Amanda M Black

Policy change eliminating body checking in non-elite ice hockey leads to a threefold reduction in injury and concussion risk in 11- and 12-year-old players

Background In ice hockey, body checking is associated with an increased risk of injury. In 2011, provincial policy change disallowed body checking in non-elite Pee Wee (ages 11–12 years) leagues. Objective To compare the risk of injury and concussion between non-elite Pee Wee ice hockey players in leagues where body checking is permitted (2011–12 Alberta, Canada) and leagues where policy change disallowed body checking (2011–12 Ontario, Canada). Method Non-elite Pee Wee players (lower 70%) from Alberta (n=590) and Ontario (n=281) and elite Pee Wee players (upper 30%) from Alberta (n=294) and Ontario (n=166) were recruited to participate in a cohort study. Baseline information, injury and exposure data was collected using validated injury surveillance. Results Based on multiple Poisson regression analyses (adjusted for clustering by team, exposure hours, year of play, history of injury/concussion, level of play, position and body checking attitude), the incidence rate ratio (IRR) associated with policy allowing body checking was 2.97 (95% CI 1.33 to 6.61) for all game injury and 2.83 (95% CI 1.09 to 7.31) for concussion. There were no differences between provinces in concussion [IRR=1.50 (95% CI 0.84 to 2.68)] or injury risk [IRR=1.22 (95% CI 0.69 to 2.16)] in elite levels of play where both provinces allowed body checking. Conclusions The rate of injury and concussion were threefold greater in non-elite Pee Wee ice hockey players in leagues where body checking was permitted. The rate of injury and concussion did not differ between provinces in elite levels, where body checking was allowed.

What strategies can be used to effectively reduce the risk of concussion in sport? A systematic review.

Aim or objective To examine the effectiveness of concussion prevention strategies in reducing concussion risk in sport. Design Systematic review according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Data sources Eleven electronic databases searched and hand-search of references from selected studies. Eligibility criteria for selecting studies The following were the study inclusion criteria: (1) contained original human research data; (2) investigated an outcome of concussion or head impact; (3) evaluated a concussion prevention intervention; (4) included sport participants; (5) analytical study designand (6) peer-reviewed. The following were the exclusion criteria: (1) review articles, case series or case studies and (2) not in English. Results The studies selected (n=48) provided evidence related to protective gear (helmets, headgear, mouthguards) (n=25), policy and rule changes (n=13) and other interventions (training, education, facilities) (n=10). Meta-analyses demonstrate a combined effect of a 70% reduction (incidence rate ratio (IRR)=0.3 (95% CI: 0.22 to 0.41)) in concussion risk in youth ice hockey leagues where policy disallows body checking, and the point estimate (IRR=0.8 (95% CI: 0.6 to 1.1)) suggests a protective effect of mouthguards in contact and collision sport (basketball, ice hockey, rugby). Summary/conclusions Highlights include a protective effect of helmets in skiing/snowboarding and the effectiveness of policy eliminating body checking in youth ice hockey. Future research should examine mouthguards in contact sport, football helmet padding, helmet fit in collision sport, policy limiting contact practice in youth football, rule enforcement to reduce head contact in ice hockey and soccer, ice surface size and board/glass flexibility in ice hockey and training strategies targeting intrinsic risk factors (eg, visual training). Systematic review registration PROSPERO 2016:CRD42016039162

The Epidemiology of Concussions: Number and Nature of Concussions and Time to Recovery Among Female and Male Canadian Varsity Athletes 2008 to 2011.

Objective: To provide incidence rates and days to symptom resolution and cognitive recovery stratified by sex and sport at a Canadian institution. Study Design: A retrospective chart analysis. Subjects: Seven hundred fifty-nine varsity level athletes competing in mens football, mens and womens soccer, mens and womens volleyball, mens and womens basketball, mens and womens ice hockey, womens field hockey, womens rugby, mens and womens tennis, mens and womens water polo, mens and womens swimming, badminton, cross-country, and track and field in the 2008 to 2009 season through the 2010 to 2011 season. Main Outcome Measures: Incidence of concussion, days to symptom recovery, and days to cognitive recovery as measured by clinical interpretation using the sports concussion assessment tool (SCAT)/SCAT2 and Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) with baseline and follow-up data. Results: A total of 81 concussions were reported and diagnosed among 759 athletes. Significantly, more female athletes were concussed than male athletes (13.08%–7.53%, respectively; P = 0.014) with the highest rates in womens rugby [incidence density (ID) = 20.00 concussions per athlete-season], womens ice hockey (ID = 18.67 per athlete-season), and mens basketball (ID = 20.00 per athlete-season). Sex differences in symptom recovery and cognitive recovery were not significant. Conclusions: The incidence of concussion across multiple sports in a Canadian varsity athlete population is of concern. There are inconsistencies found between the time an athlete claims to have no symptoms and the time of neurocognitive recovery as measured by computerized neurocognitive testing. Therefore, objective computerized testing is recommended to ensure that athletes are functionally recovered before return to play.

