Effectiveness of interventions to reduce aggression and injuries among ice hockey players: a systematic review

Incidence, Prevalence, and Burden of Health Problems in Elite Female Ice Hockey Players-A One-Season Prospective Study

Introduction: Epidemiological studies on elite female ice hockey players are lacking but needed to tailor preventive efforts in this growing group of athletes. Therefore, the aim of this study was to describe the incidence, prevalence, and burden of health problems in elite female ice hockey players. Methods: In this prospective cohort study, we asked all Swedish Women's Hockey League (SWHL) players (N = 207) to report their health status on the OSTRC-H2 weekly throughout the 2022/2023 season (28 weeks). Reported problems were categorized as injuries (acute or overuse) or illnesses and presented as incidence per player season and mean weekly prevalence. Results: A total of 129 players (62% of all SWHL players) provided 2286 health reports with a mean weekly response rate of 67%. Mean weekly prevalence of health problems was 21% (95% confidence interval [CI]: 19-23) (injuries: 15% [95% CI: 14-17] and illnesses: 6% [95% CI: 5-8]). Injury incidence was 2.1 (95% CI: 1.8-2.4) per player season (acute: 1.2 [95% CI: 1.0-1.5] and overuse: 0.8 [95% CI: 0.7-1.1]). Illness incidence was 1.3 per player season (95% CI: 1.1-1.6). Most reported health problems were acute injuries (59.4% of reported injuries). Most common among acute injuries where to the shoulder (15%), head (13%), and knee (11%). The hip/groin was the most reported (35%) and burdensome (49% of severity score) region among overuse injuries. Reported illnesses were mostly represented by respiratory infections (75%). Conclusions: In average, one in five elite ice hockey players reported a health problem at any given time during the season. Results of this study highlight the need to develop and test primary prevention strategies for shoulder, head, and knee injuries and secondary prevention strategies for hip and groin problems.

Duration of Ice Hockey Play and Chronic Traumatic Encephalopathy

Importance

Chronic traumatic encephalopathy (CTE) is a neurodegenerative tauopathy associated with repetitive head impacts (RHIs). Prior research suggests a dose-response association between American football play duration and CTE risk and severity, but this association has not been studied for ice hockey.

Objective

To investigate associations of duration of ice hockey play with CTE diagnosis and severity, functional status, and dementia.

Design, Setting, and Participants

This cross-sectional study was conducted among male brain donors in the Understanding Neurological Injury and Traumatic Encephalopathy and Framingham Heart Study Brain Banks whose primary RHI exposure was from ice hockey. Donors died, brains were donated, and data were collected between July 1997 and January 2023. Data analysis was conducted from January 2023 to May 2024.

Exposures

Ice hockey years played as an RHI proxy.

Main Outcomes and Measures

CTE neuropathological diagnosis, cumulative phosphorylated tau (ptau) burden across 11 brain regions commonly affected in CTE, informant-reported Functional Activities Questionnaire (FAQ) score at death, and consensus dementia diagnosis were assessed.

Results

Among 77 male donors (median [IQR] age, 51 [33-73] years), 42 individuals (54.5%) had CTE, including 27 of 28 professional players (96.4%). CTE was found in 5 of 26 donors (19.2%) who played fewer than 13 years, 14 of 27 donors (51.9%) who played 13 to 23 years, and 23 of 24 donors (95.8%) who played more than 23 years of hockey. Increased years played was associated with increased odds for CTE (odds ratio [OR] per 1-year increase, 1.34; 95% CI, 1.15-1.55; P < .001) and with increased ptau burden (SD increase per 1-year increase = 0.037; 95% CI, 0.017-0.057; P < .001) after adjusting for age at death, other contact sports played, age of first hockey exposure, concussion count, and hockey position. Simulation demonstrated that years played remained associated with CTE when years played and CTE were both associated with brain bank selection across widely ranging scenarios (median [full range] OR across all simulations, 1.34 [1.29-1.40]). Increased ptau burden was associated with FAQ score (βstandardized = 0.045; 95% CI, 0.021-0.070; P < .001) and dementia (OR per SD increase, 1.12; 95% CI, 1.01-1.26; P = .04) after adjusting for age at death, other contact sports played, hockey years played, enforcer status, age of first hockey exposure, concussion count, and hockey position.

Conclusions and Relevance

In this study of male former ice hockey players, a dose-response association was observed between hockey years played and risk and severity of CTE. Simulation suggested that brain bank selection may not bias the magnitude of outcomes in the association.

Association of in-competition injury risk and the degree of rapid weight cutting prior to competition in division I collegiate wrestlers

OBJECTIVES

Weight cutting is thought to offer a competitive advantage in wrestling. Dehydration has deleterious effects on physical and cognitive function, which may increase the risk of injury. The purpose of the study was to investigate whether the degree of weight cutting was associated with injury risk.

METHODS

Data were collected prospectively in a cohort of collegiate wrestlers over seven seasons. Changes in weight, body fat and lean mass were measured during the preseason, at midseason and before competition. Cox proportional-hazard ratios were calculated for risk of in-competition injury.

