Citation: Cusimano MD, Ilie G, Mullen SJ, Pauley CR, Stulberg JR, Topolovec-Vranic J, et al. (2016) Aggression, Violence and Injury in Minor League Ice Hockey: Avenues for Prevention of Injury. PLoS ONE 11(6): e0156683. https://doi.org/10.1371/journal.pone.0156683
Editor: Fabio Lucidi, University of Rome, ITALY
Received: March 18, 2015; Accepted: May 18, 2016; Published: June 3, 2016
Copyright: © 2016 Cusimano et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Due to dataset institutional restrictions, specifically the SMH’s Institutional Research Ethics Board Agreement, data/interviews cannot be made available in the manuscript, the supplemental files or a public repository. Readers, however, may contact to request the public data file underlying the findings of this study from the St. Michael’s Hospital Injury Prevention Research Office (email:email@example.com. and/or Dr. Michael Cusimano (email:firstname.lastname@example.org).
Funding: This research was supported by the Canadian Institutes of Health Research (http://www.cihr-irsc.gc.ca/e/193.html) Strategic Team Grant in Applied Injury Research #TIR-103946, the Ontario Neurotrauma Foundation (http://onf.org), as well as the St. Michael’s Hospital Foundation (http://www.stmichaelsfoundation.com/). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
For children and adolescents 10–19 years of age, 44% of injuries requiring a visit to the emergency department occur during sports or some other physical activity . Classified as a collision sport, ice hockey (hereafter called simply “hockey”), one of North America’s most popular sports, puts more than 820,000 participants into regular physical activity but also places them at risk for potentially serious injury annually [2, 3]. A report  of the Emergency Department Injury Surveillance System found that hockey was the leading sport during which injuries occurred and that 43% of hockey injuries were to the head and neck. Studies have shown that 75–88% of injuries in amateur hockey resulted from collisions, and that at least 25% of these were legal checks [4, 5]. While many players believe legal checks are acceptable in hockey culture, they still account for a significant proportion of injuries in hockey. Aggressive behaviour during hockey results in a number of injuries, ranging in severity from soft-tissue contusions, fractures to concussions, across all age groups [5–15]
The benefits from sports participation for youth are many. Sports have been found to increase physical health, cardiovascular conditioning, strength, and endurance, improve their self-image, decrease the risk of obesity, help youth learn that they can improve their performance and skills through practice and hard work, and teach cooperation and team building skills . Youth that participate in youth team sports learn how to interact with their peers, to assist those who are less skilled, and to learn from those who are more highly skilled. At the same time, we cannot ignore the risks involved in ice hockey and many other contact sports.
In many countries, including the USA and Canada, hockey injuries as a result of aggression in professional and amateur arenas garner extensive media attention [17–19]. Aggression in play has usually been operationalized as purposeful physical, verbal or gestural acts, driven both by competitiveness and an intent to cause physiological or psychological harm . The concept of “injury”, however, can be seen to encompass intrinsic risk factors related to such qualities as bone strength or previous injury history and extrinsic risk factors such as reaction to other athletes, game conditions, officiating decisions or the spectator environment  as well as the interrelationships between them . It is qualities such as the latter that were of particular interest in this study. Hockey professionals who engage in aggressive behaviours leading to injury, as well as the media, which disseminates this form of aggression as entertainment , both contribute to the socialization of aggressive play. Professional hockey players displaying aggressive play as thus operationally-defined are seen as being poor role models for young viewers [24–26]. An immediate consequence of this type of violence socialization in our culture is that viewers who are now parents have developed the idea that most violence on the ice (e.g., body checking, concussions) may be inconsequential  and, while empirical evidence may suggest that parents play many roles, including both positive and negative  there is a commonly-held belief that many encourage their children to participate in aggressive behaviours . Their children and adolescents, who are particularly influenced by both media and the way parents respond to live and televised games, become socialized into accepting these high-risk behaviours at a very young age and end up naturally enacting them on ice, rendering themselves vulnerable to injury [2, 4].
Social Learning Theory posits that the socialization journey, from infancy without any culture to the enculturated self, is the result of cultural observation and modelling while growing up . While much of human behaviour is influenced by our genetic makeup, the socialization process can mold it in particular directions by encouraging specific beliefs and attitudes as well as selectively providing experiences. To better understand the factors that influence aggressive and potentially injurious behaviours during hockey among youth, we explored the culture and socialization of youth hockey in a sample of players, parents, coaches, trainers, managers, and a game official in Toronto, Canada. Culture can be defined as “the set of shared attitudes, values, goals, and practices that characterizes an institution or organization” . To address this topic, we designed a qualitative study to provide an in-depth perspective on the culture of hockey as seen by players, parents and coaching staff involved in the organization. The first objective of this study was to provide an in-depth analysis of the culture of hockey, specifically with regards to attitudes towards aggression and how it contributes to the frequency of injury. A second objective of the study was to translate the current findings into specific recommendations for the development of preventive interventions in competitive team sports.
Study Design and Sample
Qualitative research is particularly well-suited to exploratory studies for which previous literature is limited. While there are a number of studies that explore attitudes towards aggression in minor hockey players through such means as the use of psychometric tools or player ratings of aggressive incidents on video [32–35] to our knowledge, there are no qualitative studies exploring attitudes towards aggressive play.
We chose a diverse cohort of participants using purposeful sampling from a pool of hockey teams in the Greater Toronto Area, resulting in a final total of 14 teams from a variety of competitive levels of play [36–39]. We also chose to interview a group of “reference others”, including parents, coaches, trainers, and other adults from whom players seek approval and reinforcement [30, 33, 34, 40, 41]. According to Social Learning Theory (SLT) the “reference others” group may play a significant role in shaping players’ attitude and behaviours through observation and modeling . To ensure that interviewee responses were not biased, both offense and defense positions were selected (7 centres, 5 right wing, 6 left wing, 15 defense and 5 goalies). Ten parents, 6 coaches, 4 trainers, 2 managers and a game official were also interviewed. All young players were interviewed face-to-face, 17 of the “reference others” were interviewed in person, and 6 of the “reference others” were interviewed over the phone. We selected a group of early adolescent players because injury often begins to manifest during play at this age, often due to disadvantages related to such variables as height and weight (at this age there is significant variation in young players’ sizes; of those who volunteered their height and weight, they ranged from 160 cm to 178 cm, with weights from 46 kg to 62 kg). This age group also has higher prevalence estimates of injury relative to children or adults [42–46]. The level of play for body checking league teams (competitive) was chosen based on research demonstrating that an increase in concussion frequency is seen with older players and more elite levels of play [47–50] We also had participants from a non-body-checking league (comprised of both females and males) that does not allow body checking, though physical contact still occurs within the rules of the game. All of the non-body checking league players had participated in a competitive body checking league prior to joining the non-body checking organization and we included them in this analysis because of their unique perspective of having viewed the issues from the point of view of both types of play. No other systematic differences could be inferred between groups; at the very least, however, no cohort effects could be attributed to factors such as age, as all players were between 13 and 14 years of age.
