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Bodychecking and concussions in ice hockey: Should our youth pay the price?

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    Bodychecking and concussions in ice hockey: Should our youth pay the price?

    Bodychecking and concussions in ice hockey: Should our youth pay the price?
    Anthony Marchie and Michael D. Cusimano
    Mr. Marchie and Dr. Cusimano are with the Division of Neurosurgery and the Injury Prevention Research Centre, St. Michael's Hospital, University of Toronto, Toronto, Ont. Dr. Cusimano is an Associate Professor of Surgery in the Division of Neurosurgery and Mr. Marchie is a fourth-year medical student at the University of Toronto.

    Correspondence to: Dr. Michael D. Cusimano, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, 38 Shuter St., Toronto ON M5B 1AG; or

    Ice hockey, considered Canada's national sport, has more than 500 000 registered players,1 many of whom aspire to play in the National Hockey League (NHL). With the drive to win at any cost permeating the game, it is not surprising that aggression is a commonly used tactic and has helped to turn hockey into a collision sport.2 Nor is it surprising that youth often idolize and emulate the professional enforcers who protect their team's leading scorers.3

    Bodychecking, thought by some a useful skill for winning games, is a major risk factor for injury.2,4,5,6,7 With the rising incidence of traumatic brain injury in hockey,8,9 too many Canadian youth are exposed to the lasting effects of such injuries, some of which are not fully realized until the brain completes its maturation.

    Before the start of the 2002-2003 season, Hockey Canada (previously known as the Canadian Hockey Association), reversed its 20-year stance and decided to permit players as young as 9 years old to bodycheck in games.10,11 Although the research12 that was used to justify this policy was later deemed flawed by its author and others,13 the policy stood. This ignited a debate that resounded throughout arenas, homes and league boardrooms across the country. Previously, only those aged 12-13 years and older could bodycheck, although some provinces such as British Columbia had a threshold of 14-15 years. Hockey Canada reversed its decision in May 2003 and decided to raise the starting age to 11; however, it continues to allow bodychecking starting at age 9 in an "experimental" fashion in 4 of some of the largest hockey associations in Canada.14,15,16 The meaning of "experimental" does not appear in Hockey Canada news releases.

    Those in favour of bodychecking claim that the game of hockey demands it; youth exposed to bodychecking at only a later age will be ill equipped to avoid injury. They believe that injuries result from improperly delivered or taken bodychecks and that poor technique should not deter leagues from permitting checking. They argue that the focus should be on educating coaches and teaching bodychecking skills at all levels of hockey.

    Physicians are often called upon to assess youth with hockey-associated traumatic brain injury and to counsel players and their parents about subsequent return to play. Although recommendations about return to play are numerous,17,18,19,20,21,22 none has been extensively validated.18,23 A considerable number of youth who return to play on the goodwill of these recommendations sustain repeated traumatic brain injuries.18,24,25,26,27 None of the recommendations emphasizes the importance of counselling children and their families about the risks of returning to play or the option of not playing in a body-contact league. In our opinion, too much emphasis is placed on when to return to play and not enough on whether to return after an initial traumatic brain injury. To properly counsel players and inform the debate on allowing bodychecking in hockey, physicians must fully appreciate the medical risks associated with bodychecking in hockey.

    What is the relation between bodychecking, injury and concussions?

    Bodychecking, the most common cause of trauma in hockey,2,28,29,30 accounts for 86% of all injuries among players 9-15 years old.31 Players in contact leagues are 4 times as likely to be injured (among those 9-15 years old) and 12 times as likely to receive a fracture (among those 12-13 years old) as players in non-contact leagues.2,32,33,34 Of reported injuries among players 9-15 years old, 45% are caused by legal bodychecks and 8% by illegal checks, without a significant difference in the injury profiles between the 2 types of checking.35 Stricter enforcement of rules would not, therefore, have much impact on injury rates.

