In an effort to reduce the high burden of injury in Canadian youth ice hockey, most associations have restricted bodychecking nationally among leagues for younger players (age 11–12 yr), as well as in certain nonelite divisions of play in older age categories (age 13–17 yr.) This has been shown to be associated with reduced rates of injury, including concussion.
However, despite the evidence, some argue that gaining earlier bodychecking experience may protect young players from injuries, including concussions, later on when they progress to play in leagues where bodychecking is allowed.
A study published in the CMAJ entitled Bodychecking experience and rates of injury among ice hockey players aged 15–17 years found the opposite, however. Players with more experience in bodychecking had a greater incidence of concussion.
On today’s episode, Drs. Omole and Bigham speak with two authors of the study. Paul Eliason is a postdoctoral fellow in the Sport Injury Prevention Research Centre at the University of Calgary and Carolyn Emery is a physiotherapist and epidemiologist at the University of Calgary.
They discuss the new study’s findings and their implications for policy in youth hockey. They also explore how hockey compares to other contact and non-contact sports and discuss how to keep kids both active and safe in sport.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
In an effort to reduce the high burden of injury in Canadian youth ice hockey, most associations have restricted bodychecking nationally among leagues for younger players (age 11–12 yr), as well as in certain nonelite divisions of play in older age categories (age 13–17 yr.) This has been shown to be associated with reduced rates of injury, including concussion.
However, despite the evidence, some argue that gaining earlier bodychecking experience may protect young players from injuries, including concussions, later on when they progress to play in leagues where bodychecking is allowed.
A study published in the CMAJ entitled Bodychecking experience and rates of injury among ice hockey players aged 15–17 years found the opposite, however. Players with more experience in bodychecking had a greater incidence of concussion.
On today’s episode, Drs. Omole and Bigham speak with two authors of the study. Paul Eliason is a postdoctoral fellow in the Sport Injury Prevention Research Centre at the University of Calgary and Carolyn Emery is a physiotherapist and epidemiologist at the University of Calgary.
They discuss the new study’s findings and their implications for policy in youth hockey. They also explore how hockey compares to other contact and non-contact sports and discuss how to keep kids both active and safe in sport.
Join us as we explore medical solutions that address the urgent need to change healthcare. Reach out to us about this or any episode you hear. Or tell us about something you'd like to hear on the leading Canadian medical podcast.
You can find Blair and Mojola on X @BlairBigham and @Drmojolaomole
X (in English): @CMAJ
X (en français): @JAMC
Facebook
Instagram: @CMAJ.ca
The CMAJ Podcast is produced by PodCraft Productions
Dr. Blair Bigham:
Hi, I'm Blair Bigham.
Dr. Mojola Omole:
Hi, and I'm Mojola Omole and this is a CMAJ Podcast.
Dr. Mojola Omole:
Blair, today we are talking about some really fascinating research in concussions in young hockey players that was recently published in the CMAJ.
Dr. Blair Bigham:
That's right, we're looking at bodychecking and rates of injury in ice hockey players who are aged 15 to 17 years old. Jola, I feel like this is like a perennial Canadian controversy, whether or not teenagers and kids should be checking when they play hockey.
Dr. Mojola Omole:
Yeah, for sure. I see the broad aspects to other sports too, other contact sports. It's very interesting to observe, as concussion research has been moving forward, we know that sustaining concussions at a younger age does have deleterious effects on your mental health, your mood and other things later on in life.
Dr. Blair Bigham:
Absolutely. It's interesting how they separate out checking from other physical contact. I had thought, either there's physical contact or there's not in a lot of these sports, but they really do seem to have these different grades or levels of physical contact with checking being the highest level.
Dr. Mojola Omole:
Yes. I found that some of the research was really fascinating, the fact that having more experience with checking did not lead to having a lower risk of concussions.
Dr. Blair Bigham:
Right, you would think that, if you were trained to take a hit, the hit might not be as consequential, but that doesn't seem to be the case.
