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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.

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.

Objective: To determine the perceptions and roles of referees about violence and injury in hockey games., Design: Questionnaire., Setting: Web-based survey., Participants: We contacted referees across Canada from various leagues and all levels of play, with the majority of respondents from Ontario (92%)., Main Outcome Measures: We gathered demographic information anonymously and posed questions on aggression and experience in hockey games., Results: The majority of referees (n = 632) indicated that violence is a serious concern to both players and referees at all levels of hockey. More than 90% of referees responded that they were the recipients of aggression and anger (92.1%, 95% confidence interval, 90.0-94.2), 55% had been involved in hockey games where aggressive behavior resulted in the referee losing control of the game, and 71% said that this increased aggression leads to injury. Referees' opinions are that the coach is the most responsible for managing on-ice safety (63%). To improve hockey safety, referees suggest education and more rigorous enforcement of discipline for all participants., Conclusions: Referees are important for hockey safety and need to be appropriately supported. Referees believe that increased aggression can lead to injury and that rules need to be enforced more diligently. Referees recommend that increased education about safety is needed to guide parents, coaches, and players to make hockey safer.

Object: The aim of this study was to evaluate the effectiveness of an educational intervention on concussion knowledge within a sample of junior fourth-tier ice hockey players., Methods: A prospective cohort study, called the Hockey Concussion Education Project, was conducted during 1 junior ice hockey regular season (2009-2010) with 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. All participating players were randomized into 3 concussion education intervention groups (DVD group, interactive computer module [ICM] group, or control group) before the beginning of the season. Each individual received a preintervention knowledge test prior to the intervention. The DVD and ICM groups received a posttest after the completion of their intervention. All participants were offered the same knowledge test at 15 games (50 days) and 30 games (91 days) later., Results: In the concussion education intervention component no significant group differences were observed at baseline between individuals in the control group and between individuals within the interventional group. At the 15-game follow-up, however, the difference between groups approached significance (F [1, 30] = 3.91, p = 0.057). This group difference remained consistent at the 30-game follow-up., Conclusions: This study demonstrates a positive trend concerning concussion education intervention and knowledge acquisition with either the ICMs or the educational DVD. Both forms of intervention produced a positive and sustainable improvement that approached statistical significance when compared with the control group. The control group demonstrated a negative longitudinal trend concerning concussion knowledge.

Object: The objective of this study was to measure the incidence of concussion (scaled relative to number of athlete exposures) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players (16-21 years old) during 1 regular season., Methods: A prospective cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season (2009-2010) involving 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing. If the protocol was not followed, the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels. Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer. Players who suffered a suspected concussion were evaluated at the game. If a concussion diagnosis was made, the player was subsequently examined in the physician's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated. Based on these evaluations, players were counseled on the decision of when to return to play. Athlete exposure was defined as 1 game played by 1 athlete., Results: Twenty-one concussions occurred during the 52 physician-observed games (incidence 21.5 concussions per 1000 athlete exposures). Five players experienced repeat concussions. No concussions were reported during practice sessions. A concussion was diagnosed by the physician in 19 (36.5%) of the 52 observed games. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 total concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated., Conclusions: The incidence of game-related concussions (per 100 [corrected] athlete exposures) in these fourth-tier junior [corrected] ice hockey players was 7 [corrected] times higher than [corrected] previously reported in the literature. This difference may be the result of the use of standardized direct physician observation, diagnosis, and subsequent treatment. The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings. These follow-up studies should involve other contact sports (for example football and rugby) and also include the full spectrum of gender, age, and skill levels.

