Concussion in Canadian Youth Ice Hockey: What Is Needed to Decrease the Burden?

Since many professional ice hockey players suffered career changing concussions, including Eric Lindros of the Philadelphia Flyers in 1998 and Sidney Crosby of the Pittsburgh penguins in 2011, the issue of concussion has been brought to the forefront in Canadian youth ice hockey. Recognized as Canada's national winter sport, ice hockey is played across the country with more than half-a-million youth and young adults registered annually.1 Unfortunately ice hockey has 1 of the highest sport-related injury burdens leaving numerous youth players suffering from injuries including concussion with the possibility of long-term consequences.2 In 2011, in an attempt to mitigate the high ‘concussion burden’ across youth leagues, Hockey Canada implemented the national “zero tolerance for head contact” policy.3 This policy mandated, at every level of the sport, the penalization of any player-to-player head contact.3 This change notwithstanding, the concussion burden remains high. In particular, the rate remained unchanged in youth leagues that permitted body checking with reported rates of 3.3 to 4.2 concussions/1000 game-hours.2,4,5 How can we mitigate this burden? In ice hockey, several mechanisms of injury can lead to concussion.3,6 Direct impact to the head by another player is 1 of the primary concussive mechanisms.3,6 Krolikowski and colleagues3 first evaluated the “zero tolerance for head contact” policy by comparing the change in concussion rates across the U13 (11–12-year-old, formerly Pee Wee) and U15 (13–14-year-old, formerly Bantam) playing levels. This retrospective cohort study found an increase in the rate of concussion across both levels after the “zero tolerance for head contact” policy implementation, with the primary mechanism of concussion being body checking and direct head contact. The authors cited increased concussion awareness and education after the policy change as factors that may have led to the higher concussion rates reported after this “zero tolerance” policy change. Using a prospective video-analysis cohort study, we revealed that the incidence rates of direct player-to-player head contacts did not differ pre-to-post “zero tolerance” policy implementation, validating the view that the policy did not lead to lower concussion rates.7 Furthermore, almost 10 years postpolicy implementation, we added an additional cohort to evaluate whether additional implementation time and policy amendments (increasing the severity of penalties assessed for direct head contact) had altered the rates of head contact.8 Although we found a 25% to 30% lower direct head contact rate in U15 elite games (with body checking permitted), more than 10 direct head contacts still occurred every game, leaving numerous players at risk for concussion.8 What was also revealed was that only 16% of head contacts resulted in a penalty in gameplay.8 Ironically, 84% of direct player-to-player head contacts did not result in a penalty, despite the “zero tolerance” policy.8 The research surrounding the “zero tolerance for head contact” policy has revealed that although a policy has been implemented, additional emphasis and effort need to be expended to help mitigate the concussion burden across youth ice hockey. One of the potential mitigators of injury and concussion specifically that is frequently overlooked, is the role of sport officials or referees. Referees not only have a responsibility to ensure a fair and rule-abiding match, but also to enforce policies and rules to maximize player safety. The job of the ice-hockey referee is, admittedly, incredibly difficult. Decisions must be made on a split-second basis in a dynamic environment with the ever-present risk of criticism from players, coaches, and the audience.9 Referees in the youth divisions vary widely in their age and experience.9 Using a cross-sectional study design and 100 participating Canadian youth ice-hockey referees, we identified that most such referees have the policy knowledge [approximately 85% compared with a team of top-level referees (gold standard)] to effectively enforce the “zero tolerance for head contact” policy.9 Yet, there seems to be a barrier when it comes to the on-ice enforcement, potentially because of the numerous stressors referees face (eg, skating and avoiding the players/puck, game management, external pressure from the coaches, players, and audience). In addition, research has shown that over 90% of ice-hockey referees perceive themselves as recipients of verbal abuse, with more than 50% suffering physical abuse during their time officiating the sport.10 How are referees supposed to effectively do their job to protect our youth when they are at risk of psychological and physical stressors in the game environment? If referees were to shift and highlight the importance of injury prevention, for example, to penalize most occurrences of player-to-player head contacts (instead of the 16% reported in gameplay research), which would teach the players to avoid these maneuvers, then all parties involved within the sport may begin to significantly change their behaviors with a resulting evolution of ice-hockey culture. The “zero tolerance for head contact” policy laid the foundations for an optimal primary-prevention strategy to help mitigate the concussion burden. However, more needs to be done to enhance the effectiveness of this policy. There needs to be additional support from all parties involved, including the national and provincial organizations to emphasize the importance of protecting athletes from concussion and providing additional resources to coaches, players, and parents. In addition, coaches need to be teaching their players effective strategies to not only protect themselves, but also to avoid direct contact with the head of opponents. Players need to recognize the dangers of head impacts and alter their behaviors. Finally, referees need to continually and consistently enforce this policy in accordance with the rulebook, ultimately reflecting a commitment to player safety. Such efforts, when coordinated, can be effective in enhancing the safety of countless players across the country and creating a safer sport for all. We must consider evidence-informed education and policy that will have an even greater impact in reducing concussion rates and their consequences in youth ice hockey to keep youth playing the sport they love and to improve the quality of life in our young population. Although some players go on to excel at high levels of the professional game, most youth players are there to make friends, build comradery, gain physical activity, improve skills, compete, and ultimately have fun. All in the sport have a duty to work together to inform, train, teach, and enforce behaviors that will make our nation's national winter sport safer. Sport medicine physicians and other health care practitioners can be powerful advocates for such change.

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