Dr. Mojola Omole:
Yeah, and I'm really interested in finding out what exactly the training is for kids. Dr. Mojola Omole:
Let's jump right into it with our two guests. Paul Eliason is a post-doctoral fellow at the Sports Injury Prevention Research Center at the University of Calgary, and Carolyn Emery is a physiotherapist, epidemiologist, and Canada Research Chair at the University of Calgary. Thank you both for joining us today.
Paul Eliason:
Thanks for having us.
Dr. Mojola Omole:
This research is part of a long running conversation within the sport of hockey in Canada, and about the risk and benefits of permitting bodychecking. Let's start with the benefits, what are the arguments in favour of bodychecking in hockey?
Paul Eliason:
There are some that think it's part of the game, it's really exciting, and that component is really important to keep in part of the game. Especially for the high level athletes, to prepare them for development into higher levels of hockey, and those that are going to semiprofessional and professional levels of hockey.
Dr. Mojola Omole:
Your study tested this argument specifically, what were you looking at?
Paul Eliason:
We have really strong evidence that, if you disallow bodychecking in youth ice hockey games, you're going to reduce all injuries, and you're going to reduce concussions. But there are still some in the hockey community that think that bodychecking should be introduced earlier, because that experience of bodychecking that the players will gain, will help protect them from injuries and concussions when they go up in the older age categories, where policy allows bodychecking in games. That's what we want to examine in our study, the association between bodychecking experience, rates of injury, and concussion specifically.
Dr. Mojola Omole:
When we talk about bodychecking experience, are these youth athletes actually getting... Do they have a training session on how to do bodychecking properly? Carolyn?
Carolyn Emery:
The training on the scale of bodychecking continues even in early younger age groups, and what we're talking about here is disallowing bodychecking within the game setting. In the study that Paul led, he was interested in the experience that players had in leagues that allowed bodychecking in games. So it was really important, for us as a team, to work really closely with our Hockey Canada partners and other hockey associations to really ensure that there weren't any unintended consequences of delaying bodychecking in games until an older age group and more elite levels of play. I think that this study showed in spades that there were not unintended consequences of delaying bodychecking. In fact, those kids who had fewer years of bodychecking experience in games were actually protected, and it was the kids who had three or more years of bodychecking experience that were actually at the highest risk of concussion and all injuries.
Dr. Mojola Omole:
That sounds quite counterintuitive, that the more experience you have with bodychecking, the higher your rate of concussions were. Paul, can you shed light on why do you think that was the result that you got?
Paul Eliason:
Yeah, it was actually exactly opposite of what people in the hockey community thought, which was surprising. We think that the higher rates of injury and concussion with those that had more bodychecking experience, or greater years of bodychecking experience, could be related to the higher levels of play, and the skill and speeds of play within the game. That wouldn't be captured by any of the covariates that we examined in the study.
Dr. Mojola Omole:
There were some earlier studies that looked at the differences in concussions between kids playing hockey in Quebec and Alberta. What did those studies show?
Carolyn Emery:
These were some of our very first studies over a decade ago, and we had the natural experiment here in place, because in Quebec, they've actually disallowed bodychecking in 11 and 12-year-old leagues many, many years ago, and in other provinces at that time, bodychecking was permitted in games in 11 and 12-year-old leagues. What we were able to demonstrate in that early study was that the rate of concussion was fourfold greater in Alberta leagues compared to Quebec leagues, where bodychecking was allowed in that young pediatric age group.
Dr. Mojola Omole:
That's quite staggering.
Carolyn Emery:
This early study led to the later work, which was, again, to better understand, as well, what happened when policy did change to disallow bodychecking in games in older age groups, first 13 and 14-year-olds, previously “Bantam”, and then later in “Midget” 15 to 17-year-olds in non-elite levels of play. We also demonstrated a significant protective effect in reducing the rates of injury and concussion in these older non-elite levels of play. It's important to consider, when we talk about non-elite levels of play, it's still 60 to 70% of players in the adolescent age groups who are in the non-elite levels of play, and now in many jurisdictions, not exposed to rules that allow bodychecking in games.
