analyzed. All players sustaining documented concussions were evaluated for a change to inactive or DNP ("did not participate") status. A case-control design compared franchise release rates and remaining NFL career span. Career length was analyzed via survival analysis. Salary and performance differences were analyzed with publicly available contract data and a performance-scoring algorithm based on position/player level.

RESULTS

Of the 5894 eligible NFL players over the 11-year period, 307 sustained publicly reported concussions resulting in the DNP injury protocol. Analysis of the probability of remaining in the league demonstrated a statistically significantly shorter career length for the concussion group at 3 and 5 years after concussion. The year-over-year change in contract value for the concussion group resulted in a mean overall salary reduction of $300,000 ± $1,300,000 per year (interquartile range, -$723,000 to $450,000 per year). The performance score reduction for all offensive scoring players sustaining concussions was statistically significant.

CONCLUSION

This retrospective study demonstrated that NFL players who sustain a concussion face a higher overall franchise release rate and shorter career span. Players who sustained concussions may incur significant salary reductions and perform worse after concussion. Short-term reductions in longevity, performance, and salary after concussion exist and deserve additional consideration.

Attitudes and Counseling Practices of Pediatricians Regarding Youth Sports Participation and Concussion Risks

OBJECTIVE

To examine attitudes and practices of pediatricians toward sports-related head trauma and youth participation in tackle football and ice hockey.

STUDY DESIGN

A respondent-anonymous electronic survey was distributed 3 times to members of the American Academy of Pediatrics Section of Bioethics, Council on Injury, Violence, and Poison Prevention, and Council on Sports Medicine and Fitness.

RESULTS

Of 791 eligible pediatricians, 227 (29%) responded. Most respondents (189/223; 85%) treat sports-related concussions, among whom 83% (137/165) reported access to an established return-to-play protocol within their practice. Virtually all (160/166; 96%) reported increased parental awareness/concern regarding concussions and 85% (139/163) reported increased visits for head trauma. Overall, 77% (140/183) would not allow their son to play tackle football and 35% (64/181) and 34% (63/184) would not allow their son or daughter, respectively, to participate in ice hockey. Most respondents endorsed limiting or eliminating tackling (143/176; 81%) and checking (144/179; 80%) from practice. Respondents were evenly divided in their support for counseling against youth participation in full-contact sports, with 48% in favor (87/180).

CONCLUSIONS

Most respondents would not allow their own child to play tackle football and endorsed limiting or eliminating tackling in practice. The American Academy of Pediatrics should consider recommending restrictions on tackling in football to support the current concussion concerns of its members.

Should School Boards Discontinue Support for High School Football?

A pediatrician is asked by her local school board to help them decide whether to discontinue their high school football program. She reviews the available evidence on the risks of football and finds it hopelessly contradictory. Some scholars claim that football is clearly more dangerous than other sports. Others suggest that the risks of football are comparable to other sports, such as lacrosse, ice hockey, or soccer. She finds very little data on the long-term sequelae of concussions. She sees claims that good coaching and a school culture that prioritizes the health of athletes over winning can reduce morbidity from sports injuries. In this paper, 3 experts also review the evidence about sports risks and discuss what is known and not known about the science and the ethics of high school football.

Concussions in Collision Youth Sports

Investigators from the University of Pittsburg, University of Arkansas, Lake Erie College of Osteopathic Medicine, and Boston Children's Hospital/Harvard Medical College researched the incidence of concussions in youth hockey in relation to age and activity setting.