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

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:

  1. establishing a national and international hockey database for sport-related concussion (SRC) at all levels;
  2. eliminating body-checking in Bantam youth hockey games;
  3. expanding a behaviour modification program (Fair Play) to all youth hockey levels;
  4. enforcing game ejection penalties for fighting in Junior A and professional hockey leagues;
  5. establishing objective tests to diagnose concussion at point-of-case; and
  6. 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 in this diagram:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

About The Author

Rebecca Babcock is a recent graduate of the University of Otago in New Zealand, completing a Master’s in Bioethics and Health Law. Her thesis examined the ethical and legal issues surrounding concussion management. She currently spends her time working for the Concussion Legacy Foundation – Canada as a programming coordinator and at Sunnybrook Hospital investigating concussion prevention, management, and education services. Her dream is to be a clinical ethicist at a hospital which she is starting to fulfill by volunteering as a bioethics assistant at Humber River Hospital in Toronto.

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