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 A 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‡
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 The 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 Mayo Clinic 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. The 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 play14-22 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 (ie, 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.
The Ice Hockey Summit objectives provided the template for a rigorous curriculum that met Continuing Medical Education (CME) credit standards. The attendees were actively engaged in prioritizing action items and identifying implementation strategies for a multi-factorial solution. After reviewing the literature prior to the Summit, it was hypothesized that the components of a solution to concussions in hockey were those depicted in the Figure.
FIGURE. Six priority...Image Tools
The methodology that generated the matrix of prioritized actions included a pre-summit concussion literature review,7,13 on-site shared content by presenters and panelists, as well as discussion and debate during breakout sessions. The attendees in breakout sessions identified action items for each section. Each breakout leader presented 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 (ARS). Attendees voted on preferred actions items for all six sessions. The three in each category considered the highest priority become part of the group's official recommendation. The strategic planning process assessed: Where are we at? Where must we get to?; and What strategies are necessary to implement the action plan.
The following action items from each breakout were prioritized by popular vote using ARS. The percentage of attendees voting a particular action item to be of immediate importance (in need of being tackled first) is listed below. Attendees were then asked to choose their second priority and then their third choice. NOTE: Some breakouts offered more than 3 choices. Listed are the top 3 for each breakout, thus not all equal 100%.
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, etc (18.5%); and (3) Partner with 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%); and (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) Emphasis that the helmet is only one factor that may reduce concussion risk (34%); and (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 the Hockey Education Program (Fair Play), Centers for Disease Control and Prevention's (CDC) Heads Up program, Play it Cool and ThinkFirst (6.9%); and (3) Ensure that educational efforts drive a behavioural 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 (Bantam level) (18.7%); and (3) Eliminate fighting at all levels of hockey participation (7.3%).
VI Communication (Breakout F): (1) Require an in-person, pre-season meeting each year for all hockey participants (including parents) (33.7%); (2) Provide a unified message for delivery (31.7%); and (3) Create a multi-media 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.
A strength of this Summit was the diversity of the stake holders who shared their expertise and concerns about concussion. The Rationale manuscript posted as pre-reading 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 since 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 health care provider should evaluate and manage the concussed player and guide the Return To Play (RTP) decision-making.
POST SUMMIT ACTION TAKEN
Some concerns not included in the prioritized action items are being addressed by the Post-Summit Implementation Committees. For example, an important focus of future research is prevention of concussion in female athletes, particularly in contact sports, such as hockey. Preliminary studies suggest that female hockey players sustain more concussions than 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 males, yet have a reduced neck muscle mass.42 These and other factors may increase their risks.
The need to ensure consistency of the definition of concussion was prioritized by the Data Base/Metrics breakout session. Furthermore, since concussions are under-reported at all levels of participation, 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 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 (HEP) that includes Fair Play, Play it Cool (PIC), and ThinkFirst's Smart Hockey video requires engagement of national governing bodies. Minor modifications to the content of the video and the educational programs are currently underway so that unified, multi-modal 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 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 (Bantam level) and abolish fighting requires the support of district, state, and provincial leadership. Thus, the implementation process has been initiated with USA Hockey, Hockey Canada and the International Ice Hockey Federation (IIHF).
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 four 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 this 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!”
The authors thank the industrious and gracious assistance provided by Carol Best, Anna Eskola, Daniel Gaz, Donald Roberts, Matthew Sorenson, Nancy Stuart, Casey Twardowski, and Jonathon Torrens-Burton (Mayo School of Professional Development).
1. Visek A, Watson J. Ice hockey players' legitimacy of aggression and professionalization of attitudes. Sport Psychol
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
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
4. Williamson IJS, Goodman D. Concussion in youth hockey: prevelance, risk factors, and management across observation strategies. J ASTM Int
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.
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.
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.
8. Ashare A, Greenwald R, eds. Safety in Ice Hockey
. Vol 5. West Conshohocken, PA: ASTM International; 2009.
9. Ashare AB, ed. Safety in Ice Hockey
. Vol 3. West Conshohocken, PA: ASTM International; 2000.
10. Castaldi CR, Bishop PJ, Hoerner EF, eds. Safety in Ice Hockey
. Vol 2. West Conshohocken, PA: ASTM International; 1993.
11. Castaldi CR, Hoerner EF, eds. Safety in Ice Hockey
. Vol 1. West Conshohocken, PA: ASTM International; 1989.
12. Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey
. Vol 4. West Conshohocken, PA: ASTM International; 2004.
14. Bernard D, Trudel P. The values of coaches and players about rule infractions, violence and ethics. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey
. Vol 4. West Conshohoken, PA: ASTM International; 2004:152-163. STP 1446.
15. Bernstein R, ed. The Code: The Unwritten Rules of Fighting and Retaliation in the NHL
. Chicago, IL: Triumph Books; 2006.
16. Bloom G, Vanier J. Coaches' perceptions of aggression in elite women's ice hockey. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey
. Vol 4. West Conshohoken, PA: ASTM International; 2004:12-23. STP 1446.
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
18. Crawford B, Stuart MJ, Smith AM, et al. Intimidation in ice hockey: an exploratory assessment. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey
. Vol 4. West Conshohoken, PA: ASTM International; 2004:26-37. STP 1446.
19. Link A, Stuart M, Finnoff J, et al. Dangers of helmet (locker) boxing. Hockey Education Program (HEP) Newsletter
. November 2007.
20. Link A, Stuart M, Finnoff J, et al. Talk to players about “locker boxing”. Rochester Youth Hockey Association (RYHA) Newsletter
. January 2008.
21. Marcotte G, Simard D. Fair play: an approach to hockey for the 1990s. In: Castaldi CR, Bishop PJ, Hoerner EF, eds. Safety in Ice Hockey
. Vol 2. West Conshohoken, PA: ASTM International;1993:100-108. STP 1212.
22. Smith MD. The legitimization of violence: hockey player's perceptions of their reference groups' sanctions for assault. Can Rev Sociol Anthropol
23. Dorsch K, Paskevich D. Stressful experiences among six certification levels of ice hockey officials. Psychol Sport Exerc
24. Fraser K. The Final Call
. Bolton, ON, Canada: Fenn Publishing Company; 2010.
25. Gilbert W, Trudel P. A profile of rule infractions in Bantam level ice hockey. In: Safety in Ice Hockey
. Vol. 3; 2000:291-301. STP 1341.
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
27. Scapinello R, Simpson R, eds. Between the Lines: Not-So-Tall Tales From Ray “Scampy” Scapinello's Four Decades in the NHL
. Canada: John Wiley & Sons; 2006.
28. Asplund C, Bettcher S, Borchers J. Facial protection and head injuries in ice hockey: a systematic review. Br J Sports Med
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
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. J ASTM Int
31. Halstead PD, Alexander CF, Cook EM, et al. Hockey headgear and the adequacy of current designs and standards. In: Ashare AB, ed. Safety in Ice Hockey
. Vol 3. West Conshohoken, PA: ASTM International; 2000:93-100. STP 1341.
32. LaPrade R, Broxterman J. The single strap helmet fixation system in intercollegiate ice hockey: a source of variable face protection. In: Ashare AB, ed. Safety in Ice Hockey
. Vol 3. West Conshohoken, PA: ASTM International; 2000:124-129. STP 1341.
33. Mihalik JP, McCaffrey MA, Rivera EM, et al. Effectiveness of mouthguards in reducing neurocognitive deficits following sports-related cerebral concussion. Dent Traumatol
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
35. Wennberg R. Collision frequency in elite hockey on North American versus international size rinks. Can J Neurol Sci
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(suppl 1):i32-i35.
37. Sye G, Sullivan SJ, McCrory P. High school rugby players' understanding of concussion and return to play guidelines. Br J Sports Med
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(suppl 1):i56-i67.
39. Dick RW. Is there a gender difference in concussion incidence and outcomes? Br J Sports Med
. 2009;43(suppl 1):i46-i50.
40. SCAT2, Sport Concussion Assessment Tool 2. Br J Sports Med
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
42. Tierney RT, Sitler MR, Swanik CB, et al. Gender differences in head-neck segment dynamic stabilization during head acceleration. Med Sci Sports Exerc
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
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
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
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
47. Matheson GO, Mohtadi NG, Safran M, et al. Sport injury prevention: time for an intervention? Clin J Sport Med
48. Roberts WO, Brust JD, Leonard B, et al. Fair-play rules and injury reduction in ice hockey. Arch Pediatr Adolesc Med
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
50. Emery CA, Kang J, Shrier I, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA
51. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey. Am J Sports Med
52. Goodman D, Gaetz M, Meichenbaum D. Concussions in hockey: there is cause for concern. Med Sci Sports Exerc
53. Leape L. Institute of Medicine medical error figures are not exaggerated. JAMA
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
57. Cantu RC. Head injuries in sport. Br J Sports Med
58. Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic Trainers' Association position statement: management of sport-related concussion. J Athl Train
59. Guskiewicz KM, Weaver NL, Padua DA, et al. Epidemiology of concussion in collegiate and high school football players. Am J Sports Med
60. Kelly KD, Lissel HL, Rowe BH, et al. Sport and recreation-related head injuries treated in the emergency department. Clin J Sport Med
61. Macpherson A, Rothman L, Howard A. Body-checking rules and childhood injuries in ice hockey. Pediatrics
62. Makdissi M. Is the simple versus complex classification of concussion a valid and useful differentiation? Br J Sports Med
. 2009;43(suppl 1):i23-i27.