RESULTS

Among 67 unique division 1 collegiate wrestlers (163 athlete seasons), there were 53 unique injuries affecting 46 athletes. There was no difference in absolute weight change, per cent weight change, per cent body fat change or per cent lean mass change between injured and non-injured wrestlers from the preseason to midseason measurements. From midseason to competition weight, change in body weight was -7.0%±3.2% (-5.3 kg±2.6) in injured athletes compared with -5.7%±3.3% (-4.3 kg±2.5) in non-injured athletes. For every kilogram of body weight lost, wrestlers had a 14% increased hazard of injury (HR 1.14, 95% CI 1.04 to 1.25, p=0.004). For every 1% of body weight lost, wrestlers had an 11% increased hazard of injury (HR 1.11, 95% CI 1.03 to 1.19, p=0.005).

CONCLUSION

Rapid weight cutting was associated with a higher risk of in-competition injuries in division 1 collegiate wrestlers. For every per cent in body weight lost, wrestlers had an 11% increased hazard of injury during competition.

Relationships between aggression, sensation seeking, brain stiffness, and head impact exposure: Implications for head impact prevention in ice hockey

OBJECTIVES

The objectives of this study were to (1) examine the relationship between the number of head impacts sustained in a season of men's collegiate club ice hockey and behavioral traits of aggression and sensation seeking, and (2) explore the neural correlates of these behaviors using neuroimaging.

DESIGN

Retrospective cohort study.

METHODS

Participants (n = 18) completed baseline surveys to quantify self-reported aggression and sensation-seeking tendencies. Aggression related to playing style was quantified through penalty minutes accrued during a season. Participants wore head impact sensors throughout a season to quantify the number of head impacts sustained. Participants (n = 15) also completed baseline anatomical and magnetic elastography neuroimaging scans to measure brain volumetric and viscoelastic properties. Pearson correlation analyses were performed to examine relationships between (1) impacts, aggression, and sensation seeking, and (2) impacts, aggression, and sensation seeking and brain volume, stiffness, and damping ratio, as an exploratory analysis.

RESULTS

Number of head impacts sustained was significantly related to the number of penalty minutes accrued, normalized to number of games played (r = .62, p < .01). Our secondary, exploratory analysis revealed that number of impacts, sensation seeking, and aggression were related to stiffness or damping ratio of the thalamus, amygdala, hippocampus, and frontal cortex, but not volume.

CONCLUSIONS

A more aggressive playing style was related to an increased number of head impacts sustained, which may provide evidence for future studies of head impact prevention. Further, magnetic resonance elastography may aid to monitor behavior or head impact exposure. Researchers should continue to examine this relationship and consider targeting behavioral modification programs of aggression to decrease head impact exposure in ice hockey.

Risk Factors Based on Analysis of Injury Mechanism and Protective Equipment for Ice Hockey Amateur Players

Considering the increasing popularity of ice hockey in South Korea, types of injuries and protective equipment for amateur club members need to be further studied. The purpose of the study is to investigate various injuries and protective equipment used by amateur players and to analyze different risk factors by collecting information on areas of injury and their mechanisms. The online survey for 102 participants was designed to address the general information of participants, types of injuries, information about ice hockey equipment, and open-ended questions about injuries and equipment. We conducted in-depth face-to-face interviews with five players about their experiences with injury and opinions about the protective equipment. In total, 60% of the survey participants had experienced injuries, including to the knee (22.6%), shoulder (21.6%), ankle (20.6%), and wrist (14.7%), in order of frequency. Types of injury included sprain (33.3%), contusion (31.4%), fracture (17.7%), abrasion (10.8%), and concussion (0.9%). Injury mechanisms included instances in which those with less proficiency in skating would be injured initially from player-to-player contact, and from landing on the ice or crashing into the fence afterward. We acknowledged how important wearing correctly sized equipment is for protection, and we highlighted the need to develop protective gear that accommodates Asian body measurements.

Fair Play as an Injury Prevention Intervention: Do Yellow Card Accumulation Policies Reduce High School Soccer Injuries?

OBJECTIVES

Evaluate yellow card policies' (YCPs) effectiveness in reducing competition contact injuries (CCIs).

DESIGN

Retrospective cohort.

SETTING

High schools.

PARTICIPANTS

Soccer players from High School (HS) Reporting Information Online participating schools, 2005/06 to 2017/18.

INDEPENDENT VARIABLES

Athlete exposure (AE), CCIs from HS competitions collected from states with/without YCPs.

MAIN OUTCOME MEASURES

Rate and rate ratio (RR) of athlete-athlete CCIs recorded by athletic trainers were compared between states with/without YCPs and pre-YCPs/post-YCPs among the states with YCPs using Poisson regressions. Proportions of severe athlete-athlete CCIs were also described in states with/without YCPs.

RESULTS

Fifteen states implemented YCPs between 2005/06 and 2017/18; 901 athlete-athlete CCIs occurred during 352 775 competition AEs in states with YCPs, and 3525 injuries during 1 459 708 competition AEs in states without YCPs. There was no significant difference in injury rates between schools in states with/without YCPs (RR 1.07; 95% confidence interval [CI]: 0.97-1.17). Among state with YCPs, injury rates were not significantly different between pre-YCP and post-YCP implementation (RR 1.15; 95% CI: 0.98-1.34). Although a significantly lower proportion of injuries resulting in >3 weeks' time loss (TL) occurred in states with YCPs (injury proportion ratio 0.81; 95% CI: 0.66-0.997), no significant differences were observed in proportions of other severe athlete-athlete CCIs between states with/without YCPs.

CONCLUSIONS

Yellow card policies were ineffective in lowering HS soccer athlete-athlete CCI rates, although injuries resulting in >3 weeks' TL were less prevalent in states with YCPs. Implementation of YCPs alone, without proper enforcement, may not be a sufficient injury prevention strategy.

