Behavioral Modification to Reduce Concussion in Collision Sports

Introduction Concussion awareness in contact or collision sports like ice hockey has escalated recently (16) in both genders at all levels (2). The increase in sport-related concussion (SRC) is attributed to better symptom recognition, increased player speed and size and perceived player invincibility. For example, sales of the Cascade M11 hockey helmet soared in 2009, when it was marketed as the “Enemy of Concussion.” Parents rushed to ensure their youth hockey player’s brain was protected by this “special” helmet. The aggressive advertising campaign was withdrawn due to a lack of evidence supporting the contention that the helmet reduced concussion risk. In fact, none of the commercially available helmets reduce the large linear and rotational forces transmitted to a hockey player’s head (8,9), Contrary to the players’ perception, equipment may not have protective value and modern equipment design may actually increase the incidence and severity of concussion. For example, hard shell elbow and shoulder pads may protect the wearer but may injure opponents or teammates in collisions (1). Concussion reduction efforts must address the multifaceted aspects of brain injury (16). Significant effort and expense have been directed toward producing safer equipment and better understanding of the injury process with respect to single or repetitive exposure to linear and rotational acceleration and deceleration forces. Finite element modeling (4,11) has been used to detect the strain and strain rates that cause tissue damage. New evidence is emerging on the benefits and limitations of neuroimaging and neuropsychological testing in assessing concussion severity and return to play (5,6). Fundamental research into the role of biomarkers, proteins, and enzymes was released after trauma; diffuse axonal injury, the metabolic cascade (3), and the behavior of glial cells that engulf traumatized neurons also have helped us better understand the neuropathology of concussion. Despite this body of scientific data, we have not advanced the treatment of SRC beyond removal of the concussed athlete from sport for cognitive and physical rest until the symptoms have resolved completely with vigorous activity. Considering the dictum “an ounce of prevention is worth a pound of cure,” it is surprising that little effort has been directed toward behavioral modification in injury and concussion prevention. This simple, inexpensive, evidence-based method of changing behavior is a major construct in the practice of medicine, coaching, and officiating that should be applied to injury reduction in hockey and other sports. The principles of behavioral modification, known as operant conditioning, are based on the work of Skinner (10,13). The central premise of operant conditioning (10) is that behavior is governed by reinforcing desirable behavior and punishing undesirable behavior. For example, law enforcement and insurance companies reduce the risks of speeding by suspending a driver’s license after too many citations. Conversely years of violation-free driving results in lower car insurance premiums — punish the bad behavior and reward the good. In sports medicine, patients who adhere to a daily regimen of strengthening muscle groups following injury are “rewarded” by a faster return to pain-free movement. The most effective way to decrease concussion prevalence is to implement a behavior modification program to alter the culture of collision sports where equipment improvements have made players feel “invincible.” Reducing aggressive and violent on-ice behavior will prevent the majority of SRC that are associated with illegal and unnecessarily rough behavior. Accidental collisions will still occur, but most SRCs result from on-ice infractions, many of which are not noticed by the officials. Sadly infractions may be encouraged by some coaches and general managers, who try to win by intimidation, and by fans who enjoy the violence (15). An example of a perverse use of behavioral modification in football is the provision of a financial reward when an opposing player is injured and removed from the game. Aggressive behavior is defined by most sport scientists as physical or psychosocial behavior intended to intimidate or injure (18). Most major hockey penalties are levied for injurious activities such as checking from behind (CFB), head hits, charging, boarding, high sticking, and cross-checking. On the other hand, assertive behavior is the intent to be first to the puck, control the puck, or take the puck from an opposing player. These behaviors seek to control the game but have no intent to injure. Fair Play — What is it? Ice hockey, at its best, is an exciting, fluid game, but violent play makes it a very dangerous sport. Fair Play is a behavioral modification program that uses team penalties and rewards to positively reinforce assertive behavior and negatively reinforce aggressive, injurious behavior (17). Although Fair Play applied to youth hockey was first implemented in Nova Scotia and Quebec (7), Minnesota Hockey was the first to launch a statewide Fair Play plan in 2004. Fair Play promotes sportsmanship by awarding a point for taking less than a given number of penalty minutes in a game (penalty minutes are assigned in an age-appropriate manner). Fair Play penalizes by withholding its Fair Play point if a team exceeds their penalty minute allocation. Penalties are weighted in accordance with the risk of head injury and neurotrauma they pose to players, ranging from a 2-min minor (e.g., tripping) to a 10-min misconduct or game ejection. Tournament results and team standings in league play are determined not only by wins and losses but also by the team Fair Play points. Does