Proceedings from the Ice Hockey Summit on Concussion: A Call to Action

Smith, Aynsley M. RN, PhD; Stuart, Michael J. MD; Greenwald, Richard M. PhD, MS; Benson, Brian W. MD, MSC, PhD, CCFP; Dodick, David W. MD; Emery, Carolyn BSCPT, MSC, PhD; Finnoff, Jonathan T. DO; Mihalik, Jason P. PhD, CAT(C), ATC; Roberts, William O. MD, MS; Sullivan, Carol‐Anne PhD; Meeuwisse, Willem H. MD, PhD

American Journal of Physical Medicine & Rehabilitation:
doi: 10.1097/PHM.0b013e318224736b
Consensus Statement: Concussion
Press Release

Objective: The objective of this proceeding was to integrate the concussion in sport literature and sport science research on safety in ice hockey to develop an action plan to reduce the risk, incidence, severity, and consequences of concussion in ice hockey.

Design: A rationale paper outlining a collaborative action plan to address concussions in hockey was posted for review 2 mos before the "Ice Hockey Summit: Action on Concussion." Focused presentations devoted specifically to concussion in ice hockey were presented during the summit, and breakout sessions were used to develop strategies to reduce concussion in the sport. The proceedings and a detailed scientific review (a matrix of solutions) were written to disseminate the evidence‐based information and resulting concussion reduction strategies. The manuscripts were reviewed by the authors, advisors, and contributors to ensure that the opinions and recommendations reflect the current level of knowledge on concussion in hockey.

Results: Six components of a potential solution were articulated in the "Rationale" paper and became the topics for breakout groups that followed the professional scientific lectures. Topics that formed the core of the action plan were metrics and databases; recognizing, managing, and return to play; hockey equipment and ice arenas; prevention and education; rules and regulations; and expedient communication of the outcomes. The attendees in the breakout sessions identified the action items for each section. The most highly ranked action items were brought to a vote in the open assembly, using an Audience Response System. The strategic planning process was conducted to assess the following: "Where are we at?" "Where must we get to?" "What strategies are necessary to make progress on the prioritized action items?"

Conclusions: Three prioritized action items for each component of the solution and the percentage of the votes received are listed in the body of this proceeding.

Author Information

From the Sports Medicine Center, Mayo Clinic, Rochester, Minnesota (AMS, MJS, JTF); SIMBEX, LCC, Lebanon, New Hampshire (RMG); Sport Medicine Centre, University of Calgary, Calgary, Alberta, Canada (BWB, CE, WHM); College of Medicine, Mayo Clinic, Scottsdale, Arizona (DWD); The University of North Carolina, Chapel Hill (JPM); University of Minnesota, St. Paul (WOR); Ontario Neurotrauma Foundation, Toronto, Ontario, Canada (C‐AS)

All correspondence and requests for reprints should be addressed to: Carol Best, Mayo Clinic, Sports Medicine Center, 200 First Street SW, Rochester, MN 55905 USA.

Disclosures: R. Greenwald owns Simbex, the company that makes the telemetry accelerometers that are used in the helmets to collect some of the data as discussed in the content of this article.

Editor's Note: This paper is being copublished in the American Journal of Physical Medicine and Rehabilitation, Clinical Journal of Sport Medicine, Current Sports Medicine Reports, PM&R, Sports Medicine Bulletin, and The Clinical Neuropsychologist. The manuscript was prepared by the authors and is printed here without modification, except for journal style.

Editor's Note: This paper is being copublished in the American Journal of Physical Medicine and Rehabilitation, Clinical Journal of Sport Medicine, Current Sports Medicine Reports, PM&R, Sports Medicine Bulletin, and The Clinical Neuropsychologist. The manuscript was prepared by the authors and is printed here without modification, except for journal style.

