title: Evaluation of the ThinkFirst Canada, Smart Hockey, brain and spinal cord injury prevention video Risk of injury associated with bodychecking experience among youth hockey players The impact of face shield use on concussions in ice hockey: a multivariate analysis Does padded headgear prevent head injury in rugby union football? Effectiveness of headgear in a pilot study of under 15 rugby union football Helmets for preventing head and facial injuries in bicyclists. Does Cervical Muscle Strength in Youth Ice Hockey Players Affect Head Impact Biomechanics? Examining Concussion Rates and Return to Play in High School Football Players Wearing Newer Helmet Technology: A Three-Year Prospective Cohort Study Does fair play reduce concussions? A prospective, comparative analysis of competitive youth hockey tournaments Head and neck injuries among ice hockey players wearing full face shields vs half face shields. GRADE guidelines: 3. Rating the quality of evidence. Effectiveness of an educational video on concussion knowledge in minor league hockey players: a cluster randomised controlled trial Influence of the limited interchange rule on injury rates in sub-elite Rugby League players. Risk of injury associated with body checking among youth ice hockey players. Fair-play rules and injury reduction in ice hockey.
abstract: Objective : The ThinkFirst Canada Smart Hockey program is an educational injury prevention video that teaches the mechanisms , consequences , and prevention of brain and spinal cord injury in ice hockey . This study evaluates knowledge transfer and behavioural outcomes in 11–12 year old hockey players who viewed the video . Design : R and omized controlled design . Setting : Greater Toronto Minor Hockey League , Toronto Ontario . Subjects : Minor , competitive 11–12 year old male ice hockey players and hockey team coaches . Interventions : The Smart Hockey video was shown to experimental teams at mid-season . An interview was conducted with coaches to underst and reasons to accept or refuse the injury prevention video . Main outcome measures : A test of concussion knowledge was administered before , immediately after , and three months after exposure to the video . The incidence of aggressive penalties was measured before and after viewing the video . Results : The number of causes and mechanisms of concussion named by players increased from 1.13 to 2.47 and from 0.67 to 1.22 respectively . This effect was maintained at three months . There was no significant change in control teams . There was no significant change in total penalties after video exposure ; however , specific body checking related penalties were significantly reduced in the experimental group . Conclusion : This study showed some improvements in knowledge and behaviours after a single viewing of a video ; however , these findings require confirmation with a larger sample to underst and the sociobehavioural aspects of sport that determine the effectiveness and acceptance of injury prevention interventions Background : In a previous prospect i ve study , the risk of concussion and all injury was more than threefold higher among Pee Wee ice hockey players ( ages 11–12 years ) in a league that allows  bodychecking than among those in a league that does not . We examined whether two years of bodychecking experience in Pee Wee influenced the risk of concussion and other injury among players in a Bantam league ( ages 13–14 ) compared with Bantam players introduced to bodychecking for the first time at age 13 . Methods : We conducted a prospect i ve cohort study involving hockey players aged 13–14 years in the top 30 % of divisions of play in their leagues . Sixty-eight teams from the province of Alberta ( n = 995 ) , whose players had two years of bodychecking experience in Pee Wee , and 62 teams from the province of Quebec ( n = 976 ) , whose players had no bodychecking experience in Pee Wee , participated . We estimated incidence rate ratios ( IRRs ) for injury and for concussion . Results : There were 272 injuries ( 51 concussions ) among the Bantam hockey players who had bodychecking experience in Pee Wee and 244 injuries ( 49 concussions ) among those without such experience . The adjusted IRRs for game-related injuries and concussion overall between players with bodychecking experience in Pee Wee and those without it were as follows : injury overall 0.85 ( 95 % confidence interval [ CI ] 0.63 to 1.16 ) ; concussion overall 0.84 ( 95 % CI 0.48 to 1.48 ) ; and injury result ing in more than seven days of time loss ( i.e. , time between injury and return to play ) 0.67 ( 95 % CI 0.46 to 0.99 ) . The unadjusted IRR for concussion result ing in more than 10 days of time loss was 0.60 ( 95 % CI 0.26 to 1.41 ) . Interpretation : The risk of injury result ing in more than seven days of time loss from play was reduced by 33 % among Bantam hockey players in a league where bodychecking was allowed two years earlier in Pee Wee compared with Bantam players introduced to bodychecking for the first time at age 13 . In light of the increased risk of concussion and other injury among Pee Wee players in a league where bodychecking is permitted , policy regarding the age at which hockey players are introduced to bodychecking requires further consideration Objective : To identify specific risk factors for concussion severity among ice hockey players wearing full face shields compared with half face shields ( visors ) .  