A Comprehensive Summary of Systematic Reviews on Sports Injury Prevention Strategies

Background

A large volume of systematic reviews and meta-analyses has been published on the effectiveness of sports injury prevention programs.

Purpose

To provide a qualitative summary of published systematic reviews and meta-analyses that have examined the effectiveness of sports injury prevention programs on reducing musculoskeletal injuries.

Study Design

Systematic review; Level of evidence, 4.

Methods

We searched the PubMed, CINAHL, EMBASE, and the Cochrane databases for systematic reviews and meta-analyses that evaluated the effectiveness of sports injury prevention programs. We excluded published abstracts, narrative reviews, articles not published in English, commentaries, studies that described sports injury prevention strategies but did not assess their effectiveness, studies that did not assess musculoskeletal injuries, and studies that did not assess sports-related injuries. The most relevant results were extracted and summarized. Levels of evidence were determined per the Oxford Centre for Evidence-Based Medicine, and methodological quality was assessed using the AMSTAR-2 (A MeaSurement Tool to Assess systematic Reviews, revised version).

Results

A total of 507 articles were retrieved, and 129 were included. Articles pertaining to all injuries were divided into 9 topics: sports and exercise in general (n = 20), soccer (n = 13), ice hockey (n = 1), dance (n = 1), volleyball (n = 1), basketball (n = 1), tackle collision sports (n = 1), climbing (n = 1), and youth athletes (n = 4). Articles on injuries by anatomic site were divided into 11 topics: general knee (n = 8), anterior cruciate ligament (n = 34), ankle (n = 14), hamstring (n = 11), lower extremity (n = 10), foot (n = 6), groin (n = 2), shoulder (n = 1), wrist (n = 2), and elbow (n = 1). Of the 129 studies, 45.7% were ranked as evidence level 1, and 55.0% were evidence level 2. Based on the AMSTAR-2, 58.9% of the reviews reported a priori review methods, 96.1% performed a comprehensive literature search, 47.3% thoroughly described excluded articles, 79.1% assessed risk of bias for individual studies, 48.8% reported a valid method for statistical combination of data (ie, meta-analysis), 45.0% examined the effect of risk of bias on pooled study results, and 19.4% examined the risk for publication bias.

Conclusion

This comprehensive review provides sports medicine providers with a single source of the most up-to-date publications in the literature on sports injury prevention.

The Role of Dynamic Social Norms in Promoting the Internalization of Sportspersonship Behaviors and Values and Psychological Well-Being in Ice Hockey

Conducted among parents of young ice hockey players, this field experiment tested if making salient increasingly popular (i.e., dynamic) social norms that promote sportspersonship, learning, and having fun in sports, increases parents' own self-determined endorsement of these behaviors and values, improves their psychological well-being, and impacts on their children's on-ice behaviors. Hockey parents (N = 98) were randomly assigned to the experimental condition (i.e., presenting dynamic norms that increasingly favor sportspersonship, learning, and fun) vs. control condition (i.e., presenting neutral information). Parents' motivations for encouraging their child to learn and to have fun in hockey were then assessed. Score sheets for the games that followed the study provided access to their children's on-ice behaviors (i.e., penalties), as indicators of sportspersonship. Parents in the experimental condition reported higher self-determination for encouraging their child to learn and have fun in hockey compared to parents in the control condition. Furthermore, children of parents in the experimental condition had more assists. A mediation model revealed that the dynamic norms manipulation increased parents' self-determined motivation for encouraging their child to learn and to have fun in hockey, which in turn, predicted higher psychological well-being (i.e., lower anxiety, more vitality). Together, these results provide support for the contention that highlighting increasingly popular social norms that promote sportspersonship, learning, and fun in sports, represents a promising strategy for creating positive social change in this life context.

Cervical Spine Injuries in the Ice Hockey Player: Current Concepts in Epidemiology, Management and Prevention

STUDY DESIGN

This review article examines the biomechanics that underly hockey-related cervical spine injuries, the preventative measures to curtail them, optimal management strategies for the injured player and return to play criteria.

OBJECTIVE

Hockey is a sport with one of the highest rates of cervical spine injury, but by understanding the underlying pathophysiology and context in which these injuries can occur, it is possible to reduce their incidence and successfully manage the injured player.

METHODS

Multiple online databases including PubMed, Google Scholar, Columbia Libraries Catalog, Cochrane Library and Ovid MEDLINE were queried for original articles concerning spinal injuries in ice hockey. All relevant papers were screened and subsequently organized for discussion in our subtopics.

RESULTS

Cervical fractures in ice hockey most often occur due to an increased axial load, with a check from behind the most common precipitating event.

CONCLUSIONS

Despite the recognized risk for cervical spine trauma in ice hockey, further research is still needed to optimize protocols for both mitigating injury risk and managing injured players.