The Research Ethics Board of St. Michael's Hospital 03–315 (Q) has renewed their approval for this study (titled, for their purposes, "Clues to Prevention of Injury in Hockey: A Qualitative Study") for the years 2015–2016. Written informed consent was obtained from each player, parents/guardians, and the “reference others”.
The basis for the interview outline was based on a review of the literature (peer reviewed journals and social psychology textbooks) and informal discussions with players, coaches, parents and health professionals. In-depth, semi-structured interviews were conducted with all participants. A full outline of the questions asked of participants is described in S1 Appendix. The average interview length was 38 minutes. Two pilot interviews were conducted with individuals not involved in the study, and feedback from those interviews helped to further develop the interview guide used. Upon completion of their interview, study participants were instructed not to disclose the content prior to the completion of all interviews. The voluntary nature of participation and assurances regarding privacy and confidentiality were emphasized before each interview.
All interviews were audiotaped, transcribed verbatim, and reviewed by members of the research team to identify major themes. Grounded theory methodology served generally as a framework, as categories and themes were allowed to emerge from the data inductively, as opposed to being pre-identified by a priori hypotheses [51, 52]. Text was divided into meaningful pieces of information known as meaning units (MU) coded based on similar features to create broad categories, and further classified into specific themes and sub-themes . Only the themes pertaining to attitudes towards aggression in hockey are presented herein. The responses that aided in the identification of those themes were articulated in response to questions such as “Have you ever learned how to hit another player illegally in any way from watching pro-hockey?”, “What kind of things do you see when you watch hockey that bother you?”, and “How important is checking for winning in hockey?”
A thematic analysis of the interviews revealed themes related to aggression that were divided into four main categories: 1) players’ views on aggressive behaviors performed by others (see items f and g in Section One of S1 Appendix for examples), 2) parents’, coaches’ and teammates’ perceived influence on play (see items e, f and g in Section Three of S1 Appendix for examples), 3) players’ own aggressive thoughts and acts (see item k in Section Four of S1 Appendix, for example), and 4) players’ perceptions of parents’, coaches’, and teammates’ beliefs about aggression (see l, m and n in Section Four of S1 Appendix for examples), High injury rates have been observed in minor hockey, ranging from bone fractures to traumatic brain injuries [54–56]. In this analysis, we discuss how injuries to the head are associated with a high degree of emphasis on aggression within the sport. The themes we identified are described below.
The players’ own aggressive behaviors
The players reported engaging in both instrumental and hostile aggression. Instrumental aggression is defined as legitimate action within the rules of the game, with the ultimate goal of advancing successful play. Conversely, the primary purpose of hostile aggression is to inflict harm on one’s opponent, often in cases where the player is angry .
Hostile aggression was exhibited by most of the competitive level players only as a response to a teammate being injured by an opponent. With female and non-body checking league players, anger was handled differently than in the body checking league. These players would talk about seeking revenge after a teammate was injured, but their feelings were not acted upon. One player described it in the context of major league incidents in the news where there had been severe injuries and felt that it was “right to revenge what happened to his fellow teammate, but not to that extent” and that to “stay out of the penalty box would help give their team an advantage…don’t take stupid penalties like slashing…There’s like a line where it’s ok and it’s not ok.” The desire to engage in revenge could be considered an outcome of the phenomenon known as groupthink, (the tendency of a group to make decisions in ways that discourage creative problem solving or individual responsibility) , and it is common to see this as a familiar tendency in sports teams . However, it is noteworthy that there were few instances in these interviews where team members did act on such feelings.
There are, however, a variety of factors other than groupthink that may mediate action. For example research from sports in general (and around groupthink in particular) suggests that coaches, parents, and peers may be effective at demonstrating attitudes and behaviour that create a climate that reduces anxiety , there may be subtle interactions between a team’s overall sense of collective efficacy and their performance  or there may be changes in team membership or team dynamics that mitigate undue cohesion and risk of groupthink . Moreover, such behaviour could also be because the coach’s attitude was not conducive to allowing retaliation, either because the players did not feel that acting on these feelings would be appropriate, or because of the rules of their game make physical acts of aggression illegal. In contrast, the competitive body checking-league players interviewed expressed a need to take matters into their own hands. For example, one player in our study observed that “it’s a physical game so you gotta hit to slow them down and stuff and it’s part of the game so…it’s pretty important like you have to do all of the stuff that makes you win and that’s one of them I think”.
Social identity theory provides some basis for understanding players’ feelings in this and similar scenarios, accounting for the strong feelings of responsibility on the part of group members to defend and protect each other in order to maintain the group’s cohesion [63, 64]. The relationship between participation in team sports and the development of prosocial behaviour and altruism is well-documented [65, 66], and recent research demonstrates a clear link between social identity and outcome interdependence (that is, the degree to which team performance is attributed to individual members’ performance and vice versa) .
A hockey team, like any small group, is going through a cycle of “form, storm, norm, perform, and adjourn” to form an effective team [68–70] where group cohesion serves to not only allow goals that are instrumental for the group to be pursued, but also to satisfy individual members’ affective needs [71, 72]. Similary, social conformity in sports is important as a team member may comply with an abusive or aggressive coach for the sake of social acceptance and approval. The need to maintain group cohesion through defending and protecting team mates may be contrasted with the fact that some players feel it is their role to initiate aggressive behaviors to intimidate the opponents, further intensified by their perception of their coach as emphasizing normative success and strongly wanting to win by capitalizing on “momentum”. As one player described it “if they’re scared, like if you get the momentum, that’s usually what happens, the coach wants us to get the momentum so we crank one guy and he kind of gets out of the play and starts shying off,” In such circumstances, they may perceive him or her as encouraging inappropriate aggression . These players had higher self-reported numbers of penalty minutes than the team average.