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. J ASTM Int. 2008;5:10.
65. Stuart MJ, Smith AM. Principles of ice hockey research. In: Ashare AB, ed. Safety in Ice Hockey. Vol 3. West Conshohoken, PA: ASTM International; 2000:19-31. STP 1341.
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. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey. Vol 4. West Conshohoken, PA: ASTM International; 2004:52-58. STP 1446.
67. Tator CH, Carson JD, Edmonds VE. Spinal and head injuries in ice hockey: a three decade perspective. In: Ashare AB, ed. Safety in Ice Hockey. Vol 3. West Conshohoken, PA: ASTM International; 2000:150-164. STP 1341.
68. Tegner Y. Serious spinal injuries in Swedish ice hockey. In: Ashare AB, ed. Safety in Ice Hockey. Vol 3. West Conshohoken, PA: ASTM International; 2000:165-172. STP 1341.
69. Wennberg RA, Tator CH. National Hockey League reported concussions, 1986-87 to 2001-02. Can J Neurol Sci
70. Williamson IJ, Goodman D. Converging evidence for the under-reporting of concussions in youth ice hockey. Br J Sports Med. 2006;40:128-132; discussion, 32.
71. Pocket SCAT2. Br J Sports Med. 2009;43:i89-i90.
73. Ackery A, Provvidenza C, Tator CH. Concussion in hockey: compliance with return to play advice and follow-up status. Can J Neurol Sci
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(suppl 1):i3-i12.
75. Bailey CM, Samples HL, Broshek DK, et al. The relationship between psychological distress and baseline sports-related concussion testing. Clin J Sport Med
76. Barr WB, McCrea M. Sensitivity and specificity of standardized neurocognitive testing immediately following sports concussion. J Int Neuropsychol Soc
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;78:1231-1238.
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
80. Creighton DW, Shrier I, Shultz R, et al. Return-to-play in sport: a decision-based model. Clin J Sport Med
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(suppl 1):i36-i45.
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;103:175-179.
83. Dick RW, Agel J, Hootman JM, et al. Concussion rates and gender in NCAA competitions. Med Sci Sports Exerc
. 2008;40(suppl 1):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;36:145-149.
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
87. Gioia G. Ten steps and commitments for an effective youth sports concussion program. Brain Injury Prof. 2008;4:14-15.
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(suppl 1):i13-i22.
89. Goodman D, Gall B, Miller A. Adherence to return-to-play guidelines following a sport-induced concussion. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey. Vol 4. West Conshohoken, PA: ASTM International; 2004:11. STP 1446.
90. Gordon KE. Apolipoprotein E genotyping and concussion: time to fish or cut bait. Clin J Sport Med
91. Guskiewicz KM, McCrea M, Marshall SW, et al. Cumulative effects associated with recurrent concussion in collegiate football players: the NCAA Concussion Study. JAMA
92. Guskiewicz KM, Ross SE, Marshall SW. Postural stability and neuropsychological deficits after concussion in collegiate athletes. J Athl Train
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
94. Kirkwood MW, Yeates KO, Wilson PE. Pediatric sport-related concussion: a review of the clinical management of an oft-neglected population. Pediatrics
95. Lovell MR, Collins MW, Iverson GL, et al. Recovery from mild concussion in high school athletes. J Neurosurg
96. Lovell MR, Iverson GL, Collins MW, et al. Does loss of consciousness predict neuropsychological decrements after concussion? Clin J Sport Med
97. McCrea M. Standardized mental status testing on the sideline after sport-related concussion. J Athl Train
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
100. Middleton K, Krabak BJ, Coppel DB. The influence of pediatric autonomic dysfunction on recovery after concussion. Clin J Sport Med
101. Moser RS, Iverson GL, Echemendia RJ, et al. Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol
102. Purcell L. What are the most appropriate return-to-play guidelines for concussed child athletes? Br J Sports Med
. 2009;43(suppl 1):i51-i55.
