Table 1:

Description of study characteristics

Intervention; studyStudy designParticipantsStudy groupsMethodsOutcome measuresDowns and Black score (out of 27)*
Rule changes
Regnier et al., 1989;19 Québec City, CanadaRetrospective cohort study279 Peewee-level amateur hockey players participating in 521 games (for penalty rates) or 82 games (for injury rates); 227 parents and 63 coaches were surveyed by telephoneIntervention group: Players during the 1984/85 season (bodychecking not allowed)
Comparison group: Players during the 1985/86 season (bodychecking allowed)
Penalty records were examined and analyzed to determine number and types of penalties; analysis of injuries was based on 82 direct observations and telephone surveys; circumstances leading to the injuries were also identifiedNumber and types of penalties; player injury rate and types of injuries15
Marcotte et al., 1993;20 Québec City, CanadaRetrospective cohort study23 Peewee and 24 Bantam amateur teams in third-tier competitive division in QuebecIntervention group: 7 Peewee and 8 Bantam teams using Fair Play rules
Comparison group: 16 Peewee and 16 Bantam teams not using Fair Play rules
Game sheets from 329 regular-season games in the Peewee category and 338 in the Bantam category were used to compile number and types of penalties for a comparative analysisNumber and type of penalties12
Roberts et al., 1996;21 Minnesota, United StatesRetrospective cohort study273 male hockey players in high school (age < 20 yr) on the rosters of 16 teams during the 1994 Junior Gold ice hockey tournamentIntervention group: Players in 24 tournament games using Fair Play rules (n = 882 player-exposures)
Comparison group: Players in 7 tournament games using regular rules (n = 217 player-exposures)
Injuries were recorded by an on-site certified athletic trainer, and penalties were tallied from score sheetsNumber of injuries and penalties11
Watson et al., 1996;22 Ontario, CanadaRetrospective cohort study653 injury records and 389 penalty records for 3 Ontario University Athletic Association teams that had complete records for 3 yr before and 3 yr after introduction of a bodychecking rule in 1989Intervention group: 211 games played by the 3 teams after the rule was introduced (minor 2-minute penalty for bodychecking into the boards or major 5-minute penalty if an injury resulted from that check)
Comparison group: 178 games played by the 3 teams before the rule was introduced
Data on injuries and penalties were collected from game reportsInjury and penalty rates15
Brunelle et al., 2005;23 Quebec, CanadaProspective cohort study52 elite Bantam teamsIntervention group: 13 games using Fair Play rules
Comparison group: 36 games not using Fair Play rules
49 games were systematically assessed; data on rule transgressions were obtained using a time- observation system based on the classification of adversary interactions in nonconformity with rules; injury data were collected using a self-administered questionnaireObservations of rule transgressions (nature, referee’s decision and level of transgressions) and hockey-related injuries14
Macpherson et al., 2006;24 Ontario and Quebec, CanadaRetrospective cohort studyBoys in minor hockey leagues at the Atom (10–11 yr), Peewee (12–13 yr) and Bantam (14–15 yr) levels in Ontario and Quebec leagues from September 1995 to August 2002Intervention group: Players aged 10– 13 yr in leagues that did not allow bodychecking; players aged 14–15 yr (bodychecking allowed) who had no previous experience with bodychecking
Comparison group: Players aged 10–13 in leagues that allowed bodychecking; players aged 14–15 yr (bodychecking allowed) who had previous experience (2–4 yr) with bodychecking
CHIRPP data were used to characterize hockey-related injuries experienced by players presenting at emergency departmentsInjury rate and types of injuries17
Hagel et al., 2006;25 Edmonton, CanadaRetrospective cohort study249 hockey players aged 11 yr before and after a policy change in 2002Intervention group: 98 players not exposed to bodychecking before the policy change (a change in age classification for minor ice hockey, whereby 11-year-old children were moved from the Atom level [no bodychecking] to the Peewee level [bodychecking allowed])
Comparison group: 151 players exposed to bodychecking after the policy change