The concept of designated roles, or even those that emerge informally is one that has been explored in the literature  and was revisited often throughout the interviews. Having a role on the team, even one designated as being an aggressive player, helps to secure one’s membership in the group, enhances group cohesion, and is encouraged by the players’ reference others. For example, one player identified the value of these roles thus: “making big hits and stuff would make you feel good and I guess scoring goals too. And anything to boost the team, so like energy I guess” while another noted that “if you’re big or small and you’re the guy who makes a big hit and makes the play that kind of picks up the team a bit so it helps if you have one guy who can do that”. This is also an illustration of masculinity and “being tough” linked with the players’ willingness to engage in aggressive behavior and to feel “manly” or “powerful” on the ice. This pressure still exists in the non-body checking league, but may be tempered by regulations that deter this behaviour.
There also appears to be a fundamental difference between males and females in their tolerance for aggression whether or not the male player was in the body-checking league or not. Although most of the female players interviewed said that they would be angry with a player who injured their teammate, they did not seek retribution. As one player stated, “At the time we get really mad and sometimes we’re like ‘oh let’s get her back’ or whatever, but usually we don’t.” This was evident not only with female players, but with female parents who were more likely to describe the game as extremely violent and to advocate for such regulation changes as stricter penalties for undue aggression. Although the male players intended to “hurt” another player in their pursuit of revenge, they did not believe that they were capable of seriously injuring their opponents, or were at least prone to minimize the impact of the violence. For example, male players in the body checking leagues made statements such as “the first year of hitting I hit somebody and I broke their collar bone, but like I guess I kind of did feel sorry for them and stuff, but not that guilty. I meant to hit them but I didn’t mean to put them out of the season.”, and “I’ve hit some people before, I don’t know, it was unintentional cause I didn’t expect what happened…like, I’ve hit some people and knocked them out, but I was mad at the time so I didn’t really mean to…. I just meant to show them I was there”. In other cases, they operationalized checking as just another tool to secure victory: “Checking yeah…it’s a big part of the game. You need to be physical to have a good team, so size matters a lot now, ‘cause if you’re small you’re not going to be able to check a lot. I think checking can help win a lot cause it can intimidate the other team if you’re a lot bigger than them, and you can sort of get the puck easier because they’ll be afraid of you checking them”.
Social theory states that men feel a need to exhibit aggressive behaviors through sports in order to develop their masculine identity , which may help to explain the variation in perspectives according to gender. This difference in gender perspectives is consistent across a variety of contexts [40, 76, 77]. This is an important issue to address when designing interventions, as raising the players’ awareness of the consequences of their actions may help to reduce this type of behaviour and its associated injuries.
Players’ perceptions of their parents’, coaches’ and teammates’ views on aggression
According to Bronfenbrenner  parents, coaches and teammates represent people in immediate and proximal settings in which the individual (player) lives. This micro system includes the child’s or adolescent’s family, peer group, neighborhood and school life and helps shape a person's development through direct contact. The nature of this micro system is that the individuals who have direct contact with the young hockey player will aid in the construction of the settings of this system. Players’ perceptions of their parents, coaches and teammates are very important, as their feedback influences the development of their self-image and the corresponding behavior they exhibit on the ice [40, 41]. An interesting finding from our study is that players from the same team often had contrasting interpretations of their coaches’ and teammates’ beliefs. For example, one young player stated, regarding his coach, “He encourages all of us to do hitting, cause this one time he had a challenge for us to do 10 hits per period or 30 hits for the game and we ended up getting around 40-something…so he was happy cause we may have lost the game but we outplayed them just by hitting, and by the end of the first period they didn’t want to get hit anymore. So he knows that by encouraging people to hit, it will get us more into the game”, while another, from the same team, stated that “when we got into a fight he didn’t get too mad, he said that it wasted the end of the game, cause we could have won it”. This contrast among players’ experiences suggests, in the first example, a degree of groupthink at play, with a specific game culture self-evident to the participant; however, in the second quote considerably more ambiguity was reflected. Such contrasts could be accounted for by individuals’ relationships with the coaches and the team or due to their own values and beliefs, and their influence on their perceptions [33, 79].
Of the 11 players who were asked, the majority of them (7 when asked about their parents, 9 when asked about their coach, and 8 when asked about their teammates) stated that these reference others did not like illegal hits. Others described coaches who encouraged illegal hits in certain situations (mainly revenge-seeking). Parents were seen as being occasional advocates for illegal hits, so long as their child was not the initiator (“My dad sometimes says if the guy gives you a punch don’t take it, just give him a punch back.”). A negative influence on children’s behaviour in sport is not limited to hockey. In a US study of 132 junior tennis coaches it was found that coaches deemed parents to be a positive influence on their children (players) 59% of the time, but 36% of the time they perceived children’s behaviour during play to be negatively affected by parents (e.g., too much focus on winning, setting unrealistic goals, ongoing criticism of their child) . Teammates were often seen as being occasional advocates for hitting, within proscribed limits. As one player described it, regarding his teammates’ behaviour, “Sometimes they just give a little pat on the back, like, you gotta be more aggressive out there and stuff…but nothing illegal”.
Being in the centre of the action, coaches are ideally placed to comment on sideline behaviour. Throughout the interviews, most participants clearly differentiated between legal and illegal hits, claiming that their reference others felt that checking was acceptable as long as the hit was “clean”. Clean hits refer to legal checks, while “cheap shots” refer to illegal hits, including hitting from behind, high sticking, and so forth. The two main reasons why reference others were said to express disapproval of illegal hits were that: 1) they were unfair and could result in injury and 2) that if their own players received penalties for illegal hits they might compromise the team’s chance of winning.
Players’ views on others’ aggressive behaviour
The participants largely did not approve of illegal activities in professional hockey such as “high sticking”, and “cheap shots”. Although respondents disliked professionals behaving in this fashion, they felt it could be explained by the fact that the players felt frustrated or were “caught up in the heat of the moment”. As one player stated, regarding professionals indulging in unnecessary roughness, “They’re just so into the game that they forget what’s right and wrong.” In terms of attitudes towards their own team members, they were much less forgiving if it was seen as a cheap hit. As one player described it, “Well, if one of our players does a cheap hit, then we’ll care because we’d be disappointed in him, but if it’s a clean hit then we don’t care”.