Characteristics of potential concussive events in elite male gaelic football players: A descriptive video-analysis

Gaelic football (GF) is a high-impact sport and Sport-Related Concussion (SRC) is an issue within the game. Our aim was to evaluate the characteristics of Potential Concussive Events (PCEs) that occur in the Gaelic Athletic Association National Football League and extrapolate this data to reduce the incidence and severity of SRC. PCEs may or may not lead to a clinical diagnosis of SRC, but represent high-risk events and therefore may be a useful indicator. A video-analysis approach was undertaken to identify PCEs throughout two seasons of play using broadcast footage, and characteristics of each PCE were measured based on previously validated methods. A total of 242 PCEs were identified over 111 matches (2.18 per match, 58.14 per 1000 hours of exposure). PCEs were frequently not anticipated by the player (40.5%, n = 98). The most common impact locations were the mandibular region (33.1%, n = 80) and the temporal region (21.1%, n = 51), and the most frequently observed mechanism was hand/fist to head (27.3%, n = 66). A second-hit was observed in 34 PCEs (14.0%). The findings provide initial guidance for the development of player protection strategies to reduce the incidence and severity of SRC in Gaelic Football.

Differences in Head Impact Exposures Between Youth Tackle and Flag Football Games and Practices: Potential Implications for Prevention Strategies

BACKGROUND

Interventions designed to reduce the risk for head impacts and concussion in youth football have increased over the past decade; however, understanding of the role of regular game play on head impact exposure among youth tackle and flag football athletes is currently limited.

PURPOSE

To explore head impact exposure among youth tackle and flag football athletes (age range, 6-14 years) during both practices and games.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Using the Vector MouthGuard sensor, the authors collected head impact data from 524 tackle and flag youth football athletes over the course of a football season. Quantities of interest were estimated from regression models using Bayesian methods.

RESULTS

For impacts ≥10g, a tackle football athlete had an estimated 17.55 (95% CI, 10.78-28.96) times more head impacts per practice compared with a flag football athlete (6.85 [95% CI, 6.05-7.76] and 0.39 [95% CI, 0.24-0.62] head impacts, respectively). Additionally, a tackle football athlete had an estimated 19.48 (95% CI, 12.74-29.98) times more head impacts per game compared with a flag football athlete (13.59 [95% CI, 11.97-15.41] and 0.70 [95% CI, 0.46-1.05] head impacts, respectively). Among tackle football athletes, the estimated average impact rate was 6.51 (95% CI, 5.75-7.37) head impacts during a practice and 12.97 (95% CI, 11.36-14.73) impacts during a game, resulting in 2.00 (95% CI, 1.74-2.29) times more ≥10g head impacts in games versus practices. Tackle football athletes had 2.06 (95% CI, 1.80-2.34) times more high-magnitude head impacts (≥40g) during a game than during a practice. On average, flag football athletes experienced an estimated 0.37 (95% CI, 0.20-0.60) head impacts during a practice and 0.77 (95% CI, 0.53-1.06) impacts during a game, resulting in 2.06 (95% CI, 1.29-3.58) times more ≥10g head impacts in games versus practices. Because of model instability caused by a large number of zero impacts for flag football athletes, a comparison of high-magnitude head impacts is not reported for practices or games.

CONCLUSION

This study provides a characterization of the head impact exposure of practices and games among a large population of youth tackle and flag football athletes aged 6 to 14 years. These findings suggest that a greater focus on game-based interventions, such as fair play interventions and strict officiating, may be beneficial to reduce head impact exposures for youth football athletes.

Epidemiology of Injuries Sustained in Boys' High School Contact and Collision Sports, 2008-2009 Through 2012-2013

Background:

Injury epidemiology for boys’ high school contact and collision sport has been described in several overlapping but fragmented studies. Comprehensive comparisons of injuries sustained in boys’ soccer, wrestling, football, ice hockey, and lacrosse are lacking.

Purpose:

To describe patterns of injury by severity, body site, and diagnosis among high school boys’ contact and collision sports in the United States.

Study Design:

Descriptive epidemiology study.

Methods:

Injury rates and rate ratios (RRs) were calculated for injuries sustained in boys’ high school soccer, wrestling, football, ice hockey, and lacrosse through use of the High School RIO (Reporting Information Online) surveillance data from 2008-2009 through 2012-2013. Injury patterns were described by site, diagnosis, time loss, and severity. Severe injury was defined as an injury that resulted in 21 days or more of time loss from sport participation. Risk of sustaining a concussion was compared between sports.

Results:

The risk of sustaining an injury was higher in competition compared with practice overall (RR, 4.01; 95% CI, 3.90-4.12); the same pattern was true for severe injuries (RR, 4.61; 95% CI, 4.34-4.90). Football players experienced the highest injury rate (3.87 per 1000 athlete-exposures [AEs]) and the highest severe injury rate (0.80 per 1000 AEs). Overall, the most commonly injured body site was the head/face (22.5%), and the most prevalent injury diagnosis was ligament sprain not requiring surgery (23.5%). The most frequently injured body site from severe injury was the knee (24.6%), and fracture or avulsion was the most prevalent severe injury diagnosis (37.0%). Football players had a significantly higher risk of sustaining a concussion compared with other contact or collision sport athletes (P < .05).

Conclusion:

Injuries rates were higher in competition than those in practice for boys’ high school contact and collision athletes. Football players sustained the highest injury rate, the highest severe injury rate, and the highest concussion rate among the sports included in this analysis. Understanding these patterns of injury can generate policy and rule changes to make sports safer and maintain high levels of participation.

Adolescents' engagement in multiple risk behaviours is associated with concussion

Background

The objective of this study was to investigate the relationship between engagement in multiple risk behaviours (MRB) and concussion amongst youth.

