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Implementation and Enforcement Key In Taking Effective Action on Concussion in Ice Hockey

Dec 17, 2019 | By Rebecca Babcock

Six main items were identified at the third Ice Hockey Summit in 2017 as prudent actions to take to continue handling the concussion in ice hockey problem.

A summary of the proceedings, published in early 2019, outline that:

establishing a national and international hockey database for sport-related concussion (SRC) at all levels;
eliminating body-checking in Bantam youth hockey games;
expanding a behaviour modification program (Fair Play) to all youth hockey levels;
enforcing game ejection penalties for fighting in Junior A and professional hockey leagues;
establishing objective tests to diagnose concussion at point-of-case; and
mandating baseline testing to improve concussion diagnosis for all age groups are important steps to not only identify and manage concussion, but also to reduce incidences of SRC in ice hockey.

This summit brought together a wide variety of professionals including physicians, researchers, athletic trainers, sports scientists, and engineers for 5 key objectives. These goals are listed below and the findings briefly discussed.

Objective 1: Describing Epidemiology and Psychosocial Influences on Concussion

This section outlined general patterns observed regarding concussion in ice hockey under two categories: 1) intrinsic and extrinsic risk factors; and 2) psychosocial, psychologic, and psychiatric factors. The main conclusion for both groups is that these areas require more rigorous research within the framework of hockey, particularly given these factors’ impact on concussion incidence and recovery.

Objective 2: Head Impact Causing Concussion: A Foundation For Prevention

Current concussion prevention tactics alongside methods to gain more knowledge to further inform concussion prevention strategies were the topics of this objective. Current evidence-based concussion prevention tactics identified at the Summit include the following:

neck strengthening and anticipation tactics alongside penalising infractions such as checking from behind and other blind-side hits (1-8).
removing body-checking as the concussion risk increases 3-4x with body checking;
behavioural modification (i.e. Fair Play) which can decrease injury rates including concussion (9);
eliminating fighting due to the immediate and long-term consequences (10-14).
implementing financial incentives in the NHL to discourage dangerous activities (between 2009-2012, there were salary losses of $42.8 million annually due to concussions)

Yet, gaining knowledge about concussion-inducing hits in hockey specifically is important as the evidence can help further inform SRC prevention strategies (rule changes, injury protection strategies, and helmet design) as well as trigger medical evaluation, coaching, and education. Two main methods were identified as vital ways to gain this evidence. The first is the use of head impact sensors which measure impact frequency, magnitude, and location/direction of hits and can identify an individual and team’s ‘risky’ techniques (as it relates to concussion) (15). Second, video reconstruction of SRC impacts can illustrate the effect and duration of a head impact on brain tissue. This is “critical” to evaluate sustained head trauma, manage concussion signs and symptoms, as well as inform SRC prevention strategies because it is understood at what frequency and in what contexts these impacts occur (15-20).

Objective 3: Diagnosing Concussion: What Tests Are Reliable and Evolving?

The discussion surrounding this objective fell into two categories: 1) what tests are currently used to assess concussion; and 2) what tests are evolving and hopefully will be useful in the near future?

The paper iterates that diagnosing potentially concussed hockey players rink-side should be completed by a trained professional able to assess suspected concussion and who is knowledgeable in hockey. Of course, this may prove challenging at various levels of hockey. It also supports the completion of baseline testing in order to provide comparisons (although this is not the consensus across concussion management literature). Diagnosis in a medical setting remains an examination based on the player’s medical and concussion history alongside symptoms. The assessment includes: cognitive testing via a tool like the Sport Concussion Assessment Tool 5 (SCAT5), computerized neuropsychological (NP) tests, the Standardized Assessment of Concussion (SAC), as well as testing of dynamic balance, vestibular function, oculomotor function, and vestibulo-ocular reflex. Return-to-play assessments should include neuromuscular responsiveness under sport-like conditions due to the increased risk of lower-extremity injury as a result of ongoing gait and balance issues (21-23).

Research is still needed to further validate objective diagnoses and management of concussion. Such methods include: utilising neurobiomarkers, metabolic profiling, quantified electroencephalography (QEEG), and advanced imaging techniques such as diffusion imaging, diffusion tractography, functional MRI, and MRI spectroscopy amongst others; many of these methods are showing promise (16, 24-34).

Objective 4: Taking Science and Treatment Forward: From Bench to Clinic and Rink side

This section of the paper summarized areas in which science and research can help improve diagnosis and treatment.

