Table 1:
Description of study characteristics
| Intervention; study | Study design | Participants | Study groups | Methods | Outcome measures | Downs and Black score (out of 27)* |
|---|---|---|---|---|---|---|
| Rule changes | ||||||
| Regnier et al., 1989;19 Québec City, Canada | Retrospective cohort study | 279 Peewee-level amateur hockey players participating in 521 games (for penalty rates) or 82 games (for injury rates); 227 parents and 63 coaches were surveyed by telephone | Intervention group: Players during the 1984/85 season (bodychecking not allowed) Comparison group: Players during the 1985/86 season (bodychecking allowed) |
Penalty records were examined and analyzed to determine number and types of penalties; analysis of injuries was based on 82 direct observations and telephone surveys; circumstances leading to the injuries were also identified | Number and types of penalties; player injury rate and types of injuries | 15† |
| Marcotte et al., 1993;20 Québec City, Canada | Retrospective cohort study | 23 Peewee and 24 Bantam amateur teams in third-tier competitive division in Quebec | Intervention group: 7 Peewee and 8 Bantam teams using Fair Play rules‡ Comparison group: 16 Peewee and 16 Bantam teams not using Fair Play rules |
Game sheets from 329 regular-season games in the Peewee category and 338 in the Bantam category were used to compile number and types of penalties for a comparative analysis | Number and type of penalties | 12† |
| Roberts et al., 1996;21 Minnesota, United States | Retrospective cohort study | 273 male hockey players in high school (age < 20 yr) on the rosters of 16 teams during the 1994 Junior Gold ice hockey tournament | Intervention group: Players in 24 tournament games using Fair Play rules‡ (n = 882 player-exposures) Comparison group: Players in 7 tournament games using regular rules (n = 217 player-exposures) |
Injuries were recorded by an on-site certified athletic trainer, and penalties were tallied from score sheets | Number of injuries and penalties | 11† |
| Watson et al., 1996;22 Ontario, Canada | Retrospective cohort study | 653 injury records and 389 penalty records for 3 Ontario University Athletic Association teams that had complete records for 3 yr before and 3 yr after introduction of a bodychecking rule in 1989 | Intervention group: 211 games played by the 3 teams after the rule was introduced (minor 2-minute penalty for bodychecking into the boards or major 5-minute penalty if an injury resulted from that check) Comparison group: 178 games played by the 3 teams before the rule was introduced |
Data on injuries and penalties were collected from game reports | Injury and penalty rates | 15† |
| Brunelle et al., 2005;23 Quebec, Canada | Prospective cohort study | 52 elite Bantam teams | Intervention group: 13 games using Fair Play rules‡ Comparison group: 36 games not using Fair Play rules‡ |
49 games were systematically assessed; data on rule transgressions were obtained using a time- observation system based on the classification of adversary interactions in nonconformity with rules; injury data were collected using a self-administered questionnaire | Observations of rule transgressions (nature, referee’s decision and level of transgressions) and hockey-related injuries | 14 |
| Macpherson et al., 2006;24 Ontario and Quebec, Canada | Retrospective cohort study | Boys in minor hockey leagues at the Atom (10–11 yr), Peewee (12–13 yr) and Bantam (14–15 yr) levels in Ontario and Quebec leagues from September 1995 to August 2002 | Intervention group: Players aged 10– 13 yr in leagues that did not allow bodychecking; players aged 14–15 yr (bodychecking allowed) who had no previous experience with bodychecking Comparison group: Players aged 10–13 in leagues that allowed bodychecking; players aged 14–15 yr (bodychecking allowed) who had previous experience (2–4 yr) with bodychecking |
CHIRPP data were used to characterize hockey-related injuries experienced by players presenting at emergency departments | Injury rate and types of injuries | 17† |
| Hagel et al., 2006;25 Edmonton, Canada | Retrospective cohort study | 249 hockey players aged 11 yr before and after a policy change in 2002 | Intervention group: 98 players not exposed to bodychecking before the policy change (a change in age classification for minor ice hockey, whereby 11-year-old children were moved from the Atom level [no bodychecking] to the Peewee level [bodychecking allowed]) Comparison group: 151 players exposed to bodychecking after the policy change |