Most of the female players and some of the male players reacted negatively when their teammates hit other players illegally, both because they felt that it was not appropriate and because they might get penalties and compromise the team’s chance of winning. Although it was seen as acceptable within the group to seek revenge, the goal of winning and maintaining a socially acceptable appearance was valued. As one young woman stated, “if someone hits someone else on the other team then we tell them they shouldn’t do that”. There was also a clear sense that verbal aggression, or “chirping” is seen as being a contributing factor to escalating anger and violence. As one player put it, “a lot of guys chirp…’cause they want to be tough and everything right but uh…I think it’s dumb…a lot of the time you see a guy, uh, like just being a pest and all that right and talking away or whatever. And the other guy will just like, uh, turn and slash him or elbow him or something and uh…yeah it’s dumb ‘cause then he just gets a penalty and the other guy, um…he just gets to go, right”.
Parents’, coaches’ and teammates’ influence on youth play
Since both intrinsic and extrinsic factors affect a player’s behaviours , the influence of reference others on youth hockey players was explored. Our data showed that parents of players in the body checking league were more likely to accept checking as part of the game. In contrast, all of the parents of players in the non-body checking league as well as all of the female parents were more likely to be concerned about the risk of injury. Attitudes towards aggression between players and parents werecongruent as one of the non-body checking parents expressed it, “the kids [were] getting so much bigger than he was and it was just getting too dangerous for our liking. Like I said outside, he wanted to keep playing. He said ‘it’s just not worth the risk.’ We just didn’t want the chance…we saw other kids lying on the ice and you know, concussions and uh…we just thought you know, he can have fun somewhere else”
In contrast, many coaches emphasized legal means of aggression to avoid time in the penalty box, indicating the priority was the team’s ability to win the game. As one coach articulated it, “We’re building this team to make a good run through the playoffs as far as we can go, and um, you know, if you’re going to sit in the penalty box we’re not going to get there. We really preach a lot of discipline throughout the year and say, if you guys really want to be as good as you can be, you can’t be sitting in the penalty box”. Similarly, teammates mostly encouraged aggression, but in this case to obtain revenge when a teammate had been injured, consistent with previous themes regarding retaliation that emerged in this study. One of the body checking players put it most succinctly when he stated, “We try to injure them. Because if he injures one of our best players, you have to go after one of their best players to make it fair. Revenge is fair. It’s human nature. If someone does something to you, then you would want to do it back.”
Among reference others, tolerance for aggression within the game may also correlate with one’s exposure to hockey. Participants with a greater degree of involvement in organized hockey (i.e. Board members, coaches, parents who played hockey) were more likely to endorse aggression and physical violence in hockey and to perceive changes to body checking regulations as threatening. In contrast, parents who had no experience playing hockey appeared more supportive of changes to current regulations. All female parents strongly expressed the need for new policy to increase safety within the game. None of the female parents interviewed reported any personal hockey experience.
In summary, a number of factors might be seen to be related to an increase in aggression during hockey games, including a high emphasis on winning, revenge for teammates’ injuries and variances in the social/cultural values placed upon aggressive play.
While there have been other studies that have looked at shaping attitudes towards violence in hockey though education about sport-related concussions, addressed the role of culture (teammates, coaches, and parents) in determining when a child should return to play after a possible TBI [55, 82, 83], and explored, in a variety of sports, how general attitudes towards sport violence can be mediated [84–86] the study described herein is unique in its attempts to systematically explore the culture of hockey, and how that culture, through socialization, informs and influences young players’ attitudes towards violence in the course of the game. In general, the culture of hockey appears to encourage a sense of loyalty, which includes using aggression to defend teammates in order to protect the team’s cohesion. Warsh et al. found that leagues permitting body checking saw increased injuries attributable to body checking . This relationship was also systematically explored by Emery et al. who found that Peewee players in leagues with body checking faced greater than a 3-fold risk of injury including severe concussion .
In the context of our findings, such aggression, and often the injuries that ensue, can often be attributable to impulsive, revenge-seeking behavior often modelled and encouraged by coaches, parents and teammates. This type of socialization is corroborated, encouraged and modelled also by media outlets through reporting sports violence and aggression in a light hearted manner under the auspice of sports entertainment. Together they account for socialization influences on young athletes’ developing notions of sports masculinity in a culture that promotes sports aggression and violence by deeming it entertaining. Players experience intense emotion on the ice, including anger, during which they disregard their injury-causing potential and perform an aggressive act “in the heat of the moment”. Both female players and those who have joined non-body checking leagues do not express anger in a physical sense; likewise, physical play is not reinforced by their reference others and is deterred by league regulations. In this way, our interpretation is consistent with findings by Emery et al that players in body checking leagues have a 2-fold increased risk of other intentional contact injuries, indicating they have a more aggressive style of play .
Rationalizing aggressive behavior enables the players to maintain the status of their sport, reinforcing their choice to participate in what some people may view as an uncivilized game because of the high rate of play-associated injuries. Most youth indicated that they did not respect professionals who acted like “goons”. This was reinforced by many participants who described their choice of role models as players who were smart, fast, and strong offensively rather than players known for their aggressive behaviors. Phrases such as “he’s really smart when he plays on the ice, he knows where everyone is when he’s playing” and “Crosby is just like really talented and stuff and he uses his head” are emblematic of this attitude. It is, perhaps, noteworthy that these attributes were most valued by non-body checking league players and female players.
Potential Avenues for Prevention
The results of our qualitative assessment warrant the need for a greater understanding of the ways in which youth hockey socialization and young athletes’ notions of masculinity combine to create a culture of aggression and violence. Interventions must appeal to young players’ sense of competitiveness, while simultaneously developing their respect for and awareness of injury. The results of our study and those of others [4, 18, 87, 88] suggest that such interventions to curb aggression and injury in minor hockey should focus on educating youth players and their reference others, encouraging them to accept non-violent role models, and to be fully aware of the serious consequences for aggressive behaviour or head injury on the ice [89, 90].
In order to address these areas of change, multifaceted approaches are needed, targeting all levels of minor hockey, thereby addressing the needs of a population most in need of intervention. Ideally, these would include such steps as introducing universal rule changes to all levels of hockey and their strict, uniform enforcement, as well as broad educational and economic incentives and disincentives. For example, an increase in player and team play-related penalties as well as strict economic penalties and penalties that affect league standing to teams and leagues at all levels could quickly alter this culture of aggression. It is interesting to note that a review of 18 studies on the effectiveness of interventions to reduce aggression and injuries in minor hockey leagues  clearly illustrated that changes to mandatory rules were associated with both fewer penalties for aggressive acts and fewer aggression-related injuries, although the effects of educational and cognitive behavioural interventions were less clear. It was obvious from this review that well-designed studies of multifaceted strategies combining a number of approaches are required.