Object: The authors investigated return-to-play duration for initial and recurrent concussion in the same season in 2 teams of junior (16-21-year-old) ice hockey players during a regular season., Methods: The authors conducted a prospective cohort study during 1 junior regular season (2009-2010) of 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years [SD], range 16-21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments that were determined using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete a baseline SCAT2 and ImPACT. If the protocol was not followed, the postinjury test results of a player without true baseline test results were compared with previously established age- and sex-matched group normative levels. Each game was directly observed by a physician and at least 1 neutral nonphysician observer. Players suspected of suffering a concussion were evaluated by the physician during the game. If a concussion was diagnosed, the player underwent clinical evaluation at the physician's office within 24 hours. The return-to-play decision was based on clinical evaluation guided by the Zurich return-to-play protocol (contained in the consensus statement of international expert opinion at the 3rd International Conference on Concussion in Sport held in Zurich, November 2008). This clinical evaluation and return-to-play protocol was augmented by the 2 tests (SCAT2 and ImPACT) also recommended by the Zurich consensus statement, for which baseline values had been obtained., Results: Seventeen players sustained a physician-observed or self-reported, physician-diagnosed concussion during a physician-observed ice hockey game. The mean clinical return-to-play duration (in 15 cases) was 12.8 ± 7.02 days (median 10 days, range 7-29 days); the mean number of physician office visits by players who suffered a concussion (15 cases) was 2.1 ± 1.29 (median 1.5 visits). Five of the 17 players who sustained a concussion also suffered a recurrent or second concussion. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated. The mean interval between the first and second concussions in these 5 players was 78.6 ± 39.8 days (median 82 days), and the mean time between the return-to-play date of the first and second concussions was 61.8 ± 39.7 days (median 60 days)., Conclusions: The mean rates of return to play for single and recurrent concussions were higher than rates cited in recent studies involving sport concussions. The time interval between the first and second concussions was also greater than previously cited. This difference may be the result of the methodology of direct independent physician observation, diagnosis, and adherence to the Zurich return-to-play protocol.

Objective: Measure incidence of spinal injuries in Canadian ice hockey for the 6-year period 2000-2005 and examine trends from 1943 to 2005., Design: Data about spinal injuries with and without spinal cord injury in ice hockey have been collected by ThinkFirst's Canadian Ice Hockey Spinal Injuries Registry since 1981 through questionnaires from practitioners, ice hockey organizations, and media reports., Setting: All provinces and territories of Canada., Participants: All Canadian ice hockey players., Assessment of Risk Factors: Age, gender, level of play, location, and mechanism of injury., Main Outcome Measures: Incidence and nature of injuries., Results: Forty cases occurred in 2000-2005, representing a decline in annual injuries and bringing the total registry cases to 311 during 1943-2005. Five (12.5%) of these 40 cases were severe, which includes all complete and incomplete spinal cord injuries, and is a decline from the previous 23.5% in this category. In the 311 cases, men comprised 97.7%, the median age was 18 years, 82.8% of the injuries were cervical, and 90.3% occurred in games in organized leagues. The most common mechanism of injury was impact with the boards (64.8%), and the most common cause was check/push from behind at 35.0%, which has declined. The major provincial differences in injury rates persist, with the highest in Ontario, British Columbia, New Brunswick, and Prince Edward Island and the lowest in Quebec and Newfoundland., Conclusions: There has been a recent decline in spinal injuries in Canadian ice hockey that may be related to improved education about injury prevention and/or specific rules against checking/pushing from behind.

Objectives: To determine the compliance rate among hockey players with concussion or other head injuries who were advised by a physician about return to play. To assess compliance of hockey players with return to play advice and to assess the incidence of long-term post-concussion symptoms., Methods: A retrospective chart review, telephone questionnaire and follow-up analysis of income, level of education and professional aspirations. The study examined 40 hockey players with concussion or other head injury treated at a neurosurgical ambulatory clinic, who had initial visits between 1995 and 2003, and had been seen at least two years prior to completing the questionnaire., Results: There was a 58% (23 of 40) participation rate in the study. Fifteen (65%) of the 23 participants were advised to never return to play, and 5 (33%) were non-compliant and returned to play. Four (80%) of the five noncompliant players continued to suffer from post concussion symptoms. Overall, 15 (65%) of the 23 players participating in the study continued to suffer post concussion symptoms at least two years after the clinic visit., Conclusions: Five (33%) of 15 hockey players advised to never return to play were non-compliant and returned to play, and four continued to suffer from post concussion symptoms two or more years later. After repeated concussions, 65% of hockey players had long-term sequelae that prevented return to play and produced long-term post-concussion symptoms.

Background: The problem of concussions in professional hockey has attracted much recent attention. To evaluate the current state of this injury in the National Hockey League (NHL), we analyzed the concussion incidence and time lost from play due to concussions during the past ten NHL seasons., Methods: Data were obtained from a complete review of injury reports in two different sports media sources covering the NHL seasons 1997-98 through 2007-08. Time lost from play was measured in missed games per concussion., Results: The incidence of concussions reported in the regular season ranged from a high of 1.81/1000 athlete exposures in 1998-99 to a low of 1.04/1000 athlete exposures in 2005-06. There was a downward trend in the number of concussions reported per season during the past ten years (p=0.01). However, average time lost from play per concussion increased over the same period (p<0.0005). Forwards suffered a disproportionately high percentage of concussions (p<0.0001)., Conclusions: Possibly related to injury reduction efforts, the number of concussions reported per season in the NHL has trended downward in recent years. However, the incidence of concussion remains high and the average time lost from play per concussion has increased. This may reflect increased injury severity in recent years or, alternatively, increased adherence to modern management guidelines preventing premature return to play.

