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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: August 2011 - Volume 90 - Issue 8 - p 694–703
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.

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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  1. 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%).
  2. 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%).
  3. 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%).
  4. 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%).
  5. 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%).
  6. 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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1. Visek A, Watson J: Ice hockey players' legitimacy of aggression and professionalization of attitudes. Sport Psychol 2005;19:178-92
2. Gee CJ, Leith LM: Aggressive behavior in professional ice hockey: A cross-cultural comparison of North American and European born NHL players. Psychol Sport Exerc 2007;8:567-83
3. Collins CL, Fields SK, Comstock RD: When the rules of the game are broken: What proportion of high school sports-related injuries are related to illegal activity? Inj Prev 2008;14:34-8
4. Goodman D, Williamson IW: Concussion in youth hockey: Risk factors and management across observation strategies. Safety in Ice Hockey 2009;5(STP 1516):211-30
5. Aubry M, Cantu R, Dvorak J, et al: Summary and agreement statement of the First International Conference on Concussion in Sport, Vienna 2001. Recommendations for the improvement of safety and health of athletes who may suffer concussive injuries. Br J Sports Med 2002;36:6-10
6. McCrory P, Johnston K, Meeuwisse W, et al: Summary and agreement statement of the 2nd International Conference on Concussion in Sport, Prague 2004. Br J Sports Med 2005;39:196-204
7. McCrory P, Meeuwisse W, Johnston K, et al: Consensus statement on Concussion in Sport-the 3rd International Conference on Concussion in Sport held in Zurich, November 2008. J Sci Med Sport 2009;12:340-51
8. Ashare A, Greenwald R, eds: Safety in Ice Hockey. STP 1516. West Conshohocken: Journal of ASTM International (JAI); 2009
9. Ashare AB: ed. Safety in Ice Hockey. STP 1341. West Conshohocken, PA: Journal of ASTM International (JAI); 2000
10. Castaldi CR, Bishop PJ, Hoerner EF, eds: Safety in Ice Hockey. STP 1212. Philadelphia, PA: Journal of ASTM International (JAI); 1993
11. Castaldi CR, Hoerner EF, eds: Safety in Ice Hockey. STP 1050. Philadelphia, PA: Journal of ASTM International (JAI); 1989
12. Pearsall DJ, Ashare AB, eds: Safety in Ice Hockey. STP 1446. West Conshohocken, PA: Journal of ASTM International (JAI); 2004
13. Smith AM, Stuart MJ, Dodick D, et al: Zero Tolerance for Concussions and Other Neurotrauma in Ice Hockey: Rationale for Collaborative Action (Pre-Reading Prior to Ice Hockey Summit). 2010:1-24
14. Bernard D, Trudel P: The values of coaches and players about rule infractions, violence and ethics. Safety in Ice Hockey 2004;4(STP 1446):152-63
15. Bernstein R, ed: The Code: The Unwritten Rules of Fighting and Retaliation in the NHL. Chicago: Triumph Books; 2006
16. Bloom G, Vanier J: Coaches' perceptions of aggression in elite women's ice hockey. Safety in Ice Hockey 2004;4 (STP 1446):12-23
17. Brunelle JP, Goulet C, Arguin H: Promoting respect for the rules and injury prevention in ice hockey: Evaluation of the fair-play program. J Sci Med Sport 2005;8:294-304
18. Crawford B, Stuart MJ, Smith AM, et al: Intimidation in ice hockey: An exploratory assesment. Safety in Ice Hockey 2004;4(STP 1446):26-37