Methods : A prospect i ve cohort study was conducted during one varsity hockey season ( 1997–1998 ) with 642 male ice hockey players ( median age 22 years ) from 22 teams participating in the Canadian Inter-University Athletics Union . Half of the teams wore full face shields , and half wore half shields ( visors ) for every practice and game throughout the season . Team therapists and doctors recorded on structured forms daily injury , participation , and information on face shield use for each athlete . The main outcome measure was any traumatic brain injury requiring assessment or treatment by a team therapist or doctor , categorised by time lost from subsequent participation and compared by type of face shield worn . Results : Players who wore half face shields missed significantly more practice s and games per concussion ( 2.4 times ) than players who wore full face shields ( 4.07 sessions ( 95 % confidence interval ( CI ) 3.48 to 4.74 ) v 1.71 sessions ( 95 % CI 1.32 to 2.18 ) respectively ) . Significantly more playing time was lost by players wearing half shields during practice s and games , and did not depend on whether the athletes were forwards or defence , rookies or veterans , or whether the concussions were new or recurrent . In addition , players who wore half face shields and no mouthguards at the time of concussion missed significantly more playing time ( 5.57 sessions per concussion ; 95 % CI 4.40 to 6.95 ) than players who wore half shields and mouthguards ( 2.76 sessions per concussion ; 95 % CI 2.14 to 3.55 ) . Players who wore full face shields and mouthguards at the time of concussion lost no playing time compared with 1.80 sessions lost per concussion ( 95 % CI 1.38 to 2.34 ) for players wearing full face shields and no mouthguards . Conclusions : The use of a full face shield compared with half face shield by intercollegiate ice hockey players significantly reduced the playing time lost because of concussion , suggesting that concussion severity may be reduced by the use of a full face shield BACKGROUND Concussion is a serious problem in many contact sports , including rugby union football . The study 's primary aim was to measure the efficacy of padded headgear in reducing the rates of head injury or concussion . METHODS A cluster r and omized controlled trial with three arms was conducted with rugby union football teams as the unit of r and omization . Teams consisted of males participating in under 13- , 15- , 18- , and 20-yr age group competitions . The interventions were " st and ard " and " modified " padded headgear .  Headgear wearing and injury were measured for each study team at each game over two seasons . RESULTS Eighty-two teams participated in year 1 and 87 in year 2 . A total of 1493 participants ( 10,040 player hours ) were in the control group , 1128 participants ( 8170 player hours ) were assigned to the st and ard headgear group , and 1474 participants ( 10,650 player hours ) were assigned to the modified headgear group .  The compliance rates were low in all groups , but 46 % of participants wore st and ard headgear . An intention-to-treat analysis showed no differences in the rates of head injury or concussion between controls and headgear arms . Incidence rate ratios for st and ard headgear wearers referenced to controls were 0.95 and 1.02 for game and missed game injuries . Analyses of injury rates based on observed wearing patterns also showed no significant differences . Incidence rate ratios for st and ard headgear wearers referenced to nonwearers were 1.11 and 1.10 for game and missed game injuries . CONCLUSIONS Padded headgear does not reduce the rate of head injury or concussion . The low compliance rates are a limitation . Although individuals may choose to wear padded headgear , the routine or m and atory use of protective headgear can not be recommended Objective —To determine whether protective headgear reduced the incidence of concussion in a pilot study of under 15 rugby union . Methods —Sixteen under 15 rugby union teams were recruited from three interschool competitions in metropolitan Sydney and the adjacent country region . A prospect i ve study was undertaken over a single competitive season . The study had two arms : a headgear arm and a control arm . Headgear