Methods

This was a cross-sectional study that used survey data collected from 3059 students in grades 6–10 (approximate ages 11–15 years) from Ontario, Canada. Students reported whether or not they had a medically diagnosed concussion within the previous 12 months and the frequency that they participated in several risky behaviours including fighting, bullying, smoking, drinking alcohol, using illicit drugs, drinking caffeinated beverages, not using protective equipment, and having unsafe sex. Responses to the risky behavior items were used to create a MRB score. The association between MRB and concussion was explored using logistic regression that controlled for several confounding variables.

Results

Approximately 10.7% of students reported that they had a medically diagnosed concussion within the past year. A dose-response relationship was found between MRB and concussion among students in grades 9–10, while in grades 6–8 students only those in the highest MRB quartile had an increased likelihood of concussion. The relative odds for concussion in the highest versus the lowest MRB quartile were 4.67 (95% confidence interval: 2.33, 9.35) in grades 9–10 students and 2.94 (95% confidence interval, 1.90, 4.56) in grades 6–8 students.

Conclusions

Engagement in MRB may be an important etiologic component of adolescent concussion. Future studies should address whether behavioural interventions designed to decrease engagement in MRB reduce the risk of concussion and other injuries.

Epidemiology of Shoulder Instability Injuries in Collision Collegiate Sports From 2009 to 2014

PURPOSE

To describe the types, mechanisms, and severity of shoulder instability injuries in collegiate collision athletes during the 2009-2010 through 2013-2014 academic years using the National Collegiate Athletic Association Injury Surveillance Program; to compare the injury incidence between men's collision sports and their women's non-collision counterparts, when possible; and to compare injury outcomes between Divisions I, II, and III.

METHODS

Data regarding men's football, wrestling, ice hockey, and lacrosse, as well as women's ice hockey and lacrosse, were obtained. Injuries requiring attention from a health care provider were reported. Incidence rates per 100,000 athlete-exposures (AEs) were calculated with 95% confidence intervals (CIs). Analysis of variance was used to compare time loss (TL), and χ² analysis was used to compare surgery rates between divisions.

RESULTS

A total of 445 shoulder instability injuries occurred in 1,421,561 AEs from 2009-2010 to 2013-2014 (incidence rate, 31.30 injuries/100,000 AEs; 95% CI, 28.4-34.21 injuries/100,000 AEs). Subluxation accounted for 59.1% of injuries, with anterior subluxation (35.3%) being the most common injury. Dislocation resulted in the most TL per injury (17.58 days). Mean TL for all injuries was 8.17 days (standard deviation, 7.21 days). When non-time-loss injuries were excluded from analysis, players experienced a mean TL of 18.34 days (standard deviation, 8.44 days). Divisions I (4.77 days), II (20.52 days), and III (11.23 days) differed significantly in mean TL (P = .01). Of the injuries, 29.3% required surgery. The surgery rates for Divisions I (32.9%), II (38.1%), and III (19.4%) also differed significantly (P = .04). Men's ice hockey and lacrosse players sustained a 2.17-fold (95% CI, 1.04-4.50) higher incidence of shoulder instability than their female counterparts.

CONCLUSIONS

Anterior subluxation and dislocation accounted for 52.1% of all shoulder instability injuries. Injured athletes missed 8 days on average, and nearly 30% of injuries required surgery. Surgery rates and TL were significantly different between Divisions I, II, and III. Female athletes playing non-collision ice hockey and lacrosse experienced significantly lower shoulder instability rates than their male counterparts.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Contact sport related head and neck injuries in pediatric athletes

OBJECTIVES

To describe the type and frequency of sports related pediatric head and neck trauma.

METHODS

The National Electronic Injury Surveillance System (NEISS) was searched for football, basketball, soccer, lacrosse and ice hockey related facial injuries. Cross-sectional analysis of incidence, age, and sex and specific injury diagnoses, mechanisms, and facial locations were performed. We focused on craniofacial and soft tissue injuries and excluded patients with concussion or other neurological injuries.

RESULTS

A total of 24,905 cases were identified in the NEISS database, corresponding to an estimated, 764,293 emergency department visits. The most hazardous sports were basketball, accounting for 356,188 visits (46.6%), football with 249,633 visits (32.6%), and soccer with 128,113 (14.7%) visits. Lacrosse and ice hockey accounted for 16,869 (1.9%) and 13,490 (1.5%) visits, respectively. There has been a decrease in injuries over the past 10 years, particularly for football (53%), ice hockey (46%), and lacrosse (41%). Soccer (13%) and basketball (9%) noticed the smallest decreases.

CONCLUSION

Children who play basketball, football and soccer are especially prone to emergency department visits related to the head and neck. Overall, there has been an improvement in number of injuries across the five sports investigated. Sports amenable to head and neck protective equipment saw the largest improvement (football, ice hockey, lacrosse), whereas only small decreases were noted in basketball and soccer. Changes in regulations for sports not amenable to more protective equipment may help decrease adverse events.