19. Link A, et al: Dangers of helmet (locker) boxing. HEP Newsletter 2007.
20. Link A, Stuart M, Finnoff J, et al: Talk to players about 'locker boxing'. RYHA Newsletter 2008.
21. Marcotte G, Simard D: Fair play: An approach to hockey for the 1990s. Safety in Ice Hockey 1993;2(STP 1212):100-8
22. Smith MD, et al: The legitimization of violence: hockey player's perceptions of their reference groups' sanctions for assault. Can Rev Sociol Anthropol 1975;12:72-80
23. Dorsch K, Paskevich D: Stressful experiences among six ceritfication levels of ice hockey officials. Psychol Sport Exerc 2007;8:585-93
24. Fraser K: The Final Call: Key Porter Books. 2010
25. Gilbert W, Trudel P: A profile of rule infractions in Bantam level ice hockey. Safety in Ice Hockey 2000;3(STP 1341):291-301
26. Mihalik JP, Greenwald RM, Blackburn JT, et al: Effect of infraction type on head impact severity in youth ice hockey. Med Sci Sports Exerc 2010;42:1431-8
27. Scapinello R, Simpson R, eds: Between the Lines: Not-So-Tall Tales From Ray "Scampy" Scapinello's Four Decades in the NHL. Wiley; 2006
28. Asplund C, Bettcher S, Borchers J: Facial protection and head injuries in ice hockey: A systematic review. Br J Sports Med 2009;43:993-9
29. Benson BW, Rose MS, Meeuwisse WH: The impact of face shield use on concussions in ice hockey: A multivariate analysis. Br J Sports Med 2002;36:27-32
30. Bishop PJ: Preliminary evaluation of selected hockey equipment tested according to EN TS15256: Protective clothing-hand, arm, leg, genital, and neck protectors for use in ice hockey-protectors for players other than goalkeepers-requirements and test methods. Safety in Ice Hockey 2008;5(STP 1516):171-85
31. Halstead PD, Alexander CF, Cook EM, et al: Hockey headgear and the adequacy of current designs and standards. Saf Ice Hockey 2000;3(STP 1341):93-100
32. LaPrade R, Broxterman J: The single strap helmet fixation system in intercollegiate ice hockey: A source of variable face protection. Safety in Ice Hockey 2000;3(STP 1341):124-9
33. Mihalik JP, McCaffrey MA, Rivera EM, et al: Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion. Dent Traumatol 2007;23:14-20
34. Watson RC, Nystrom MA, Buckolz E: Safety in Canadian junior ice hockey: The association between ice surface size and injuries and aggressive penalties in the Ontario Hockey League. Clin J Sport Med 1997;7:192-5
35. Wennberg R: Collision frequency in elite hockey on North American versus international size rinks. Can J Neurol Sci 2004;31:373-7
36. Echemendia RJ, Herring S, Bailes J: Who should conduct and interpret the neuropsychological assessment in sports-related concussion? Br J Sports Med 2009;43:i32-5
37. Sye G, Sullivan SJ, McCrory P: High school rugby players' understanding of concussion and return to play guidelines. Br J Sports Med 2006;40:1003-5
38. Benson BW, Hamilton GM, Meeuwisse WH, et al: Is protective equipment useful in preventing concussion? A systematic review of the literature. Br J Sports Med 2009;43:i56-67.