wearing rates and injury data were reported to the investigators and verified using spot checks . Results —A total of 294 players participated in the study . There were 1179 player exposures with headgear and 357 without headgear . In the study time frame , there were nine incidences of concussion ; seven of the players involved wore headgear and two did not . There was no significant difference between concussion rates between the two study arms . Conclusions —Although there is some controversy about the desirability of wearing protective headgear in football , this pilot study strongly suggests that current headgear does not provide significant protection against concussion in rugby union at a junior level BACKGROUND : Each year , in the United states , approximately 900 persons die from injuries due to bicycle crashes and over 500,000 persons are treated in emergency departments . Head injury is by far the greatest risk posed to bicyclists , comprising one-third of emergency department visits , two-thirds of hospital admissions , and three-fourths of deaths . Facial injuries to cyclists occur at a rate nearly identical to that of head injuries . Although it makes inherent sense that helmets would be protective against head injury , establishing the real-world effectiveness of helmets is important . A number of case-control studies have been conducted demonstrating the effectiveness of bicycle helmets . Because of the magnitude of the problem and the potential effectiveness of bicycle helmets , the objective of this review is to determine whether bicycle helmets reduce head , brain and facial injury for bicyclists of all ages involved in a bicycle crash or fall . OBJECTIVES : To determine whether bicycle helmets reduce head , brain and facial injury for bicyclists of all ages involved in a bicycle crash or fall . SEARCH STRATEGY : We search ed The Cochrane Controlled Trials Register , MEDLINE , EMBASE , Sport , ERIC , NTIS , Exp and ed Academic Index , CINAHL , PsycINFO , Occupational Safety and Health , and Dissertations Abstract s. We checked reference lists of past review s and review articles , studies from government agencies in the United States , Europe and Australia , and contacted colleagues from the International Society for Child and Adolescent Injury Prevention , World Injury Network , CDC funded Injury Control and Research Centers , and staff in injury research agencies around the world . SELECTION CRITERIA : Controlled studies that evaluated the effect of helmet use in a population of bicyclists who had experienced a crash . We required that studies have complete outcome ascertainment , accurate exposure measurement , appropriate selection of the comparison group and elimination or control of factors such as selection bias , observation bias and confounding . DATA COLLECTION AND ANALYSIS : Five published studies met the selection criteria . Two abstract ors using a st and ard abstract ion form independently abstract ed data . Odds ratios with 95 % CI were calculated for the protective effect of helmet for head and facial injuries . Study results are presented individually . Head and brain injury results were also summarized using meta- analysis techniques . MAIN RESULTS : No r and omized controlled trials were found . This review identified five well conducted case control studies which met our selection criteria . Helmets provide a 63%-88 % reduction in the risk of head , brain and severe brain injury for all ages of bicyclists .  Helmets provide equal levels of protection for crashes involving motor vehicles ( 69 % ) and crashes from all other causes ( 68 % ) . Injuries to the upper and mid facial areas are reduced 65 % . REVIEW ER 'S CONCLUSIONS : Helmets reduce bicycle-related head and facial injuries for bicyclists of all ages involved in all types of crashes including those involving motor vehicles Objective : To evaluate the effect of cervical muscle strength on head impact biomechanics . Design : Prospect i ve cohort . Setting : Field setting . Participants : Thirty-seven volunteer ice hockey players ( age = 15.0 ± 1.0 years , height = 173.5 ± 6.2 cm , mass = 66.6 ± 9.0 kg , playing experience = 2.9 ± 3.7 years ) . Interventions : Participants were equipped with accelerometer-instrumented helmets to collect  head impact biomechanics ( linear and rotational acceleration ) throughout an entire playing season . Before the season , isometric cervical muscle strength was measured for the anterior neck flexors , anterolateral neck flexors , cervical rotators , posterolateral neck extensors , and upper trapezius . Data were analyzed using r and om intercept general mixed linear models , with each individual player as a repeating factor/cluster . Main Outcome Measures : Dependent variables included linear and rotational head accelerations . Cervical strength data were categorized into