Are Rule Changes the Low-Hanging Fruit for Concussion Prevention in Youth Sport?

Abstract

Sport-related concussions are most common in youths. It is expected that 1 in 10 youths (ages 11-18 years) will sustain a sport-related concussion annually. 1 The risk of concussion is highest in youths participating in collision sport (eg, rugby and ice hockey), with concussion rates ranging from 0.5 to 4.2 concussions per 1000 athlete exposures. 1 Sustaining a concussion can have negative health consequences including future physical activity participation, school performance, and postconcussion syndrome. 1 A systematic review 1 informing the International Consensus on Concussion in Sport regarding primary prevention strategies for concussion highlights rule changes, equipment recommendations, and training strategies. 1 Of all primary concussion prevention strategies, rule changes may be considered the low-hanging fruit regarding the greatest potential population health effect in reducing the risk of concussion in youth sport.In youth ice hockey, rule changes to prohibit body checking are associated with lower rates of concussion. Body checking is a tactic used to gain competitive advantage by changing direction or leaving the established skating lane to make contact with the body of the opponent or using hips, shoulders, or arms to push off and separate the opponent from the puck. 2 The optimal age of introduction to body checking has been a topic of debate in North America for more than a decade. In 2005, a working partnership between researchers and Hockey Canada was established to better understand the risks of body checking in youth ice hockey.Prior to any policy change disallowing body checking in youth ice hockey, the concussion rate in Peewee leagues (ages 11-12 years) of 1.5 concussions per 1000 player-hours was found to be similar to that in the National Hockey League (1.8 concussions per 1000 player-hours). 2 Policy allowing body checking has frequently been identified as a significant risk factor for all injury (>2-fold increased risk) inyouthicehockey. 1 Ameta-analysis 1 includingcohortstud-iesusingvalidatedinjurysurveillancedemonstrateda67% lower concussion risk after body checking was disallowed in Peewee leagues (incidence rate ratio, 0.33; 95% CI, 0.25-0.45). 1 Supporting this, evaluation of a national evidence-informed policy change in Canada disallowing body checking at all levels of play in Peewee leagues resulted in a 64% reduction in concussion risk (incidence risk ratio, 0.36; 95% CI, 0.22-0.58). 3 Preliminary analyses suggest that disallowing body checking in nonelite (lowest 60% by division of play) Bantam ice hockey (ages 13-14 years) was associated with a greater than 50% lower incidence of all injuries. 4 An evaluation of policy change disallowing body checking in older age groups in nonelite levels may also have an important public health impact.

Persisting Concussion Symptoms from Bodychecking: Unrecognized Toll in Boys’ Ice Hockey

“…We agree with Emery and Black 44 that in high-impact sports like hockey and football rule changes may have the greatest potential population health effect in reducing the risk of concussion in sport. In our view, the effect of concussion education is also of major importance as has been demonstrated in hockey by Cook et al 21…”

“…Indeed, our studies of PCS show the seriousness of this condition because many sufferers never fully recover. 14 We agree with Emery and Black 44 that in high-impact sports like hockey and football rule changes may have the greatest potential population health effect in reducing the risk of concussion in sport. In our view, the effect of concussion education is also of major importance as has been demonstrated in hockey by Cook et al 21 Opponents to an age change for permissible bodychecking might also raise concern that the transition to college/university and professional hockey would be changed by raising the permissible bodychecking age to age 18, but we would argue that the health of the players is of paramount importance, and that at age 18 learning how to give or receive a bodycheck would be quickly acquired.…”

Factors Associated With Concussion Rates in Youth Ice Hockey Players: Data From the Largest Longitudinal Cohort Study in Canadian Youth Ice Hockey

“…This finding is well supported by previous studies and bodychecking policy continues to be the most readily modifiable risk factor to prevent injury and concussion in youth ice hockey. 9,10,18,20,22,33 The substantial evidence showing significant reductions in injury risk following policy disallowing bodychecking, 9,10,20,22 provides further support that the greatest public health impact specific to youth ice hockey is realized through disallowing bodychecking. Furthermore, follow-up studies examining injury risk after policy restricting bodychecking in under-13 and non-elite levels of play in under-15 and under-18 have shown no unintended injury consequences related to fewer years of bodychecking experience for adolescent players playing in leagues allowing bodychecking.…”

Prevalence of Suspected Concussions Among K‐12 Students in Utah: Findings From Utah's Student Injury Reporting System

“…Contact sports place students at increased risk for concussion primarily due to the possibility of collisions with other athletes 15 . The use of contact restrictions and noncontact sport options, 16,17 rule changes that reduce high‐risk activities, 18‐21 and strict officiating, 22,23 are promising strategies schools may implement to reduce the risk for concussions in contact sports. Due to limited evidence, future research may be conducted to identify effective strategies to reduce physical activity‐related injuries in school, both in and outside of organized sports 24 …”