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A Systematic Review of the Association Between Body Checking and Injury in Youth Ice Hockey

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A Systematic Review of the Association Between Body Checking and Injury in Youth Ice Hockey CRITICAL REVIEW A Systematic Review of the Association Between Body Checking and Injury in Youth Ice Hockey Joel M. Warsh, BSc(Hons),* Sxerban A. Constantin, BSc,* Andrew Howard, MD, MSc,† and Alison Macpherson, PhD* Canada’s national sports. In Canada, more than 500 000 young Objective: The objective of this study is to systematically examine players are registered.1 The United States has more than the risk of injury associated with body checking in youth ice hockey. 250,0002 children playing the game, whereas European coun- tries like Finland have more than 60 000 registered players.3 Data Sources: A systematic review of the relevant electronic One important element of hockey at the professional level databases was conducted including PubMed and Web of Science. The among adults is body checking, which is defined by Hockey main search terms included ‘‘hockey, ice hockey, injury, body Canada as ‘‘an individual defensive tactic designed to legally checking, child, adolescent, and pediatric.’’ separate the puck carrier from the puck. The action of the Study Selection: The initial search identified 898 potential articles, defensive player is deliberate and forceful in an opposite and, after verifying inclusion criteria, 260 articles were selected for direction to which the offensive player is moving.’’4 further assessment. The Downs and Black instrument for non- There has been controversy associated with the age at randomized studies (Downs 1998) was used to assess the quality of which body checking should be permitted and legal in the the articles. preprofessional setting. Professional and competitive leagues permit body checking, but most recreational leagues for Data Extraction: Studies included reported on body checking as children do not. Hockey Canada groups the players based on a mechanism of injury and compared injury rates in checking to non- age into Initiation (5, 6 years), Novice (7, 8 years), Atom (9–10 checking leagues in children 20 years or younger. years), Peewee (11–12 years), Bantam (13–14 years), and 2 Data Synthesis: Twenty studies met the inclusion criteria and they Midget (15–17 years). predominantly found increased injuries associated with body Ontario has been at the forefront of the body checking checking. The relative risk of injury associated with body checking debate because the Ontario Hockey Association implemented a trial where body checking is introduced in the competitive in comparative studies ranged from 0.6 to 39.8. Checking was the 5,6 reported mechanism of injury between 2.9% and 91% of injuries. All Atom (9-year-olds) leagues. Recently, the Ontario Hockey but 1 study that met our inclusion criteria found an increased risk of Federation rescinded that decision and will allow checking in injuries when body checking was permitted. the competitive leagues in the Peewee (11–12 years) division and above in the 2008–2009 season.7 Other provinces, Conclusions: Increased injuries attributable to checking were found including Quebec, do not start checking until Bantam (13- where checking was allowed. This study supports policies that year-olds), whereas many European countries never allow disallow body checking to reduce injuries in young children. checking.2,3 The heterogeneity of rules leads to debate on the risks and benefits of early introduction to checking. Key Words: body checking, child, hockey, injury, sports (Clin J Sport Med 2009;19:134–144) Burden of Injury Hockey is associated with high rates of injury; of particular concern are the rates of traumatic brain injury. Up to 5% of sport injuries are concussions, and the US Centers for INTRODUCTION Disease Control and Prevention estimates that 300 000 sport- Ice hockey is a popular sport around the world, related concussions occur yearly in the United States, but that especially in northern countries, and is considered one of number includes only athletes who lost consciousness.8 Hockey-related fatality and injury rates are more than twice Submitted for publication June 10, 2008; accepted December 10, 2008. as high as those in football.6 Nonfatal catastrophic spinal cord From the *School of Kinesiology and Health Science, York University, and brain injury rates are 2.6 per 100 000 for hockey players Toronto, Ontario, Canada; and †Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Ontario, Canada. and 0.7 per 100 000 for football players, among high school 6 The authors state that they have no financial interest in the products mentioned athletes. In Ontario alone, more than 3000 children aged 16 within this article. years or below visited emergency departments during the Reprints: Joel Warsh, Bsc(Hons), MSc Candidate, c/o Alison Macpherson, 2002–2003 season.2 PhD, School of Kinesiology and Health Science, 337 Bethune College, York University, 4700 Keele St, Toronto, ON M3J IP3, Canada (e-mail: Without conclusive evidence, changing the policies [email protected]). related to body checking within the younger age groups in the Copyright