Bodychecking in hockey.

ing violent acts perpetrated by hockey teams in Stanley Cup final series, as in-dicated by recorded penalties,2Marchie and Cusimano note that “teams playing with less violence were more likely to win. Compared with more violent teams, they had on average over 7 more shots on goal per game and 53 more shots on goal over a 7-game se-ries.” Stating that victory resulted from less violence is a fallacy. Teams can play with extreme violence yet contain their actions to that which is within the rules; no penalty is incurred, even though significant violence is em-ployed. In addition, less skilled teams may resort to a more physical and thus more violent strategy in an attempt to win the game.Neal H. ShawTeacherOakville, Ont.References1.Marchie A, Cusimano MD. Bodychecking andconcussions in ice hockey: Should our youth pay the price? [editorial]. CMAJ2003;169(2):124-8.2.McCaw ST, Walker JD. Winning the StanleyCup final series is related to incurring fewer penalties for violent behavior. Tex Med 1999;95(4):66-9.T he excellent article by Anthony Marchie and Michael Cusimano1 highlighted the fact that even minor concussions are serious injuries. The authors recommend caution in decid-ing when or whether hockey players should return to play after a concus-sion. This principle should apply to athletes in all sports, not just ice hockey. Traumatic brain injury can oc-cur in a variety of sports,2and other sports with high risks for head injury include boxing, football, wrestling, soc-cer and rugby.3For example, one study showed evidence of neuropsychological impairment in amateur soccer players,4 whose performance on tests of plan-ning and memory was inferior to that of amateur athletes involved in swim-ming and track. As pointed out by Marchie and Cusimano,1physicians need to educate the public about brain injury and help to reduce the risk of our youth experiencing permanent cognitive deficits as a result of sports.Stephen D. AndersonClinical Associate ProfessorDepartment of PsychiatryFaculty of MedicineUniversity of British ColumbiaVancouver, BCReferences1.Marchie A, Cusimano MD. Bodychecking andconcussions in ice hockey: Should our youth paythe price? [editorial]. CMAJ2003;169(2):124-8.2.Corsellis JA. Brain damage in sport. Lancet1976;1:401-2.3.Wojtys EM, Hovda D, Landry G. Current con-cepts. Concussion in sports. Am J Sports Med1999;27(5):676-87.4.Matser EJ, Kessels AG, Lezak MD, Jordan BD,Troost J. Neuropsychological impairment inamateur soccer players. JAMA1999;282(10):971-3.[The authors respond:]A s R. van Reekum notes, legal body-checks are often the cause oftrauma and concussions; only 8% of in-juries are caused by illegal checks.1However, stricter enforcement of exist-ing rules would not solve the problem,as Angus Juckes and Ian Ross suggest.It is difficult to see how anyone canperceive entertainment value in body-checking, especially if its victims arechildren and youth. The American Psy-chiatric Association has concluded that,in addition to desensitizing viewers, vi-olence in entertainment promotes moresuch violence.2Neal Shaw’s suggestionthat violence and aggression are oftenmanifested in legal bodychecking raisesthe important question of whetherthese are values we wish to foster in thenext generation of citizens.Yet remaking the game is unneces-sary. For example, most high schooland women’s hockey games are alreadyplayed without bodychecking, and theinjury rates in these settings are muchlower than in the National HockeyLeague (NHL).3What needs remakingis attitude: we need to refocus the gameon fun, skill and sportsmanship, ratherthan violence and aggression.Although his review of our refer-ences is admirable, Ross’s commentsare limited in applicability, given thatmany athletes underreport injuries suchas concussions. Because concussions areoften missed or misdiagnosed,4the inci-dence is probably much higher thanthat reported.3,5Ross also fails to men-tion that Honey’s review6indicated that2 studies reporting no concussions didnot have large enough sample sizes toallow definitive conclusions. Nonethe-less, a conservative estimate of 1 or 2concussions per 1000 player hours,6for560000 registered minor hockey play-ers who average 15 hours on ice perseason, would yield at least 8000 to16000 concussions alone for the up-coming season in Canada. On the basisof an injury rate of 15 per 100 players(9 to 15 years of age) per season,7wewould expect bodychecking to accountfor the majority of the 84000 injuriesin the 2003/04 minor hockey season.Some people, including various me-dia pundits, coaches, parents and healthcare professionals, have suggested —erroneously — that the benefits ofchecking outweigh the risks, even foryoung children and adolescents. Theyargue that this technique must belearned to minimize the risk of injury atolder ages, but the data do not supportthis contention. The incidence of con-cussion and other injuries consistentlyincreases with increase in bodycheckingexperience, reaching its zenith at theelite levels in collegiate leagues and theNHL,3,6,8and is associated with signifi-cant risk of fracture,9-11concussion8,12and spinal injury.13One concussion is arisk factor for a second one, and thosewho have sustained 3 or more concus-sions are 9 times more likely to have al-tered mental status than those withoutprior concussion.14A frequently over-looked cost is that of attrition from thesport, which is greatest in those 13 and14 years of age, when differences in thesize and weight of players are also attheir greatest.11When these reasons against body-checking are considered along with theconcept of patient autonomy, we arecompelled to recommend banningbodychecking until players are at least17 or 18 years of age. It should be per-mitted thereafter only if players havegiven proper informed consent. Parentsand young players need to know therisks before starting play in a contactleague, and physicians should take intoaccount not just when but if a player 16JAMC • 6 JANV. 2004; 170 (1)。