In terms of the relationship between exposure to hockey and tolerance for aggression, our findings support altering the makeup and renewal processes of governing bodies and governance structures. This could be accomplished by implementing time-limited terms of service for hockey organizations and increasing the presence of expert opinion in injury prevention. Such changes could promote relatively rapid change of hockey culture.
Physicians, health professionals, researchers, and concerned parents for their part, can help advocate for such interventions; serve as role models for a healthy approach to sport; counsel players, parents and coaches, and raise awareness about safe play and the risks associated with certain practices in this sport and other similar ones like rugby, American football and soccer.
The utility of qualitative data is strongly linked with the effectiveness of the researcher’s interviewing techniques. Although every attempt was made to keep interviews standardized and semi-structured not all interviews were conducted face-to-face. This may have introduced systematic variations in the type and detail of information shared.
Moreover, response bias in the expressed perspectives of those who chose to participate is a limitation of this study. Representativeness of the data in a qualitative study is important. Given the voluntary nature of the study, not all viewpoints may be represented. For example, coaches who refused to have their team participate in this study (and the team members as well as their parents) may have represented divergent positions which were not represented in the data. However, the range of expressed narratives obtained suggests indeed that the results are representative. While it might be argued that certain groups (i.e. only 2 managers; only 4 trainers) were not large enough on their own to attain saturation, it could be argued that the perspectives shared by the larger group of “reference others” did represent a large enough sample to allow for the emergence of meaningful themes. Certainly, given their key roles, these reference-others should be the focus of future research. To be certain, our sample size was large in comparison to many qualitative studies, but future work could try to gain greater representation of particular sets of reference others (i.e. game officials, female players).
The dominant theme that emerged from our study showed that aggression is a part of the sport and participants justify it as a means to seek revenge, even if injury is a by-product of that aggression. Such revenge is not only seen as acceptable, but also reinforced by teammates, coaches, the media and the professional players whom the youth aspired to emulate, particularly in the context of competitive male body-checking leagues. With this new awareness about hockey culture, we encourage pursuing avenues to alter this dominant theme. Concerted efforts by all stakeholders inside and outside the sport using varied strategies will be required to achieve real change.
Conceived and designed the experiments: MC GI SM JS JTV SZ. Performed the experiments: SM JS. Analyzed the data: MC GI SM JS JTV SZ. Wrote the paper: MC GI SM JS JTV SZ CP.
- 1. Surveillance, Epidemiology Division CfCDPPHAoC. Chronic disease and injury indicator framework: quick stats, Fall 2014 edition. Chronic diseases and injuries in Canada. 2014;34(4):272–5. pmid:25408189.
- 2. Pediatrics AAo. Safety in youth ice hockey: the effects of body checking. Pediatrics. 2000;105(3 Pt 1):657–8. pmid:10699128
- 3. Bawa H BM, DeGagne D, Guanghong H, Smith D. Sports Related Injury Data Report 2001–2003: Emergency Department Injury Surveillance System: BC Research and Injury Prevention Unit; 2004. Available from: http://www.injuryresearch.bc.ca/wp-content/uploads/2014/08/EDISS-Sports-Related-Data-Report-2004.pdf.
- 4. Brust JD, Leonard BJ, Pheley A, Roberts WO. Children's ice hockey injuries. Am J Dis Child. 1992;146(6):741–7. pmid:1595632.
- 5. Emery CA, Hagel B, Decloe M, Carly M. Risk factors for injury and severe injury in youth ice hockey: a systematic review of the literature. Inj Prev. 2010;16(2):113–8. pmid:20363818.
- 6. Emery CA, Kang J, Shrier I, Goulet C, Hagel BE, Benson BW, et al. Risk of injury associated with body checking among youth ice hockey players. JAMA. 303(22):2265–72. Epub 2010/06/10. 303/22/2265 [pii] pmid:20530780.
- 7. Emery CA, Meeuwisse WH. Injury rates, risk factors, and mechanisms of injury in minor hockey. Am J Sports Med. 2006;34(12):1960–9. Epub 2006/07/25. 0363546506290061 [pii] pmid:16861577.
- 8. Fu T, Jing R, Cusimano M. Lifetime costs of traumatic brain injury identified in the emergency department in Ontario. Canadian Journal of Neurological Sciences. 2015;42.
- 9. Laker SR. Epidemiology of concussion and mild traumatic brain injury. PM R. 3(10 Suppl 2):S354–8. Epub 2011/11/09. S1934-1482(11)00498-9 [pii] pmid:22035677.
- 10. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med. 40(4):747–55. Epub 2012/01/31. 0363546511435626 [pii] pmid:22287642.
- 11. Marchie A, Cusimano MD. Bodychecking and concussions in ice hockey: Should our youth pay the price? CMAJ. 2003;169(2):124–8. Epub 2003/07/23. pmid:12874161.
- 12. Roberts WO. Hitting in amateur ice hockey: not worth the risk. The Physician and sportsmedicine. 1999;27(12):35–41. pmid:20086683.
- 13. Shirazi M, Cusimano M, McFaull S. Violence-related brain injuries sustained in youth ice hockey. Canadian Journal of Neurological Sciences. 2015;42.
- 14. Stuart MJ, Smith AM, Nieva JJ, Rock MG. Injuries in youth ice hockey: a pilot surveillance strategy. Mayo Clin Proc. 1995;70(4):350–6. pmid:7898141.
- 15. Warsh JM, Constantin SA, Howard A, Macpherson A. A systematic review of the association between body checking and injury in youth ice hockey. Clin J Sport Med. 2009;19(2):134–44. pmid:19451769.
- 16. Wojtys EM. Young Athletes. Sports Health: A Multidisciplinary Approach. 2015;7(2):108–9.
- 17. R M. The Bertuzzi Incident: On-Ice Attack Renews Debate About Violence in Hockey. Canada's Troubled Game Suffers Yet Another Blow. The Globe and Mail. 2004 March 10;Sect. A: 1.
- 18. Bertuzzi's savage attack should land him in court. The Globe and Mail. 2004 March 10;Sect. A.
- 19. Sports C. NHL Hockey Injuries: Canadian Broadcasting Corporation; 2015. Available from: http://sportsstats.cbc.ca/hockey/nhl-injuries.aspx?page=/data/nhl/injury/injuries.html%3f*hf=off*.
- 20. Sheldon JP, Aimar CM. The role aggression plays in successful and unsuccessful ice hockey behaviors. Research Quarterly for Exercise and Sport. 2001;72(3):304–9. pmid:11561397
- 21. Almeida PL, Rubio VJ, Palou P, Olmedilla Zafra A. Psychology in the realm of sport injury. Revista de psicología del deporte. 2014;23(2):0395–400.