Pros and Cons of 19 Sport-Related Concussion Educational Resources in Canada: Avenues for Better Care and Prevention

Objective: The goal of this research was to assess the effectiveness of available concussion educational resources in Canada, the means used to disseminate this knowledge and the impact of these educational resources on players' concussion prevention knowledge. Methods: We assessed concussion knowledge before and after exposure to one or more of 19 resources introduced through a national program aimed to increase awareness and knowledge of concussion. The effectiveness of the mode of delivery was measured by changes in concussion knowledge scores (CKS) between pre and pro scores. Measures: Concussion knowledge scores (CKS) were calculated for pre- and post- exposure to concussion educational resources and used as a measure of both, the effectiveness of each resource as well as the effectiveness of the delivery method. The effectiveness of each educational resource was also measured by the respondents' rating of each concussion educational resource. Results: Respondents in post-survey had higher CKS than those in pre-survey. Two out of the 19 newly developed concussion educational resources were effective in improving the resource users' CKS. Linear regression showed that using more resources further increased CKS. Four out of six modes of delivery enhanced respondents' concussion knowledge. Conclusion: Our findings demonstrate that the newly developed Canadian concussion educational resources were effective at improving users' concussion knowledge. Our data demonstrates that using three or more resources further enhanced the users' concussion knowledge. Future research, however, is critical to assess whether concussion prevention knowledge is sufficient to reduce injuries and factors influencing it.

Knowledge, Attitudes and Concussion Information Sources Among First Nations in Ontario

OBJECTIVE

Hockey is a popular sport played by many First Nation youth. Concussion frequently goes unrecognized and unreported in youth hockey. Unintentional injuries among Indigenous youth occur at rates three to four times the national Canadian average. The study sought to examine knowledge, attitudes and sources of concussion information among First Nations people attending a provincial hockey tournament.

METHODS

A cross-sectional survey was undertaken. The survey by Mzazik et al. were modified to use in this study. Participants included youth (6-18 years) hockey players (n=75), parents (n=248) and coaches (n=68). The main outcome measure was total knowledge index (TKI) which consisted of the sum of correct responses to 15 multiple choice questions. Additional data gathered included demographics, concussion history, attitudes toward concussion and sources of information. Descriptive statistics included proportion comparisons. Variables were tested using χ 2 and analysis of variance.

RESULTS

Overall TKI scores (out of a total of 15) were low; players (5.9±2.8), parents (7.5±2.6) and coaches (7.9±2.6). Participants with higher knowledge scores reported more appreciation of the seriousness of concussion. Sources of information about concussion differed by study group, suggesting the need for multiple knowledge translation strategies to reach youth, parents and coaches.

CONCLUSIONS

Future initiatives are urgently needed to improve education and prevention of concussion in First Nations youth hockey. Collaborating and engaging with communities can help to ensure an Indigenous lens for culturally safe interventions.

Understanding the resistance to creating safer ice hockey: essential points for injury prevention

Introduction

Despite the known negative health outcomes of concussions in minor level boys’ hockey, there has been significant resistance to creating a safer game with less body checking.

Methods

To better understand cultural barriers that prevent making the sport safer for youth and adolescents, semistructured interviews, with 20 ice hockey stakeholders, were conducted and analysed using thematic analysis.

Results

Through this analysis, two primary concepts arose from respondents. The first concept is that body checking, despite the harm it can cause, should be done in a respectful sportsmanlike fashion. The second concept is the contradiction that the game of ice hockey is both dynamic and unchangeable.

Discussion

Using structural functionalist theory, we propose an argument that the unfortunate perpetuation of violence and body checking in youth ice hockey serves to maintain the social order of the game and its culture. Any strategies aimed at modifying and promoting healthy behaviour in the game should take these concepts into account.

Injury Surveillance of Head, Neck, and Facial Injuries in Collegiate Ice Hockey Players, 2009-2010 Through 2013-2014 Academic Years

CONTEXT

  Ice hockey is a high-speed, full-contact sport with a high risk of head/face/neck (HFN) injuries. However, men's and women's ice hockey differ; checking is allowed only among men.

OBJECTIVES

  To describe the epidemiology of HFN injuries in collegiate men's and women's ice hockey during the 2009-2010 through 2013-2014 academic years.

DESIGN

  Descriptive epidemiology study.

SETTING

  Ice hockey data from the National Collegiate Athletic Association (NCAA) Injury Surveillance Program during the 2009-2010 through 2013-2014 academic years.

PATIENTS OR OTHER PARTICIPANTS

  Fifty-seven men's and 26 women's collegiate ice hockey programs from all NCAA divisions provided 106 and 51 team-seasons of data, respectively.

MAIN OUTCOME MEASURE(S)

  Injury rates per 1000 athlete-exposures and rate ratios with 95% confidence intervals (CIs).

RESULTS

  The NCAA Injury Surveillance Program reported 496 and 131 HFN injuries in men's and women's ice hockey, respectively. The HFN injury rate was higher in men than in women (1.75 versus 1.16/1000 athlete-exposures; incidence rate ratio = 1.51; 95% CI = 1.25, 1.84). The proportion of HFN injuries from checking was higher in men than in women for competitions (38.5% versus 13.6%; injury proportion ratio = 2.82; 95% CI = 1.64, 4.85) and practices (21.9% versus 2.3%; injury proportion ratio = 9.41; 95% CI = 1.31, 67.69). The most common HFN injury diagnosis was concussion; most concussions occurred in men's competitions from player contact while checking (25.9%). Player contact during general play comprised the largest proportion of concussions in men's practices (25.9%), women's competitions (25.0%), and women's practices (24.0%). While 166 lacerations were reported in men, none were reported in women. In men, most lacerations occurred from player contact during checking in competitions (41.8%) and player contact during general play in practices (15.0%).

CONCLUSIONS

  A larger proportion of HFN injuries in ice hockey occurred during checking in men versus women. Concussion was the most common HFN injury and was most often due to player contact. Lacerations were reported only among men and were mostly due to checking. Injury-prevention programs should aim to reduce checking-related injuries.