Objectives: Study objectives were: (a) to examine the causes and incidence of major spinal cord injuries sustained by ice hockey players; and (b) to add recently reported Canadian cases to the Canadian Ice Hockey Spinal Injury Registry to determine the effectiveness of prevention efforts., Methods: The study was a review of questionnaires returned retrospectively by physicians and other sources reporting ice hockey related spinal injuries in Canada. Physicians reported on the mechanism of injury, vertebral level of injury, presence of neurologic deficit, type of event, and type of fracture., Results: Between 1943 and 1999, 271 major spinal injuries were reported in Canadian ice hockey players, of which 49.0% occurred to players 16-20 years of age. Ontario has had a disproportionately large number of injuries compared to some provinces, especially Quebec. Of the spinal cord injuries, 65.8% resulted from colliding with the boards, and 36.6% were due to players being pushed or checked from behind. The recent survey shows that there has been a decline in the number of major spinal cord injuries in Canadian ice hockey, especially those causing paralysis due to checking or pushing from behind., Conclusions: Impact of the head with the boards after being checked or pushed from behind was the most common mechanism of spinal cord injury. Injury prevention programs are becoming effective in reducing the overall number of injuries, especially those due to checking from behind. Greater awareness of the occurrence and mechanisms of injury through educational programs and rules changes by organized hockey have reduced the annual incidence of catastrophic spinal injuries in Canadian ice hockey.

Objective: The ThinkFirst Canada Smart Hockey program is an educational injury prevention video that teaches the mechanisms, consequences, and prevention of brain and spinal cord injury in ice hockey. This study evaluates knowledge transfer and behavioural outcomes in 11-12 year old hockey players who viewed the video., Design: Randomized controlled design., Setting: Greater Toronto Minor Hockey League, Toronto Ontario., Subjects: Minor, competitive 11-12 year old male ice hockey players and hockey team coaches., Interventions: The Smart Hockey video was shown to experimental teams at mid-season. An interview was conducted with coaches to understand reasons to accept or refuse the injury prevention video., Main Outcome Measures: A test of concussion knowledge was administered before, immediately after, and three months after exposure to the video. The incidence of aggressive penalties was measured before and after viewing the video., Results: The number of causes and mechanisms of concussion named by players increased from 1.13 to 2.47 and from 0.67 to 1.22 respectively. This effect was maintained at three months. There was no significant change in control teams. There was no significant change in total penalties after video exposure; however, specific body checking related penalties were significantly reduced in the experimental group., Conclusion: This study showed some improvements in knowledge and behaviours after a single viewing of a video; however, these findings require confirmation with a larger sample to understand the sociobehavioural aspects of sport that determine the effectiveness and acceptance of injury prevention interventions.

Objectives: To examine the longitudinal media reported rate of concussions in the National Hockey League (NHL) over the period 1986-87 to 2001-02., Methods: All injury reports published in the weekly sports newspaper The Hockey News for the 16 seasons 1986-87 through 2001-02 were reviewed for reported concussions. The Hockey News reports are based on weekly injury reports released by the NHL, which derive from reports submitted to the league by individual team offices., Results: Adjusted for changes in the number of teams and games per season over the 16 year study period, and expressed as: number of concussions per 1000 games, results by season (starting with 1986-87) were 4, 8, 7, 7, 5, 5, 7, 7, 6, 8, 13, 20, 30, 27, 30, 25. Comparing each season with the prior season, significant increases were reported in 1997-98 and 1998-99 (p < 0.05 and 0.025, respectively), with no change since 1998-99., Conclusions: The reported concussion rate in the NHL during the last five years is more than triple that of the previous decade. Bigger, faster players, new equipment and harder boards and glass have all theoretically increased the risk of concussion in the NHL in recent years. However, the abrupt increase and subsequent plateau in concussion rate since 1997 suggests that increased recognition and reporting may be primarily responsible for the apparent increase in incidence.