ACCS data were used to identify records of children aged 10–12 yr who were injured playing ice hockey during the 2000/01 to 2003/04 seasons | Injury rates | 18† |
| Gee et al., 2007;26 United States and Canada | Retrospective cohort study | 50 National Hockey League (NHL) games played before and after the Todd Bertuzzi incident on Mar. 8, 2004 (a widely publicized incident of highly aggressive and injurious behaviour for which Todd Bertuzzi received a high-profile legal charge) | Intervention group: 50 games after the incident Comparison group: 50 games before the incident |
All penalty infractions were coded according to type, score differential, aggressor team’s status at the time of the infraction and whether the act occurred before or after the Todd Bertuzzi incident; the frequency of each aggressive infraction was compared before and after the incident | Frequency and type of penalty called | 16† |
| Emery et al., 2009;27 Calgary, Canada | Prospective cohort study | 283 players at the Peewee (11–12 yr), Bantam (13–14 yr) and Midget (15–16 yr) levels in the Calgary Minor Hockey Association | Intervention group: 138 players on 24 teams in the league that did not allow bodychecking Comparison group: 145 players on 13 teams in the league that allowed bodychecking |
A series of self-administered questionnaires were completed by players to assess their bodychecking attitudes, empathy and aggression. Injury report forms were completed by the study coordinator (with consultation of a physiotherapist for accuracy) | Injury rates | 18 |
| Emery et al., 2010;28 Alberta and Quebec, Canada | Prospective cohort study | 2154 hockey players at the Peewee level (11–12 yr) in the top 60% of divisions of play during the 2007/08 season | Intervention group: 1046 players on 76 teams in Quebec (bodychecking not allowed) Comparison group: 1108 players on 74 teams in Alberta (bodychecking allowed) |
Injury report forms were completed by trained study personnel | Injury and concussion rate ratios | 22 |
| Kukaswadia et al., 2010;29 Kingston, Canada | Retrospective cohort study | Minor hockey players aged 7–14 yr before and after the introduction of a rule change in Ontario minor ice hockey in 2002 | Intervention group: Players in games during the 1997/98 to 2001/02 seasons, before the rule change (introduction of bodychecking at the Atom level [9–10 yr] instead of at the Peewee level [12–13 yr]) Comparison group: Players in games during the 2002/03 to 2006/07 seasons, after the rule change |
CHIRPP data were used to identify injuries experienced by players presenting at 2 emergency departments | Injury rates | 16† |
| Cusimano et al., 2011;30 Canada | Retrospective cohort study | Male hockey league players aged 6–17 yr before and after a rule change in 1998/99 | Intervention group: Injuries from bodychecking before the rule change (lowering of the age when bodychecking is allowed from 11 to 9 yr) Comparison group: Injuries from bodychecking after the rule change |
CHIRPP data on 8552 hockey-related injuries from September 1994 to May 2004 were collected from 5 hospitals in Ontario; injuries were classified as being related to or not related to bodychecking | Injury rates, and the odds ratio of an emergency department visit because of a bodychecking-related injury | 18† |
| Emery et al., 2011;31 Canada | Prospective cohort study | 1971 Bantam hockey players (13–14 yr) in the top 30% of divisions of play during the 2008/09 season | Intervention group: 995 players on 68 teams in Alberta who had 2 years of bodychecking experience Comparison group: 976 players on 62 teams in Quebec who had no bodychecking experience |
Baseline questionnaires about attitudes toward bodychecking and injury report forms were used | Incidence of all injuries and concussions | 17† |
| Educational intervention | ||||||
| Trudel et al., 2000;32 Ottawa and Québec City, Canada | Before–after study | 28 coaches of 42 Bantam (14–15 yr) hockey teams from 5 competitive leagues before and after the 1988/89 season | Intervention group: Games played during the 1988/89 hockey season, when a two-stage self-supervision strategy was in place (stage 1: coaches watched instructional videos on the teaching of proper hockey skills and the concept of self-supervision; stage 2: coaches prepared players for the proper use of bodychecking through the use of videos and training sessions) Comparison group: Games played during the 1987/88 season before the strategy was introduced; 1 of the 5 leagues did not add the educational intervention in the 1988/89 season and was considered the control group |