Evaluation, management and prevention of lower extremity youth ice hockey injuries

Ice hockey is a fast-paced sport played by increasing numbers of children and adolescents in North America and around the world. Requiring a unique blend of skill, finesse, power and teamwork, ice hockey can become a lifelong recreational activity. Despite the rising popularity of the sport, there is ongoing concern about the high frequency of musculoskeletal injury associated with participation in ice hockey. Injury rates in ice hockey are among the highest in all competitive sports. Numerous research studies have been implemented to better understand the risks of injury. As a result, rule changes were adopted by the USA Hockey and Hockey Canada to raise the minimum age at which body checking is permitted to 13–14 years (Bantam level) from 11–12 years (Pee Wee). Continuing the education of coaches, parents and players on rules of safe play, and emphasizing the standards for proper equipment use are other strategies being implemented to make the game safer to play. The objective of this article was to review the evaluation, management and prevention of common lower extremity youth hockey injuries.

Aggression, Violence and Injury in Minor League Ice Hockey: Avenues for Prevention of Injury

Background

In North America, more than 800,000 youth are registered in organized ice hockey leagues. Despite the many benefits of involvement, young players are at significant risk for injury. Body-checking and aggressive play are associated with high frequency of game-related injury including concussion. We conducted a qualitative study to understand why youth ice hockey players engage in aggressive, injury-prone behaviours on the ice.

Methods

Semi-structured interviews were conducted with 61 minor ice hockey participants, including male and female players, parents, coaches, trainers, managers and a game official. Players were aged 13–15 playing on competitive body checking teams or on non-body checking teams. Interviews were manually transcribed, coded and analyzed for themes relating to aggressive play in minor ice hockey.

Results

Parents, coaches, teammates and the media exert a large influence on player behavior. Aggressive behavior is often reinforced by the player’s social environment and justified by players to demonstrate loyalty to teammates and especially injured teammates by seeking revenge particularly in competitive, body-checking leagues. Among female and male players in non-body checking organizations, aggressive play is not reinforced by the social environment. These findings are discussed within the framework of social identity theory and social learning theory, in order to understand players’ need to seek revenge and how the social environment reinforces aggressive behaviors.

Conclusion

This study provides a better understanding of the players’ motivations and environmental influences around aggressive and violent play which may be conducive to injury. The findings can be used to help design interventions aimed at reducing aggression and related injuries sustained during ice hockey and sports with similar cultures and rules.

Does Exercise Reduce Aggressive Feelings? An Experiment Examining the Influence of Movement Type and Social Task Conditions on Testiness and Anger Reduction

In the present study, it was assumed that a decrease in aggressive feelings is stronger with movements that are unlike aggressive actions compared with those that are similar to aggressive actions. Furthermore, cooperative exercise tasks were expected to lead to lower aggressive feelings compared with competitive tasks. After undergoing an induction of aggressive feelings, 60 participants were randomly assigned to one of six experimental treatment groups, each differing in "movement type" (rowing and combat exercise) and "social task condition" (cooperation, competition, and individualization). A significant reduction of aggressive feelings was only found for participants exercising individually in the rowing condition compared with the individual combat exercise condition. There were no sole effects of "movement type" and "social task condition."

Update and Overview of Spinal Injuries in Canadian Ice Hockey, 1943 to 2011: The Continuing Need for Injury Prevention and Education

OBJECTIVE

To identify spinal injuries in Canadian ice hockey from 2006 to 2011 and to discuss data from 1943 to 2011 and impact of injury prevention programs.

DESIGN

Data about spinal injuries with and without spinal cord injury in ice hockey have been collected by ThinkFirst's (now Parachute Canada) Canadian Ice Hockey Spinal Injuries Registry since 1981 through questionnaires from practitioners, ice hockey organizations, and media.

SETTING

All Canadian provinces and territories.

PARTICIPANTS

All registered Canadian ice hockey players.

ASSESSMENT OF RISK FACTORS

Age, gender, level of play, location, mechanism of injury.

MAIN OUTCOME MEASURES

Incidence, incidence rate, prevalence, and nature (morbidity) of the injuries.

RESULTS

Between 2006 and 2011, 44 cases occurred, 4 (9.1%) of which were severe. The incidence in the recent years continues to be lower than the peak years. From 1943 to 2011, 355 cases have been documented, primarily males (97.7%) and cervical spine injuries (78.9%), resulting from impact with the boards (64.2%). Check or push from behind (36.0%) was still the most common cause of injury, although slightly lower during 2006 to 2011. From 1943 to 2011, Prince Edward Island, New Brunswick, and British Columbia/Yukon had the highest injury rates. Ontario and Quebec continued to show markedly different injury rates, with Ontario more than twice that of Quebec.

CONCLUSIONS

Current data for 2006 to 2011 indicate that spinal injuries in ice hockey continue to occur, although still at lower rates than the peak years 1982 to 1995. It is imperative to continue educating players and team officials about spinal injury prevention and to reinforce the rules against checking or pushing from behind to reduce the incidence of these serious injuries.

Safe-Play Knowledge, Aggression, and Head-Impact Biomechanics in Adolescent Ice Hockey Players

CONTEXT

Addressing safe-play knowledge and player aggression could potentially improve ice hockey sport safety.

OBJECTIVES

To compare (1) safe-play knowledge and aggression between male and female adolescent ice hockey players and (2) head-impact frequency and severity between players with high and low levels of safe-play knowledge and aggression during practices and games.