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Advisory Committee and Contributors

Alan B. Ashare, MD

St. Elizabeth's Medical Center, Boston, Massachusetts

Mark Aubry, MD

Ottawa Sport Medicine Centre, Ottawa, Ontario, Canada

Charles H. Tator, MA, PhD

University of Toronto, Department of Surgery, Toronto, Ontario, Canada

Ruben Echemendia, PhD

National Hockey League, Director of Neuropsychological Testing Program, New York, New York

Kerry Fraser

Blue Anchor, New Jersey

James Johnson

Scottsdale, Arizona

David Krause, PT, MBA, DSC, OCS

Mayo Clinic, Sports Medicine Center, Rochester, Minnesota

Mark Lovell, PhD

University of Pittsburgh Medical Center, Sports Medicine Concussion Program, Pittsburgh, Pennsylvania

Joan Mariconda, MA, BA

Anthony Mariconda

USA Hockey, Colorado Springs, Colorado

James Whitehead

American College of Sports Medicine, Indianapolis, Indiana

Diane M. Wiese‐Bjornstal, PhD

University of Minnesota, St. Paul, Minnesota

Thomas W. Babson, BA, MFA

Sports Legacy Institute, Boston, Massachusetts

Jeffrey J. Bazarian, MD, MPH

University of Rochester, Rochester, New York

Patrick J. Bishop, PhD

University of Waterloo, Waterloo, Ontario, Canada

Alison Brooks, MD, MPH

University of Wisconsin, Madison, Wisconsin

Randall Dick, FACSM

Health and Safety Sports Consultants, LLC, Carmel, Indiana

Paul Echlin, MD

The Hockey Neurotrauma and Concussion Initiative National Research Committee, London, Ontario, Canada

Susan L. Forbes, PhD

Lakehead University, Thunder Bay, Ontario, Canada

Kirk Gill

Rochester Youth Hockey Association, Rochester, Minnesota

Gerard A. Gioia, PhD

Childrens National Medical Center, Washington D.C.

Kevin M. Guskiewicz, PhD, ATC

The University of North Carolina, Chapel Hill, North Carolina

P. David Halstead

University of Tennessee College of Engineering, Sports Biomechanics Impact Research Laboratory, Knoxville, Tennessee

Stanley A. Herring, MD

University of Washington, Seattle, Washington

T. Blaine Hoshizaki, PhD

University of Ottawa, Ottawa, Ontario, Canada

Robert F. LaPrade, MD, PhD

The Steadman Clinic, Vail, Colorado

Nicole M. LaVoi, PhD

University of Minnesota, St. Paul, Minnesota

Alison Macpherson, PhD

York University, Toronto, Ontario, Canada

Ann C. McKee, MD

Boston University School of Medicine, Boston, Massachusetts

Daniel Moore

Haley Moore

Team Wendy, Cleveland, Ohio

William Montelpare, PhD, MSC

University of Leeds, Woodhouse, Leeds, United Kingdom

Margot Putukian, MD

Princeton University, Princeton, New Jersey

Kelly Sarmiento, MPH

Centers for Disease Control and Prevention, Atlanta, Georgia

Doug Stacey, MSc, BHScPT

Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada

Ronald Szalkowski, BSc Chem Eng

Team Wendy, Cleveland, Ohio

Ice hockey is a fast collision sport played by both sexes in all age groups and at all skill levels1 predominantly in North America, Europe, and countries of the former Soviet Union.2 Speed, hard ice, boards, sticks, pucks, player collisions, body checks, and illegal on‐ice activity3 contribute to the prevalence of concussion.4 The evidence‐based foundation for the "Ice Hockey Summit: Action on Concussion," held at the Mayo Clinic in 2010, was derived from research on concussion and focused on recognition, assessment, management, and return‐to‐play guidelines (Zurich, 2008)5–7 integrated with ice hockey‐specific research. Sport science research addressed equipment, impact forces, standards testing, at‐risk behaviors, rule enforcement, education, and behavioral modification programs.8–13 Although quality guidelines for sport‐related concussion management have been written,5–7 there are unique features that distinguish ice hockey from other contact sports. Professional hockey is a skilled exciting game, rooted in a heavily reinforced culture of aggressive play,14–22 and it is the only professional sport, other than boxing and mixed martial arts, that "tolerates" fighting during play. To eliminate behaviors or major penalties that increase the risk of concussive brain injury and related neurotrauma (i.e., head hits, blind‐side hits, fighting, and checking from behind), consistent educational messages must be delivered, compliance with rules must be rewarded, and infractions must be penalized across all levels of participation.23–27 Other aspects of prevention pertain to player equipment28–33 and facilities.34,35 As important as prevention is, there is also a recognized need for astute detection, accurate diagnoses, optimal management, and appropriately followed return‐to‐play guidelines.5–7,36,37 The goal of the summit was to identify appropriate strategies to decrease concussion in hockey.