    A comparison with football injuries helps highlight the issue of serious injury in hockey. Direct fatality and injury rates for football are half those for hockey: 1.8 per 100 000 football players in high school and 7.0 per 100 000 in college.36 Nonfatal catastrophic spinal cord and brain injury rates are 2.6 per 100 000 hockey players and 0.7 per 100 000 football players among high school athletes.37

    Among the serious injuries caused by bodychecking, concussions are of particular concern because of the risk of permanent sequelae. In studies involving youth and adults, concussions have ranged from a brief period of neural dysfunction to loss of consciousness and amnesia.38,39,40,41 There may be headache, cognitive, memory and executive-function disturbances, visual abnormalities, motor and sensory changes,38,39,40,41,42 and seizures.43 Permanent electrophysiological changes in brain function have been observed in injured junior hockey players 16-20 years old who had recovered and returned to play.44 Some reported concussions are shown to be contusions on CT scanning.

    Repeated mild brain injuries in youth and adults occurring over months or years can result in cumulative deficits.24,25,26 High school athletes with a history of 3 concussions are 9 times more likely than those with no history of concussion to have changes in their mental status.25 These patients have "long-lasting alterations in neurological motor functions," 27 and some have had to relearn how to stand.45

    The younger developing brain is at an even higher risk of injury. Repeated concussions may lead to permanent learning disabilities and other neurological and psychiatric problems.46,47,48,49 Pre-adolescent youth with a traumatic brain injury may never fully develop the social and cognitive skills characteristic of adults and may be more violent than those without such an injury.50,51

    Each season, 10%-12% of minor league hockey players 9-17 years old who are injured report a head injury,45 most commonly a concussion.38,39,52 Concussions are most often caused by bodychecking38,39,40,53 and rarely by being struck with a puck.38 A review of the literature published between 1966 and 1997 revealed that youth aged 5-17 years had about 2.8 concussions per 1000 player-hours of ice hockey; the number per 1000 player-hours was about the same among high school players, as high as 4.2 among university hockey players and 6.6 among elite amateurs.38 Among Canadian amateur hockey players over 18 years old, the rate is 4.6-6.0 concussions per 1000 player-hours.39 When 14 years was the age at which bodychecking was first allowed in British Columbia, 15 years was the average age at which players had their first concussion.39 Undoubtedly, this threshold age will decline as the new rules about bodychecking are implemented across the country.

    Reports of injuries involving youth and adult hockey players show that, despite advances in equipment design, the number of concussions is increasing.8,9,29,52 Based on these findings and Hill's criteria for causal association,54 the link between bodychecking and injury and concussion is convincing. It makes sense, given our knowledge of the disease process. The link is analogous to the association between smoking and lung cancer.54 Findings from meta-analyses28,38 and prospective29,39,40 and retrospective39,40,52 studies support the association between bodychecking and concussion. In addition, the incidence rates of concussion and other hocky-related injuries increase with increasing age, when more bodychecking is expected, and with higher levels of play, which suggests a dose-response effect. Learning to bodycheck when young does not reduce a player's rate of injury as he or she ages, and it prolongs the risk exposure.38,40,55,56

    Return to play?

    Even minor concussions are serious injuries42,57 because they can lead to second-impact syndrome or cumulative effects in the event of another concussion. Second-impact syndrome is often the main reason for delaying a sports player's return to play after a concussion. The syndrome is caused when players who remain symptomatic sustain a second blow to the head. Even if this second blow is minor, the brain may swell rapidly, resulting in extensive further injury, or uncal herniation and death, probably because of the loss of autoregulation of the cerebral vasculature.58,59,60

    There are expert guidelines17,19,22,24,25,26,61 on when players can return to play, without specific reference to age, but no mention of if players should return to play. Our experience indicates that players who have had a second concussion, or their parents, often wished they had been given the option of whether to return to play at all. Physicians should counsel patients and their families about the risks and benefits of continued play62 and should explain the importance of being realistic about ambitions for a future in hockey - only 1 of every 4000 minor league hockey players will ever play in the NHL,63 and only 1.3 of every 1000 will earn an athletic scholarship to an American university.64 Because symptoms often worsen with exercise and because the length of time the brain is vulnerable after a concussion is unknown,65,66,67 prudence dictates erring on the side of caution when deciding on when or whether athletes should return to play.