Dr. Mojola Omole:
Wow. What has the response been from the hockey associations to this research?
Carolyn Emery:
I think it's fair to say we've been working really closely with Hockey Canada, our provincial associations and local associations for, certainly, well over 15 years now. I can say that, early on, there was certainly a lot of decision-making based on pressure from the community, and I would suggest that over time, they became more interested in understanding, really, the evidence to support these important decisions to bring more safety to the game, to protect kids from concussion and other severe injuries, and frankly, to keep more kids playing the game. We continue to work very closely with them, and this is why it was really important. It wasn't a done deal that bodychecking is only at certain age groups and certain levels of play. They really want to understand the potential unintended consequences of significant policy changes such as these.
Dr. Mojola Omole:
Let's pivot to girls hockey, where there's no checking. What's causing the high rates of concussions in girls hockey?
Paul Eliason:
We still see, despite not having bodychecking allowed in the female game, there's still a significant amount of collisions that occur. If anyone that's watched some of the female games, they certainly see that they're very full of contact, they have a lot of contact in their games, and a lot of that has led to some of the concussions that we see. We don't have as much evidence in female hockey, I'd say, that we do in some of the predominantly boys leagues. Carolyn, anything that you want to add to that?
Carolyn Emery:
No, just to say it's a high pace game, in some respects, a collision sport, and that we're still seeing bodychecking in the game. It's not always penalized, even though it's not permitted within the game on the girls' side. Certainly high speeds, high contacts, and then other risk factors that are borne by female players. Such as a previous concussion history, differential sizes, and things like that, are also important considerations. We do still see high rates of concussion and injury on the girls’ side of the game.
Dr. Mojola Omole:
Carolyn, I just wanted to touch base a bit on, what are some of the ramifications that we've seen with this age group having exposure to concussion earlier in their life?
Carolyn Emery:
One of the big factors is that we, probably, have about 50% of players in adolescent league have had a previous concussion and having a previous concussion also increases the risk of future concussion. We don't know if this is related to that previous concussion, or if it's inherent in the risk factors associated with an individual, their genetics, and other factors, but we do see a huge risk of multiple concussions in ice hockey that we want to avoid. I would say also that, obviously, on the management side of things, really critical, people are familiar with Rowan's Law in Ontario and now in other provinces, where it's really important to make sure that players are not going back onto the ice if they have had a suspected concussion and, as well, that they are managed appropriately, so they seek medical advice, they are assessed by a physician, and that they go through appropriate return to play strategies to ensure that they're safe when they do go back and that they have recovered fully from their previous concussion.
Dr. Mojola Omole:
Practically speaking, does that actually happen?
Carolyn Emery:
I'd say that we've come a long way in the last decade. Paul's still playing, coaching, and he's refereed a lot, but I would say we have come a long way in terms of coaches identifying kids who may have had a suspected concussion and keeping them off the ice. There's certainly much more awareness for a number of reasons, but I'll let Paul talk about his experience, because it's been quite a few years since I've been on the ice coaching with my kids.
Dr. Mojola Omole:
Yeah. Paul, tell us a little bit about that from the coach's perspective.
Paul Eliason:
I would say it's all the way from the management down. Club associations are more aware about concussions and the importance of concussions; it trickles down to the coaches, as well as to the players. Players are more aware about concussions, certainly more the older players than, I guess, the younger age groups, but there is still that shift that Carolyn talked about 10 years ago. Concussion awareness certainly being reported in the media must have helped for players to help report symptoms to their coaches, to the medical staff, if their team has that. Certainly, for coaches to be more aware of looking for signs of concussion and then pulling their player if they're worried about it, if they suspect a concussion. It's come a long way about the awareness of concussion, really from top down, in my opinion.