DESIGN

Cohort study.

SETTING

On field.

PATIENTS OR OTHER PARTICIPANTS

Forty-one male (n = 29) and female (n = 12) adolescent ice hockey players.

INTERVENTION(S)

Players completed the Safe Play Questionnaire (0 = less knowledge, 7 = most knowledge) and Competitive Aggressiveness and Anger Scale (12 = less aggressive, 60 = most aggressive) at midseason. Aggressive penalty minutes were recorded throughout the season. The Head Impact Telemetry System was used to capture head-impact frequency and severity (linear acceleration [g], rotational acceleration [rad/s(2)], Head Impact Technology severity profile) at practices and games.

MAIN OUTCOME MEASURE(S)

One-way analyses of variance were used to compare safe play knowledge and aggression between sexes. Players were categorized as having high or low safe-play knowledge and aggression using a median split. A 2 × 2 mixed-model analysis of variance was used to compare head-impact frequency, and random-intercept general linear models were used to compare head-impact severity between groups (high, low) and event types (practice, game).

RESULTS

Boys (5.8 of 7 total; 95% confidence interval [CI] = 5.3, 6.3) had a trend toward better safe-play knowledge compared with girls (4.9 of 7 total; 95% CI = 3.9, 5.9; F1,36 = 3.40, P = .073). Less aggressive male players sustained significantly lower head rotational accelerations during practices (1512.8 rad/s (2) , 95% CI = 1397.3, 1637.6 rad/s(2)) versus games (1754.8 rad/s (2) , 95% CI = 1623.9, 1896.2 rad/s(2)) and versus high-aggression players during practices (1773.5 rad/s (2) , 95% CI = 1607.9, 1956.3 rad/s (2) ; F1,26 = 6.04, P = .021).

CONCLUSIONS

Coaches and sports medicine professionals should ensure that athletes of all levels, ages, and sexes have full knowledge of safe play and should consider aggression interventions for reducing head-impact severity among aggressive players during practice.

Recognizing the Symptoms of Mental Illness following Concussions in the Sports Community: A Need for Improvement

OBJECTIVE

To evaluate the awareness of concussion-related symptoms amongst members of the sports community in Canada.

METHODS

A cross-sectional national electronic survey was conducted. Youth athletes, parents, coaches and medical professionals across Canada were recruited through mailing lists from sports-related opt-in marketing databases. Participants were asked to identify, from a list of options, the symptoms of a concussion. The proportion of identified symptoms (categorized as physical, cognitive, mental health-related and overall) as well as participant factors associated with symptom recognition were analyzed.

RESULTS

The survey elicited 6,937 responses. Most of the respondents (92.1%) completed the English language survey, were male (57.7%), 35-54 years of age (61.7%), with post-secondary education (58.2%), or high reported yearly household income (>$80,000; 53.0%). There were respondents from all provinces and territories with the majority of respondents from Ontario (35.2%) or British Columbia (19.1%). While participants identified most of the physical (mean = 84.2% of symptoms) and cognitive (mean = 91.2% of symptoms), they on average only identified 53.5% of the mental health-related symptoms of concussions. Respondents who were older, with higher education and household income, or resided in the Northwest Territories or Alberta identified significantly more of the mental health-related symptoms listed.

INTERPRETATION

While Canadian youth athletes, parents, coaches and medical professionals are able to identify most of the physical and cognitive symptoms associated with concussion, identification of mental health-related symptoms of concussion is still lagging.

Modifying factors in sports-related concussion: dangerous style of play

In its third iteration, the Concussion in Sport Group identified 10 modifying factors that were presumed clinically to influence the investigation and management of concussions in sports. "Dangerous style of play" was delineated as one of these factors, most likely based on clinical lore. These modifying factors were retained in a more recent Concussion in Sport Group statement. To date, there has been no concerted effort to support or refute the inclusion of this constellation of behaviors as a modifying factor in sports-related concussion. This article reviews and summarizes the limited evidence related to a dangerous style of play in sports-related concussion, offers a preliminary assessment of its relevance as a modifying factor, and provides additional information on other aspects of player, coach, and governing body behavior and their potential effect(s) on reducing concussive injuries.

Pilot Randomized Evaluation of Publically Available Concussion Education Materials

Many states and sports leagues are instituting concussion policies aimed at reducing risk of morbidity and mortality; many include mandates about the provision of concussion education to youth athletes. However, there is limited evidence if educational materials provided under these typically vague mandates are in fact effective in changing concussion risk-related behavior or any cognition predictive of risk-related behavior. The purpose of this pilot randomized controlled study was to conduct a theory-driven evaluation of three publically available concussion education materials: two videos and one informational handout. Participants were 256 late adolescent males from 12 teams in a single league of ice hockey competition in the United States. Randomization of educational condition occurred at the team level. Written surveys assessing postimpact symptom reporting behavior, concussion knowledge, and concussion reporting cognitions were completed by participants immediately before receiving their educational intervention, 1 day after, and 1 month after. Results indicated no change in any measure over any time interval, with the exception of perceived underreporting norms. In one of the video conditions, perceived underreporting norms increased significantly 1 day after viewing the video. Possible content and viewing environment-related reasons for this increase are discussed. Across all conditions, perceived underreporting norms increased 1 month after intervention receipt, raising the possibility that late in the competitive season underreporting may be perceived as normative. The need for the development of theory-driven concussion education materials, drawing on best practices from health behavior scholars, is discussed.