SPECIAL COMMUNICATION

Proceedings from the Summit on Concussion: A Call to Action

Authors: Aynsley M. Smith, RN, PhD*; Michael J. Stuart, MD*; 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¶; William O. Roberts, MD, MS€; Carol-Anne Sullivan, PhDU; Willem H. Meeuwisse, MD, PhD‡ Advisory Committee: Alan B. Ashare, MDV; Mark Aubry, MD#; Charles H. Tator, MA, PhD-; Ruben Echemendia, PhD+; Kerry Fraser?;JamesJohnsonT; David Krause, PT, MBA, DSC, OCS*; Mark Lovell, PhD^; Joan Mariconda, MA, BA~; Anthony Mariconda~; James Whiteheadl; Diane M. Wiese-Bjornstal, PhD€; Contributors to the Process: Thomas W. Babson, BA, MFA$; Jeffrey J. Bazarian, MD, MPH=; Patrick J. Bishop, PhD3; Alison Brooks, MD, MPHR; Randall Dick, FACSMZ; Paul Echlin, MDb; Susan L. Forbes, PhD^;KirkGill/; Gerard A. Gioia, PhD$; Kevin M. Guskiewicz, PhD, ATC¶;P.DavidHalsteadZ; Stanley A. Herring, MD"; T. Blaine Hoshizaki, PhD-; Robert F. LaPrade, MD, PhDa;NicoleM.LaVoi,PhD€; Alison Macpherson, PhD¯; Ann C. McKee, MDp; Daniel Moore7; Haley Moore7; William Montelpare, PhD, MSCQ; Margot Putukian, MD&; Kelly Sarmiento, MPHS; Doug Stacey, MSc, BHScPT,; and Ronald Szalkowski, BSc Chem Eng7

Introduction Objective Ice hockey is a fast, collision sport The objective of this proceeding is to integrate the concussion in sport played by both sexes in all age groups literature and sport science research on safety in ice hockey to develop an and at all skill levels (1) predominantly action plan to reduce the risk, incidence, severity, and consequences of in North America, Europe and coun- concussion in ice hockey. tries of the former Soviet Union (2). The speed, hard ice, boards, sticks,

*Mayo Clinic, Sports Medicine Center, Rochester, Minnesota; †SIMBEX, LCC, Lebanon, New Hampshire; ‡University of Calgary, Sport Medicine Centre, Calgary, Alberta, ; **Mayo Clinic, College of Medicine, Scottsdale, Arizona; ¶The University of North Carolina, Chapel Hill, North Carolina; €University of Minnesota, St. Paul, Minnesota; UOntario Neurotrauma Foundation, Toronto, , Canada VSt. Elizabeth’s Medical Center, Boston, Massachusetts, USA; # Sport Medicine Centre, Ottawa, Ontario, Canada; -University of Toronto, Department of Surgery, Toronto, Ontario, Canada; +, Director of Neuropsychological Testing Program, , New York; ?Blue Anchor, New Jersey; TScottsdale, Arizona; ^University of Pittsburgh Medical Center, Sports Medicine Concussion Program, Pittsburgh, , USA; ~USA Hockey, Colorado Springs, Colorado, USA; lAmerican College of Sports Medicine, Indianapolis, Indiana, USA; $Sports Legacy Institute, Boston, Massachusetts, USA; =University of Rochester, Rochester, New York, USA; 3University of Waterloo, Waterloo, Ontario, Canada; ZHealth and Safety Sports Consultants, LLC, Carmel, Indiana, USA; RUniversity of Wisconsin, Madison, Wisconsin, USA; bThe Hockey Neurotrauma and Concussion Initiative National Research Committee, London, Ontario, Canada; ^Lakehead University, Thunder Bay, Ontario, Canada; /Rochester Youth Hockey Association, Rochester, Minnesota, USA; $Childrens National Medical Center, D.C., USA; ZUniversity of Tennessee College of Engineering, Sports Biomechanics Impact Research Laboratory, Knoxville, Tennessee, USA; "University of Washington, Seattle, Washington, USA; pUniversity of Ottawa, Ottawa, Ontario, Canada; aThe Steadman Clinic, Vail, Colorado, USA; ¯York University, Toronto, Ontario, Canada; -Boston University School of Medicine, Boston, Massachusetts, USA; 7Team Wendy, Cleveland, Ohio, USA; QUniversity of Leeds, Woodhouse, Leeds, United Kingdom; &Princeton University, Princeton, New Jersey; SCenters for Disease Control and Prevention, Atlanta, Georgia, USA; ,Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada.