In-vitro experimental models can look at damage done on cells from various forces, thereby helping learn more about concussion pathways, potential treatment, and long-term effects (35-39).
Animal behavioural models can provide insight into how head impacts produce brain deformations and can test relationships relating head impact to head rotation, direction, magnitude, age, sex, and previous history of SRC.
Pharmacologic interventions may be used to minimise or prevent the biochemical and molecular cascades that occur after head impact or alternatively address the symptoms of SRC; more research however, is required (40-45).
Supplements such as fish oil, creatine, vitamin C, vitamin D, and vitamin E (amongst others) are “hypothesized to provide neuroprotective/therapeutic results” but more evidence is needed (46-51).
Guided aerobic exercise has many health benefits directly relating to changes that occur after SRC. Furthermore, exercise may reduce post-concussion syndrome (PCS) incidence as well as speed-up recovery. In fact, prolonged rest may prolong recovery. These conclusions challenge the current world consensus that athletes rest until symptoms stabilise (52-56).

In saying that, preventing initial and recurrent concussion is the ultimate priority. One area specifically discussed was to eliminate fighting from hockey alongside having “rigorous rule enforcement” to sustain a zero tolerance for all head trauma.

A brief discussion of developing science into policy also occurred via this objective. 50 states have enacted youth concussion law but the issue remains that there is a lack of accountability to ensure that these policies are executed in practice alongside the issue that these policies may not vary depending on regional, socioeconomic, and racial differences (57).

Objective 5: Integrating Science and Clinical Care into Our Action Plan

The action plan developed from the Summit is summarised.

Conclusion

With 1.8% of the population playing hockey in Canada (631,295 people) and 0.17% (555.935) playing in the US, these action items are necessary to protect thousands of people from both the harm of concussion as well as its short and long-term impacts. This summit for concussion in ice hockey, the discussions that occurred, and the development of action plans are important steps to move towards a safer sport environment that takes concussion seriously. Once again though, following through on action items through implementation and ensuring that they are enforced is key to ensure that these goals become a reality.

For more information on the Summit’s proceedings and conclusions, the journal article can be found here: https://journals.lww.com/acsm-csmr/fulltext/2019/01000/Proceedings_from_the_Ice_Hockey_Summit_III__Action.8.aspx

