Recreational Injury Interventions

Ice Hockey

Background

In Canada, hockey remains the leading cause of eye injuries and blindness in sport, Devenyi et al, 1999. In the 1972-1973 season there were 287 eye injuries reported from hockey and 20 blind eyes. After compulsory eye protection for players under 18 playing organized hockey was instituted in the late 1970s the number of eye injuries dropped. In 1997-1998 there were 23 eye injuries and 4 blind eyes reported from playing hockey. However, current regulations in this country do not require all players to wear full-face protection. In minor hockey all players are required to wear full-face protection. In major junior hockey, half-visors are compulsory; in the National Hockey League, no compulsory eye protection is required, and in nonorganized children's ball hockey (i.e. schools, Boy Scouts, etc.) no compulsory eye protection is required.

While, current regulations have reduced the frequency of facial and eye injuries by making the use of full facial protection for athletes mandatory across many different age groups and levels of play, in Canada and the United States a trend of increasing catastrophic hockey-related injuries has appeared, Benson et al, 1999. Some speculate that the increased frequency of injuries to the cervical spine are attributed to the use of full-face shields. The biomechanical alterations or changes in style of play may increase players' risk of sustaining a concussion or neck injury. Two studies outlined below evaluate the benefits and risks of face protection.

In addition to the implementation of equipment injury prevention interventions, rules and regulations have been instituted to reduce the number of hockey-related injuries by increasing playing surface size and by penalizing players for aggressive play. The junior Ontario Hockey League (OHL) has a higher number of smaller than standard surface sizes (43.75%) compared to the rest of the country, and it has been reported that hockey in Ontario produces proportionately greater number of spinal injuries than other parts of the country. It has been speculated that more space might decrease contact and injuries (including spinal injury) between players, and lead to fewer aggressive penalities, Watson et al, 1997.

The Canadian Amatuer Hockey Association (CAHA) was developed to generate and implement safety-related rules. Since 1965, three important safety rules were introduced. The first, made the use of helmets mandatory. The second, introduced mandatory use of full-face masks, and the third introduced penalities for checking from behind (CFB), Watson et al, 1996. Despite addition of these rules spinal injuries continued to increase. As a result, the CAHA intoduced stricter penalities for CFB during the 1989-1990 hockey season. Three studies below investigate the impact of safety-related rules and regulations in ice hockey across age groups and levels of play. Furthermore, several of the studies below outline programs and regulations that have been implemented on an amatuer level, thus providing a significant quantity of data for child injury prevention.


Review of ice hockey studies:

Author

Devenyi, et al., 1999

Study design and target population

Canadian Ophthalmological Society Survey-Eye Injuries in Canadian Sports.

Population: all eye injuries reported by all Canadian Ophthalmologists.

Intervention

For 26 years, between (1972-1998), sport related eye injuries in Canda were tabulated & analyzed.

Outcomes

Sport involved, mechanism of injury, severity of injury, treatment required, presence of protective equipment, & visual acuity achieved were reported.

Results

Of 4524 eye injuries 1883 were due to ice hockey injury, 302 of these were blind eyes. No eye injuries were reported for players wearing a full-face mask. 294 of the blind eyes occurred in patients wearing no eye protection.

Most eye injuries reported in players wearing half-visors were wearing the visor incorrectly, with a loose neck strap and the visor pushed up onto the forehead.

Study quality and conclusions

Full-face masks protect against eye injuries in ice hockey.

Development of equipment is therefore not the top priority. Public education is needed. Rules and regulations are also needed to make mandatory in all types of hockey, in particular in nonorganized children's hockey where eye protection is not enforced.

Authors suggest efficacy of visors could be improved by replacing standard neck strap with a chin-strap similar to the type worn in North American football. Upward slippage of visor would be reduced.


Author

Benson, et al., 1999

Study design and target population

Non-random controlled trial.

Conducted during the 1997-1998 Canadian Inter-University Athletics Union hockey season.

Population: 2 groups of 642 malecollegiate ice hockey athletes, (Mean Age=22 yrs.)

Intervention

Reported episodes of specific injury to team physicians for 11 teams wearing full face shields during competition and 11 teams wearing half face shields.

Outcomes

Reportable injuries defined as: any event requiring assessment or treatment by a team physician, any mild traumatic brain injury or brachial plexus stretch, categorized by time lost from subsequent participation and compared by type of face sheild.

Results

195 (61.6%) of 319 athletes with full face shields had at least 1 injury.

204 (63.2%) of 323 athletes with half face shields had at least 1 injury.

The risk of sustaining a facial laceration and dental injury was 2.31 (95% confidence interval [CI], 1.53-3.48; P<.001) and 9.90 (95% CI, 1.88-52.1; P=.007) times greater for players respecitvely for player wearing half vs full face shields.

No statistically significant risk difference were found for neck, concussion, or other injuries.

Study quality and conclusions

Use of full face shields significantly reduces risk of facial and dental injuries, without an increase in the risk of neck injuries, concussions, or other injuries.

Study design strong: Injury surveillance system utilized to collect nearly 100% complete data. Between group variables controlled.

Accuracy of data collection may be offset because relative severity of injury between groups was not determined, and the results may not be generalizable to high school and younger, skeletally immature players.


Author

Watson, et al., 1996

Study design and target population

A study of injury and penalty data.

