Authors: Aynsley M. Smith, RN, PhD Michael J. Stuart, MD Concussion Richard M. Greenwald, PhD, MS Brian W. Benson, MD, MSC, PhD, CCFP David W. Dodick, MD Carolyn Emery, BSCPT, MSC, PhD Jonathan T. Finnoff, DO Jason P. Mihalik, PhD, CAT(C), ATC CONSENSUS STATEMENT William O. Roberts, MD, MS Carol-Anne Sullivan, PhD Willem H. Meeuwisse, MD, PhD

Affiliations: Proceedings from the From the Sports Medicine Center, Summit on Concussion Mayo Clinic, Rochester, Minnesota (AMS, MJS, JTF); SIMBEX, LCC, A Call to Action Lebanon, New Hampshire (RMG); Sport Medicine Centre, University of Calgary, Calgary, Alberta, (BWB, CE, WHM); College of Medicine, Mayo Clinic, Scottsdale, Arizona ABSTRACT (DWD); The University of North Carolina, Chapel Hill (JPM); University Smith AM, Stuart MJ, Greenwald RM, Benson BW, Dodick DW, Emery C, Finnoff of Minnesota, St. Paul (WOR); JT, Mihalik JP, Roberts WO, Sullivan C-A, Meeuwisse WH: Proceedings from the Neurotrauma Foundation, Toronto, Ontario, Canada (C-AS) ice hockey summit on concussion: a call to action. Am J Phys Med Rehabil 2011;90:694Y703. Correspondence: Objective: The objective of this proceeding was to integrate the concussion in All correspondence and requests for sport literature and sport science research on safety in ice hockey to develop an reprints should be addressed to: Carol action plan to reduce the risk, incidence, severity, and consequences of concussion Best, Mayo Clinic, Sports Medicine Center, 200 First Street SW, Rochester, in ice hockey. MN 55905 USA. Design: A rationale paper outlining a collaborative action plan to address con- Disclosures: cussions in hockey was posted for review 2 mos before the ‘‘Ice Hockey Summit: R. Greenwald owns Simbex, the Action on Concussion.’’ Focused presentations devoted specifically to concussion company that makes the telemetry in ice hockey were presented during the summit, and breakout sessions were used accelerometers that are used in the to develop strategies to reduce concussion in the sport. The proceedings and a helmets to collect some of the data as discussed in the content of this article. detailed scientific review (a matrix of solutions) were written to disseminate the evidence-based information and resulting concussion reduction strategies. The Editor’s Note: manuscripts were reviewed by the authors, advisors, and contributors to ensure that This paper is being copublished in the the opinions and recommendations reflect the current level of knowledge on con- American Journal of Physical Medicine and Rehabilitation, Clinical Journal of cussion in hockey. Sport Medicine, Current Sports Results: Six components of a potential solution were articulated in the ‘‘Rationale’’ Medicine Reports, PM&R, Sports Medicine Bulletin, and The Clinical paper and became the topics for breakout groups that followed the professional Neuropsychologist. The manuscript scientific lectures. Topics that formed the core of the action plan were metrics and was prepared by the authors and is databases; recognizing, managing, and return to play; hockey equipment and ice printed here without modification, except for journal style. arenas; prevention and education; rules and regulations; and expedient commu- nication of the outcomes. The attendees in the breakout sessions identified the 0894-9115/11/9008-0694/0 American Journal of Physical action items for each section. The most highly ranked action items were brought to a Medicine & Rehabilitation vote in the open assembly, using an Audience Response System. The strategic Copyright * 2011 by Lippincott planning process was conducted to assess the following: ‘‘Where are we at?’’ Williams & Wilkins ‘‘Where must we get to?’’ ‘‘What strategies are necessary to make progress on the

DOI: 10.1097/PHM.0b013e318224736b prioritized action items?’’ Conclusions: Three prioritized action items for each component of the solution and the percentage of the votes received are listed in the body of this proceeding. Key Words: Concussion, Hockey