tertiles , creating groups with high , moderate , and low strength . Strength measures were averaged and normalized to body mass . Results : Significant differences in cervical muscle strength existed across our strength groups ( P < 0.05 ) . No differences were observed in linear or rotational acceleration across strength groups for the anterior neck flexors ( PLin = 0.399 ; PRot = 0.060 ) , anterolateral neck flexors ( PLin = 0.987 ; PRot = 0.579 ) , cervical rotators ( PLin = 0.136 ; PRot = 0.238 ) , posterolateral neck extensors ( PLin = 0.883 ; PRot = 0.101 ) , or upper trapezius ( PLin = 0.892 ; PRot = 0.689 ) . Conclusions : Our hypothesis that players with greater static neck strength would experience lower result ant head accelerations was not supported . This contradicts the notion that cervical muscle strength mitigates head impact acceleration . Because we evaluated cervical strength isometrically , future studies should consider dynamic ( ie , isokinetic ) methods in the context of head impact biomechanics OBJECTIVE : The purpose of this study was to compare concussion rates and recovery times for athletes wearing newer helmet technology compared to traditional helmet design . METHODS : This was a three-year , prospect i ve , naturalistic , cohort study . Participants were 2,141 high school athletes from Western Pennsylvania . Approximately half of the sample wore the Revolution helmet manufactured by Riddell , Inc.  ( n = 1,173 ) and the remainder of the sample used  st and ard helmets ( n = 968 ) . Athletes underwent computerized neurocognitive testing through the use of ImPACT at the beginning of the study . Following a concussion , players were reevaluated at various time intervals until recovery was complete . RESULTS : In the total sample , the concussion rate in athletes wearing the Revolution was 5.3 % and in athletes wearing st and ard helmets was 7.6 % [ & khgr;2 ( 1 , 2 , 141 ) = 4.96 , P < 0.027 ] . The relative risk estimate was 0.69 ( 95 % confidence interval = 0.499– 0.958 ) . Wearing the Revolution helmet was associated with approximately a 31 % decreased relative risk and 2.3 % decreased absolute risk for sustaining a concussion in this cohort study . The athletes wearing the Revolution did not differ from athletes wearing st and ard helmets on the mechanism of injury ( e.g. , head-to-head strike ) , on-field concussion markers ( e.g. , amnesia or loss of consciousness ) , or on-field presentation of symptoms ( e.g. , headaches , dizziness , or balance problems ) . CONCLUSION : Recent sophisticated laboratory research has better eluci date d injury biomechanics associated with concussion in professional football players . This data has led to changes in helmet design and new helmet technology , which appears to have beneficial effects in reducing the incidence of cerebral concussion in high school football players Background / aim To determine if Boys Bantam and Peewee and Girls U14 sustain fewer concussions , head hits , ‘ other injuries ’ and penalties in hockey tournaments governed by intensified fair play ( IFP ) than non-intensified fair play ( NIFP ) . Methods A prospect i ve comparison of IFP , a behaviour modification programme that promotes sportsmanship , versus control ( non-intensified , NIFP ) effects on numbers of diagnosed concussions , head hits without diagnosed concussion ( HHWDC ) , ‘ other injuries ’ , number of penalties and fair play points ( FPPs ) .  1514 players , ages 11–14 years , in 6 IFP ( N=950 ) and 5 NIFP ( N=564 ) tournaments were studied . Results Two diagnosed concussions , four HHWDC , and six ‘ other injuries ’ occurred in IFP tournaments compared to one concussion , eight HHWDC and five ‘ other injuries ’ in NIFP . There were significantly fewer HHWDC in IFP than NIFP ( p=0.018 ) . However , diagnosed concussions , ‘ other injuries ’ , penalties and FPPs did not differ significantly between conditions . In IFP , a minority of teams forfeited the majority of FPPs . Most diagnosed concussions , HHWDC , and other injuries occurred to Bantam B players and usually in penalised teams that forfeited their FPPs . Conclusions In response to significant differences in HHWDC between IFP and NIFP tournaments , the following considerations are encouraged : m and atory implementation of fair play in regular season and tournaments , empowering tournament directors to not accept heavily penalised teams , and introducing ‘ no body checking ’ in Bantam CONTEXT Speculation exists that use of a full face shield by ice hockey players may increase their risk of concussions and neck injuries , off setting the benefits of protection from dental , facial , and ocular injuries , but , to our knowledge , no data exist regarding this possibility . OBJECTIVE To determine the risk of sustaining a head or neck injury among intercollegiate ice hockey players wearing full face shields  compared with those wearing  half shields . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study conducted during the 1997 - 1998 Canadian Inter-University Athletics Union hockey season of 642 male hockey players ( mean age , 22 years ) from 22 teams . Athletes from 11 teams wore full face shields and athletes from 11 teams wore half face shields during play . MAIN OUTCOME MEASURE Reportable injury , defined as any event requiring assessment or treatment by a team therapist or physician or any mild traumatic brain injury or brachial plexus stretch , categorized by time lost from subsequent participation and compared by type of face shield . RESULTS Of 319 athletes who wore full face shields  , 195 ( 61.6 % ) had at least 1 injury during the study season , whereas of 323 who wore half face shields  , 204 ( 63.2 % ) were injured . 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 , respectively , for players wearing half vs full face shields . No statistically significant risk differences were found for neck injuries , concussion , or other injuries , although time lost from participation because of concussion was significantly greater in the half shield group ( P<.001 ) , than in the group wearing full shields . CONCLUSIONS These data provide evidence that the use of full face shields is associated with significantly reduced risk of sustaining facial and dental injuries without an increase in the risk of neck injuries , concussions , or other injuries This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence Background With the heightened awareness of concussions in all sports , the development and implementation of effective prevention strategies are necessary . Education has been advocated as an effective injury prevention intervention . Purpose To examine the effectiveness of the ‘ Smart Hockey : More Safety , More Fun ’ video on knowledge transfer among minor league hockey players . Study Design Cluster-r and omised controlled trial . Methods A total of 267 participants from two age divisions and competitive levels were assigned to either a video or no-video group . The video was shown ( or not shown ) to the entire team as a result of r and om assignment . To evaluate the effectiveness of the educational video , question naires specific to concussion knowledge and players ’ attitudes and behaviours were completed . Results There was a significant increase in the players ’ concussion knowledge scores immediately following exposure to the video ( F(1,103)=27.00 , p<0.001 ) . However , concussion knowledge at 2 months was not significantly different between the video and no-video groups , after controlling for prior knowledge level , age and competitive level ( F(1,115)=0.41 , p=0.523 ) . Similarly , players ’ attitudes and behaviour scores at 2 months did not differ between groups ( F(1,115)=0.41 , p=0.507 ) . Conclusions We were able to show that a single viewing of an educational video in hockey could immediately improve knowledge about concussion but that this effect was transient and lost at 2-month follow-up . Future prevention endeavours in hockey and other sports should attempt to incorporate strategies and modalities to enhance knowledge retention This study investigated the incidence of injury in sub-elite Rugby League players before and after the introduction of the limited interchange rule .  The incidence of injury was prospect ively studied in one sub-elite Rugby League club over three competitive seasons . Two seasons were played under the unlimited interchange rule , while the third season was played under the limited interchange rule .  Players participated in 91 matches under the unlimited interchange rule and 44 matches under the limited interchange rule .  Injury was defined as any pain , disability or injury that occurred as a result of a competition game that caused the player to miss a subsequent game . The relative risk ( RR ) of injury significantly decreased ( RR = 0.70 [ 0.65 to 0.75 ] , P<0.05 ) following the introduction of the limited interchange rule , with the incidence of injury decreasing from 72.5 ( 58.2 to 86.8 ) per 1000 playing hr under the unlimited interchange rule to 51.0 ( 33.8 to 68.1 ) per 1000 playing hr under the limited interchange rule . The risk of sustaining thigh and calf injuries ( RR= 0.27 [ 0.12 to 0.59 ] , P < 0.05 ) , muscular strains ( RR= 0.23 10.17 to 0.31 ] . , P<0.05 ) , and high intensity running injuries ( RR= 0.16 [ 0.04 to 0.691 , P<0.05 ) was significantly reduced following the introduction of the limited interchange rule . These findings demonstrate that the risk of injury in sub-elite Rugby League players is significantly reduced following the introduction of the limited interchange rule . The reduced injury risk may reflect a fatigue-induced reduction in match speed and impact forces associated with physical collisions and tackles CONTEXT Ice hockey has one of the highest sport participation and injury rates in youth in Canada .  