- 22. Wiese-Bjornstal DM. Reflections on a Quarter-Century of Research in Sports Medicine Psychology. Revista de psicología del deporte. 2014;23(2):0411–421.
- 23. Cusimano MD, Sharma B, Lawrence DW, Ilie G, Silverberg S, Jones R. Trends in North American newspaper reporting of brain injury in ice hockey. PLoS One. 2013;8(4):e61865. Epub 2013/04/25. PONE-D-12-40215 [pii]. pmid:23613957.
- 24. Celozzi MJ, Kazelskis R, Gutsch KU. The relationship between viewing televised violence in ice hockey and subsequent levels of personal aggression. Journal of sport behavior. 1981.
- 25. Nash JE, Lerner E. Learning from the pros: violence in youth hockey. Youth & Society. 1981;13(2):229–44.
- 26. Villani S. Impact of media on children and adolescents: a 10-year review of the research. J Am Acad Child Adolesc Psychiatry. 2001;40(4):392–401. pmid:11314564.
- 27. DeMatteo CA, Hanna SE, Mahoney WJ, Hollenberg RD, Scott LA, Law MC, et al. My child doesn't have a brain injury, he only has a concussion. Pediatrics. 2010;125(2):327–34. pmid:20083526
The frequency and potential long-term effects of sport-related traumatic brain injuries (TBI) make it a major public health concern. The culture within contact sports, such as ice hockey, encourages aggression that puts youth at risk of TBI such as concussion. Newspaper reports play an important role in conveying and shaping the culture around health-related behaviors. We qualitatively studied reports about sport-related TBI in four major North American newspapers over the last quarter-century. We used the grounded-theory approach to identify major themes and then did a content analysis to compare the frequency of key themes between 1998–2000 and 2009–2011. The major themes were: perceptions of brain injury, aggression, equipment, rules and regulations, and youth hockey. Across the full study period, newspaper articles from Canada and America portrayed violence and aggression that leads to TBI both as integral to hockey and as an unavoidable risk associated with playing the game. They also condemned violence in ice hockey, criticized the administrative response to TBI, and recognized the significance of TBI. In Canada, aggression was reported more often recently and there was a distinctive shift in portraying protective equipment as a solution to TBI in earlier years to a potential contributing factor to TBI later in the study period. American newspapers gave a greater attention to ‘perception of risks’ and the role of protective equipment, and discussed TBI in a broader context in the recent time period. Newspapers from both countries showed similar recent trends in regards to a need for rule changes to curb youth sport-related TBI. This study provides a rich description of the reporting around TBI in contact sport. Understanding this reporting is important for evaluating whether the dangers of sport-related TBI are being appropriately communicated by the media.
Citation: Cusimano MD, Sharma B, Lawrence DW, Ilie G, Silverberg S, Jones R (2013) Trends in North American Newspaper Reporting of Brain Injury in Ice Hockey. PLoS ONE 8(4): e61865. https://doi.org/10.1371/journal.pone.0061865
Editor: Brian Christie, University of Victoria, Canada
Received: December 18, 2012; Accepted: March 14, 2013; Published: April 17, 2013
Copyright: © 2013 Cusimano et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This research was supported by the Canadian Institutes of Health Research Strategic Team Grant in Applied Injury Research # TIR-103946, and the Ontario Neurotrauma Foundation. The authors have completed this study on behalf of the Canadian Brain Injury and Violence Research Team. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Concussions and other forms of mild traumatic brain injuries occur at least 1.7 million times a year in North America and account for about 75% of all traumatic brain injuries (TBI) , , . Sport-related head trauma is a common cause of TBI in youth, and every year in North America, nearly half million youth aged 14 years or less need hospital-based care for this injury , . The Centers for Disease Control and Prevention (CDC) recently declared that sport concussions are a “silent epidemic” and that they deserve further research .
Repeated concussions and TBI are of particular concern as they may cause life-lasting cognitive and psychosocial deficits , . These injuries are common in all contact sports, but those who play ice hockey are at particular injury risk , , , . The potential long-lasting effects of TBI suggest that these injuries are an important threat to public health . Prevention of sport-related TBIs requires multifaceted approaches that consider issues related to the nature of play and the culture existent within ice hockey , .
At elite levels, such as the National Hockey League (NHL), aggression (i.e., a purposeful physical act driven by intent to cause physiological or psychological harm) is valued and has been considered to be an effective success strategy , . Aggressive players are quickly recognized for their style of play by coaches, management, other players, and fans . Moreover there still exists, among the sports community, a widespread attitude that concussions are “a part of the game” and resiliency to medical council is considered a sign of “toughness” . These issues hinder prevention and treatment efforts and call for research to address these concerns.
An attitude that stresses “toughness” and “ruggedness” of players who can “heroically brush off” injuries often pressures players to neglect their own safety and health for the game . Social learning theory proposes that such aggressive play is encouraged and fostered in ice hockey culture, and by learning of the positive rewards of aggression in ice hockey, aggressive behaviour continues within the sport . Since aggressive play in ice hockey can increase injury incidence by making high-speed collisions more likely and by fostering an “intent-to-harm” attitude among players , understanding the media portrayal of TBI in ice hockey is important for evaluating whether the clinical severity of these injuries is being appropriately communicated.
To better understand how the mass media and popular culture report TBI in sports like ice hockey, we studied a sample of newspaper articles. The manner by which newspapers portray ice hockey-related TBIs and how this has changed over time has not yet been examined. The purpose of our paper was to inductively identify themes in Canadian and American newspaper reports of ice hockey-related TBIs, and to determine if, over time, there has been any change in the content and nature of these reports. Our goal was to understand the reporting of these injuries and the implications of this reporting.
We performed a qualitative analysis of newspaper articles published, between 1985 and 2011, in the: Chicago Tribune (CT), New York Times (NYT), Toronto Star (TS), and Vancouver Sun (VS). We selected these newspapers based on the size of their readership. Furthermore, we sought to represent: (1) Canada and the United States: (2) east and west coast ice hockey media reports; and (3) both original-six and expansion-era ice hockey teams. We chose newspapers with a local nature rather than a national coverage because they would likely report in more detail about local hockey market issues. Furthermore, by analyzing local instead of national newspapers, it was possible to evaluate whether the ice hockey culture in different localities was consistent within and across localities. The four newspapers had a cumulative average weekly circulation of over 13 million copies in 2011 , .