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The Ice Hockey Summit objectives provided the template for a rigorous curriculum that met Continuing Medical Education credit standards. The attendees were actively engaged in prioritizing action items and identifying implementation strategies for a multifactorial solution. After reviewing the literature before the Summit, it was hypothesized that the components of a solution to concussions in hockey were those depicted in Figure 1.

The methodology that generated the matrix of prioritized actions included a presummit concussion literature review,7,13 an on‐site shared content by presenters and panelists, and discussion and debate during breakout sessions. The attendees in the breakout sessions identified the action items for each section. Each breakout leader presented the action items based on agreement, along with a strategic plan, to the general assembly. The most highly ranked action items were brought to a vote in the open assembly, using an Audience Response System. The attendees voted on the preferred actions items for all six sessions. The three in each category that were considered to be the highest priority become part of the group's official recommendation. The strategic planning process assessed the following: "Where are we at?" "Where must we get to?" "What strategies are necessary to implement the action plan?"

The following action items from each breakout were prioritized by popular vote using the Audience Response System. The percentage of attendees voting for a particular action item to be of immediate importance (in need of being tackled first) is listed in "RESULTS." The attendees were then asked to choose their second priority and then their third choice. Some breakouts offered more than three choices. Listed are the top three for each breakout; therefore, not everything sums up to 100%.

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I. Databases and Metrics (Breakout A): (1) Collect concussion data using a consistent hockey‐specific definition in small, well‐designed studies (60.9%). (2) Standardize funded hockey concussion research similar to football, lacrosse, and others (18.5%). (3) Partner with a pending legislative action to collect concussion data (15.2%).

II. Recognizing, Diagnosing, Management, and Return to Play (Breakout B): (1) Mandate education for coaches, parents, and referees (46.5%). (2) Remove athletes from play for all suspected concussions (39.4%). (3) Ensure that concussed athletes do not return to play (practice or game) until cleared by medical personnel (14.1%).

III. Player Equipment and Facilities (Breakout C): (1) Educate the hockey community on the actual role of equipment (53%). (2) Emphasize that the helmet is only one factor that may reduce concussion risk (34%). (3) Continue to support research that develops and tests both equipment and facilities (13%).

IV. Prevention and Education (Breakout D): (1) Engage organizations (USA Hockey, Hockey Canada, International Ice Hockey Federation, etc.) to educate coaches, parents and student athletes (79.2%). (2) Take advantage of the currently available educational content in programs such as Hockey Education Program (Fair Play), Centers for Disease Control and Prevention's Heads Up program, Play it Cool, and ThinkFirst (6.9%). (3) Ensure that educational efforts drive a behavioral and cultural change (5.0%).

V. Rules and Enforcement (Breakout E): (1) Eliminate all head contact (intentional and unintentional) (74%). (2) Postpone legal body checking in youth games until age 13 yrs (Bantam level) (18.7%). (3) Eliminate fighting at all levels of hockey participation (7.3%).

VI. Communication (Breakout F): (1) Require an in‐person, preseason meeting each year for all hockey participants (including parents) (33.7%). (2) Provide a unified message for delivery (31.7%). (3) Create a multimedia package, including a robust social media presence (19.8%).

The prioritized action items from each breakout group were accompanied by a strategic planning process that was unique to each component of the solution, but there were some areas of overlap.

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A strength of this summit was the diversity of the stakeholders who shared their expertise and concerns on concussion. The "Rationale" manuscript posted as prereading on the registration Web site raised many questions that were subsequently discussed from the podium and during the breakout sessions. Many hockey enthusiasts hoped that advances in hockey equipment, especially the technology of hockey helmet design, could further dissipate the kinetic energy transmitted to the brain. Engineers, biomechanics experts, and equipment standards committee members on the faculty agreed that hockey helmets currently perform well in preventing focal injuries to the skull. However, contemporary helmets are not designed to manage linear and rotational accelerations that are linked to brain tissue deformation and concussive injury. Nonetheless, all agree that players should wear a properly fitted, certified helmet to protect from focal injury. The helmet must be well secured to maintain proper position on the head and to prevent it from falling off. Players should also wear a custom‐fitted mouth guard that remains in place during play to protect the mouth, teeth and jaw, even though there is no current strong evidence that mouth guards decrease the risk of concussion.38 Elbow and shoulder equipment should have sufficient padding because contact of the hard plastic shell to the head may result in an increased force transmission.30 In addition to improving the protection offered by helmets, concussion prevention must also be achieved via rule changes and enforcement, educational programs, and behavioral modification. When a concussion is suspected, accurate detection, removal from play, individualized management, and a monitored physical and cognitive progression protocol must be followed. A qualified healthcare provider should evaluate and manage the concussed player and guide the return‐to‐play decision‐making.