SportSmart Canada maintains a registry of spinal injuries in hockey and has documented 214 cases of fracture or dislocation of the spine, occurring mainly in North America since 1966. The current annual incidence is approximately 15 cases per year and may be declining as a result of intense prevention programs. Most of the injuries have been to the cervical spine in players 16 to 20 years of age playing supervised games. Checking from behind causing impact of the head against boards has been an important cause of injury, especially for those injuries resulting in neurological deficit.

Objectives: In this study, we wished to examine the nature and incidence of major spinal injuries sustained by ice hockey players and to add reported cases to a permanent registry., Design: The study was a retrospective review of questionnaires returned by physicians reporting spinal injuries due to ice hockey., Setting: Canada primarily, with reported cases from other nations., Patients: Two hundred forty-one cases of fracture or dislocation of the spine have been reported., Main Outcome Measures: The registry includes annual incidence and mortality incidence as well as documentation of sex, age, mechanism of injury, vertebral level of injury, neurologic deficit, type of event, and type of fracture for most cases., Results: Between 1982 and 1993, an average of 16.8 ice hockey related major spinal injuries were reported each year. Many of these injuries occurred to the cervical spine of players aged 16-20 years who were playing in supervised games., Conclusions: Prevention programs are beginning to become effective in decreasing the number of severe injuries and the number of injuries caused by a check from behind, although there has not been a significant decrease in the total number of injuries reported annually.

A registry, established by the Committee on Prevention of Spinal Cord Injuries Due to Hockey, of major injuries to the spine or spinal cord sustained while playing ice hockey contains 117 cases entered between January 1966 and March 1987; 112 of these injuries were sustained in Canada. Between 1981 and 1986 up to 15 hockey related major spinal injuries were reported in Canada each year. Most injuries occurred in teenagers and players under 30 years of age who were playing in supervised games. The most common cause of injury was a push or check from behind, which caused the player to be catapulted head first into the boards. The authors describe the programs currently being implemented to prevent the occurrence of major spinal injuries. Unfortunately, these programs have not decreased the number of injuries reported annually.

Previously unrecognized, major neck injuries in hockey have become a common problem in Canada and they have increased markedly in the 1980s. At the present time, the incidence remains high and has shown no sign of diminishing. The etiology of the problem appears to be multifactorial. Several epidemiologic factors have been identified and a reporting system established so that prevention programs can be monitored. It is hoped that greater awareness of the risk factors among players, coaches, leagues, referees, and parents will be an effective prophylactic measure in itself. Prevention must involve several approaches by hockey organizations and leagues, players, equipment manufacturers, and health care professionals and researchers.

There has been an alarming increase in the number of spinal injuries in hockey players. Between 1976 and 1983, 42 were reported to the Committee on Prevention of Spinal Injuries due to Hockey. The median age of the injured players was 17 years. Of the 42 players 28 had spinal cord injuries, and 17 of them had complete paralysis below the vertebral level of the injury. Strikes from behind and collisions with the boards were common mechanisms of injury. Many of the players had suffered a burst fracture of the cervical spine following a blow to the top of the helmet when the neck was slightly flexed. The committee studied a number of possible etiologic factors and made several recommendations regarding prevention. League officials, coaches, players and equipment manufacturers can all play a role in prevention.

Although many types of sports and recreational activities have been identified as common causes of acute spinal cord injury, hockey has been a rare cause of acute cord injury in Canada or elsewhere. For example, from 1948 to 1973 there were no patients with cord injuries due to hockey in a series of 55 patients with acute cord injuries due to sports or other recreational activities admitted to two Toronto hospitals. In contrast, between 1974 and 1981, the Acute Spinal Cord Injury Unit, Sunnybrook Medical Centre treated six patients with cervical spinal injury due to hockey, five of whom were seen during a 13 month period from September, 1980 to October, 1981. Five of the six sustained a severe acute cervical spinal cord injury, and one a cervical root injury. The cord injury was complete in two cases, while three had complete motor loss but incomplete sensory loss below the level of the lesion. All were males aged 15 to 26 years. Of the players with cord injury, four struck the boards with the neck flexed, and one struck another player with the neck flexed. The one player without cord injury struck the boards with his neck extended. The commonest bony injury was a burst fracture of C5 or C6. One of the patients with a complete cord injury died three months later of a pulmonary embolus, and the other patients with cord injury showed some recovery of root function, but little or no cord recovery. The reasons for the increase in spinal injuries in hockey are unknown.