Address for correspondence: Aynsley M. Smith, RN, PhD, Mayo Clinic, Sports Medicine Center, Rochester, Minnesota (E-mail: [email protected]).

1537-890X/1004/233Y239 Current Sports Medicine Reports Copyright 2011 * The Concussion Executive Committee (derived from the Mayo Clinic Ice Hockey Summit: Action on Concussion committees). All rights reserved. The CEC has granted the Publisher permission for the reproduction of this article.

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Copyright 2011 © The Concussion Executive Committee (derived from the Mayo Clinic Ice Hockey Summit: Action on Concussion committees). All rights reserved. The CEC has granted the Publisher permission for the reproduction of this article. Y Methods (5 7,36,37). The goal of the Summit A rationale paper outlining a collaborative action plan to address con- was to identify appropriate strategies to cussions in hockey was posted for review two months prior to the Ice decrease concussion in hockey. Hockey Summit: Action on Concussion. Focused presentations devoted specifically to concussion in ice hockey were presented during the Sum- mit and breakout sessions were used to develop strategies to reduce Methods concussion in the sport. This proceedings and a detailed scientific review The Ice Hockey Summit objectives (a matrix of solutions) were written to disseminate the evidence-based provided the template for a rigorous information and resulting concussion reduction strategies. The manu- curriculum that met Continuing Medi- scripts were reviewed by the authors, advisors and contributors to ensure cal Education (CME) credit standards. that the opinions and recommendations reflect the current level of The attendees were actively engaged in knowledge on concussion in hockey. prioritizing action items and identify- ing implementation strategies for a Results multi-factorial solution. After review- Six components of a potential solution were articulated in the Rationale ing the literature prior to the Summit, it paper and became the topics for breakout groups that followed the pro- was hypothesized that the components fessional, scientific lectures. Topics that formed the core of the action of a solution to concussions in hockey plan were: metrics and databases; recognizing, managing and return to were those depicted in the Figure. play; hockey equipment and ice arenas; prevention and education; rules The methodology that generated the and regulations; and expedient communication of the outcomes. The matrix of prioritized actions included attendees in breakout sessions identified action items for each section. a pre-summit concussion literature re- The most highly ranked action items were brought to a vote in the open view (7,13), on-site shared content by assembly, using an Audience Response System (ARS). The strategic presenters and panelists, as well as dis- planning process was conducted to assess: Where are we at?; Where cussion and debate during breakout must we get to?; and What strategies are necessary to make progress on sessions. The attendees in breakout the prioritized action items? sessions identified action items for each section. Each breakout leader pre- Conclusions sented action items based on agreement Three prioritized action items for each component of the solution and along with a strategic plan to the gen- the percentage of the votes received are listed in the body of this pro- eral assembly. The most highly ranked ceeding. action items were brought to a vote in the open assembly, using an Audience Response System (ARS). Attendees pucks, player collisions, body checks and illegal on-ice voted on preferred actions items for all six sessions. The activity (3) contribute to the prevalence of concussion (4). three in each category considered the highest priority The evidence-based foundation for the Ice Hockey Summit: become part of the group’s official recommendation. The Action on Concussion, held at Mayo Clinic 2010, was strategic planning process assessed: Where are we at?; derived from research on concussion and focused on rec- Where must we get to?; and What strategies are necessary to ognition, assessment, management, and return to play implement the action plan. guidelines (Zurich, 2008) (5Y7) integrated with ice hockey specific research. The sport science research addressed equipment, impact forces, standards testing, at-risk behav- The following action items from each breakout were iors, rule enforcement, education and behavioral mod- prioritized by popular vote using ARS. The percentage ification programs (8Y13). Although quality guidelines for of attendees voting a particular action item to be of sport related concussion management have been written immediate importance (in need of being tackled first) (5Y7), there are unique features that distinguish ice hockey is listed below. Attendees were then asked to choose from other contact sports. Professional hockey is a skilled, their second priority and then their third choice. exciting game, rooted in a heavily reinforced culture of NOTE: Some breakouts offered more than three aggressive play (14Y22) and it is the only professional sport, choices. Listed are the top three for each breakout, other than boxing and mixed martial arts, that ‘tolerates’ thus not all equal 100%. fighting during play. To eliminate behaviors or major pen- alties that increase the risk of concussive brain injury and related neurotrauma (i.e., head hits, blind side hits, fighting, Results and checking from behind), consistent educational messages I. Databases and Metrics (Breakout A):1)Collect must be delivered, compliance with rules must be rewarded concussion data using a consistent hockey-specific defi- and infractions must be penalized across all levels of par- nition in small, well-designed studies (60.9%); 2) Stand- ticipation (23Y27). Other aspects of prevention pertain to ardize funded, hockey concussion research similar to player equipment (28Y33) and facilities (34,35). As impor- football, lacrosse, etc. (18.5%); and 3) Partner with pend- tant as prevention is, there is also a recognized need for ing legislative action to collect concussion data (15.2%). astute detection, accurate diagnoses, optimal management II. Recognizing, Diagnosing, Management and Re- and appropriately followed Return to Play guidelines turn to Play (Breakout B): 1) Mandate education for