We retrieved all newspaper articles electronically from the ProQuest™ database, an online periodical index part of the Cambridge Information Group. To locate and retrieve newspaper articles that discussed ice hockey brain injuries we used the following search terms: Hockey (in citation and document text) AND “concuss*” OR “head injur*” OR “head trauma” OR “brain injur*” OR “brain trauma” OR “banged head” OR “bell rung” OR “conscious*” (in citation and abstract). Key scientific and colloquial terms were included in the search algorithm as newspapers were likely to use both sets of terms. We included newspaper articles in our study if they referred to one or more of the key terms a minimum of three times within the body and/or headline of that article.
Newspaper articles published before January 1st, 1985 were not available from ProQuest™; we collected data after this point until the end of the 2011 NHL season (June 15th, 2011). We reviewed and analyzed articles from each of 4 time intervals, that is1985–1989, 1990–1999, 2000–2009, and 2010–2011. The number of analyzed articles published in each time interval varied. A total of 541 newspaper articles were analyzed; 49, 185, 187, 120 were published in 1985–1989, 1990–1999, 2000–2009, and 2010–2011, respectively. Furthermore, the number of newspaper articles published by each print media source varied, as 120, 126, 140, 155 articles were analyzed from the CT, NYT, TS, and VS, respectively.
We used the grounded-theory approach as a framework for a thematic analysis to provide rich descriptions of the nature and character of newspaper articles on the topic of interest over time ; categories and themes were allowed to emerge from the data inductively and were not pre-identified by a priori hypotheses , . We recorded data into meaningful pieces of information known as meaning units (MU) . After we coded MUs, they were used to create broad categories, which were later classified into specific themes and sub-themes. We used the constant comparison method throughout the coding process in that as each MU emerged, it was compared to other MUs that were similarly categorized to determine appropriate classification. In addition, we did a content analysis by counting the frequency with which MUs occurred within the sample text .
All retrieved newspaper articles were imported as text files into HyperRESEARCH™ qualitative research software, formerly used in qualitative healthcare investigations , , . The MUs from each article were coded using HyperRESEARCH™. Three members of the research team, who met on a weekly basis to discuss the coding process, independently completed all coding. We continued to review newspaper articles until we reached saturation of information in each time interval. In all cases, analyzing 50 articles per newspaper per time interval exceeded data saturation .
To investigate specific trends over time, we focused on the time periods 1998–2000 and 2009–2011. Since the time period of 2009–2011 is four years after the 2004–2005 NHL lockout, we chose a comparison time period that was four years before this lockout (i.e. 1998–2000). We compared these time periods by means of a thematic and content analysis to explore the nature of and frequency distribution of MUs between time periods and geographical regions (i.e., Canada and America). Three members of the team reviewed the articles, and collaboratively discussed any discrepancies in the classifications of MUs. We assessed coder agreement by means of inter-rater reliability (Cronbach's alpha for coding of MUs was 0.91).
Five main themes, each comprised of several subthemes, emerged and they are described in Table 1. These five themes were highly recurrent across all media sources in all time intervals and were prominent in both countries.
Canadian newspapers disapproved of and condemned needless aggression and violence in ice hockey as expressed in these excerpts:
I know of no other way of expressing our shame and dissatisfaction with the violence and unnecessary fighting that seems to be the present image for hockey – VS, 1999
Canadians were just treated to some amazing hockey at the Olympics and nowhere was fighting or head-hunting seen. The game can survive and thrive without it – TS, 2010
Canadian newspapers consistently reported that TBIs in ice hockey were serious injuries. However, these newspapers also reported that these injuries are just a part of the game, and that they are essentially an unavoidable occupational hazard.
In the earlier time period, protective equipment was often described as a solution to ice hockey's brain injury problem; wearing more protective equipment was thought to improve player safety. In contrast, during the recent time period, the emphasis shifted distinctly and it was reported that protective equipment makes players feel invulnerable to injury, and this causes them to take more potentially harmful physical liberties.
Canadian newspapers consistently reported how poor the NHL was at enforcing rules on player safety. Although the need for a culture change in ice hockey was consistently discussed, recent reports placed responsibility on the NHL to make the game safer:
It would be nice to say the NHL is attacking this [concussion] problem with zest, but, as is generally the case with Bettman's aimless administration, the words aren't being backed up with action – TS, 2000
To their great discredit, the league and its general managers have dragged their feet on the [brain injury] issue… the league took some half-hearted steps to protect players against the worst effects of head-injuries – TS, 2011
Recently, reports began to state there is enough inherent excitement in ice hockey given the finesse of the sport that the need for aggressive and violent play is unnecessary. Table 2 provides quotes that illustrate the themes seen in Canadian newspapers.
Similar themes and trends emerged in the American newspaper articles. In both time periods, American newspapers reported that aggression was an integral ingredient to ice hockey and that brain injuries should be accepted as a part of ice hockey. However, both American and Canadian newspapers expressed much more concern recently about the potential long-term clinical impacts of brain injuries. The focus during the earlier time period was to report TBIs only when they occurred to star players, with little mention to the overall extent of the issue:
The league is concerned about the growing number of concussions that sidelined such headliners as Paul Kariya, Eric Lindros and Pat LaFontaine last season – CT, 1998
In contrast, the more recent trend has been to describe the broader impact of TBIs to the cross section of the league and to set star players' injuries into the bigger context of the overall problem:
Repeated concussions can have long-lasting effects and head injuries have caused several hockey players in recent years to end their careers prematurely, including Eric Lindros, Pat Lafontaine and Keith Primeau – CT, 2009
The serious nature of these injuries was noted in both time periods but the more recent reports stressed the need for a serious culture change within the sport because of TBIs:
Only in the past few years has the NHL dropped its historically cavalier attitude toward concussions – NYT, 1998
Calls are proliferating for changes to the culture of a sport that many see as too accepting of reckless body contact and serious injury – NYT, 2010
Reference to better equipment as a hazard as opposed to a protective factor was also noted in more recent American reports, as well as the need for the league to strengthen rules in an attempt to make the game safer by preventing brain injury. Although the risks of TBI to youth hockey players were consistently reported over time, more recently, calls for the elimination of such injuries to youth became more prominent. Table 3 provides illustrative quotes from American newspapers.
A summary of the number of MUs associated with each theme and newspaper in both time periods is provided in Table 4. The findings from newspapers in each country were similar; there were only international, not intra-national, differences in media reporting of ice hockey head-injuries.