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Advisory Committee and Contributors Susan L. Forbes, PhD Alan B. Ashare, MD Lakehead University, Thunder Bay, St. Elizabeth’s Medical Center, Ontario, Canada Boston, Massachusetts Kirk Gill Mark Aubry, MD Rochester Youth Hockey Association, Sport Medicine Centre, Ottawa, Rochester, Minnesota Ontario, Canada Gerard A. Gioia, PhD Charles H. Tator, MA, PhD Childrens National Medical Center, University of Toronto, Department of Surgery, D.C. Toronto, Ontario, Canada Kevin M. Guskiewicz, PhD, ATC Ruben Echemendia, PhD The University of North Carolina, , Director of Chapel Hill, North Carolina Neuropsychological Testing Program, P. David Halstead , New York University of Tennessee College of Engineering, Kerry Fraser Sports Biomechanics Impact Research Laboratory, Blue Anchor, New Jersey Knoxville, Tennessee James Johnson Stanley A. Herring, MD Scottsdale, Arizona University of Washington, Seattle, Washington David Krause, PT, MBA, DSC, OCS T. Blaine Hoshizaki, PhD Mayo Clinic, Sports Medicine Center, University of Ottawa, Ottawa, Rochester, Minnesota Ontario, Canada Robert F. LaPrade, MD, PhD Mark Lovell, PhD The Steadman Clinic, Vail, Colorado University of Pittsburgh Medical Center, Sports Medicine Concussion Program, Nicole M. LaVoi, PhD Pittsburgh, University of Minnesota, St. Paul, Minnesota Joan Mariconda, MA, BA Anthony Mariconda Alison Macpherson, PhD USA Hockey, Colorado Springs, Colorado York University, Toronto, Ontario, Canada James Whitehead American College of Sports Medicine, Ann C. McKee, MD Indianapolis, Indiana Boston University School of Medicine, Boston, Massachusetts Diane M. Wiese-Bjornstal, PhD University of Minnesota, St. Paul, Minnesota Daniel Moore Haley Moore Thomas W. Babson, BA, MFA Team Wendy, Cleveland, Ohio Sports Legacy Institute, Boston, Massachusetts William Montelpare, PhD, MSC Jeffrey J. Bazarian, MD, MPH University of Leeds, Woodhouse, University of Rochester, Rochester, New York Leeds, United Kingdom Patrick J. Bishop, PhD Margot Putukian, MD University of Waterloo, Waterloo, Ontario, Canada Princeton University, Princeton, Alison Brooks, MD, MPH New Jersey University of Wisconsin, Madison, Wisconsin Kelly Sarmiento, MPH Randall Dick, FACSM Centers for Disease Control and Prevention, Health and Safety Sports Consultants, LLC, Atlanta, Georgia Carmel, Indiana Doug Stacey, MSc, BHScPT Fowler Kennedy Sport Medicine Clinic, London, Paul Echlin, MD Ontario, Canada The Hockey Neurotrauma and Concussion Initiative National Research Committee, London, Ronald Szalkowski, BSc Chem Eng Ontario, Canada Team Wendy, Cleveland, Ohio www.ajpmr.com Ice Hockey Summit on Concussion 695

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Btolerates[ fighting during play. To eliminate Ice hockey is a fast collision sport played by both behaviors or major penalties that increase the risk sexes in all age groups and at all skill levels1 of concussive brain injury and related neurotrauma predominantly in North America, Europe, and (i.e., head hits, blind-side hits, fighting, and countries of the former Soviet Union.2 Speed, hard checking from behind), consistent educational ice, boards, sticks, pucks, player collisions, body messages must be delivered, compliance with rules checks, and illegal on-ice activity3 contribute to the must be rewarded, and infractions must be Y prevalence of concussion.4 The evidence-based penalized across all levels of participation.23 27 foundation for the BIce Hockey Summit: Action Other aspects of prevention pertain to player Y on Concussion,[ held at the Mayo Clinic in 2010, equipment28 33 and facilities.34,35 As important as was derived from research on concussion and prevention is, there is also a recognized need for focused on recognition, assessment, management, astute detection, accurate diagnoses, optimal man- and return-to-play guidelines (Zurich, 2008)5Y7 agement, and appropriately followed return-to-play Y integrated with ice hockey-specific research. Sport guidelines.5 7, 36,37 The goal of the summit was to science research addressed equipment, impact identify appropriate strategies to decrease concus- forces, standards testing, at-risk behaviors, rule sion in hockey. enforcement, education, and behavioral modifica- tion programs.8Y13 Although quality guidelines for METHODS sport-related concussion management have been The Ice Hockey Summit objectives provided written,5Y7 there are unique features that distin- the template for a rigorous curriculum that met guish ice hockey from other contact sports. Continuing Medical Education credit standards. The Professional hockey is a skilled exciting game, attendees were actively engaged in prioritizing ac- rooted in a heavily reinforced culture of aggressive tion items and identifying implementation strate- play,14Y22 and it is the only professional sport, other gies for a multifactorial solution. After reviewing the than boxing and mixed martial arts, that literature before the Summit, it was hypothesized

