Stop the violence and play hockey

Dear Editor,

Thank you for this stand against in violence in Hocky game (1). The manner of violence and fight that happens in the game is brutal. The way games are handled and players are encouraged, it seems we are watching one of those movies or reading stories from history book of civilization (e.g. gladiator). What is the use of Hocky governing body and match officials out there? They just stand there and let them fight!!! Fans do seem enjoying indeed (most of them, if not all). I understand there are some players who have that arrogant attitude. Okay, there is problem.

Therefore, where does the issue lie? We know some degree of fight does occur in similar sorts of sports e.g in Soccer. But players are penalized, fans are tracked and even Country can be banned by World Football governing body (Soccer body)(2). Why not in Hockey? What is the stumbling block?

I think it is kind of society, business and some type of those violent players. Why do fans from society go and enjoy it? What is the Hockey governing body looking for? What are the match officials for? And what about these clubs that earn huge amount of money? Finally, if all stops, there should be government who should come to intervene this. I think this kind of unmitigated violence in Hockey (in its name) is unjust and needs to be banned as soon as possible.

The research and donating brain to the research institutes is just nothing but news. To me it seems like hoax. We let the violence go and do research by slicing postmortem brains (or when they have consequences)! I thought 'prevention is better' is pretty old saying. It seems we are happy to hide dust under the carpet.

References:

1. Editorial. Stop the violence and play hockey. CMAJ February 21, 2012 vol. 184

2. FIFA. International Federation of Association Football . http://www.fifa.com/worldcup/index.html

Conflict of Interest:

None declared

I read the Editorial "Stop the violence and play hockey" with interest. Concussions and headshots have become a front-page issue not only in the NHL, but also throughout minor hockey since Sidney Crosby's unfortunate injury January 2011 and his subsequent re-injury. The NHL's marquis player sitting on the sidelines and professing that he "may be able to play at 90%, but he won't comeback until he's 100%"1 has done a lot to encourage other hockey players, both pro and amateur, to follow his lead. It seems less and less a stigma to report your concussion as a player and to deal with it properly. Prevention of concussion is a major factor in the solution to the problem. Any possible solution or reduction in concussive injury in hockey will only be the result of a number of changes, recommendations and actions coming together to effect change; such as rule changes (Rule 48), equipment changes (smaller elbow pads and shoulder pads) and possibly changes to the rink (larger international rinks have a lower incidence of concussion). Behavioral changes may be required as well, and this is the area of change touched upon by this Editorial.

It seems logical to assume that fighting must be a significant cause of head trauma in the NHL. And if this is the case, then it also must be a factor contributing to the findings of CTE in the brains of former NHL'ers like Reggie Fleming, Rick Martin, Bob Probert and Derek Boogaard. I do not think that this Editorial viewpoint is supported by recent evidence as published in the Annals of Emergency Medicine by Pasternac, Weiner, and Milzman of Georgetown University (Annals of Emergency Medicine Volume 48, 4S: October 2011, pg S330). Their article entitled "Results of 1,300 Consecutive NHL Fights: Fists of Fury With Minimal Injuries" 2 reported the following:

"1,239 preseason and regular season games from the 2010-2011 campaign (were studied and) resulted in a total of 710 fights. There were 17 injuries resulting from fights during the 2010-2011 regular and preseason NHL campaign, resulting in an injury rate of 1.12% per combatant/per fight. Concussion rate per fight was 0.39%. The overall concussion rate from fighting is nearly non-existent compared to regular headshots from checking on ice. The brutality of fighting is clearly over-rated in terms of short and long term injuries."

CTE is more likely the result of accumulated sub-concussive and concussive blows suffered by players over the course of their career. Blows received in fights may add to the combined effects of multiple sub- concussive blows to the body or the head of a player. However, the study cited above, the only study to date which has looked at the incidence and type of injuries resulting from fighting in the NHL, has clearly shown that fighting is an over-stated cause of injury to the head of NHL players, and by deduction, also a minor factor in the subsequent development of CTE. The forces created by a hockey body check have been reported as between 20-180 G's, whereas the forces reported to cause a concussion have been reported in the range of 80 - 100 G's (a G is the force of acceleration due to gravity) 3. Not all body checks of course cause a concussion. However it is clear from these comparative forces that many body checks reach sub-concussive thresholds. I think it is more logical and rational to assume that this is a major factor in the accumulated head trauma contributing to CTE.

In writing this response to the Editor, I am neither advocating nor decrying fighting in hockey; it is my intent and belief that there are other more significant factors that contribute to the development of CTE in hockey players, and it seems logical to assume that these factors also play into the concussion epidemic that hockey is facing. Fighting in hockey is not a major factor in either concussion or CTE as reported by Pasternac et al in the "Annals of Emergency Medicine", so those who continue to advocate for the removal of fighting from hockey need to put forward a different argument to support this change. Guskiewicz and Mihalik have published an article on the Biomechanics of Sports Concussion and commented on hockey injuries as follows:

"Elbowing, head contact, and high sticking infractions resulted in greater linear acceleration than collisions with no infraction. A strong trend for higher rotational accelerations in this infraction type compared with legal collisions also was present. We concluded that athletes and coaches should conform to playing rules, and officials should more stringently enforce existing rules and assess more severe penalties to participants who purposefully attempt to foul an opponent at the youth ice hockey level."4

Maybe the solution to all this is just to play within the rules!

