A prospective study of physician-observed concussions during junior ice hockey: implications for incidence rates
Authors: Echlin Paul Sean , Tator Charles H. , Cusimano Michael D. , Cantu Robert C. , Taunton Jack E. , Upshur Ross E. G. , Hall Craig R. , Johnson Andrew M. , Forwell Lorie A. , Skopelja Elaine N. 
Published: November 2010

Object
The objective of this study was to measure the incidence of concussion (scaled relative to number of athlete exposures) and recurrent concussion within 2 teams of fourth-tier junior ice hockey players (16–21 years old) during 1 regular season.

Methods
A prospective cohort study called the Hockey Concussion Education Project was conducted during 1 junior ice hockey regular season (2009–2010) involving 67 male fourth-tier ice hockey players (mean age 18.2 ± 1.2 years, range 16–21 years) from 2 teams. Prior to the start of the season, every player underwent baseline assessments using the Sideline Concussion Assessment Tool 2 (SCAT2) and the Immediate Post-Concussion Assessment and Cognitive Test (ImPACT). The study protocol also required players who entered the study during the season to complete baseline SCAT2 and ImPACT testing. If the protocol was not followed, the postinjury test results of a player without true baseline test results would be compared against previously established age and gender group normative levels. Each regular season game was observed by a qualified physician and at least 1 other neutral nonphysician observer. Players who suffered a suspected concussion were evaluated at the game. If a concussion diagnosis was made, the player was subsequently examined in the physician's office for a full clinical evaluation and the SCAT2 and ImPACT were repeated. Based on these evaluations, players were counseled on the decision of when to return to play. Athlete exposure was defined as 1 game played by 1 athlete.

Results
Twenty-one concussions occurred during the 52 physician-observed games (incidence 21.5 concussions per 1000 athlete exposures). Five players experienced repeat concussions. No concussions were reported during practice sessions. A concussion was diagnosed by the physician in 19 (36.5%) of the 52 observed games. One of the 5 individuals who suffered a repeat concussion sustained his initial concussion in a regular season game that was not observed by a physician, and as a result this single case was not included in the total of 21 total concussions. This initial concussion of the player was identified during baseline testing 2 days after the injury and was subsequently medically diagnosed and treated.

Conclusions
The incidence of game-related concussions (per 100 athlete exposures) in these fourth-tier junior ice hockey players was 7 times higher than the highest rate previously reported in the literature. This difference may be the result of the use of standardized direct physician observation, diagnosis, and subsequent treatment. The results of this study demonstrate the need for follow-up studies involving larger and more diverse sample groups to reflect generalizability of the findings. These follow-up studies should involve other contact sports (for example football and rugby) and also include the full spectrum of gender, age, and skill levels.