CMAJ Analysis Concussion in youth ice hockey: It’s time to break the cycle L. Syd M. Johnson MA PhD See article by Benson and colleagues on page 905 and at www.cmaj.ca/cgi/doi/10.1503/cmaj.092190 and commentary by Sojka on page 887 and at www.cmaj.ca/cgi/doi/10.1503/cmaj.110504. ittsburgh Penguins captain Sidney concussion in a single season, a rate of concus - Competing interests: None Crosby suffered a hard blow to the head sion seven times higher than the highest rate declared. P in a blind-side collision during the 2011 previously reported in the literature. 9 This article has been peer Winter Classic hockey game. He crashed to the An estimated half-million youths play orga - reviewed. ice, staggered to his feet and slowly left the rink. nized minor ice hockey in Canada. 11 The pediatric Correspondence to: In a game a few days later, Crosby was population is known to be more vulnerable to Dr. L. Syd M. Johnson, slammed against the boards, fell to the ice and concussion and to experience more serious short- [email protected] exited the game. 1 He’s been sidelined indefi - and long-term symptoms of concussion than CMAJ 2011. DOI:10.1503 nitely with a concussion and, according to the adults. 12–15 Youth athletes with concussion may /cmaj.110282 concussion protocols of the National Hockey experience fatigue, inattention, lack of concentra - League (NHL), can’t return to the game until tion, memory loss and headaches, which can he’s free of symptoms. 2 have devastating effects on both athletic and aca - Crosby has a lot of company in the NHL, demic performance. 12–16 Subtle cognitive deficits where the number of concussions doubled in the may persist for up to a year in some youths. 16 2010/11 season. 3 The NHL commissioner attrib - Youth athletes who sustain minor brain trauma utes the increase in concussions to accidental are also at risk for so-called second-impact syn - hits: players being struck by pucks, colliding drome, a rare but catastrophic neurologic condi - with teammates, or striking the ice or the boards tion that is almost always fatal. 17 A history of after being hit legally. 3 The fact is that the vast concussion results in substantially increased sus - majority of concussions, and hockey injuries ceptibility to additional concussions and more overall, at all levels of play, are caused by legal severe symptoms of concussion. 18 bodychecking. 4–8 It’s safe to say that as long as Repeat concussions are also a risk factor for bodychecking is a part of ice hockey, a high rate chronic traumatic encephalopathy (CTE), which of concussions will also be a part of hockey. is associated with a spectrum of sequelae in - Neither of the blows suspected of causing cluding memory loss, behavioural and personal - Crosby’s concussion were illegal. That’s impor - ity changes, depression, early dementia and tant — concussion is not a problem the NHL can motor neuron disease. 19 In one-half of the con - solve without radically modifying the sport’s firmed instances of CTE in athletes, symptoms rules of contact. developed within four years of the athletes stop - ping play. 19 Subconcussion impacts of the kind Concussion in youth ice hockey common in contact and collision sports, such as hockey and tackle football, are also implicated The NHL’s problem with concussions is just in CTE. The deposition of tau proteins indica - the tip of the iceberg; concussion is all too com - mon in youth ice hockey, with evidence that, Key points despite educational efforts, the number of con - cussions continues to be substantially under - • Concussion is a common, serious injury in youth ice hockey, affecting up to 25% of players per season by one estimate. reported. 4,9,10 A study published in late 2010 • Bodychecking is a major cause of injury and concussion in hockey, yet found an alarming rate of concussions in junior some Canadian provinces allow players as young as nine years to 9 hockey. In the prospective study, which in - engage in bodychecking. volved two teams of hockey players aged 16– • Reducing rates of concussion requires eliminating bodychecking for 21 years, 17 of 67 players sustained a concus - all except elite hockey players aged 16 years and older, as per the sion during a single season, with five of those recommendations of the Canadian Academy of Sports and Exercise players also suffering a second concussion. Medicine. That is, 25.3% of players sustained at least one © 2011 Canadian Medical Association or its licensors CMAJ, May 17, 2011, 183(8) 921 Analysis tive of CTE have been found on autopsy in the concluded that bodychecking “can be taught at the brains of American football players with no his - younger age levels in a manner that does not lead tory of concussion, as well as athletes as young to a higher incidence of injuries.” 