234 Volume 10 & Number 4 & July/August 2011 Special Communication

Copyright 2011 © The Concussion Executive Committee (derived from the Mayo Clinic Ice Hockey Summit: Action on Concussion committees). All rights reserved. The CEC has granted the Publisher permission for the reproduction of this article. Figure: 6 Priority Action Areas. The symbol in each box is depicted below adjacent to the reference numbers appropriate to each component of the solution. Adapted from figure prepared by Ann Braatas, Mayo Clinic-Rochester, published in the Mayo Clinic Orthopedic Update, 2011.

coaches, parents and referees (46.5%); 2) Remove ath- unified message for delivery (31.7%); and 3) Create a letes from play for all suspected concussions (39.4%); multi-media package, including a robust social media and 3) Ensure that concussed athletes do not return to presence (19.8%). play (practice or game) until cleared by medical person- The prioritized action items from each breakout group nel (14.1%). were accompanied by a strategic planning process that was III. Player Equipment and Facilities (Breakout C):1) unique to each component of the solution, but there were Educate the hockey community on the actual role of some areas of overlap. equipment (53%); 2) Emphasis that the helmet is only one factor that may reduce concussion risk (34%); and 3) Continue to support research that develops and tests Discussion both equipment and facilities (13%). A strength of this Summit was the diversity of the stake IV. Prevention and Education (Breakout D): 1) Engage holders who shared their expertise and concerns about con- organizations (USA Hockey, , IIHF, etc.) cussion. The Rationale manuscript posted as pre-reading to educate coaches, parents and student athletes on the registration web site raised many questions that (79.2%); 2) Take advantage of the currently available were subsequently discussed from the podium and during educational content in programs such as Hockey Edu- the breakout sessions. Many hockey enthusiasts hoped that advances in hockey equipment, especially the technology cation Program (Fair Play), Centers for Disease Control of hockey helmet design could further dissipate the kinetic and Prevention’s (CDC) Heads Up program, Play it Cool energy transmitted to the brain. Engineers, biomechanics and ThinkFirst (6.9%); and 3) Ensure that educational experts and equipment standards committee members on efforts drive a behavioural and cultural change (5.0%). the faculty agreed that hockey helmets currently perform V. Rules and Enforcement (Breakout E): 1) Eliminate well in preventing focal injuries to the skull. However, con- all head contact (intentional and unintentional) (74%); temporary helmets are not designed to manage linear and 2) Postpone legal body checking in youth games until age rotational accelerations that are linked to brain tissue defor- 13 (Bantam level) (18.7%); and 3) Eliminate fighting at mation and concussive injury. Nonetheless, all agree that all levels of hockey participation (7.3%). players should wear a properly fitted, certified helmet to VI. Communication (Breakout F): 1) Require an in- protect from focal injury. The helmet must be well secured to person, pre-season meeting each year for all hockey maintain proper position on the head and to prevent it from participants (including parents) (33.7%); 2) Provide a falling off. Players should also wear a custom-fitted mouth