    Should bodychecking be allowed in youth hockey?

    Many proponents of bodychecking argue that it is an important skill that allows players to take control of the puck, creates scoring opportunities and helps with defensive positioning and coverage, making it valuable to overall team play.18 Teams often have a checking line of 3 players who play against an opposing team's top scoring line to minimize their scoring opportunities and tire them out. As is evident in any playoff series, this checking is often used as physical and mental intimidation to gain control of the game.31,68

    However, the relation between aggressive play and winning is much weaker than the proponents of bodychecking believe. In a study of 1462 recorded penalties in all 18 Stanley Cup final series from 1980 to 1997, teams playing with less violence were more likely to win.69 Compared with more violent teams, they had on average over 7 more shots on goal per game and 53 more shots on goal over a 7-game series. Losing teams engaged in more violence early in the game, which suggests that their motivation was not frustration of defeat but, rather, the mistaken belief that violence contributes to winning.69

    Although the contribution of bodychecking to a team's success is questionable, it is such an integral part of the game at the professional level that it is unlikely to be eliminated soon. However, players should not be introduced to bodychecking until they can make a mature, informed choice regarding the issue. Enforced league policies that disallow bodychecking are still the best hope for reducing young players' injuries.70

    The risks of bodychecking make it clear that checking is not necessary for play at the Canadian minor league hockey level55 - a position supported by the Canadian Academy of Sport Medicine.4 The American Academy of Pediatrics recommends limiting bodychecking among players 15 years of age and less.2 Variations in body size and strength34 occur in all age groups, but they are most pronounced from 13 to 15 years; differences of 53 kg in body mass and 55 cm in height between the smallest and largest players have been reported in this age group.31 Since most physical growth is not complete before a person is 17 or 18 years old, bodychecking and hitting should be banned until at least that age. Leagues with players old enough to give consent should obtain informed consent from players before they join the body-contact league. The standard waiver that players are asked to sign to release leagues of all responsibility in the event of injury does not reach the standard of consent expected in activities with more than minimal potential harm. Also, it is unclear how informed consent will be obtained from the 9-year-old players in the 4 hockey associations who will be participating in Hockey Canada's "experiment" 15 and whether the process conforms to Tri-Council Policy.71

    Awareness of injury prevention is fortunately being raised through programs such as the recently implemented Fair Play in minor hockey leagues.72 Such programs have been shown to reduce injury rates.32 Another strategy for maximizing player safety is education.73,74,75 Hockey Canada has recognized this need and has launched 2 programs to help coaches improve their skills: the Competency Based Educational Program and the Coaches Mentorship Program.55

    Although coaches have a responsibility to teach safety techniques and coaches and parents should act as role models for good sportsmanship, these actions rarely happen consistently.69 Recently, 22 of 34 minor league coaches refused to participate in a video about concussion prevention because they thought that watching the video would make their players less aggressive and successful as a team.45,73 In one community, players 14-15 years old were less likely than younger players to believe that sportsmanship was "real important."31,70 Moreover, 26% of players 12-15 years old who understood that bodychecking from behind could cause serious injury or death reported that they would be willing to do so if they were angry or wanted "to get even." 31

    In addition, parents may be encouraging their children to win at all costs in the hope of their pursuing scholarships and professional contracts.76 In one study, 32% of injured players said that they would continue to bodycheck to ensure a win; an additional 6% said they would do so in order to injure another player.77 Since aggression may be a learned behaviour rewarded in sport,78 youth and the public in general must be educated about its dangers and social unacceptability. Ideally, as role models for youth,79 professional players and media personnel should emphasize nonviolence.