Bodychecking was analyzed by 3 coders using video recordings of the games; penalties were counted and categorized using game reports; injury statistics were gathered during games via data collection | Observation of the frequency of legal bodychecks, the type and frequency of penalties, and the number of injuries during games | 12 |
| Cook et al., 2003;33 Toronto, Canada | Randomized controlled trial | Male hockey players on 5 competitive-level Atom (11–12 yr) teams and their coaches in the Greater Toronto Hockey League during the 2001/02 season | Intervention group: 45 players on 3 teams who watched ThinkFirst Canada’s Smart Hockey video at midseason (a video about the mechanisms, consequences and prevention of brain and spinal cord injury in ice hockey) Comparison group: 30 players on 2 teams who did not watch the video |
Players completed a test on their knowledge of concussions at different times throughout the season; the total number of penalties received during the season was collected; coaches were given a qualitative interview by a single blinded observer | Test of concussion knowledge; incidence of aggressive penalties | 14† |
| Smith et al., 2009;34 Minnesota, United States | Before–after study | 55 900 players at Squirt, Peewee, Bantam and Junior Gold levels, and all girls’ hockey groups in the Minnesota Hockey League, as well as coaches and officials registered in the league; 17 678 records of game data were obtained, 4420 (25%) of which were randomly selected for analysis of the Fair Play Program | Intervention group: Games played in 2007/08 season, after introduction of the Hockey Education Program in 2003 (program consists of 3 primary components: skill development, coaching excellence and fair play; an empirically based curriculum was created for hockey coaches to help improve players’ development of hockey skills; a Fair Play scoring component was also introduced‡) Comparison group: Games played in 2004/05 season, soon after the program’s introduction |
The program was implemented to all players, coaches, parents and officials. For the analysis of the Fair Play Program, data from 4 seasons were collected from game sheets | Attrition of girls (under 10, 12 and 14 yr) and boys (Squirt, Pee Wee, Bantam and Junior Gold), coaches and officials; Fair Play points; and prevalence and types of penalties collected | 16† |
| Psychosocial interventions | ||||||
| Mattesi, 2002;35 West Virginia, United States | Before–after study | Male hockey players in the West Virginia University collegiate club | Intervention group: 3 players who received a 3-week aggression-management training intervention program (3 sessions of psychological skills training that included positive self-talk, deep breathing and coping imagery) Comparison group: The same 3 players before the intervention program |
Demographic questionnaire was given to players; the Bredemeier Athletic Aggression Inventory (BAAGI) was used to assess aggression | Number of penalty minutes and BAAGI aggression scores | 15 |
| Lauer et al., 2009;36 United States | Before–after study | 3 ice hockey players aged 12–14 yr described as physical, tough players who also received penalties for dirty play | Intervention group: 3 players enrolled in the Playing Clean and Tough Hockey Program (a program designed to teach players how to play the game of hockey “tough” and intensely while playing it “clean” by learning emotional control skills in adverse situations) Comparison group: The same 3 players before the intervention |
Players had to commit to 9 sessions and complete all activities, logs and postgame reports. Postgame self-reported emotions and feelings stated in logs, program test results, program evaluations and descriptive statistics were used. Aggressive behaviours were video recorded and visually inspected by 2 independent coders | Frequency of aggressive acts per game | 13 |
Note: ACCS = Ambulatory Care Classification System, CHIRPP = Canadian Hospitals Injury Reporting and Prevention Program.
*
The score reflects how many of the 27 Downs and Black criteria18 were clearly met by the study. See Appendix 3 for details about the criteria (available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.112017/-/DC1).
†
Includes qualified responses (e.g., “yes, probably” and “yes, likely”).
‡
Fair Play rules: each team can earn points for good conduct based on the number of penalty minutes called by referees; the points are added to the general standings after each game.