The Effect of the “Zero Tolerance for Head Contact” Rule Change on the Risk of Concussions in Youth Ice Hockey Players

Background: Ice hockey is a popular winter sport in Canada. Concussions account for the greatest proportion of all injuries in youth ice hockey. In 2011, a policy change enforcing “zero tolerance for head contact” was implemented in all leagues in Canada. Purpose: To determine if the risk of game-related concussions and more severe concussions (ie, resulting in >10 days of time loss) and the mechanisms of a concussion differed for Pee Wee class (ages 11-12 years) and Bantam class (ages 13-14 years) players after the 2011 “zero tolerance for head contact” policy change compared with players in similar divisions before the policy change. Study Design: Cohort study; Level of evidence, 3. Methods: The retrospective cohort included Pee Wee (most elite 70%, 2007-2008; n = 891) and Bantam (most elite 30%, 2008-2009; n = 378) players before the rule change and Pee Wee (2011-2012; n = 588) and Bantam (2011-2012; n = 242) players in the same levels of play after the policy change. Suspected concussions were identified by a team designate and referred to a sport medicine physician for diagnosis. Incidence rate ratios (IRRs) were estimated based on multiple Poisson regression analysis, controlling for clustering by team and other important covariates and offset by game-exposure hours. Incidence rates based on the mechanisms of a concussion were estimated based on univariate Poisson regression analysis. Results: The risk of game-related concussions increased after the head contact rule in Pee Wee (IRR, 1.85; 95% CI, 1.20-2.86) and Bantam (IRR, 2.48; 95% CI, 1.17-5.24) players. The risk of more severe concussions increased after the head contact rule in Pee Wee (IRR, 4.12; 95% CI, 2.00-8.50) and Bantam (IRR, 7.91; 95% CI, 3.13-19.94) players. The rates of concussions due to body checking and direct head contact increased after the rule change. Conclusion: The “zero tolerance for head contact” policy change did not reduce the risk of game-related concussions in Pee Wee or Bantam class ice hockey players. Increased concussion awareness and education after the policy change may have contributed to the increased risk of concussions found after the policy change.

The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change

Background In 2013, Hockey Canada introduced an evidence-informed policy change delaying the earliest age of introduction to body checking in ice hockey until Bantam (ages 13–14) nationwide. Objective To determine if the risk of injury, including concussions, changes for Pee Wee (11–12 years) ice hockey players in the season following a national policy change disallowing body checking. Methods In a historical cohort study, Pee Wee players were recruited from teams in all divisions of play in 2011–2012 prior to the rule change and in 2013–2014 following the change. Baseline information, injury and exposure data for both cohorts were collected using validated injury surveillance. Results Pee Wee players were recruited from 59 teams in Calgary, Alberta (n=883) in 2011–2012 and from 73 teams in 2013–2014 (n=618). There were 163 game-related injuries (incidence rate (IR)=4.37/1000 game-hours) and 104 concussions (IR=2.79/1000 game-hours) in Alberta prior to the rule change, and 48 injuries (IR=2.16/1000 game-hours) and 25 concussions (IR=1.12/1000 game-hours) after the rule change. Based on multivariable Poisson regression with exposure hours as an offset, the adjusted incidence rate ratio associated with the national policy change disallowing body checking was 0.50 for all game-related injuries (95% CI 0.33 to 0.75) and 0.36 for concussion specifically (95% CI 0.22 to 0.58). Conclusions Introduction of the 2013 national body checking policy change disallowing body checking in Pee Wee resulted in a 50% relative reduction in injury rate and a 64% reduction in concussion rate in 11-year-old and 12-year-old hockey players in Alberta.

The effect of a national body checking policy change on concussion risk in youth ice hockey players

Objective To determine if the risk of game-related concussion differs for Pee Wee (11–12 years) ice hockey players in the season following a national policy change disallowing body checking (2013/2014) when compared to a season (2011/2012) when body checking was allowed. Design Historical cohort study. Setting Community ice hockey rinks. Participants Pee Wee players were recruited from 59 teams in all divisions of play in Alberta (n=883) in 2011/12 prior to the rule change and from 73 teams in 2013/14 following the rule change (n=617). Assessment of risk factors Pee Wee ice hockey players before and after a national body checking policy change. Outcome measures Suspected concussions were identified by a team therapist/safety designate and referred to a sport medicine physician. Concussions were included if they met the Zurich 2013 Consensus definition of concussion. Main results There were 104 game-related concussions (IR=2.79/1000 game-hours) in Alberta prior to the rule change and 24 concussions (IR=1.08/1000 game-hours) after. Based on a multivariable Poisson regression model adjusting for player size, age, body checking attitudes, previous injury, level of play, and position, accounting for clustering by team, the rate of concussion declined following the policy change [IRR=0.34 (95% CI; 0.21 – 0.56)]. Overall, a physician diagnosed 67.3% and 79.1% of suspected game concussions in 2011/2012 and 2013/2014, respectively. Conclusions Introduction of the national policy change disallowing body checking in Pee Wee resulted in a 66% reduction in the Alberta Pee Wee ice hockey concussion rate. These findings have important implications for youth ice hockey policy. Competing interests None.