    Moreover, although the use of protective equipment may prevent some injuries, it may foster the attitude that it can prevent all injuries, it may lead to more lenient enforcement of the rules and, paradoxically, it may increase the number of serious injuries.74,75,80,81,82,83

    Education and the elimination of bodychecking remain the most effective strategies for preventing concussions and other hockey-related injuries. Eliminating bodychecking could refocus the game on fun and skill - on skating, shooting, passing and team play. Physicians must play their roles as socially responsible citizens: the future of our youth and the game depend on it.


    This article has been peer reviewed.

    Contributors: Both authors contributed substantially to the writing of the manuscript and approved the final version.

    Acknowledgements: Dr. Cusimano is supported by research grants from the Ontario Neurotrauma Foundation. The opinions expressed in this article are those of the authors and do not necessarily reflect those of the foundation.

    Competing interests: None declared.


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    Related articles in eCMAJ:

    Highlights of this issue

    eCMAJ 2003 169: 97. [Full Text]

    Bodychecks, not pucks, cause most harm

    Bodychecks, not pucks, cause most harm

    From Wednesday's Globe and Mail

    UPDATED AT 1:58 AM EDT Wednesday, Jul. 30, 2003


    Nearly two in three serious injuries suffered by young hockey players are the result of bodychecks - far more than the combination of stick and puck injuries, data from Ontario hospital emergency rooms suggest.

    The figures compiled for The Globe and Mail indicate that almost 8,000 hockey players required treatment in Ontario hospitals last year and prompted renewed calls to ban hitting in recreational hockey, among youngsters in particular.

    Young teenagers were the most likely to be hurt, but players up to age 80 were injured.

    "These numbers demonstrate that there is a heavy price to pay for having bodychecking, and we have to ask ourselves if our youth should be paying that price," said Michael Cusimano, director of research for the National Head and Spinal Cord Injury Prevention Foundation.

    He said that checking should be banned until age 17 or 18, when physical growth is complete, and that all players in full-contact leagues should be required to provide informed consent, including being fully informed of the risks of bodychecking.

    Dr. Cusimano, a neurosurgeon, said hockey players in contact leagues are four times as likely to be injured and 12 times as likely to suffer fractures as are those in non-contact leagues.

    Hockey Canada policies allow players to bodycheck from age 11, though the starting age is 9 in four of the largest hockey associations in the country.

    Hockey Canada lowered the checking age to 9 last year but reversed itself after an outcry and revelations that research to justify the change was flawed.

    Those who favour bodychecking at a young age argue that it is an integral part of the game and that youth exposed to hitting only at older ages will be ill-equipped to avoid injury.

    The emergency-room data do not appear to support that argument. Rather, they indicate that bodychecking injuries are most frequent in the 14-to-16 group - after players have been exposed to checking for several years.

    Dr. Cusimano said that the more experience players have with checking the higher the injury rate and that injuries drop in older age groups because so many players drop out of the game.

    Among hockey players 18 and under, 62 per cent of injuries were caused by bodychecking, 24 per cent by hitting with sticks and 16 per cent by being hit with pucks, the data indicate.

    In the youngest age group, 9 and under where bodychecking is not allowed, the vast majority of injuries - 56 per cent - were caused by sticks; hitting (accidental and otherwise) accounted for 29 per cent and pucks 15 per cent.

    Among adults, the breakdown of injuries is markedly different than among young players: Forty per cent of serious injuries were caused by pucks, 31 per cent by sticks and 29 per cent by bodychecks.

    Most adult leagues are non-contact and tend to be lax about requiring facial protection, which may explain the much higher rate of puck-related injuries.

    The data suggest that hockey players across the age spectrum - some as old as 80 - are being injured, and some of those injuries are severe.

    Of the 7,962 hockey injuries treated in Ontario emergency rooms, 93 resulted in the person being admitted to hospital; 15 of those were admitted directly to critical-care units.

    Just over 93 per cent of the injured were boys and men, with the balance girls and women. (Female hockey is exclusively non-contact.)

    The figures were drawn from a new database, the National Ambulatory Care Reporting System. Data from about 60 per cent of Ontario hospitals are included, so the total number of hockey injuries is underestimated.