Population: 3 teams from Ontario University Athletic Association (OUAA) Hockey League that reported 653 injuries and 389 penalities.

Intervention

Data collected for 3 years prior to introduction of checking-from-behind (CFB) rule and 3 years following the introduction of CFB rule in 1989.

Records supplied by team trainer or athletic therapist of the 3 teams for duration of study.

Outcomes

Injury rates defined as any injury during a game that was reported to the doctor or team trainer associated with a pre or post CFB rule.

Players' behavior as indicated by penalty rates in OUAA hockey league.

Results

Head/neck injuries decreased from 6.16 per 1,000 player games to 4.49 in the post period. Back injuries decreased from 4.98 per 1,000 to 4.49 and shoulder injuries increased 16.11 to 19.38 in the post period.

CFB rates exhibited significant indepdence (chi square =16.58, df=2, p<0.001) from body contact and stick-related penalties. Thus indicating that the CFB rule had selective association with CFB penalities and none with contact and stick penalties.

Study quality and conclusions

Introduction of CFB rule related to safer playing environment. There were significant decreases in injury rates for the head/neck and back.

Increased CFB penatly rate reflects a crackdown on existing behavior rather tha an actual increase in acts of CFB.

Involvement of medical community and supporting clinical data demonstrating CFB-related injuries helps create safety without significantly changing player behavior.

Study included player injuries when the player continued to participate despite injury after immediate medical attention.



Author

Watson, et al., 1997

Study design and target population

Ecologic group study.

Population: all 16 teams in the Ontario Hockey League (OHL) in 1993-1994 season. Age range: 16-20 years.

Intervention

328 injury reports completed by trainers and athletic therapists and kept by the International Hockey Center of Excellence in Calgary, Canada.

538 penalty records were obtained from OHL official game sheets.

Outcomes

Injury including neurotraumas, penalty data (aggressive and nonaggressive), and surface size; (LTS) larger than standard, (S) standard, and (STS) smaller than standard.

Results

Rates of injury per game were inversely related to ice surface size (95% confidence intervals: LTS, 0.33 + 0.20; S, 0.58 + 0.08; and STS, 0.76 + 0.06). Comparisons of rates of injury with ice surface size were statistically significant (P<0.01).

No significant association between rates of all penalties and ice surface size.

Study quality and conclusions

Ice surface size is a risk factor in all ice-hockey related injuries. The larger the surface size the lower injury rate is.

Penalty data do not appear to be important factors in relation to ice surface size.

Study findings are only representative of the OHL population for the 1993-1994 season.

Big and small players were distributed across all teams regardless of surface size.


Author

Roberts, et al., 1996

Study design and target population

Non-random controlled trail. A prospective evaluation of injuries.

Population: 273 male players younger than 20 years and in high school.

Intervention

3 day community organized 31 game ice hockey tournament in Minnesota.

On-site certified athletic trainers recorded injuries, and penalties were tallied from score sheets.

Outcomes

Injury rate, type, and severity of injuries measured and penalties assessed.

Variables assessed during qualifying fair-play games (where points for playing without excessive penalities were awarded), and during championship games with "regular" rules, where winner advances.

Results

Injury rates for all injuries were 26.4 injuries per 1,000 athlete exposures and 273.8 injuries per 1,000 player hours.

Injury rates for noteable injuries (concussion, facial laceration, or moderate level of severity and above) were 10 per 1,000 athlete exposures and 103.9 per 1,000 player hours.

Ratio of noteable injuries during fair play to notebale injuries during regular-rules competition was 1: 4.8.

Average number penalties per game in fair play was 7.1 compared to 13 in regular-rules competition. Penalties related to rough play and injury occurred up to 4x more frequently in regular-rules competition.

Study quality and conclusions

The fair play concept can reduce injury rates, penalty rates, and severity of penalties and should be considered for ice hockey at all levels of play.

Fair play concept could be applied to other contact sports to reduce injury rates and rules infractions.

Some concussions may have gone unreported.

Varying skill levels and motivation between fair play and regular-rules competition could artifically influence rate of penalties and injuries

Summary of ice hockey interventions

The studies reviewed indicate that full face masks significantly reduce risk against eye, facial, and dental injuries, without an increase in the risk of neck injuries, concussions, or other injuries. Therefore, it appears that the protective equipment currently available is effective in preventing certain injuries when worn properly. Further studies may be indicated. Public education and tougher rules and regulations are needed to make mandatory in all types of hockey, proper use of protective equipment and implementation of safety-related rules. Introduction of CFB rules have related to safer playing environments. Additinally, larger surface size may lower rates for all ice-hockey related injuries.

Recommendations on ice hockey programs

Comprehensive intervention programs should incorporate introduction of CFB rules, mandate proper use of protective equipment, implementation of public education programs, and provide support from governing bodies, medical communities, players, and coaches, and fans to officials who enforce new rules. Public education is an essential factor in the incoporation of CFB rules into all levels of competition and in making mandatory proper use of protective equipment for all levels. An emphasis is placed on all levels as professional players serve as important role models for youngsters who can influence behavior.

Recommendations for future research

Even though ice hockey has experienced a number of safety-oriented changes in the recent past. Further studies are needed to assess the efficacy of the fair play concept, the impact of surface size on injury rates, and the role protective equipment plays in possibly contributing to hockey-related injuries. Additionally, assessments of whether face masks with a chin-strap similar to the type worn in North American football are effective in reducing injury.