The value of computerised neurocognitive testing at medical clearance to return to play following a sport-related concussion in youth ice hockey players

Objective To determine the value of the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) tool in measuring neurocognitive recovery following concussion. Design Nested case-control. Setting Sport Medicine Centre, Alberta, Canada. Participants Ice hockey players (n=96; 88.5% male, 11-17 years old) following concussion who completed ImPACT at baseline and medical clearance to return to play (RTP) were compared to controls (n=31) matched for age, sex, and testing time interval. Assessment of risk factors Players who sustained a concussion were referred to a study physician for assessment and RTP clearance based on clinical assessment and SCAT2/3. Physicians were blinded to ImPACT scores. Outcome measures ImPACT composite scores were measured (i.?e., verbal memory, visual memory, reaction time, visual motor) at each time interval [i.e., baseline and RTP (cases)/second measurement (controls)]. Between-interval ImPACT reliable change scores (80%CI) were compared. Main results At RTP (Median days since injury: 22, range: 2–84), 43/96 (44.8%) concussed players and 11/31 (35.5%) controls had ≥1 composite scores reliably worse than at baseline. Conditional logistic regression analysis (n=31 matched pairs) did not demonstrate a difference in the odds of having ≥1 reliably worse composite score between concussed and controls [OR=2.00 (95% CI: 0.5–8.0)] or ≥1 reliably better composite score [OR=1.2 (95% CI: 0.37–3.93)]. Conclusions The utility of baseline ImPACT scores in medical decisions to RTP may be limited by the reliability of composite scores in youth populations. Caution is warranted when interpreting ImPACT scores post-concussion on an individual level using baseline performance. Future research including multivariable analyses is warranted in a larger sample. Competing interests Brian Brooks is a co-author of a paediatric memory test for which he receives royalties. No financial interests in ImPACT are declared. None for all other authors.

Prevention of Sport-related Facial Injuries

There is evidence that eye protection, mouth guards, helmets, and face guards are effective in reducing the risk of facial injury; however, such safety practices are not adopted universally by all athletes playing high-risk sports. Underlying beliefs about risk perception, comfort, ineffectiveness, utility, and a lack of awareness or enforcement have been identified as reasons people may not adopt preventive measures. There are several high-risk sports that have not mandated or do not enforce use of protective equipment. Valid evidence can assist with addressing the resistance caused by prevailing beliefs and could be essential in influencing rule changes.

Epidemiology of facial injuries in sport

Facial injuries can pose a large health burden for athletes, potentially resulting in time loss and surgery. This article reviews the incidence, common mechanisms, and risk factors of facial injuries in several sports globally. Estimates of facial injury rates are complicated by a lack of, or inconsistent, reporting on specific types of injury. Much of the epidemiologic literature is based on hospital-based injury surveillance and there is a paucity of literature examining sport-specific risk factors. Future research should focus on prospective injury surveillance methodologies with consistent injury definitions examining risk factors and the effectiveness of facial injury prevention efforts.

The effect of age on symptom reporting on the adult and child post concussion symptom scale in youth ice hockey players

Objective To determine symptom reporting differences for children completing the adult and child version of the Post-Concussion Symptom Scale (PCSS) on the Sport Concussion Assessment Tool 3 (SCAT3). Design Cross-Sectional study. Setting Community ice hockey teams, Alberta, Canada. Participants Youth hockey players (n=891; 91.58% male, 10–14 years) who completed the PCSS on the Adult and Child version of the SCAT3 during a preseason baseline assessment. Assessment of risk factors Adult versus child PCSS stratified by categorical age (10–12, 13–14). Outcome measures Total number of symptoms, symptoms reported, and proportion equally reporting symptoms (0, ≥1) on both PCSS scales. Main results Participants reported a median of 2 symptoms [Interquartile Range (IQR):0–21] on the adult scale (/22) and 5 (IQR:0-20) on the child scale (/20). There was no evidence of a difference in the proportion of participants reporting symptoms (0, ≥1) on both scales between age groups 10–12 (525/729, 72.02%) and 13–14 (121/160, 75.63%) (difference: −3.61% (95% confidence interval (−11.40%, 4.18%)). The most frequent symptoms reported on the adult PCSS by participants with no symptoms on the child PCSS were nervousness (11.27%) and neck pain (10.56%). Participants with no symptoms on the adult PCSS most commonly reported being easily distracted (45.29%) and forgetful (39.49%) on the Child PCSS. Conclusions A greater number of symptoms were endorsed for all 10-14 year old subjects when using the Child SCAT3 PCSS. Neck pain was a commonly reported symptom for all age groups on the Adult SCAT3 PCSS, but this symptom is absent from the Child SCAT3. Competing interests None.