Concussions

Pre-Season Concussion Education

All Hockey Alberta member participants are expected to review and sign-off on pre-season concussion education yearly, at the time of registration, through the concussion waiver found on the HCR.

Despite recent increased attention focusing on concussion there is a continued need to improve concussion education and awareness. Hockey Canada has provided the following pre-season concussion education learning tools for our use.

• Pre-Season Concussion Education (Player – Parent/Guardian)
• Pre-Season Concussion Education (Team Staff)
• Pre-Season Concussion Education (Officials)

Concussions are brain injuries caused by the brain moving inside of the skull. The movement causes damage that changes how brain cells function, leading to symptoms that can be:

• physical (headaches, dizziness)
• cognitive (problems remembering or concentrating), and/or
• emotional (feeling depressed).

A concussion can result from any impact to the head, face or neck or a blow to the body which causes a sudden jolting of the head.

Because of the contact nature of hockey and the speed with which the game is played, the brain is vulnerable to injury. Trauma may occur through direct contact to the head or face or indirectly through a whiplash effect. Injuries to the brain are characterized by an altered state of mind. An altered state of mind is the key thing to look for with any head injury.

A concussion is a common injury, but since it cannot be detected on X-rays or CT scans, concussions have been difficult to fully investigate and understand. Fortunately, there have been many important advances in our knowledge of concussions, including how to identify, manage and recover from a concussion. Although concussions are often referred to as ‘mild traumatic brain injuries’ and often resolve uneventfully, ALL concussions have the potential for serious and long-lasting symptoms and so must be treated carefully and in consultation with a physician.

Children are more sensitive to the effects of a concussion and will need to have a longer period of rest prior to returning to activity and the sport.

Additional Education Resources

Certified Education for Coaches - Coaching Association of Canada Concussion Awareness Program

Parachute Canada Concussion Education

NHL Concussion Education Facts Video (13-min video)

The potential impact of a Concussion

In February 2012, during a hockey practice drill, Nathan Fraser, age 12, sustained a concussion. In the nine months following the incident, Nathan and his parents, Christine and Adam, learned about the symptoms of concussion, the steps to take if a concussion occurs, and how to play safe to minimize the likelihood of a concussion.

NATHAN’S STORY >

PREVENTION

The most important step in preventing concussions is RESPECT.

Coaches, team staff and parents/guardians play a big role in helping to develop an atmosphere of respect for the safety wand well-being of all participants in the game. You can make player safety a priority at your team meetings, talk about concussion prevention, and ensure that all players understand the consequences of violent actions and dangerous hits.

Respect for the players

• If you are a fellow player never check to the head, hit someone from behind, or attempt to injure a fellow player
• If you are a coach:
  • encourage safe competition and discourage reckless or malice behavior,
  • set expectations for behaviors and potential consequences, and
  • focus on proper skill development.
• If you are a parent:
  • be a positive influence,
  • encourage and celebrate positive behaviors like teamwork and skill development rather than negative behaviors like intimidation.

Respect for the rules

• Everyone should understand the rules and the reasons they are in place
• As a coach:
  • educate players on the techniques and game play,
  • ensure the players are playing within the rules, and
  • educate the players on why a penalty was assessed.
• As a parent:
  • gain an understanding of the rules,
  • support rule emphasis within the team environment, and
  • communicate to your child why certain rules are being emphasized.

Respect for the officials

All participants should avoid setting a negative example when a penalty is called and be patient with officials as they refine game management techniques to make the game safer and more exciting for the players.

Hockey Canada has passed a zero tolerance rule to any contact above the shoulders. This rule - combined with education awareness, strong player development and respect for the game - will reduce injuries like concussions and help to keep the game fun for all. The keys to preventing concussions from occurring are:

• Reducing violence in the game.
• Reducing head contact.
• Reducing hitting from behind.
• Educating all participants on prevention and recognition of head injuries and responsible return to play.
• Encouraging respect and fair play.