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(suppl 1):i28-i31.
104. Sandler SJ, Figaji AA, Adelson PD. Clinical applications of biomarkers in pediatric traumatic brain injury. Childs Nerv Syst
105. Schatz P, Pardini JE, Lovell MR, et al. Sensitivity and specificity of the ImPACT Test Battery for concussion in athletes. Arch Clin Neuropsychol
106. Stålnacke BM, 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
107. Stålnacke BM, 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
108. Stuart MJ, Link AA, Smith AM, et al. Skate blade neck lacerations: a survey and case follow-up. Clin J Sport Med
109. Bishop PJ. The acceleration-axonal strain relationship and MTBI: future direction for head protection. J ASTM Int. 2009;6:4.
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;6:141-151.
111. Rousseau P, Post A, Hoshizaki TB. A comparison of peak linear and angular headform accelerations using ice hockey helmets. J ASTM Int. 2008;6:152-170.
116. Ciavorro C, Dobson M, Goodman D. Implicit learning as a strategy for learning games: alert hockey. Comput Human Behav
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
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-S24.
119. Cusimano MD. Canadian minor hockey participants' knowledge about concussion. Can J Neurol Sci
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
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;28:6-7.
125. Mihalik JP, Blackburn JT, Greenwald RM, et al. Collision type and player anticipation affect head impact severity among youth ice hockey players. Pediatrics
126. Montelpare W, McPherson M, Sutherland M, et al. Introduction to the play it cool safe hockey program. J Sports Sci Coaching. 2010;5:61-74.
127. Provvidenza CF, Johnston KM. Knowledge transfer principles as applied to sport concussion education. Br J Sports Med
. 2009;43(suppl 1):i68-i75.
128. Roberts WO. Is the risk of injury greater in Pee Wee hockey leagues that permit body checking? Clin J Sport Med
129. Roberts WO, Brust JD, Leonard B. Youth ice hockey tournament injuries: rates and patterns compared to season play. Med Sci Sports Exerc
130. Smith AM. Power Play: Mental Toughness for Hockey and Beyond. 3rd ed. Flagler Beach, FL: USA Hockey, Athletic Guide Publishing; 1999.
131. Smith AM, Stuart MJ, Aml C, et al. A psychosocial perspective of aggression in ice hockey. In: Ashare AB, ed. Safety in Ice Hockey. Vol 3. West Conshohoken, PA: ASTM International; 2000:199-215. STP 1341.
132. Rudolph M. Rule changes: their effect on the safety in ice hockey. In: Castaldi CR, Hoerner EF, eds. Safety in Ice Hockey. Vol 1. West Conshohoken, PA: ASTM International;1989:35-36. STP 1050.
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
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
135. Mariconda J, Mariconda A. Rediscovering youth sportsmanship. In: Pearsall DJ, Ashare AB, eds. Safety in Ice Hockey. Vol 4. West Conshohoken, PA: ASTM International; 2004:135-138. STP 1446.
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
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
Advisory Committee: 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 (Department of Surgery, University of Toronto, Toronto, Ontario, Canada), Ruben Echemendia, PhD (Director of Neuropsychological Testing Program, National Hockey League, New York, New York), Kerry Fraser (Blue Anchor, New Jersey), James Johnson (Scottsdale, Arizona), David Krause, PT, MBA, DSC, OCS (Sports Medicine Center, Mayo Clinic, Rochester, Minnesota), Mark Lovell, PhD (Sports Medicine Concussion Program, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania), Joan Mariconda, MA, BA (USA Hockey, Colorado Springs, Colorado), Anthony Mariconda (USA Hockey, Colorado Springs, Colorado), James Whitehead (American College of Sports Medicine, Indianapolis, Indiana), and Diane M. Wiese-Bjornstal, PhD (University of Minnesota, St Paul, Minnesota).
Contributors to the Process: 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 District of Columbia), Kevin M. Guskiewicz, PhD, ATC (The University of North Carolina, Chapel Hill, North Carolina), P. David Halstead (Sports Biomechanics Impact Research Laboratory, College of Engineering, University of Tennessee, 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 (Team Wendy, Cleveland, Ohio), 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), and Ronald Szalkowski (Team Wendy, Cleveland, Ohio).
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