ACCS data were used to identify records of children aged 10–12 yr who were injured playing ice hockey during the 2000/01 to 2003/04 seasonsInjury rates18
Gee et al., 2007;26 United States and CanadaRetrospective cohort study50 National Hockey League (NHL) games played before and after the Todd Bertuzzi incident on Mar. 8, 2004 (a widely publicized incident of highly aggressive and injurious behaviour for which Todd Bertuzzi received a high-profile legal charge)Intervention group: 50 games after the incident
Comparison group: 50 games before the incident
All penalty infractions were coded according to type, score differential, aggressor team’s status at the time of the infraction and whether the act occurred before or after the Todd Bertuzzi incident; the frequency of each aggressive infraction was compared before and after the incidentFrequency and type of penalty called16
Emery et al., 2009;27 Calgary, CanadaProspective cohort study283 players at the Peewee (11–12 yr), Bantam (13–14 yr) and Midget (15–16 yr) levels in the Calgary Minor Hockey AssociationIntervention group: 138 players on 24 teams in the league that did not allow bodychecking
Comparison group: 145 players on 13 teams in the league that allowed bodychecking
A series of self-administered questionnaires were completed by players to assess their bodychecking attitudes, empathy and aggression. Injury report forms were completed by the study coordinator (with consultation of a physiotherapist for accuracy)Injury rates18
Emery et al., 2010;28 Alberta and Quebec, CanadaProspective cohort study2154 hockey players at the Peewee level (11–12 yr) in the top 60% of divisions of play during the 2007/08 seasonIntervention group: 1046 players on 76 teams in Quebec (bodychecking not allowed)
Comparison group: 1108 players on 74 teams in Alberta (bodychecking allowed)
Injury report forms were completed by trained study personnelInjury and concussion rate ratios22
Kukaswadia et al., 2010;29 Kingston, CanadaRetrospective cohort studyMinor hockey players aged 7–14 yr before and after the introduction of a rule change in Ontario minor ice hockey in 2002Intervention group: Players in games during the 1997/98 to 2001/02 seasons, before the rule change (introduction of bodychecking at the Atom level [9–10 yr] instead of at the Peewee level [12–13 yr])
Comparison group: Players in games during the 2002/03 to 2006/07 seasons, after the rule change
CHIRPP data were used to identify injuries experienced by players presenting at 2 emergency departmentsInjury rates16
Cusimano et al., 2011;30 CanadaRetrospective cohort studyMale hockey league players aged 6–17 yr before and after a rule change in 1998/99Intervention group: Injuries from bodychecking before the rule change (lowering of the age when bodychecking is allowed from 11 to 9 yr)
Comparison group: Injuries from bodychecking after the rule change
CHIRPP data on 8552 hockey-related injuries from September 1994 to May 2004 were collected from 5 hospitals in Ontario; injuries were classified as being related to or not related to bodycheckingInjury rates, and the odds ratio of an emergency department visit because of a bodychecking-related injury18
Emery et al., 2011;31 CanadaProspective cohort study1971 Bantam hockey players (13–14 yr) in the top 30% of divisions of play during the 2008/09 seasonIntervention group: 995 players on 68 teams in Alberta who had 2 years of bodychecking experience
Comparison group: 976 players on 62 teams in Quebec who had no bodychecking experience
Baseline questionnaires about attitudes toward bodychecking and injury report forms were usedIncidence of all injuries and concussions17
Educational intervention
Trudel et al., 2000;32 Ottawa and Québec City, CanadaBefore–after study28 coaches of 42 Bantam (14–15 yr) hockey teams from 5 competitive leagues before and after the 1988/89 seasonIntervention group: Games played during the 1988/89 hockey season, when a two-stage self-supervision strategy was in place (stage 1: coaches watched instructional videos on the teaching of proper hockey skills and the concept of self-supervision; stage 2: coaches prepared players for the proper use of bodychecking through the use of videos and training sessions)
Comparison group: Games played during the 1987/88 season before the strategy was introduced; 1 of the 5 leagues did not add the educational intervention in the 1988/89 season and was considered the control group