FIGURE 1 Six Priority Action Areas. Adapted from figure prepared by Ann Braatas, Mayo Clinic-Rochester, published in the Mayo Clinic Orthopedic Update, 2011. The symbol in each box is depicted below adjacent to the reference numbers appropriate to each component of the solution.

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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. that the components of a solution to concussions phasize that the helmet is only one factor that in hockey were those depicted in Figure 1. may reduce concussion risk (34%). (3) Con- The methodology that generated the matrix of tinue to support research that develops and prioritized actions included a presummit concus- tests both equipment and facilities (13%). sion literature review,7,13 an on-site shared content IV. Prevention and Education (Breakout D): by presenters and panelists, and discussion and (1) Engage organizations (USA Hockey, Hockey debate during breakout sessions. The attendees in Canada, International Ice Hockey Federation, the breakout sessions identified the action items for etc.) to educate coaches, parents and student each section. Each breakout leader presented the athletes (79.2%). (2) Take advantage of the action items based on agreement, along with a currently available educational content in strategic plan, to the general assembly. The most programs such as Hockey Education Program highly ranked action items were brought to a vote (Fair Play), Centers for Disease Control and in the open assembly, using an Audience Response Prevention’s Heads Up program, Play it Cool, System. The attendees voted on the preferred and ThinkFirst (6.9%). (3) Ensure that edu- actions items for all six sessions. The three in each cational efforts drive a behavioral and cultural category that were considered to be the highest change (5.0%). priority become part of the group’s official recom- V. Rules and Enforcement (Breakout E): (1) mendation. The strategic planning process assessed Eliminate all head contact (intentional and the following: BWhere are we at?[BWhere must we unintentional) (74%). (2) Postpone legal body get to?[BWhat strategies are necessary to imple- checking in youth games until age 13 yrs ment the action plan?[ (Bantam level) (18.7%). (3) Eliminate fighting The following action items from each breakout at all levels of hockey participation (7.3%). were prioritized by popular vote using the Audience VI. Communication (Breakout F): (1) Require Response System. The percentage of attendees an in-person, preseason meeting each year for all voting for a particular action item to be of imme- hockey participants (including parents) (33.7%). diate importance (in need of being tackled first) is (2) Provide a unified message for delivery listed in BRESULTS.[ The attendees were then (31.7%). (3) Create a multimedia package, in- asked to choose their second priority and then their cluding a robust social media presence (19.8%). third choice. Some breakouts offered more than The prioritized action items from each break- three choices. Listed are the top three for each out group were accompanied by a strategic plan- breakout; therefore, not everything sums up to ning process that was unique to each component of 100%. the solution, but there were some areas of overlap.

RESULTS DISCUSSION A strength of this summit was the diversity of I. Databases and Metrics (Breakout A): (1) the stakeholders who shared their expertise and Collect concussion data using a consistent concerns on concussion. The BRationale[ manu- hockey-specific definition in small, well- script posted as prereading on the registration designed studies (60.9%). (2) Standardize funded Web site raised many questions that were subse- hockey concussion research similar to foot- quently discussed from the podium and during the ball, lacrosse, and others (18.5%). (3) Partner breakout sessions. Many hockey enthusiasts hoped with a pending legislative action to collect that advances in hockey equipment, especially the concussion data (15.2%). technology of hockey helmet design, could fur- II. Recognizing, Diagnosing, Management, ther dissipate the kinetic energy transmitted to and Return to Play (Breakout B): (1) the brain. Engineers, biomechanics experts, and Mandate education for coaches, parents, and equipment standards committee members on the referees (46.5%). (2) Remove athletes from faculty agreed that hockey helmets currently per- play for all suspected concussions (39.4%). (3) form well in preventing focal injuries to the skull. Ensure that concussed athletes do not return However, contemporary helmets are not designed to play (practice or game) until cleared by to manage linear and rotational accelerations that medical personnel (14.1%). are linked to brain tissue deformation and concus- III. Player Equipment and Facilities (Break- sive injury. Nonetheless, all agree that players out C): (1) Educate the hockey community on should wear a properly fitted, certified helmet to the actual role of equipment (53%). (2) Em- protect from focal injury. The helmet must be well www.ajpmr.com Ice Hockey Summit on Concussion 697

Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. secured to maintain proper position on the head programs such as the Hockey Education Program and to prevent it from falling off. Players should also that includes Fair Play, Play it Cool, and ThinkFirst’s wear a custom-fitted mouth guard that remains in Smart Hockey video requires the engagement of place during play to protect the mouth, teeth and national governing bodies. Minor modifications jaw, even though there is no current strong evi- to the content of the video and educational pro- dence that mouth guards decrease the risk of con- grams are currently underway so that unified, cussion.38 Elbow and shoulder equipment should multimodal messages on concussion are dissemi- have sufficient padding because contact of the hard nated. Part of the dissemination process under dis- plastic shell to the head may result in an increased cussion includes the development of a Web site to force transmission.30 In addition to improving the serve as a repository for all concussion education protection offered by helmets, concussion preven- materials suited to players, coaches, parents, and tion must also be achieved via rule changes and healthcare providers. In addition to the mandatory enforcement, educational programs, and behavioral education of hockey coaches, players, and parents, modification. When a concussion is suspected, ac- there is a need for universal education of health- curate detection, removal from play, individualized care providers. The curriculum and Web-based management, and a monitored physical and cogni- e-learning programs are being addressed by na- tive progression protocol must be followed. A tional organizations. Rule changes to eliminate all qualified healthcare provider should evaluate and head contact, delay legal body checking in games manage the concussed player and guide the return- until age 13 yrs (Bantam level), and abolish fight- to-play decision-making. ing requires the support of district, state, and provincial leadership. Therefore, the implementa- Postsummit Action Taken tion process has been initiated with USA Hockey, Some concerns not included in the prioritized , and the International Ice Hockey action items are being addressed by the postsummit Federation. implementation committees. For example, an im- portant focus of future research is the prevention of concussion in female athletes, particularly in con- CONCLUSIONS tact sports, such as hockey. Preliminary studies Recently, the authors of a thoughtful paper47 suggest that female hockey players sustain more discussed the failure of sports medicine healthcare concussions than do males,39 acknowledge more professionals and sports scientists to engage in in- baseline symptoms on the Sport Concussion As- jury prevention for youth athletes. They hypothe- sessment Tool,40 may self-report more frequently,41 sized that tension exists at the interface between and activate neck musculature earlier than men, yet sport and medicine based on differences in core have a reduced neck muscle mass.42 These and values. Sport values competition and success; other factors may increase their risks. whereas, medicine values wellness and prevention. The need to ensure the consistency of the The author stated that one exception pertained to definition of concussion was prioritized by the an investigation of the use of Fair Play rules in a database/metrics breakout session. Furthermore, hockey tournament.48 Suffice to say that injuries because concussions are underreported at all levels and penalties related to rough play were 4 times less of participation, the players who admit symptoms frequent in hockey games using Fair Play rules.21,48 and those who are observed to sustain a mechanism National governing bodies continue to explore of injury that may have caused a concussion should strategies to recruit youth hockey players and grow be removed from play and promptly evaluated. This the sport. In Minnesota, where Fair Play has been observational strategy has been used in both youth4 in place since 2004, youth hockey (boys and girls and Junior A43Y46 studies to gather more accurate combined) grew by 14.9% between 2005 and concussion incidence data. A diligent approach to 2007,49 a positive trend that continues. concussion identification is already practiced by The evidence-based action items, prioritized at many rink-side athletic trainers/therapists and the BIce Hockey Summit: Action on Concussion[ physicians, but more emphasis is needed. described in these proceedings, are clear, hockey- It was determined at the Summit that con- specific, and appropriate. These actions include rule cussion prevention and stakeholder instruction changes and education of all players, coaches, and requires the mandatory education of coaches, par- parents using available educational and behavioral ents, and athletes. The educational content to meet modification content to reduce major penalties and these needs is currently available. Dissemination of reward sportsmanship. Implementation efforts are

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