39. Dick RW: Is there a gender difference in concussion incidence and outcomes? Br J Sports Med 2009;43:i46-50
40. SCAT2, Sport Concussion Assesment Tool 2. Br J Sports Med 2009;43:i85-8
41. Schneider KJ, Emery CA, Kang J, et al: Examining Sport Concussion Assessment Tool ratings for male and female youth hockey players with and without a history of concussion. Br J Sports Med 2010;44:1112-7
42. Tierney RT, Sitler MR, Swanik CB, et al: Gender differences in head-neck segment dynamic stabilization during head acceleration. Med Sci Sports Exerc 2005;37:272-9
43. Echlin PS: Concussion education, identification, and treatment within a prospective study of physician-observed junior ice hockey concussions: Social context of this scientific intervention. Neurosurg Focus 2010;29:E7
44. Echlin PS, Johnson AM, Riverin S, et al: A prospective study of concussion education in 2 junior ice hockey teams: implications for sports concussion education. Neurosurg Focus 2010;29:E6
45. Echlin PS, Tator CH, Cusimano MD, et al: Return to play after an initial or recurrent concussion in a prospective study of physician-observed junior ice hockey concussions: implications for return to play after a concussion. Neurosurg Focus 2010;29:E5
46. Echlin PS, Tator CH, Cusimano MD, et al: A prospective study of physician-observed concussions during junior ice hockey: Implications for incidence rates. Neurosurg Focus 2010;29:E4
47. Matheson GO, Mohtadi NG, Safran M, et al: Sport injury prevention: Time for an intervention? Clin J Sport Med 2010;20:399-401
48. Roberts WO, Brust JD, Leonard B, et al: Fair-play rules and injury reduction in ice hockey. Arch Pediatr Adolesc Med 1996;150:140-5
49. Smith AM, Jorgenson M, Sorenson MC, et al: Hockey Educational Program (HEP): A statewide measure of fair play, skill development, and coaching excellence. J ASTM Int 2009;6:1-14
50. Emery CA, Kang J, Shrier I, et al: Risk of injury associated with body checking among youth ice hockey players. JAMA 2010;303:2265-72
    51. Emery CA, Meeuwisse WH: Injury rates, risk factors, and mechanisms of injury in minor hockey. Am J Sports Med 2006;34:1960-9
    52. Goodman D, Gaetz M, Meichenbaum D: Concussions in hockey: There is cause for concern. Med Sci Sports Exerc 2001;33:2004-9
      53. Leape L: Institute of Medicine medical error figures are not exaggerated. JAMA 2000;284:95-7
        54. Facts & Prevention Tips. ThinkFirst Foundation. Available at: Accessed on: June 11, 2010.
          55. Benson BW, Mohtadi NG, Rose MS, et al: Head and neck injuries among ice hockey players wearing full face shields vs half face shields. JAMA 1999;282:2328-32
            56. Heads Up: Concussion in Youth Sports. 2009 May 25; Injury Prevention & Control: Traumatic Brain Injury]. Available at: Accessed on: June 15, 2010
              57. Cantu RC: Head injuries in sport. Br J Sports Med 1996;30:289-96
                58. Guskiewicz KM, Bruce SL, Cantu RC, et al: National Athletic Trainers' Association Position Statement: Management of sport-related concussion. J Athl Train 2004;39:280-97
                  59. Guskiewicz KM, Weaver NL, Padua DA, et al: Epidemiology of concussion in collegiate and high school football players. Am J Sports Med 2000;28:643-50
                  60. Kelly KD, Lissel HL, Rowe BH, et al: Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med 2001;11:77-81
                    61. Macpherson A, Rothman L, Howard A: Body-checking rules and childhood injuries in ice hockey. Pediatrics 2006;117:e143-7
                      62. Makdissi M: Is the simple versus complex classification of concussion a valid and useful differentiation? Br J Sports Med 2009;43:i23-7
                        63. Mueller F, Cantu R: Nineteenth Annual Report of the National Center for Catastrophic Sports Injury Research: Fall 1982-Spring 2001. Chapel Hill, NC: National Center for Catastrophic Sports Injury Research; 2002
                          64. Stuart MJ, Dajani KA, Crawford BJ: A synthesis of the world literature of ice hockey injuries: epidemiologic principles and future directions. Safety in Ice Hockey 2009;5(STP 1516):11-72
                            65. Stuart MJ, Smith AM: Principles of ice hockey research. Safety in Ice Hockey 2000;3(STP 1341):19-31
                              66. Stuart MJ, Smith AM, Larson DR: The power of the denominator: A proposal for more comprehensive modeling of risk factors in ice hockey injuries. Safety in Ice Hockey 2004;4(STP 1446):52-8
                                67. Tator CH, Carson JD, Edmonds VE: Spinal and head injuries in ice hockey: A three decade perspective. Safety in Ice Hockey 2000;3(STP 1341):150-64
                                  68. Tegner Y: Serious spinal injuries in Swedish ice hockey. Safety in Ice Hockey 2000;3(STP 1341):165-72
                                    69. Wennberg RA, Tator CH: National Hockey League reported concussions, 1986-87 to 2001-02. Can J Neurol Sci 2003;30:206-9
                                      70. Williamson IJ, Goodman D: Converging evidence for the under-reporting of concussions in youth ice hockey. Br J Sports Med 2006;40:128-32; discussion 32