www.acsm-csmr.org Current Sports Medicine Reports 235

Copyright 2011 © The Concussion Executive Committee (derived from the Mayo Clinic Ice Hockey Summit: Action on Concussion committees). All rights reserved. The CEC has granted the Publisher permission for the reproduction of this article. guard that remains in place during play to protect the mouth, level) and abolish fighting requires the support of district, teeth and jaw, even though there is no current strong evidence state, and provincial leadership. Thus, the implementation that mouth guards decrease the risk of concussion (38). process has been initiated with USA Hockey, Hockey Canada Elbow and shoulder equipment should have sufficient pad- and the International Ice Hockey Federation (IIHF). ding since contact of the hard plastic shell to the head may result in an increased force transmission (30). In addition Conclusions to improving the protection offered by helmets, concussion Recently, the authors of a thoughtful paper (47) discussed prevention must also be achieved via rule changes and the failure of sports medicine healthcare professionals and enforcement, educational programs and behavioral mod- sports scientists to engage in injury prevention for youth ification. When a concussion is suspected, accurate detec- athletes. They hypothesized that tension exists at the inter- tion, removal from play, individualized management, and a face between sport and medicine based on differences in monitored physical and cognitive progression protocol must core values. Sport values competition and success; whereas, be followed. A qualified health care provider should evaluate medicine values wellness and prevention. The author stated and manage the concussed player and guide the Return To that one exception pertained to an investigation of the use Play (RTP) decision-making. of Fair Play rules in a hockey tournament (48). Suffice to say that injuries and penalties related to rough play were four Post Summit Action Taken times less frequent in hockey games using Fair Play rules Some concerns not included in the prioritized action (21,48). National governing bodies continue to explore items are being addressed by the Post-Summit Imple- strategies to recruit youth hockey players and grow the mentation Committees. For example, an important focus of sport. In Minnesota, where Fair Play has been in place since future research is prevention of concussion in female ath- 2004, youth hockey (boys and girls combined) grew by letes, particularly in contact sports, such as hockey. Pre- 14.9% between 2005 and 2007 (49), a positive trend that liminary studies suggest that female hockey players sustain continues. more concussions than males (39), acknowledge more The evidence-based action items, prioritized at the Ice baseline symptoms on the Sport Concussion Assessment Hockey Summit: Action on Concussion described in this Tool (40), may self report more frequently (41), and activate Proceedings, are clear, hockey-specific and appropriate. neck musculature earlier than males, yet have a reduced These actions include rule changes and education of all neck muscle mass (42). These and other factors may in- players, coaches and parents using available educational crease their risks. and behavioral modification content to reduce major pen- The need to ensure consistency of the definition of con- alties and reward sportsmanship. Implementation efforts cussion was prioritized by the Data Base/Metrics breakout are underway as a collaborative effort from individuals, session. Furthermore, since concussions are under-reported national governing bodies, and the media to grow the game at all levels of participation, players who admit symptoms and make hockey safer for all participants. To reduce the and those who are observed to sustain a mechanism of risk of concussion in ice hockey, we must all respond to this injury that may have caused a concussion should be re- ‘‘Call for Action!’’ moved from play and promptly evaluated. This observa- tional strategy has been used in both youth (4) and Junior A Acknowledgments Y (43 46) studies to gather more accurate concussion inci- Joint Sponsors of the Ice Hockey Summit: Action on Concussions: dence data. A diligent approach to concussion identification Hockey Equipment Certification Council is already practiced by many rink side athletic trainers/ International Ice Hockey Federation therapists and physicians, but more emphasis is needed. Ontario Neurotrauma Foundation It was determined at the Summit that concussion pre- USA Hockey vention and stakeholder instruction requires mandatory education of coaches, parents and athletes. The educational Partial Support by: content to meet these needs is currently available. Dissem- Team Wendy and the Johannson-Gund Endowment ination of programs such as the Hockey Education Program (HEP) that includes Fair Play, Play it Cool (PIC), and References ThinkFirst.ca’s Smart Hockey DVD requires engagement 1. Visek A, Watson J. Ice hockey players’ legitimacy of aggression of national governing bodies. Minor modifications to the and professionalization of attitudes. 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