Works Cited

Black AM, Hagel BE, Palacios-Derflingher L, Schneider KJ, Emery CA. The risk of injury associated with body checking among Pee Wee ice hockey players: an evaluation of Hockey Canada’s national body checking policy change. Br J Sports Med. 2017; 51(24):1767-1772.
Schmidt JD, Pierce AF, Guskiewicz KM, Register-Mihalik JK, Pamukoff DN, Mihalik JP. Safe-Play Knowledge, Aggression, and Head-Impact Biomechanics in Adolescent Ice Hockey Players. J Athl Train. 2016; 51(5):366- 372.
Eckner JT, Oh YK, Joshi MS, Richardson JK, Ashton-Miller JA. Effect of neck muscle strength and anticipatory cervical muscle activation on the kinematic response of the head to impulsive loads. The American Journal of Sports Medicine. 2014; 42(3):566-576.
Mansell J, Tierney RT, Sitler MR, Swanik KA, Stearne D. Resistance training and head-neck segment dynamic stabilization in male and female collegiate soccer players. Journal of Athletic Training. 2005; 40(4):310.
Black A, Palacios-Derflingher L, Schneider KJ, Hagel BE, Emery CA. The effect of a national body checking policy change on concussion risk in youth ice hockey players. Br J Sports Med. 2017; 51(11):A70-A71.
Emery CA, Kang J, Schneider KJ, Meeuwisse WH. Risk of injury and concussion associated with team performance and penalty minutes in competitive youth ice hockey. Br J Sports Med. 2011; 45(16):1289-1293.
Benson BW, Meeuwisse WH, Rizos J, Kang J, Burke CJ. A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program. Can Med Assoc J. 2011; 183(8):905-911.
Emery C, Kang J, Shrier I, et al. Risk of injury associated with bodychecking experience among youth hockey players. Can Med Assoc J. 2011; 183(11):1249-1256.
Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA. 2010; 303(22):2265-2272.
Donaldson L, Li B, Cusimano MD. Economic burden of time lost due to injury in NHL hockey players. Inj Prev. 2014; 20(5):347-349.
Hiploylee C, Wennberg R, Tator CH. The financial toll of career-ending concussions in professional hockey. Concussion. 2016; 1(4):CNC20.
Barkhoudarian G, Hovda DA, Giza CC. The Molecular Pathophysiology of Concussive Brain Injury – an Update. Phys Med Rehabil Clin N Am. 2016; 27(2):373- 393.
Black A, Palacios-Derflingher L, Schneider KJ, Hagel BE, Emery CA. The effect of a national body checking policy change on concussion risk in youth ice hockey players. Br J Sports Med. 2017; 51(11):A70-A71.
Giza CC, Hovda DA. The new neurometabolic cascade of concussion. Neurosurgery. 2014; 75(S4):S24-33.
Beckwith JG, Greenwald RM, Chu JJ, et al. Timing of concussion diagnosis is related to head impact exposure prior to injury. Med Sci Sports Exerc. 2013; 45(4):747.
Smith AM, Stuart MJ, Roberts WO, et al. Concussion in ice hockey: current gaps and future directions in an objective diagnosis. Clin J Sport Med. 2017; 27(5):503- 509.
Oeur RA, Gilchrist MD, Hoshizaki TB. Interaction of impact parameters for simulated falls in sport using three different sized Hybrid III headforms. Int J Crashworthiness. 2018:1-10.
Post A, Oeur A, Hoshizaki B, Gilchrist MD. Examination of the relationship between peak linear and angular accelerations to brain deformation metrics in hockey helmet impacts. Comput Methods Biomech Biomed Eng. 2013; 16(5):511-519.
Sano K, Nakamura N, Hirakawa K. Correlative studies of dynamics and pathology in whip-lash and head injuries. Scand J Rehabil Med. 1972; 4(2):47-54.
Hoshizaki B, Post A, Kendall M, Karton C, Brien S. The relationship between head impact characteristics and brain trauma. J Neurol Neurophysiol. 2013; 5(1):1-8.
Howell DR, Osternig LR, Chou L-S. Single-task and dual-task tandem gait test performance after concussion. J Sci Med Sport. 2017; 20(7):622-626.
Howell DR, Lynall RC, Buckley TA, Herman DC. Neuromuscular control deficits and the risk of subsequent injury after a concussion: a scoping review. Sports Med. 2018:1-19.
Howell DR, Stillman A, Buckley TA, Berkstresser B, Wang F, Meehan 3rd WP. The utility of instrumented dual-task gait and tablet-based neurocognitive measurements after concussion. J Sci Med Sport. 2018; 21(4):358-362.
Ghosh Hajra S, Liu CC, Song X, et al. Developing brain vital signs: initial framework for monitoring brain function changes over time. Front Neurosci. 2016; 10:211.
Ghosh Hajra S, al. e. Multimodal characterization of the semantic N400 response with a rapid evaluation brain vital sign framework. J Transl Med. 2018; 16:151.
Daley M, Dekaban G, Bartha R, et al. Metabolomics profiling of concussion in adolescent male hockey players: a novel diagnostic method. Metabolomics. 2016; 12(12):185.
Zhou Y, Kierans A, Kenul D, et al. Mild traumatic brain injury: longitudinal regional brain volume changes. Radiology. 2013; 267(3):880-890.
Lipton ML, Kim N, Zimmerman ME, et al. Soccer heading is associated with white matter microstructural and cognitive abnormalities. Radiology. 2013; 268(3):850- 857.
Huang M-X, Theilmann RJ, Robb A, et al. Integrated imaging approach with MEG and DTI to detect mild traumatic brain injury in military and civilian patients. J Neurotrauma. 2009; 26(8):1213-1226.
Slobounov SM, Zhang K, Pennell D, Ray W, Johnson B, Sebastianelli W. Functional abnormalities in normally appearing athlets following mild traumatic brain injury: a functional MRI study. Exp Brain Res. 2010; 202(2):341-354
Mihalik JP, Guskiewicz KM, Marshall SW, Blackburn JT, Cantu RC, Greenwald RM. Head impact biomechanics in youth hockey: comparisons across playing position, event types, and impact locations. Ann Biomed Eng. 2012; 40(1):141-149.