Ó 2009 by Lippincott Williams & Wilkins game remains controversial. Proponents of body checking 134 Clin J Sport Med Volume 19, Number 2, March 2009 Clin J Sport Med Volume 19, Number 2, March 2009 Systematic Review of Body Checking Injuries claim that it is an integral part of the game, and teaching this Study Selection 6 skill early prevents injuries in later years of play. Opponents After the identification of possible studies for inclusion of body checking for young children, such as the Canadian using the search strategy listed above, 2 of the authors 9 Academy of Sport Medicine, believe that body checking is independently assessed the studies against inclusion criteria the most common source of all injury types in hockey and that (Table 2). Twenty studies met the inclusion criteria. There were it should be eliminated from all recreational levels and only no disagreements between authors on study inclusion. introduced in the elite levels at the Bantam (13–14 years) age or Midget (15–17 years) age. The American Academy of Quality Assessment Pediatrics10 echoes these sentiments and recommends banning The Downs and Black instrument for nonrandomized body checking at 15 years of age and below. studies (Downs 1998) was used to assess the quality of studies. The objective of this article is to conduct a systematic The reviewers used the instrument to rate the studies. The review of the literature to summarize the reported association instrument consists of a 27-item checklist that rates studies on between body checking and injuries in youth ice hockey. the following key areas: reporting, external validity, internal validity, bias, confounding, and power. A narrative approach was adopted to discuss the performance of each included study METHODS on these methodological areas. Literature Search Data Extraction and Synthesis Articles were found mainly through electronic databases Data were extracted that measured the association with a combination of key medical subject headings and between body checking and injury. Data from several studies11–15 Boolean operators. The search consisted of terms including were extracted and synthesized into usable data for this ‘‘(‘‘body-checking’’ OR ‘‘body checking’’) AND (hockey OR review. All other data were extracted as recorded in the original ‘‘ice hockey’’) AND athletic AND injury AND (child OR studies. A narrative approach was adopted to describe and adolescent OR pediatric).’’ Articles were limited through synthesize the results due to the heterogeneity of the data a ‘‘limit’’ function to prospective, retrospective, cohort, and the uniqueness of methodological design for each in- random, case, and cross-sectional designs. The initial search cluded study. identified 898 potential articles as seen in Table 1. After verifying inclusion criteria, 260 unique articles were selected for further assessment and deemed potentially relevant. RESULTS Relevant references in selected articles were retrieved through ‘‘snowballing’’ techniques. In addition to literature Description of Studies searches using electronic databases, articles were also found The 20 studies that met the inclusion criteria are through specific searches on Web sites including the Canadian presented in Table 3. Studies were from around the world, Hospitals Injury Reporting and Prevention Program, Canadian including 9 from Canada, 9 from the United States, and 2 from Institute for Health Information, Google Scholar, Ontario Hockey Finland. Scores on the articles from the Downs and Black Federation, and Hockey Canada. Finally, international experts instrument ranged from 19 to 25, which is in the fair to good were contacted and asked for published or unpublished data. range. Studies were categorized as comparative if they had a clear comparison between a checking and non-checking group and as descriptive if they did not include a calculable or clear relative risk, odds ratio, or rate ratio. TABLE 1. Electronic Search Strategy The association between body checking and injury in Electronic Database No. of References each of the comparative studies is presented in Table 4. The PubMed 13 relative risk of injury associated with body checking ranged MEDLINE 11 from 0.63 to 39.79. Body checking was described as the mechanism of injury for 2.9%–91% of injuries. Only the HealthSTAR 12 12 12 CINAHL 5 Montelpare study found no evidence of a harmful effect. SportDiscuss 7 EMBASE 9 Web of Science 5 TABLE 2. Inclusion and Exclusion Criteria Canadian Electronic Library 4 Inclusion criteria Physical Education Index 1 Studies involving hockey players 20 years of age or less (male or female) PsycINFO 1 Study must include an assessment of both body checking and injuries Health Sciences 0 Injury must be sustained in ice hockey Early Canadiana 0 Studies must have original data BioOne Abstracts 0 All study designs except letters and case reports Cochrane Database of Systematic Reviews 0 Exclusion criteria Allied and Complementary Medicine 0 Studies on a broad range of ages (no specific age range) OLDMEDLINE 0 Studies on a broad range of sports (no specific data on ice hockey) Compendex 0 Non-English articles q 2009 Lippincott Williams & Wilkins 135 136 Warsh et al TABLE 3.
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