HOCKEY CANADA RULE BOOK > 

EDUCATION

Equipment

Players, parents, and coaches should ensure that proper equipment is worn at all times. This includes ensuring the equipment is the proper size and used in the manner it was intended.

It is important to remember that no study has yet to show that any equipment - including helmets and mouth guards - prevents a concussion. However, helmets and mouth guards provide protection against localized injuries such as skull fractures and dental/oral damage.  Therefore, it is important to think first and keep respect in the game.

PARACHUTE CANADA VIDEO > | HOCKEY CANADA EQUIPMENT VIDEO >

Skill Development

Another important factor in preventing concussions is skill development, especially in checking. Checking should not be confused with body checking.

Checking is a 4-step progression starting at the novice and atom levels focusing on skating, positioning, and angling and progressing as the players develop and mature to initiating body contact, confidence in body contact, and finally body checking.

Teaching players the proper skills will give them confidence on the ice to move around in a safe manner, will create awareness for them to avoid dangerous situations, and ensure they reduce the potential to injure another participant.

HOCKEY CANADA CHECKING SKILLS PROGRAM > | HOCKEY ALBERTA CHECKING SKILLS COURSE > 

Avoiding unnecessary behaviour

Players should avoid activities that result in direct impacts to the head such as fighting or “locker boxing” regardless if a helmet or face mask is worn.

Coaches and team leaders need to work to eliminate this type of behavior both in the dressing room and in areas where this behaviour can potentially occur by implementing prevention plans and team rules against locker boxing and fighting, and by clearly defining these to all players, coaches, team managers, safety people and parents throughout the season. When combined with player and parent education with respect to concussions, this will help to eliminate this type of behavior.

RECOGNITION

ALL individuals including players, parents/guardians, coaches, trainers, Safety Personnel, team staff, and officials are responsible for the recognition and reporting of participants with a suspected concussion.

This is particularly important because many teams will not have access to on-site licensed healthcare professionals, symptoms and signs can have a delayed onset, and concussions do not necessarily occur because of a massive impact or a direct below to the head.

Observing Symptoms/Signs of Concussion

A concussion should be suspected if a participant sustains an impact to the head, face, neck, or body and:

• demonstrates one or more observable signs of a suspected concussion OR reports one or more symptoms of suspected concussion (as detailed in the Concussion Recognition Tool 6).

Even if the impact was not witnessed, or if symptoms come and go, if there is a suspected concussion (one or more observable signs or the participant reports one or more symptoms) the participant is removed from play the day of the injury, does not return that day and sees a licensed healthcare professional for Medical Assessment as soon as possible.

CONCUSSION RECOGNITION TOOL >

Red Flags:  IF ANY OF THE FOLLOWING SIGNS ARE OBSERVED OR ARE REPORTED BY A PARTICIPANT FOLLOWING AN IMPACT TO THE HEAD OR BODY, INITIATE YOUR EMERGENCY ACTION PLAN. THE PARTICIPANT SHOULD BE IMMEDIATELY REMOVED FROM PLAY AND TRANSPORTED FOR URGENT MEDICAL CARE BY A LICENSED HEALTHCARE PROFESSIONAL.

• Neck pain or tenderness
• Loss of vision or double vision
• Seizure, ‘fits’, or convulsion
• Loss of consciousness
• Increased confusion or deteriorating conscious state (becoming less responsive, drowsy)
• Weakness or numbness/tingling in more than one arm or leg
• Repeated Vomiting
• Severe or increasing headache
• Increasingly restless, agitated or combative
• Visible deformity of the skull

Every team should have an Emergency Action Plan in place for when a suspected concussion is identified. EAP’s are for all injuries, including concussions, and must be documented and reported.

EMERGENCY ACTION PLAN FLOWCHART >

IF NO RED FLAGS EXIST, USE THE VISIBLE CLUES, PHYSICAL SYMPTOMS, CHANGES TO EMOTIONS AND THINKING, AND AWARENESS QUESTIONS ON PAGE 2 OF THE CONCUSSION RECOGNITION TOOL TO HELP IDENTIFY IF A POSSIBLE CONCUSSION MAY HAVE OCCURRED.