                                        71. Pocket SCAT2. Br J Sports Med 2009;43:i89-90
                                          72. STOP Sports Injuries. 2010. Available at: Accessed on: June 16, 2010.
                                            73. Ackery A, Provvidenza C, Tator CH: Concussion in hockey: Compliance with return to play advice and follow-up status. Can J Neurol Sci 2009;36:207-12
                                              74. Alla S, Sullivan SJ, Hale L, et al: Self-report scales/checklists for the measurement of concussion symptoms: A systematic review. Br J Sports Med 2009;43:i3-12
                                                75. Bailey CM, Samples HL, Broshek DK, et al: The relationship between psychological distress and baseline sports-related concussion testing. Clin J Sport Med. 2010;20:272-7
                                                  76. Barr WB, McCrea M: Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion. J Int Neuropsychol Soc 2001;7:693-702
                                                    77. Bazarian J. Blood test for brain injuries gains momentum. March 31, 2009. Available at: Accessed on: June 16, 2010
                                                      78. Chen JK, Johnston KM, Collie A, et al: A validation of the post concussion symptom scale in the assessment of complex concussion using cognitive testing and functional MRI. J Neurol Neurosurg Psychiatry 2007;78:1231-8
                                                        79. Collins MW, Iverson GL, Lovell MR, et al: On-field predictors of neuropsychological and symptom deficit following sports-related concussion. Clin J Sport Med 2003;13:222-9
                                                          80. Creighton DW, Shrier I, Shultz R, et al: Return-to-play in sport: A decision-based model. Clin J Sport Med 2010;20:379-85
                                                            81. Davis GA, Iverson GL, Guskiewicz KM, et al: Contributions of neuroimaging, balance testing, electrophysiology and blood markers to the assessment of sport-related concussion. Br J Sports Med 2009;43:i36-45
                                                              82. deKruijk JR, Leffers P, Meerhoff P, et al: S-100B and neuron specific enolase in serum of mild traumatic brain injury patients: A comparison with healthy controls. Acta Neurol Scand 2001;103:175-9
                                                                83. Dick RW, Agel J, Hootman JM, et al: Concussion rates and gender in NCAA competitions. Med Sci Sport Exerc 2008;40:S231
                                                                  84. Echemendia R: Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury. New York, NY: Gilford Press; 2006
                                                                    85. Ferrara MS, McCrea M, Peterson CL, et al: A survey of practice patterns in concussion assessment and management. J Athl Train 2001;36:145-9
                                                                      86. Field M, Collins MW, Lovell MR, et al: Does age play a role in recovery from sports-related concussion? A comparison of high school and collegiate athletes. J Pediatr 2003;142:546-53
                                                                        87. Gioia G: Ten steps and commitments for an effective youth sports concussion program. Brain Inj Prof 2008;4:14-5
                                                                          88. Gioia GA, Schneider JC, Vaughan CG, et al: Which symptom assessments and approaches are uniquely appropriate for paediatric concussion? Br J Sports Med 2009;43:i13-22
                                                                            89. Goodman D, Gall B, Miller A: Adherence to return-to-play guidelines following a sport-induced concussion. Safety in Ice Hockey 2004;4(STP 1446):11
                                                                              90. Gordon KE: Apolipoprotein E genotyping and concussion: Time to fish or cut bait. Clin J Sport Med 2010;20:405-6
                                                                                91. Guskiewicz KM, McCrea M, Marshall SW, et al: Cumulative effects associated with recurrent concussion in collegiate football players: The NCAA Concussion Study. JAMA 2003;290:2549-55
                                                                                  92. Guskiewicz KM, Ross SE, Marshall SW: Postural stability and neuropsychological deficits after concussion in collegiate athletes. J Athl Train 2001;36:263-73
                                                                                    93. Kaut KP, DePompei R, Kerr J, et al: Reports of head injury and symptom knowledge among college athletes: Implications for assessment and educational intervention. Clin J Sport Med 2003;13:213-21
                                                                                      94. Kirkwood MW, Yeates KO, Wilson PE: Pediatric sport-related concussion: A review of the clinical management of an oft-neglected population. Pediatrics 2006;117:1359-71
                                                                                        95. Lovell MR, Collins MW, Iverson GL, et al: Recovery from mild concussion in high school athletes. J Neurosurg 2003;98:296-301
                                                                                          96. Lovell MR, Iverson GL, Collins MW, et al: Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med 1999;9:193-8
                                                                                            97. McCrea M: Standardized mental status testing on the sideline after sport-related concussion. J Athl Train 2001;36:274-9