27 Several studies as 18 years old. 20 Concussion causes detectable have confirmed, however, that injury rates rise dra - but subtle symptoms and can be diagnosed by matically when bodychecking is introduced, 5–7,21,28 properly trained and vigilant physicians, trainers that players typically sustain their first concussion and coaches, but subconcussion impacts cause within a year of starting bodychecking 4 and that silent, invisible, lifelong damage to the brains of education in “proper” bodychecking technique youth athletes. does not reduce rates of injury. 6 The evidence strongly suggests that substantial harm may result The role of bodychecking from teaching youth players bodychecking at an earlier age. 5,6,28 Bodychecking is a major cause of serious injury, USA Hockey, the governing body for minor including concussion, in hockey players. 4,21,22 The hockey in the United States, permits bodycheck - American Academy of Pediatrics recommends ing at the Peewee level (ages 11–12), but is cur - that bodychecking be prohibited for children rently considering a rule change to raise the age younger than 15 years. 23 Among the reasons to the Bantam level (ages 13–14), based on a cited by the academy is that there can be pro - recommendation by the USA Hockey Player nounced variations in body size, physical matu - Development Sub-committee on Body Check - rity and strength among players in younger age ing. 29 The proposed change is motivated by two groups, resulting in heightened risk to smaller factors. First, skill development is hindered players who are matched against much larger when bodychecking is introduced, because play - players in the same age bracket. 23 ers focus on hitting and avoiding being hit rather than on skating, puck- and stick-handling, re - Bodychecking in minor hockey introduces ceiving, shooting and other hockey skills. 29 The subcommittee argues that players will benefit substantial risks of serious injury, from two more years of skill development, unhindered by bodychecking. 29 This is in con - including the risk of concussion and trast to Hockey Canada’s assertion that training lasting brain damage. in bodychecking benefits player development. 25 Second, the US subcommittee cited concerns about player safety, noting a threefold increase The more conservative recommendation of in game-related injuries, “including concussion, the Canadian Academy of Sports and Exercise severe injury and severe concussion,” among Medicine calls for bodychecking to be elimi - players aged 11–12 years following the introduc - nated from all levels of minor hockey “which are tion of bodychecking. 8,29 not designed as training for professional and The increased incidence of serious injuries international ranks,” and only beginning in elite related to bodychecking has also been observed Rep or All Star leagues in the 16- to 17-year in other countries where bodychecking is not (Midget level) age group. 24 Hockey Canada, the permitted for younger players. 7,28 In Finland, governing body of minor hockey, allows body - Mölsä and coauthors observed a disproportionate checking at the Peewee level (ages 12–13) and increase in injuries related to bodychecking, above for male players; the Saskatchewan, compared with other mechanisms of injury, in Ontario and Ottawa hockey leagues permit the age group for which bodychecking is first bodychecking at the Atom level (ages 9–10) on introduced. 7 Additionally, bodychecking was an experimental basis. Quebec permits body - found to be the dominant mechanism of injury in checking at the Bantam level (ages 14–15). 25 older groups. 7 Quebec is the only province in Canada that has seen growth, rather than decline, in the number The way forward of children playing minor hockey, a trend that has been attributed in part to the late introduction Rates of concussion in hockey are among the of bodychecking. 26 highest in all contact sports. 4,30 There is consider - Hockey Canada’s position is that checking able evidence to support the conclusion that to skills are critical to the game of hockey and that substantially reduce the number of concussions “players must learn and master all aspects of the and subconcussion impacts in junior hockey checking game to become effective and complete would require a comprehensive set of changes to players.” 25 A 2004 study sponsored by the Cana - how minor hockey is played, including the elimi - dian Hockey Association (now Hockey Canada) nation of bodychecking. 5–9,21,24,28 The recommen - 922 CMAJ, May 17, 2011, 183(8) Analysis dation of the Canadian Academy of Sport and duce bodychecking, as well as the best practices Exercise Medicine to eliminate bodychecking in for teaching bodychecking at elite levels to mini - all levels of minor hockey except elite leagues, mize injury, would be a valuable and needed and then only for players aged 16 and older, is a contribution to the literature on safety in hockey.