Consult the Concussion Protocol for Recognition and Concussion Assessment Scenarios.

REMOVE

When a participant is suspected of having a concussion regardless of whether the concussion occurs on or off the ice, even if the impact was not witnessed, or if symptoms come and go, if there is a suspected concussion (one or more observable signs or the participant reports one or more symptoms) the participant:

• is immediately removed from practice or play
• if RED FLAGS exist, the participant is immediately referred to / transported to urgent medical care
• is not permitted to return to play/practice that same day
• should not return to any sport activity until assessed medically by a licensed healthcare professional. The Medical Assessments Letter or a traditional medical document needs to be provided following assessment of a suspected or diagnosed concussion.
• Coaches, parents/guardians are informed, and provided information about the 6 step Hockey-Specific return to sport strategy
• is not permitted to return to play or practice until all the return to sport requirements are met, including receiving medical clearance

NOTE: Second impact syndrome, although rare, can occur in players who return to activity to soon or with ongoing symptoms. Monitoring of return to play is essential. Always err on the side of caution.

RESPONSIBLE RETURN TO PLAY

No member of the hockey community in Alberta - including coaches, safety personnel, and parents/guardians - is to pressure any participant to return to play until they have completed the 6 step Hockey-Specific return to play strategy and is medically cleared by a physician.

Participants diagnosed with a concussion are to be managed according to their Return-to-School (if applicable) and Hockey-Specific Return-to-Sport Strategies under the supervision of a medical doctor. When available, participants should be encouraged to work with their team’s licensed healthcare professional to optimize progression through their Hockey-Specific Return-to-Sport Strategy.

The stepwise progressions for Return-to-School and Hockey-Specific Return-to-Sport Strategies are outlined in the Concussion Protocol, both these strategies begin at the same time, can happen concurrently and the first step of both is the same.

The participant should spend a minimum of 24 hours at each step before progressing on to the next. It is common for a participant’s symptoms to worsen slightly with activity. This is acceptable as they progress through steps 1 to 3 of return to sport, so long as symptom exacerbation is:

• mild: symptoms worsen by only one to two points on a zero-to-10 scale, and
• brief: symptoms settle back down to pre-activity levels within 1 hour.

If the participant’s symptoms worsen more than this, they should stop the activity and try resuming the next day at the same step.

Before progressing to step 4 of the Hockey-Specific return to play strategy, participants must:

• successfully complete all steps of the Return-to-School Strategy (if applicable), and
• provide their coach with a Medical Clearance Letter or traditional medical documentation indicating they have been medically cleared to return to activities with risk of falling or contact.

If the participant experiences concussion symptoms after medical clearance (i.e., during steps 4 to 6), they should return to step 3 to establish full resolution of symptoms. Medical clearance will be required again before progressing to step 4.

6 Step Return to Play Process

The Hockey-Specific return to sport strategy is comprised of six steps and are intended to be a gradual progression and increase of tolerance to activity.

The participant should spend a minimum of 24 hours at each step before progressing on to the next, however progression can vary and the key to proper recovery is not to rush through each step.

The stepwise progressions for Return-to-School and Hockey-Specific Return-to-Sport Strategies are outlined in the Concussion Protocol, both these strategies begin at the same time, can happen concurrently and the first step of both is the same.

IMPORTANT NOTE: Additional concussions on top of one or more sustained concussions can lead to substantially more damage than one concussion alone. The effect of concussions is cumulative, and the result of several concussions could be ongoing symptoms. If not properly managed the result could be the end of participation in sport and affect other aspects of life.

 Sufficient time between the concussion and return to play is critical. If there are previous concussions, it is important to report this to the physician. Children are more sensitive to the effects of a concussion and will need to have a longer period before returning to sport. Use symptoms rather than a set time frame when assessing return to play. Always follow the advice of a physician.