Body checking is the predominant mechanism of injury in leagues in which it is permitted . OBJECTIVE To determine if risk of injury and concussion differ for Pee Wee ( ages 11 - 12 years ) ice hockey players in a league in which body checking is permitted ( Alberta , Canada ) vs a league in which body checking is not permitted ( Quebec , Canada ) . DESIGN , SETTING , AND PARTICIPANTS Prospect i ve cohort study conducted in Alberta and Quebec during the 2007 - 2008 Pee Wee ice hockey season . Participants ( N = 2154 ) were players from teams in the top 60 % of divisions of play . MAIN OUTCOME MEASURES Incidence rate ratios adjusted for cluster based on Poisson regression for game- and practice -related injury and concussion . RESULTS Seventy-four Pee Wee teams from Alberta ( n = 1108 players ) and 76 Pee Wee teams from Quebec ( n = 1046 players ) completed the study . In total , there were 241 injuries ( 78 concussions ) reported in Alberta ( 85 077 exposure-hours ) and 91 injuries ( 23 concussions ) reported in Quebec ( 82 099 exposure-hours ) . For game-related injuries , the Alberta vs Quebec incidence rate ratio was 3.26 ( 95 % confidence interval [ CI ] , 2.31 - 4.60 [ n = 209 and n = 70 for Alberta and Quebec , respectively ] ) for all injuries , 3.88 ( 95 % CI , 1.91 - 7.89 [ n = 73 and n = 20 ] ) for concussion , 3.30 ( 95 % CI , 1.77 - 6.17 [ n = 51 and n = 16 ] ) for severe injury ( time loss , > 7 days ) , and 3.61 ( 95 % CI , 1.16 - 11.23 [ n=14 and n=4 ] ) for severe concussion ( time loss , > 10 days ) . The estimated absolute risk reduction ( injuries per 1000 player-hours ) that would be achieved if body checking were not permitted in Alberta was 2.84 ( 95 % CI , 2.18 - 3.49 ) for all game-related injuries , 0.72 ( 95 % CI , 0.40 - 1.04 ) for severe injuries , 1.08 ( 95 % CI , 0.70 - 1.46 ) for concussion , and 0.20 ( 95 % CI , 0.04 - 0.37 ) for severe concussion . There was no difference between provinces for practice -related injuries . CONCLUSION Among 11- to 12-year-old ice hockey players , playing in a league in which body checking is permitted compared with playing in a league in which body checking is not permitted was associated with a 3-fold increased risk of all game-related injuries and the categories of concussion , severe injury , and severe concussion OBJECTIVE To determine the rate , type , and severity of injuries incurred and penalties assessed during the qualifying fair-play ( points for playing without excessive penalties ) and championship " regular " rules ( winner advances ) portions of a 1994 Junior Gold ice hockey tournament . DESIGN A prospect i ve evaluation of injuries by certified athletic trainers at the tournament site . SETTING A community-organized , 3-day , 31-game tournament in Minnesota . PARTICIPANTS Two hundred seventy-three male players , younger than 20 years and in high school . MEASUREMENTS /MAIN RESULTS Injuries were recorded by an on-site certified athletic trainer , and the penalties were tallied from the score sheets . The injury rates for the total number of injuries were 26.4 injuries per 1000 athlete exposures and 273.8 injuries per 1000 player hours . When only notable injuries ( concussion , facial laceration , or moderate level of severity and above ) were considered , the injury rates were 10 per 1000 athlete exposures and 103.9 per 1000 player hours . The ratio of notable fair-play to notable regular-rules injuries was 1:4.8 . The number of penalties assessed per game averaged 7.1 penalties during fair-play rules and 13 penalties during the regular-rules competition . Penalties related to rough play and injury occurred four times more frequently during games with regular rules than those with fair-play rules . 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 . The fair-play concept could be applied to other contact sports to reduce injury rates and rules infractions
target: Conditional recommendations are made supporting preventive interventions concussion education and rules prohibiting high-risk activity for both pediatric and adult amateur athletes and neck strengthening exercise in adult amateur athletes .
  Strong recommendations are supported for head protective equipment in both pediatric and adult amateur athletes .
  Strong recommendations regarding newer football helmet technology in adult amateur athletes and rules governing the implementation of body-checking in youth ice hockey are supported .
background: Background Awareness of the magnitude of contact sports-related concussions has risen exponentially in recent years .
  Our objective is to conduct a prospect ively registered systematic review of the scientific evidence regarding interventions to prevent contact sports-related concussions .