Concussion in youth ice hockey: It’s time to break the cycle

Concussion in youth ice hockey

The NHL’s problem with concussions is just the tip of the iceberg; concussion is all too common in youth ice hockey, with evidence that, despite educational efforts, the number of concussions continues to be substantially under-reported.4^,9^,10 A study published in late 2010 found an alarming rate of concussions in junior hockey.9 In the prospective study, which involved two teams of hockey players aged 16–21 years, 17 of 67 players sustained a concussion during a single season, with five of those players also suffering a second concussion. That is, 25.3% of players sustained at least one concussion in a single season, a rate of concussion seven times higher than the highest rate previously reported in the literature.9

An estimated half-million youths play organized minor ice hockey in Canada.11 The pediatric population is known to be more vulnerable to concussion and to experience more serious short-and long-term symptoms of concussion than adults.12^–15 Youth athletes with concussion may experience fatigue, inattention, lack of concentration, memory loss and headaches, which can have devastating effects on both athletic and academic performance.12^–16 Subtle cognitive deficits may persist for up to a year in some youths.16 Youth athletes who sustain minor brain trauma are also at risk for so-called second-impact syndrome, a rare but catastrophic neurologic condition that is almost always fatal.17 A history of concussion results in substantially increased susceptibility to additional concussions and more severe symptoms of concussion.18

Repeat concussions are also a risk factor for chronic traumatic encephalopathy (CTE), which is associated with a spectrum of sequelae including memory loss, behavioural and personality changes, depression, early dementia and motor neuron disease.19 In one-half of the confirmed instances of CTE in athletes, symptoms developed within four years of the athletes stopping play.19 Subconcussion impacts of the kind common in contact and collision sports, such as hockey and tackle football, are also implicated in CTE. The deposition of tau proteins indicative of CTE have been found on autopsy in the brains of American football players with no history of concussion, as well as athletes as young as 18 years old.20 Concussion causes detectable but subtle symptoms and can be diagnosed by properly trained and vigilant physicians, trainers and coaches, but subconcussion impacts cause silent, invisible, lifelong damage to the brains of youth athletes.

The role of bodychecking

Bodychecking is a major cause of serious injury, including concussion, in hockey players.4^,21^,22 The American Academy of Pediatrics recommends that bodychecking be prohibited for children younger than 15 years.23 Among the reasons cited by the academy is that there can be pronounced variations in body size, physical maturity and strength among players in younger age groups, resulting in heightened risk to smaller players who are matched against much larger players in the same age bracket.23

The more conservative recommendation of the Canadian Academy of Sports and Exercise Medicine calls for bodychecking to be eliminated from all levels of minor hockey “which are not designed as training for professional and international ranks,” and only beginning in elite Rep or All Star leagues in the 16- to 17-year (Midget level) age group.24 Hockey Canada, the governing body of minor hockey, allows body-checking at the Peewee level (ages 12–13) and above for male players; the Saskatchewan, Ontario and Ottawa hockey leagues permit bodychecking at the Atom level (ages 9–10) on an experimental basis. Quebec permits body-checking at the Bantam level (ages 14–15).25 Quebec is the only province in Canada that has seen growth, rather than decline, in the number of children playing minor hockey, a trend that has been attributed in part to the late introduction of bodychecking.26

Hockey Canada’s position is that checking skills are critical to the game of hockey and that “players must learn and master all aspects of the checking game to become effective and complete players.”25 A 2004 study sponsored by the Canadian Hockey Association (now Hockey Canada) concluded that bodychecking “can be taught at the younger age levels in a manner that does not lead to a higher incidence of injuries.”27 Several studies have confirmed, however, that injury rates rise dramatically when bodychecking is introduced,5^–7^,21^,28 that players typically sustain their first concussion within a year of starting bodychecking4 and that education in “proper” bodychecking technique does not reduce rates of injury.6 The evidence strongly suggests that substantial harm may result from teaching youth players bodychecking at an earlier age.5^,6^,28

USA Hockey, the governing body for minor hockey in the United States, permits bodychecking at the Peewee level (ages 11–12), but is currently considering a rule change to raise the age to the Bantam level (ages 13–14), based on a recommendation by the USA Hockey Player Development Sub-committee on Body Checking.29 The proposed change is motivated by two factors. First, skill development is hindered when bodychecking is introduced, because players focus on hitting and avoiding being hit rather than on skating, puck- and stick-handling, receiving, shooting and other hockey skills.29 The subcommittee argues that players will benefit from two more years of skill development, unhindered by bodychecking.29 This is in contrast to Hockey Canada’s assertion that training in bodychecking benefits player development.25 Second, the US subcommittee cited concerns about player safety, noting a threefold increase in game-related injuries, “including concussion, severe injury and severe concussion,” among players aged 11–12 years following the introduction of bodychecking.8^,29

The increased incidence of serious injuries related to bodychecking has also been observed in other countries where bodychecking is not permitted for younger players.7^,28 In Finland, Mölsä and coauthors observed a disproportionate increase in injuries related to bodychecking, compared with other mechanisms of injury, in the age group for which bodychecking is first introduced.7 Additionally, bodychecking was found to be the dominant mechanism of injury in older groups.7