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Postsummit Action Taken

Some concerns not included in the prioritized action items are being addressed by the postsummit implementation committees. For example, an important focus of future research is the prevention of concussion in female athletes, particularly in contact sports, such as hockey. Preliminary studies suggest that female hockey players sustain more concussions than do males,39 acknowledge more baseline symptoms on the Sport Concussion Assessment Tool,40 may self‐report more frequently,41 and activate neck musculature earlier than men, yet have a reduced neck muscle mass.42 These and other factors may increase their risks.

The need to ensure the consistency of the definition of concussion was prioritized by the database/metrics breakout session. Furthermore, because concussions are underreported at all levels of participation, the players who admit symptoms and those who are observed to sustain a mechanism of injury that may have caused a concussion should be removed from play and promptly evaluated. This observational strategy has been used in both youth4 and Junior A43–46 studies to gather more accurate concussion incidence data. A diligent approach to concussion identification is already practiced by many rink‐side athletic trainers/therapists and physicians, but more emphasis is needed.

It was determined at the Summit that concussion prevention and stakeholder instruction requires the mandatory education of coaches, parents, and athletes. The educational content to meet these needs is currently available. Dissemination of programs such as the Hockey Education Program that includes Fair Play, Play it Cool, and ThinkFirst's Smart Hockey video requires the engagement of national governing bodies. Minor modifications to the content of the video and educational programs are currently underway so that unified, multimodal messages on concussion are disseminated. Part of the dissemination process under discussion includes the development of a Web site to serve as a repository for all concussion education materials suited to players, coaches, parents, and healthcare providers. In addition to the mandatory education of hockey coaches, players, and parents, there is a need for universal education of healthcare providers. The curriculum and Web‐based e‐learning programs are being addressed by national organizations. Rule changes to eliminate all head contact, delay legal body checking in games until age 13 yrs (Bantam level), and abolish fighting requires the support of district, state, and provincial leadership. Therefore, the implementation process has been initiated with USA Hockey, Hockey Canada, and the International Ice Hockey Federation.

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Recently, the authors of a thoughtful paper47 discussed the failure of sports medicine healthcare professionals and sports scientists to engage in injury prevention for youth athletes. They hypothesized that tension exists at the interface between sport and medicine based on differences in core values. Sport values competition and success; whereas, medicine values wellness and prevention. The author stated that one exception pertained to an investigation of the use of Fair Play rules in a hockey tournament.48 Suffice to say that injuries and penalties related to rough play were 4 times less frequent in hockey games using Fair Play rules.21,48 National governing bodies continue to explore strategies to recruit youth hockey players and grow the sport. In Minnesota, where Fair Play has been in place since 2004, youth hockey (boys and girls combined) grew by 14.9% between 2005 and 2007,49 a positive trend that continues.

The evidence‐based action items, prioritized at the "Ice Hockey Summit: Action on Concussion" described in these proceedings, are clear, hockey‐specific, and appropriate. These actions include rule changes and education of all players, coaches, and parents using available educational and behavioral modification content to reduce major penalties and reward sportsmanship. Implementation efforts are underway as a collaborative effort from individuals, national governing bodies, and the media to grow the game and make hockey safer for all participants. To reduce the risk of concussion in ice hockey, we must all respond to this "Call for Action!"

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The "Ice Hockey Summit: Action on Concussion" received assistance from Carol Best, Anna Eskola, Daniel Gaz, Donald Roberts, Matthew Sorenson, Nancy Stuart, Casey Twardowski, and Jonathon Torrens‐Burton (Mayo School of Professional Development).

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