Bodychecking was analyzed by 3 coders using video recordings of the games; penalties were counted and categorized using game reports; injury statistics were gathered during games via data collectionObservation of the frequency of legal bodychecks, the type and frequency of penalties, and the number of injuries during games12
Cook et al., 2003;33 Toronto, CanadaRandomized controlled trialMale hockey players on 5 competitive-level Atom (11–12 yr) teams and their coaches in the Greater Toronto Hockey League during the 2001/02 seasonIntervention group: 45 players on 3 teams who watched ThinkFirst Canada’s Smart Hockey video at midseason (a video about the mechanisms, consequences and prevention of brain and spinal cord injury in ice hockey)
Comparison group: 30 players on 2 teams who did not watch the video
Players completed a test on their knowledge of concussions at different times throughout the season; the total number of penalties received during the season was collected; coaches were given a qualitative interview by a single blinded observerTest of concussion knowledge; incidence of aggressive penalties14
Smith et al., 2009;34 Minnesota, United StatesBefore–after study55 900 players at Squirt, Peewee, Bantam and Junior Gold levels, and all girls’ hockey groups in the Minnesota Hockey League, as well as coaches and officials registered in the league; 17 678 records of game data were obtained, 4420 (25%) of which were randomly selected for analysis of the Fair Play ProgramIntervention group: Games played in 2007/08 season, after introduction of the Hockey Education Program in 2003 (program consists of 3 primary components: skill development, coaching excellence and fair play; an empirically based curriculum was created for hockey coaches to help improve players’ development of hockey skills; a Fair Play scoring component was also introduced)
Comparison group: Games played in 2004/05 season, soon after the program’s introduction
The program was implemented to all players, coaches, parents and officials. For the analysis of the Fair Play Program, data from 4 seasons were collected from game sheetsAttrition of girls (under 10, 12 and 14 yr) and boys (Squirt, Pee Wee, Bantam and Junior Gold), coaches and officials; Fair Play points; and prevalence and types of penalties collected16
Psychosocial interventions
Mattesi, 2002;35 West Virginia, United StatesBefore–after studyMale hockey players in the West Virginia University collegiate clubIntervention group: 3 players who received a 3-week aggression-management training intervention program (3 sessions of psychological skills training that included positive self-talk, deep breathing and coping imagery)
Comparison group: The same 3 players before the intervention program
Demographic questionnaire was given to players; the Bredemeier Athletic Aggression Inventory (BAAGI) was used to assess aggressionNumber of penalty minutes and BAAGI aggression scores15
Lauer et al., 2009;36 United StatesBefore–after study3 ice hockey players aged 12–14 yr described as physical, tough players who also received penalties for dirty playIntervention group: 3 players enrolled in the Playing Clean and Tough Hockey Program (a program designed to teach players how to play the game of hockey “tough” and intensely while playing it “clean” by learning emotional control skills in adverse situations)
Comparison group: The same 3 players before the intervention
Players had to commit to 9 sessions and complete all activities, logs and postgame reports. Postgame self-reported emotions and feelings stated in logs, program test results, program evaluations and descriptive statistics were used. Aggressive behaviours were video recorded and visually inspected by 2 independent codersFrequency of aggressive acts per game13
  • Note: ACCS = Ambulatory Care Classification System, CHIRPP = Canadian Hospitals Injury Reporting and Prevention Program.

  • * The score reflects how many of the 27 Downs and Black criteria18 were clearly met by the study. See Appendix 3 for details about the criteria (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.112017/-/DC1).

  • Includes qualified responses (e.g., “yes, probably” and “yes, likely”).

  • Fair Play rules: each team can earn points for good conduct based on the number of penalty minutes called by referees; the points are added to the general standings after each game.