Fair Play Work? Teams in a Junior Gold tournament were compared while playing under Fair Play rules during round robin play to playing under traditional rules during the single elimination portion of the tournament and the traditional rules portion of the tournament (12). Similar to earlier Canadian studies, teams playing by Fair Play had fewer major penalties and fewer injuries, such as concussion (12). In Fair Play competition, penalties are weighted based on severity of potential consequences. For example, CFB or a head hit costs 12-min of penalty time, which is subtracted from the 16-min penalty allowance for a Bantam team. Thus that team could only incur two additional minor penalties (2 min each) before forfeiting their Fair Play Point. Hockey benefits from Fair Play because it has “much to gain” by assertive play and “much to lose” from the aggressive behavior of players. Tracking the Data by Level of Participation and Gender Minnesota Hockey and the Mayo Clinic Sports Medicine Center have tracked the number and type of penalties recorded for 8 years. The Fair Play points earned at all levels of youth hockey participation, including Junior Gold, were documented also (Fig. 1).Figure 1: Total penalty minutes per 100 games.Each season, the Mayo Clinic Sports Medicine Center hockey research team receives the score sheets from Minnesota Hockey. The research team sorts and counts by age group before 25% samples are selected randomly for analysis. Girls earn over 90% of Fair Play points until U19 when the percentage earned declines to 80%. Boys earn about 90% in Pee-Wee, 82% in Bantam, and this past year, Junior Gold players improved from 72% to 83%. Fair Play points earned by levels of participation for boys’ hockey are depicted in Figure 2.FIGURE 2: Boys Fair Play percentage earned per level (2004–2012).After body checking was removed from Pee-Wee, CFB penalties decreased from an average of eight to two per 100 games. In 2012, a highly publicized CFB infraction occurred in high school game in Minnesota, which resulted in a spinal cord injury. Following that incident, CFB became a 5-min major penalty and 10-min misconduct for all Minnesota high school teams. The significant loss of a player from the game after a major penalty is powerful because the penalty does not end with a power play goal. Holding Coaches Accountable At a recent youth hockey association meeting, a well-respected player, coach, and father emphasized that coaches should be held responsible if their team’s players are taking dangerous major penalties. Teams repeatedly losing Fair Play points should be identified because players may not be learning sportsmanship and might put their opponents at risk of serious injury, as a result of coaching demands. What negative consequences are assigned to a coach who emphasizes mean, aggressive play? The Fair Play point in Minnesota can be forfeited by a player, coach, or parent if their actions are not compatible with a culture of sportsmanship. Furthermore players coached in accordance with Fair Play will not become passive, unsuccessful opponents. A successful, seasoned Bantam hockey coach helped his team win all of their Fair Play points during the season. Their tough, disciplined, but fair play brought them to the Minnesota State Bantam Tournament championship game that they lost in overtime. Taking Checking out of Pee-Wee Level Hockey When USA Hockey rallied to promote skill development and reduce injury risk by removing body checking in games from Pee-Wee hockey, there were many naysayers. The pushback was surprising, because the Pee-Wee injury rate, including concussion, was unacceptably high and primarily related to illegal and legal body checking. Informal polls show that those who opposed the change to postpone checking in games until the Bantam age level are thrilled to see Pee-Wee players skating fast and developing their skills at “over-speed” without the threat of being checked into the boards whenever they touch the puck. Conclusions It is important to continue hockey injury research that enhances diagnosis, identifies mechanisms, calculates incidence, quantifies tissue damage, and provides evidence-based treatment options; the bottom line is that head trauma must stop (16). The behavioral modification principles of rewarding good sportsmanship with a point that is calculated into the team’s season standings, along with primary interventions like delaying the introduction of body checking, have a strong likelihood of decreasing head and neck neurotrauma (14). In concert with appropriate evidence-based rule modifications, Fair Play will help modify and ensure that rink culture is conducive to player safety. In 2014, aided by a grant from the USA Hockey Foundation, prevalence of concussion and related injuries, individual exposure time, and participant satisfaction (players, parents, coaches, and officials) in Bantam A and B hockey tournaments run by Fair Play will be compared to a similar tournament run under traditional rules. It is encouraging that in 2013, 150 of 600 (25%) of Minnesota Invitational Tournaments will voluntarily be run under the Fair Play tournament guidelines. If we are making a difference, it is because behavioral modification produces desirable behavior, by improving compliance to the rules in hockey and other sports. Behavioral modification has tremendous potential to reinforce positive behavior and extinguish undesirable behavior from all levels of hockey. Applying the Fair Play principles to other contact sports will promote safety and make sports a more enjoyable experience for participants. Acknowledgment This study was funded by USA Hockey, Minnesota Hockey, and the Mayo Clinic Johannson-Gund Endowment Fund.

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