Most participants who sustain a concussion while participating in sport will make a complete recovery and be able to return to full school without any concussion-related accommodations and full sport participation without restrictions within four weeks of injury. However, approximately 15 to 30 per cent of participants will experience symptoms that last longer beyond this time frame.

Participants who experience persisting symptoms (longer than four weeks) may benefit from referral to specialized interdisciplinary concussion care for assessment and care that addresses the participant’s individual symptoms and needs.

INJURY REPORTS

Don’t forget that part of your participation fee includes insurance coverage – this insurance can be accessed for many sport related injuries and requires the  Hockey Canada Injury Report form to be completed and submitted.

Concussions are injuries, even if you don’t think you have use for insurance during or immediately after the concussion recovery process the Hockey Canada Injury Report form should be filled out.

Parents/Guardians, the team, and a physician/dentist are all required to fill out sections of the form. Make sure you are aware of who needs to fill out what information so that the form can be submitted in a timely (within 90 days) and completed manner.

As a best practice the Hockey Canada Injury Report form needs to be submitted within 90 days from the date of injury to receive the appropriate supports form the insurance program. However, all injuries are encouraged to be reported (even past the 90-day deadline) for accurate tracking and follow-up.

WHEN NO CONCUSSION IS DIAGNOSED

Participants who have been determined to have not sustained a concussion AND provide a Medical Assessment Letter or traditional medical documentation indicating that they can return to hockey-related activities without restriction, may resume all hockey-related activities.

WHEN A CONCUSSION HAS BEEN DIAGNOSED

Participants who have been diagnosed with a concussion can be considered for medical clearance to return to sport activities with risk of contact or fall only once they have successfully completed:

• all steps of the Return-to-School Strategy (if applicable), and
• steps 1 to 3 of the Hockey-Specific Return to Play Strategy.

The final decision to medically clear a player to return to activity with risk of falls and contact should be based on the clinical judgment of the medical doctor.

To progress to step 4 of return to sport, the player must provide the appropriate people (e.g., coach, trainer, Safety Personnel, organization administrators) with a Medical Clearance Letter that specifies that a medical doctor has personally evaluated the patient and has cleared the participant to return to sport. Virtual medical clearness may occur, consult Step 7 of the Concussion Protocol for details on virtual clearance.

Participants who have been provided with a Medical Clearance Letter or traditional medical documentation may progress through steps 4, 5 and 6 of the Hockey-Specific Return to Play Strategy to gradually return to full, unrestricted hockey-related activities.

If the participant experiences any new concussion-like symptoms during these steps, they should be instructed to stop the activity and return to step 3 until their symptoms are fully resolved. Medical clearance is required again before progressing to step 4. This information should be provided to the appropriate people (e.g., coach, trainer, Safety Personnel, organization administrators).

Hockey Alberta determines and administers discipline for any club, team or individual who knowingly disregards the return to play process and their responsibility of requiring a physician’s written permission permitting a player to return to play following a concussion.

Parachute Canada

Parachute developed the Canadian Guideline on Concussion in Sport to ensure that athletes with a suspected concussion receive timely and appropriate care, and proper management to allow them to return to their sport.

Canadian Guideline on Concussion in Sport (2024) >

Hockey Canada Concussion Resources:

As the national body for our sport and a leader in creating a safe environment for sport, Hockey Canada has worked with numerous partners to develop a series of Concussion resources and a toolbox for all associations to use including:

• Prevention & the Hockey Canada Network App
  • Team meeting formats, emergency action plan
• CRT6 and SCAT6 concussion recognition and assessment tools
• Concussion Toolbox
• Concussion Pathway

HOCKEY CANADA CONCUSSION DOWNLOADS AND RESOURCES >

General Resources

• Concussion Recognition Tool 6 (CRT6) >
• Sport Concussion Assessment Tool 6 (SCAT6) >
• Child Sport Concussion Assessment Tool 6 (Child SCAT 6) >
• Return to Play Strategy >
• Concussion Protocol Summary >