Dr. Mojola Omole:
Do you think the study really solidifies that there shouldn't be bodychecking in non-elite hockey for kids?
Paul Eliason:
I think so. This really shows that a thought in the hockey community that more experience is going to be better, it's going to protect players from injury and concussion specifically, is not true, it doesn't hold. The prior work that showed the significant reductions in injury and concussions by disallowing bodychecking at the non-league age groups has been really strong. For the under-15, under-18 age groups, disallowing bodychecking at non-elite levels, is really important to protect against injuries and concussions, keep them healthy, keep them in the game, playing longer, and also an opportunity for them to continue to focus on their skill development.
Dr. Mojola Omole:
Are there sports that are safer than hockey? The concussion rates in other sports, are they any different? We focus a lot on hockey, is that because it's Canada's national sport or are other sports equally dangerous when it comes to concussion?
Carolyn Emery:
I can speak to that. Certainly, ice hockey with bodychecking in the game, is certainly one of the top four sports for concussion, in terms of high concussion rates. The others would be American football or tackle football, rugby, and lacrosse. There's a lot of opportunity to reduce this risk through various prevention strategies, and one of those is the laws of the game, or in this case, policy in youth ice hockey. Providing opportunities for competitive play without bodychecking permitted within the game setting certainly reduces this risk substantially, and at the same time, I'm going to say that Hockey Canada, and provincial and local associations put a lot of emphasis on the development of the skill of bodychecking, so that kids don't miss out on this skill development for when they're of the right age, size, and competitive to be part of a more elite league. That's a really important piece.
Carolyn Emery:
This policy didn't come into play without the consideration of opportunities for kids who may not be at a level to play in an elite league in a younger age group, but may become larger, more skilled, and then able to play in bodychecking leagues. It is very important that skill development continues and that is certainly a big priority for Hockey Canada.
Dr. Mojola Omole:
Is the type of helmets, mouth guard... Do those make a difference in terms of what the research shows?
Carolyn Emery:
That's a great question, Jola. We're doing quite a bit of work in ice hockey, as well as other helmeted sports to better understand the risk that's associated with the way that a helmet is fit. There's some preliminary evidence to suggest that is an important feature to protect against concussion. Further to that, we have, certainly, some very strong evidence now in ice hockey to support the protective effect of mouth guards. We know that in all collision sports mouth guards are not mandated, and this is something that we're developing very strong evidence across quite large cohorts and multi-year cohort studies to support the fact that some mouth guards are protective of concussion in sports, such as ice hockey.
Dr. Blair Bigham:
I just want to pause. If we go up to the 30,000 foot view of keeping kids safe, there's a lot of people who say that we're bubble-wrapping our kids and that we're overly-protective. How do you balance that belief while still trying to prevent severe injury and concussion in sport, but still letting kids stay active and keep them having fun?
Carolyn Emery:
I can start with that. When we were looking at concussion and injury rates in 11- and 12-year-olds that were similar to what we see in the NHL, it's not acceptable. Arguably, we need to look at strategies so that our kids can be competitive, they can play the sports that they love, and keep them on the ice. It's, arguably, not appropriate to have 11- and 12-year-old kids on the ice, different sizes of players, and learning the skill of a bodychecking at that young age, when their decision making capacity isn't optimal. Arguably, there are a number of different strategies that we can look at to consider the protection against concussion at those early age groups, so these kids can still continue to play and, perhaps, have a chance of being the survivors who aspire to the dream of playing in a more elite level of play. I would argue that it's the exact opposite to bubble wrapping the kids.
Dr. Mojola Omole:
My question is, I have a toddler and I'm starting to think about, "Okay, what sports to put him in?" Would you pull your kids into less concussion prone activities?