McCrea M, Meier T, Huber D, et al. Role of advanced neuroimaging, fluid biomarkers and genetic testing in the assessment of sport-related concussion: a systematic review. Br J Sports Med. 2017:bjsports-2016-097447.
Zetterberg H, Smith DH, Blennow K. Biomarkers of mild traumatic brain injury in cerebrospinal fluid and blood. Nature Reviews Neurology. 2013; 9(4):201.
Manning KY, Schranz A, Bartha R, et al. Multiparametric MRI changes persist beyond recovery in concussed adolescent hockey players. Neurology. 2017; 89(21):2157-2166.
Alford PW, Dabiri BE, Goss JA, Hemphill MA, Brigham MD, Parker KK. Blast-induced phenotypic switching in cerebral vasospasm. Proceedings of the National Academy of Sciences. 2011; 108(31):12705-12710.
Hemphill MA, Dabiri BE, Gabriele S, et al. A possible role for integrin signaling in diffuse axonal injury. PLoS One. 2011; 6(7):e22899.
Kilinc D, Gallo G, Barbee KA. Mechanically-induced membrane poration causes axonal beading and localized cytoskeletal damage. Exp Neurol. 2008; 212(2):422- 430.
LaPlaca MC, Cullen DK, McLoughlin JJ, Cargill RS. High rate shear startin of three-dimensional neural cell cultures: a new in vitro traumatic brain injury model. J Biomech. 2005; 38(5):1093-1105.
Montenigro PH, Alosco ML, Martin BM, et al. Cumulative head impact exposure predicts later-life depression, apathy, executive dysfunction, and cognitive impairment in former high school and college football players. J Neurotrauma. 2017; 34(2):328-340.
Hoffer BJ, Pick CG, Hoffer ME, Becker RE, Chiang YH, Greig NH. Repositioning drugs for traumatic brain injury – N-acetyl cysteine and Phenserine. J Biomed Sci. 2017; 24(1):71.
Ferrari MD, Klever RR, Terwindt GM, Ayata C, van den Maagdenberg AM. Migraine pathophysiology: lessons from mouse models and human genetics. The Lancet Neurology. 2015; 14(1):65-80.
Hoffer ME, Balaban C, Slade MD, Tsao JW, Hoffer B. Amelioration of acute squelae of blast induced mild traumatic brain injury by N-acetyl cysteine: a double-blind, placebo controlled study. PLoS One. 2013; 8(1):e54163. 97.
Baratz-Goldstein R, Deselms H, Heim LR, et al. Thioredoxin-mimetic-peptides protect cognitive function after mild traumatic brain injury (mTBI). PLoS One. 2016; 11(6):e0157064.
Ji X, Peng D, Zhang Y, et al. Astaxanthin improves cognitive performance in mice following mild traumatic brain injury. Brain Res. 2017; 1659:88-95.
Mills JD, Bailes JE, Sedney CL, Hutchins H, Sears B. Omega-3 fatty acid supplementation and reduction of traumatic axonal injury in a rodent head injury model. J Neurosurg. 2011; 114(1):77-84.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus staement on concussion in sport- the 3rd International Conference on concussion in sport, held in Zurich, November 2008. J Clin Neurosci. 2009; 16(6):755-763.
Giza CC, Hovda DA. The neurometabolic cascade of concussion. Journal of Athletic Training. 2001; 36(3):228-235.
Bailes JE, Patel V. The potential for DHA to mitigate mild traumatic brain injury. Mil Med. 2014; 179(suppl 11):112-116.
Sakellaris G, Nasis G, Kotsiou M, Tamiolaki M, Charissis G, Evangeliou A. Prevention of traumatic headiache, dizinness, and fatigue with creatine administration. A pilot study. Acta Paediatr. 2008; 97(1):31-34.
Tang H, Hua F, Wang J, et al. Progesterone and vitamin D combination therapy modulates inflammatory response after traumatic brain injury. Brain Inj. 2015; 29(10):1165-1174.
LeBlanc ES, Perrin N, Johnson JD, Ballatore A, Hillier T. Over-the-counter and compounded vitamin D: is potency what we expect? JAMA Internal Medicine. 2013; 173(7):585-586.
Polak P, Leddy JJ, Dwyer MG, Willer B, Zivadinov R. Diffusion tensor imaging alterations in patients with postconcussion syndrome undergoing exercise treatment: a pilot longitudinal study. The Journal of Head Trauma Rehabilitation. 2015; 30(2):E32-E42.
Clausen M, Pendergast DR, Willer B, Leddy J. Cerebral blood flow during treadmill exercise is a marker of physiological postconcussion syndrome in female athletes. The Journal of head trauma rehabilitation. 2016; 31(3):215-224.
Leddy JJ, Willer B. Use of graded exercise testing in concussion and return-to-activity management. Curr Sports Med Rep. 2013; 12(6):370-376.
Schneider KJ, Leddy JJ, Guskiewicz KM, et al. Rest and treatment/rehabilitation following sport-related concussion: a systematic review. Br J Sports Med. 2017.
Leddy JJ, Hinds AL, Miecznikowski JC, et al. Safety and prognostic utility of provocative exercise testing in acutely concussed adolescents: a randomized trial. Clin J Sport Med. 2018; 28(1):13-20.
Shen FX. Are Youth Sports Concussion Statutes Working. Duq L Rev. 2018; 56:7.

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Rebecca Babcock

Rebecca Babcock graduated from the University of Otago in New Zealand with a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time assisting with marketing and communications development for Pure Motion, including helping to develop their concussion program. She also spends her time working at the Dahdaleh Institute for Global Health Research at York University as a research assistant where she is assisting with two projects: 1) The Ethics of Natural Language Processing in Humanitarian Needs Assessments; and 2) A Risk-Benefit Analysis of Digital Contact Tracing in the COVID-19 Pandemic.

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