REFERENCES:

1. Crosby says he'll make full recovery http://www.sportsnet.ca/hockey/2011/09/07/penguins_crosby_conference/

2. Results of 1,300 Consecutive NHL Fights: Fists of Fury With Minimal Injuries K. Pasternac, D. Weiner, D.P. Milzman Annals of Emergency Medicine - October 2011 (Vol. 58, Issue 4, Supplement, Page S330, DOI: 10.1016/j.annemergmed.2011.06.482)

3. "Most Concussions Deliver 95 G's, Neuropsychologist Says" TEDxDU - Kim Gorgens - 05/13/10 http://tedxdu.com/2010/05/kim-gorgens-mind-your-matter-what-you-need-to- know-about-concussions/ Or sportsmedicine.about.com/b/.../concussions-pack-a-major-punch.htm

4. Biomechanics of Sport Concussion: Quest for the Elusive Injury Threshold: Concussion Injury Threshold Kevin M. Guskiewicz and Jason P. Mihalik http://www.medscape.com/viewarticle/735057_4

Conflict of Interest:

Owner/Operator Sports Concussion Management

Thank you again for a timely and well written editorial in volume 184 [3] of the CMAJ. Violent play in hockey has been going on for years. Keep up the good work and your great editorials. I have been speaking out against violence and fair play in hockey since I was a ' hockey Doc' for 13 years for the Kamloops Blazers junior hockey team. I also looked after players in the Midget hockey tournaments in Kamloops, BC, for years as well. The only NHL player that has written about fighting and 'head shots' is former all-star goal-keeper for Montreal and Federal Minister in Parliament, Ken Dryden. His articles and essays have been outstanding. Perhaps the CMAJ could get him to write a piece and get his take on the problems and the solutions? Perhaps the NHL governors, owners and the commissioner will listen to him they certainly haven't listened to the doctors and the players affected by this hockey violence.

Conflict of Interest:

None declared

Dear CMAJ editor,

As a family doc who despises the violence in all levels of hockey, I would LOVE to see the CMAJ set up an online petition for physicians to sign to try and minimize head and other serious injuries. Physicians have been involved with implementing car seat belt and bike helmet use. I'd welcome leadership in hockey related head / other injury prevention.

I must say that I love hockey. My husband and I have travelled to Buffalo from Toronto to see our beloved Canadiens play, but I have a hard time allowing my 5 year old daughter to watch the NHL games on TV due to the violent content. Instead, we take her to watch local minor league games which she loves.

When will enough be enough?

Thanks for your efforts thus far.

Conflict of Interest:

None declared

I'm surprised at the Canadian Medical Association Journal for publishing such an opinionated article/editorial, on head damage from fighting in hockey, without backing it up with facts. It is easy to "hop on a bandwagon" when there are problems. However, to attribute all hockey concussions (70 athletes apparently were used in your study) to fighting is irresponsible on your part. I have seen televised replays of several of the recent incidents which led to "concussion-like symptoms." In many of those cases there have been collisions between players, but no fighting involved. I can only think of one specific incident where a punch has led to a concussion recently.

I would have no problem with CMAJ saying that it is concerned about concussions, nor would I complain about suggestions to improve head- protection gear. Using a player who played without a helmet as an example to prove a point is ridiculous, given that the last helmetless NHL hockey player (Craig McTavish) quit playing over a decade ago. (Two boxers???)

Perhaps CMAJ would be well advised to deal with facts rather than emotions.

Also, perhaps CMAJ would be further advised to deal with problems which are much more prevalent and have much more affect on our society (like mental illness, addiction, malnutrition, physical diseases, etc.)

I would hope that CMAJ would consider a retraction, or a restatement of its position on head trauma in ice hockey.

Conflict of Interest:

None declared

Congratulations to Dr Kale and the CMAJ for advocating for the cessation of fighting in hockey. Those that control the sport believe violence in hockey is inherent in the game and is a positive aspect of the game. We can see from international hockey tournaments and in NHL Playoff games where there is zero to a minimal amount of fighting that the hockey is of a high quality and enjoyable to watch. Even if there wasn't a link between fighting in hockey and concussions fighting in hockey (assault) should not be allowed. I believe the NHL and Hockey Leagues across Canada should place a moratorium of 3 years against fighting and see how the players and fans enjoy the game. If NHL and Hockey Leagues in Canada can not police themselves Provincial governments should give these leagues notice that they will enforce assault laws in the hockey rinks and start to do so after the period of notice and intent expires. Keep up your advocacy and good work.

Conflict of Interest:

None declared

I was so pleased to see that you have taken a stand against this terrible problem. Just as health care professionals have long taken a stand against the senseless brain damage caused in the so-called sport of boxing, you are to be commended for calling for an end to fighting in hockey. More than 30 years ago, I attended a hockey game with my 10 year old daughter, only to be forced to leave when fighting and blood on the ice took over. Fighting and physical violence have no part in sport. The game is exciting and thrilling enough. The NHL has to take a stand on this and the time has come. We have seen enough young men suffer horrible damage and it's time the "game" returned to its real nature and got away from mindless violence. Let saner minds prevail. Thank you.

Conflict of Interest:

None declared