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February 18, 2019

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

Author Affiliations
  • 1Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada
  • 2Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
JAMA Pediatr. 2019;173(4):309-310. doi:10.1001/jamapediatrics.2018.5498

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 review1 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) in youth ice hockey.1 A meta-analysis1 including cohort studies using validated injury surveillance demonstrated a 67% 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.

One of the major criticisms of disallowing body checking in Peewee ice hockey is the belief that lack of body-checking experience may lead to a greater risk of concussion for players who go on to participate in ice hockey in older age groups. A cohort study found no evidence that body-checking experience in Peewee leagues was associated with a lower risk of concussion at the Bantam level.5 With consistency in age of introduction of body checking (age 13 years), youth ice hockey players will be exposed to similar body checking experience when entering Bantam age group. However, further research is needed to evaluate the influence of body checking policy differences across divisions of play.

While the beneficial changes to injury risk associated with the policy change are significant, it is important to examine how policy influences player behavior. The effect of such policy change on game physical contacts and player performance was examined using video analysis. Preliminary analyses comparing leagues where body checking was permitted with leagues where it was not permitted suggests a significant reduction in high-intensity trunk impacts, all other player-to-player contacts, and primary (player-to-player) and secondary (player to ice surface, boards, and net) head impact.4 Preliminary evidence suggests no negative influence of body checking on offensive performance (eg, shots on goal and completed offensive passes).6 Further research examining player behaviors (eg, contact behaviors and penalties), game strategies (eg, incidence of body checking), and player performance is critical in evaluating the overall effect of policy change.

In June 2013, the Hockey Canada Board of Directors voted to enact an evidence-informed national policy disallowing body checking in Peewee.7 Similarly, an evidence-informed national policy change was implemented by USA Hockey in 2011. The focus of Hockey Canada and USA Hockey continues to be the appropriate and timely development of body-checking skills so that players are prepared appropriately for body checking in Bantam and older. Research is ongoing to further examine the effects of body-checking experience in Bantam age group on injury risk in Midget age group (ages 15-17) and how body-checking experience may impact future risk. There is a lack of evidence examining body-checking skill development, coaching skills, and skill progression. The effect of body-checking policy to date has been significant in reducing the public health burden of concussions.

The lessons learned during a decade of research examining body-checking policy change in youth ice hockey may have implications for other team sports such as US football, rugby, lacrosse, and soccer. Other studies evaluating rule changes in sport report an association of a high school football policy restricting teams to no more than 2 collision practices a week with fewer head contacts in games and practices, and combined with coach training, the policy is associated with lower rates of concussion in practices.1 Further research is required to determine whether fewer head contacts will be associated with lower risks of concussion in games. There is a need for future research evaluating rule changes in other youth sport contexts (eg, enforcement of head contact policies in soccer and ice hockey, heading rules in soccer, and tackle rules in rugby).

Rule and contact policy changes have exceeded the public health effect of other concussion prevention approaches, such as training strategies and the use of protective equipment.1 Consequently, rule changes and contact policy changes in youth sport may be considered the low-hanging fruit in implementing primary prevention strategies to reduce the concussion epidemic in youth sport. This is consistent with other public health examples of successful public policy changes, leading to positive population health effects (eg, public smoking policies and seat belt laws). Ongoing evidence evaluating rule and policy changes on player contact behaviors and player performance should be generated in partnership with the sport community.1-7 Research evidence that addresses concerns from members of the sport community is critical to inform best practice and policy in youth sport to maximize participation and counter the other burgeoning epidemic of obesity and chronic illness in our youth population. Rule changes occur frequently in elite and professional sports (eg, enforcement of head contact policies in soccer and ice hockey, instant replay laws in American football, and scrum engagement in rugby of “crouch, bind, set”). Perhaps those concerned with the effect of rule and contact policy changes on the tradition of the game and viewer experience should also consider that maintenance of the health of young athletes through injury prevention will avert the long-term consequences of traumatic brain injury, keep the best players in the game, and maximize sport participation of all youth that will have a sustained effect on the future health of our young population.

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Article Information

Corresponding Author: Carolyn A. Emery, PT, PhD, Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, AB T2N1N4, Canada (caemery@ucalgary.ca).

Published Online: February 18, 2019. doi:10.1001/jamapediatrics.2018.5498

Conflict of Interest Disclosures: None reported.

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