    "These numbers are incomplete, but we hope they will help those in decision-making positions to make informed choices," said Greg Webster, manager of clinical registries at the Canadian Institute for Health Information.

    "There are obviously a large number of injuries related to hockey, so we will continue to expand our efforts to collect data in this area," Mr. Webster said, adding that the database eventually will provide detailed national figures.

    More than four million Canadians play hockey, and at least 500,000 young people play in organized leagues.

    Dr. Cusimano is not alone in his call to raise the checking age considerably. The Canadian Academy of Sport Medicine says there should be no checking in minor hockey, and the American Academic of Pediatrics says bodychecking should not be allowed among players 15 and younger.

    © 2003 Bell Globemedia Interactive Inc. All Rights Reserved


      Therien cites high number of injuries in urging an end to full contact for kids

      Therien cites high number of injuries in urging an end to full contact for kids


      UPDATED AT 6:54 PM EDT Thursday, Jul. 31, 2003


      "If we don't ban bodychecking, minor hockey as we know it in Canada will come to an end."

      That warning came from Émile Therien, president of the Canada Safety Council, after reviewing the latest injury statistics.

      The Canadian Institute for Health Information found that almost 8,000 people were treated for hockey-related injuries in Ontario emergency rooms last year, suggesting more than 25,000 people were injured nationwide.

      Among young hockey players, 62 per cent of injuries were a result of checking, far more than the injuries caused by sticks and pucks combined.

      "The numbers are high but they vastly underestimate the true extent of injuries," Therien said. "A lot of kids who are hurt, and hurt pretty seriously, are told to skate it off."

      In an interview yesterday, Therien added his voice to growing calls to ban bodychecking until age 17. "This is an important health and safety issue and there should be a national standard," he said.

      SmartRisk, the Toronto-based injury prevention group, also called for an end to full-contact recreational hockey, saying it poses too great a risk to children.

      "We feel bodychecking is a dangerous practice that is causing frequent injury and unnecessary risk to young children as they grow," said Catherine Clark, the communications co-ordinator for SmartRisk. "Ideally, we would like bodychecking to become a thing of the past."

      Currently, Hockey Canada recommends that bodychecking begin at age 11, but the starting age varies. In some hockey associations, checking begins at nine years of age for boys. There is no checking in girls' hockey.

      Therien said bodychecking threatens the future of recreational hockey for two reasons: Insurance rates are skyrocketing and children are leaving the sport in droves at the age when checking is introduced.

      "Insurers aren't going to stand for this level of injury, particularly when it's preventable," he said.

      Years ago, Therien said, helmets and visors became mandatory because of pressure from insurers, after claims for head and eye injuries mounted.

      Today, the claims are from hockey players who suffer spinal cord injuries and concussions from bodychecking.

      Therien, whose son Chris plays for the Philadelphia Flyers of the National Hockey League, said bodychecking is ruining the game.

      He said a lot of hockey players are leaving the game, particularly in their early teens, when hitting begins and there are disparities in the size of players. "A lot of the kids are saying 'Screw this. It's not fun anymore.' That's a sad indictment of our national sport."

      Jean Côté, a professor of sports psychology at Queen's University and an expert on the psychological effects of violence, said that in addition to the physical harm caused to children, parents should consider the psychological harm.

      "The one reason kids want to play sports, like hockey, is to have fun. And the main reason they drop out is because they stop having fun," he said.

      Proponents of bodychecking say it is an integral part of the game, and players should be taught young so they can become accustomed to the physical aspect of the game.

      Dr. Côté disagrees: "You don't need 10,000 hours of practice to learn how to bodycheck. It's just, Bang. You can learn that when you're older."

      Approximately one in every 4,000 hockey players has a chance to play in the NHL. For that reason alone, Dr. Côté said, there is no reason that amateur hockey has to mirror the NHL game.

      "Hockey at age 11 doesn't have to be the same game they're going to play at age 25, " he said. "They're just kids. Why don't we just let them play?"

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