Carolyn Emery:
Yeah, both my kids did play ice hockey and I don't think I would've changed that, that was their passion at the time. It's important to let the kids gravitate to the sports that they're drawn to and that they love. It is important to have a variety of opportunities, it brings up, also, the notion of allowing your kids to try different sports and see what they do love to play. Actually, our kids that are seven and eight-year-olds probably don't need to be playing ice hockey 12 months a year, give them an opportunity to develop other fundamental movement skills that are not just in one sport. Certainly, there's building evidence around the importance of reducing sport specialization early and giving our kids the opportunity to play in multiple sports.
Paul Eliason:
Yeah. I think you nailed it, Carolyn. Kids want to play the sports that they love and they're passionate about, so just trying to keep them safe and keep them injury free, so they can continue to participate in the sports that they love is really important. You have a great point that it's great to give your kids opportunities and different sports to try different things, find out what they like, what they don't like, what they want to continue with, and absolutely develop other fundamental skills other than just one sport year round. Especially at the younger age groups.
Dr. Mojola Omole:
Thank you so much for joining us today.
Paul Eliason:
Thank you, Jola. Thank you, Blair.
Carolyn Emery:
Thanks so much for having us.
Dr. Mojola Omole:
Paul Eliason is a postdoctoral fellow at the Sports Injury Prevention Research Center at the University of Calgary, and Carolyn Emery is a Physiotherapist, Epidemiologist and Canada Research Chair at the University of Calgary.
Dr. Blair Bigham:
All right, Jola. When your son grows up, is he going to be checking in hockey?
Dr. Mojola Omole:
I like to joke that in this family we're math-letes, not athletes. Completely a joke, because I grew up playing sports. I would really want him to do sports, if he shows interest in it. I feel like playing sports at a young age shows you discipline, helps you to also develop confidence. If it's hockey that your child is interested in, it would be great to be able to introduce it to them, but also to keep them safe.
Dr. Blair Bigham:
Yeah. What do you think about this staged approach to physical contact, where there's still some physical contact, but not the full body check?
Dr. Mojola Omole:
For me, after listening to Paul and Carolyn and reading their research, I don't think, personally, I would put my child in a contact sport. I don't think it's worth it for them to be exposing themselves to harm, when at the end of the day, they're probably going to have a boring job, like be a doctor. To me, I don't think that's worth it. Not just hockey, but any other sport that has a lot of high level contact, like rugby or lacrosse.
Dr. Blair Bigham:
Right. There are those other sports, where maybe it's not as common to get a concussion, but a lot of performance skiers… there's a lot of sports out there where kids are still getting head injuries.I think it's hard, as an emergency doctor... I'm sure for family doctors, it's tough to keep all the best advice to give parents at the tip of your tongue. A lot of the time parents want to know a lot of details about post-concussion care and, for me, I feel like it's often too early to get into that with them, because I'm seeing them on day one of their head injury. I always get a little bit uncomfortable around concussion advice, I feel like we could still find a better way to be able to give that information succinctly and clearly.
Dr. Mojola Omole:
I would say that some of the points that came out from our conversation, that we all, as caregivers, as physicians, can keep in mind, is that there's some good research around, and they're working on the research around helmets and mouthguards…not just hanging from the mouths of the players, because I've seen that, but actually in the mouths of the players…that they could help reduce the risk of concussions. If your child is still interested in doing contact in sports, those are some of the mitigating factors that could be in play.
Dr. Blair Bigham:
Yeah. Mitigating factors is the key term there, because there's not really controversy anymore around the dangers of checking in this age group, it's more about, "How do we keep kids safe while still advancing them to be able to check when they're of a safer age in a safe manner?"
Dr. Blair Bigham:
That's it for this week on the CMAJ Podcast, tune in two weeks for our next episode. In the meantime, we'd really appreciate it if you could share this podcast, wherever it is you download your audio. I'm Blair Bigham.
Dr. Mojola Omole:
I'm Mojola Omole, and until next time. Be well.