                                                                                              98. McCrea M, Randolph C, Kelly J: Standardized Assessment of Concussion (SAC): Manual for Administration, Scoring and Interpretation. Waukesha, WI: CNS Inc; 1997
                                                                                                99. McKee AC, Cantu RC, Nowinski CJ, et al: Chronic traumatic encephalopathy in athletes: Progressive tauopathy after repetitive head injury. J Neuropathol Exp Neurol 2009;68:709-35
                                                                                                  100. Middleton K, Krabak BJ, Coppel DB: The influence of pediatric autonomic dysfunction on recovery after concussion. Clin J Sport Med 2010;20:491-2
                                                                                                    101. Moser RS, Iverson GL, Echemendia RJ, et al: Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol 2007;22:909-16
                                                                                                      102. Purcell L: What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sports Med 2009;43:i51-5
                                                                                                        103. Putukian M, Aubry M, McCrory P: Return to play after sports concussion in elite and non-elite athletes? Br J Sports Med 2009;43:i28-31
                                                                                                          104. Sandler SJ, Figaji AA, Adelson PD: Clinical applications of biomarkers in pediatric traumatic brain injury. Childs Nerv Syst 2010;26:205-13
                                                                                                            105. Schatz P, Pardini JE, Lovell MR, et al: Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol 2006;21:91-9
                                                                                                              106. Stålnacke B-M, Ohlsson A, Tegner Y, et al: Serum concentrations of two biochemical markers of brain tissue damage S-100B and neurone specific enolase are increased in elite female soccer players after a competitive game. Br J Sports Med 2006;40:313-6
                                                                                                                107. Stålnacke B-MM, Tegner YM, Sojka PM: Playing ice hockey and basketball increases serum levels of S-100B in elite players: A pilot study. Clin J Sport Med 2003;13:292-301
                                                                                                                  108. Stuart MJ, Link AA, Smith AM, et al: Skate blade neck lacerations: A survey and case follow-up. Clin J Sport Med 2009;19:494-7
                                                                                                                    109. Bishop PJ: The acceleration-axonal strain relationship and MTBI: Future direction for head protection. Safety in Ice Hockey 2009;5(STP 1516):3-8
                                                                                                                      110. Coulson NR, Foreman SE, Hoshizaki TB: Translational and rotational accelerations generated during reconstructed ice hockey impacts on a Hybrid III head form. J ASTM Int 2009;6
                                                                                                                        111. Rousseau P, Post A, Hoshizaki TB: A comparison of peak linear and angular headform accelerations using ice hockey helmets. J ASTM Int 2008;6
                                                                                                                          112. St. John A. Anatomy of a NASCAR Crash. Popular Mechanics. 2009. Available at: Accessed on: June 15, 2010
                                                                                                                            113. To err is human: building a safer health system. 1999. Available at: Accessed on: June 12, 2010
                                                                                                                              114. Heads Up Hockey. 2010. Available at: Accessed on: June 16, 2010
                                                                                                                                115. Hockey Education Program. Minnesota Hockey HEP 2010. Available at: Accessed on: August 4, 2010
                                                                                                                                  116. Ciavorro C, Dobson M, Goodman D: Implicit learning as a strategy for learning games: Alert Hockey. Comput Human Behav 2008;24:2862-72
                                                                                                                                    117. Cook DJ, Cusimano MD, Tator CH, et al: Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video. Inj Prev 2003;9:361-6
                                                                                                                                      118. Cusimano M, Cook D, Tator C, et al: The effectiveness of an injury prevention educational intervention in teaching young hockey players about concussion. Can J Neurol Sci 2002;29:S23-4
                                                                                                                                        119. Cusimano MD: Canadian minor hockey participants' knowledge about concussion. Can J Neurol Sci 2009;36:315-20
                                                                                                                                          120. Faught BE, Baker J, Cairny J, et al: Measuring athletic exposure and body contact using time on task technology in ice hockey. J ASTM Int 2009;6.
                                                                                                                                            121. Gladwell M: The Tipping Point: How Little Things Can Make a Big Difference. Boston, MA: Little, Brown; 2000
                                                                                                                                              122. Glang A, Koester MC, Beaver SV, et al: Online training in sports concussion for youth sports coaches. Int J Sports Sci Coach 2010;5:1-12
                                                                                                                                                123. Goodman D, Bradley NL, Paras B, et al: Video gaming promotes concussion knowledge acquisition in youth hockey players. J Adolesc 2006;29:351-60
                                                                                                                                                  124. McPherson MN, Montelpare WJ, Keightley M, et al: An analysis of head impact profiles and safe hockey behaviors in youth hockey players. J ASTM Int 2009;6:7
                                                                                                                                                    125. Mihalik JP, Blackburn JT, Greenwald RM, et al: Collision type and player anticipation affect head impact severity among youth ice hockey players. Pediatrics 2010;125:e1394-401
                                                                                                                                                      126. Montelpare W, McPherson M, Sutherland M, et al: Introduction to the Play it Cool Safe Hockey Program. J Sports Sci Coach 2010;5:61-74
                                                                                                                                                        127. Provvidenza CF, Johnston KM: Knowledge transfer principles as applied to sport concussion education. Br J Sports Med 2009;43:i68-75
                                                                                                                                                          128. Roberts WO: Is the risk of injury greater in Pee Wee hockey leagues that permit body checking? Clin J Sport Med 2010;20:500-1
                                                                                                                                                            129. Roberts WO, Brust JD, Leonard B: Youth ice hockey tournament injuries: Rates and patterns compared to season play. Med Sci Sports Exerc 1999;31:46-51
                                                                                                                                                              130. Smith AM: Power Play: Mental Toughness for Hockey and Beyond. ed 3. Flagler Beach, FL: USA Hockey, Athletic Guide Publishing; 1999
                                                                                                                                                                131. Smith AM, Stuart MJ, AML C, et alet al: A psychosocial perspective of aggression in ice hockey. Safety in Ice Hockey 2000;3(STP 1341):199-215
                                                                                                                                                                  132. Rudolph M: Rule changes: Their effect on the safety in ice hockey. Safety in Ice Hockey 1989;1(STP 1050):35-6
                                                                                                                                                                    133. Watson RC, Singer CD, Sproule JR: Checking from behind in ice hockey: A study of injury and penalty data in the Ontario University Athletic Association Hockey League. Clin J Sport Med 1996;6:108-11
                                                                                                                                                                      134. Klugl M, Shrier I, McBain K, et al: The prevention of sport injury: An analysis of 12,000 published manuscripts. Clin J Sport Med 2010;20:407-12
                                                                                                                                                                      135. Mariconda J, Mariconda A: Rediscovering youth sportsmanship. Safety in Ice Hockey 2004;4(STP 1446):135-8
                                                                                                                                                                        136. Stuart MJ, Smith AM, Malo-Ortiguera SA, et al: A comparison of facial protection and the incidence of head, neck, and facial injuries in Junior A hockey players. A function of individual playing time. Am J Sports Med 2002;30:39-44
                                                                                                                                                                        137. Warsh JM, Constantin SA, Howard A, et al: A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med 2009;19:134-44

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