Canadian print media discussed aggression in ice hockey equally during both time periods. The content of discussions of TBI in the more recent time period more often dealt with the severity and impact of the injury. Discussion of rules and regulations recently increased in Canada.
In comparison to Canadian newspapers, American newspapers less frequently discussed aggression as a contributor to TBI in ice hockey but more often discussed perception of risks of brain injury. In contrast to Canadian newspapers, American ones more often report on equipment and rules during both time periods. Both American and Canadian media showed similar recent trends to increasingly report on the need for rule changes and the need to protect youth ice hockey players from TBI.
We found several important trends about the reporting of TBIs in ice hockey. There has been a shift in not only reporting brain injuries when they occur to star players but also in reporting them more broadly across a variety of levels of skill. There is also a trend to recognizing the long-term severity and impact of TBI to the player and the need to take action against aggression, particularly at the youth levels. However, at the same time, there is a persistence of the theme that head injuries are just a part of the game, and that anyone who plays ought to just accept this occupational risk or not play. Exposure to these conflicting views may make it difficult for the reader to adopt a stance on the issue of sport-related TBIs. This can be concerning as it has been shown that media messages that create confusion in the population can lead to unhealthy behaviours . Furthermore, a shift in focus on equipment as a protective device to a potential cause of more aggressive behavior was seen in both countries. A shift in concern towards making youth play safer through rule changes was manifest recently in both countries and a call on the professional league to take responsibility and action towards effective solutions was also seen in the recent newspaper articles. The articles that we analyzed echo the recent shift in scientific literature that documents the detrimental effects of TBI in sport , , . The effect of TBI on the cognitive and psychosocial development of youth also seems to be accurately portrayed in the analyzed newspaper articles , . Reports of brain injury as an unchanging “occupational hazard” reflect a stark contrast to the calls for rule changes and action by the most elite professionals in these newspaper articles.
Several useful models help us to understand how the media shapes individuals' knowledge, attitudes, and practices of injury-related risk-taking. Iyengar's (1991) model focuses on the intended and real effects of media including information-provision, setting agendas, framing, and persuasion . By contrast, McGuire's (2001) approach considers the following factors important to media impact: source (credibility), message and content, channel, and audience variables . Together, these models describe two dimensions of communication relevant to understanding the impact of the media on individuals' knowledge, attitudes, and practices of risk-taking: the intended and real effects (at an intermediate or macro-social level) of communication, as well as the qualities of presentation, content, and context that have been shown to produce changes in individuals' opinions and behaviours.
We are sensitive to Herman and Chomsky's classic argument that media discourse can be biased and reflect the interests of power elites including government officials and corporate or industry groups . We like others, found that media reports often emphasized the aggressive and violent nature of games often in what seemed to be means to incite interest in the event by as many people as possible.
The role that such media reports have on youth attitudes and the culture of hockey cannot be ignored. While we recognize that family and close personal friends can influence individuals' formation of opinions and judgments, we also share Katz and Lazarfield's (1955) argument that individuals' interpretation of media messages can be directly shaped by opinion leaders in their communities as reported in the media . Since young media consumers are particularly impressionable , it is not surprising that research has shown that youth exposed to themes of aggression and violence in the media are more likely to develop tendencies of physical aggressiveness, violent and delinquent behaviour, and conduct issues . Furthermore, studies show that youth who are repeatedly exposed to violence and aggression in the media view violence and aggression as the appropriate means for solving conflict in all aspects of life . So, it is likely that the reporting on TBI that we have documented is also a likely factor that contributes to a culture that normalizes aggressive and violent behaviour , .
Media reporting on health issues can also help shape positive health-related attitudes and behaviours . During the SARS crisis, media reports on this disease outbreak were largely responsible for altered consumer behaviours, causing many to change their travel plans to avoid areas that the media decreed highly infectious . Chapman et al. (2005) found that in four Australian states, in the two weeks after the media announced singer and pop-icon Kylie Minogue was diagnosed with breast cancer, bookings for mammographies increased by 40% . This sort of reporting may also have unhealthy effects . Jordan et al. (2008) propose that the media has contributed to the childhood obesity pandemic by advertising the unhealthy foods and beverages that children now demand and regularly consume . This suggests that media reports of an issue such as TBI in sport can contribute to an altered culture. Those charged with promoting healthy behaviors would benefit from understanding these trends in the media reports.
The results and implications of this study need to be considered in light of the investigation's limitations. Although the newspapers analyzed in this investigation are highly circulated, they represent only a small proportion of all daily, paid North American newspapers. Additionally, we only reviewed the articles of 4 largely circulated newspapers – it is not clear whether similar trends were reported in other newspapers, on radio, television and through other online sources. To assess the impact on such media reports on the public would require prospective studies with large numbers of people, a study beyond the scope of the present investigation.
We have shown that reporting of TBI and its context has changed substantially over time. That our findings were consistent within and across countries, with scientific reporting around TBI and over time provides evidence for the robustness of our findings. Future work that builds upon our findings should focus on how reporting of TBI in ice hockey can affect public discourse and the shaping of programs and policies that have positive effects on public health.
This work is dedicated to the memory of Randy Starkman, the Toronto Star's veteran athletics journalist and a two-time National Newspaper Award winner, who died April 16, 2012.
Conceived and designed the experiments: MDC BS DWL GI SS RJ. Performed the experiments: MDC BS DWL GI SS RJ. Analyzed the data: MDC BS DWL GI SS RJ. Wrote the paper: MDC BS DWL GI SS RJ.
- 1. Bazarian JJ, Veazie P, Mookerjee S, Lerner EB (2006) Accuracy of mild traumatic brain injury case ascertainment using ICD-9 codes. Acad Emerg Med 13: 31–38.
- 2. Faul M, Xu L, Coronado VG (2010) Traumatic brain injury in the United States: emergency department visits, hospitalizations, and deaths. CDC National Center for Injury Prevention and Control, United States.
- 3. National Center for Injury Prevention & Control (2003) Report to Congress on mild traumatic brain injury in the United States: Steps to prevent a serious public health problem. Atlanta, GA: Centers for Disease Control and Prevention.
- 4. Halstead ME, Walter KD (2010) Sport-related concussion in children and adolescents. Pediatrics 126: 597–615.
- 5. Wetjen NM, Pichelmann MA, Atkinson JL (2010) Second impact syndrome: concussion and second injury brain complications. J Am Coll Surg 4: 553–557.
- 6. Lord-Maes J, Obrzut JE (1996) Neuropsychological consequences of traumatic brain injury in children and adolescents. J Learn Disabil 29: 609–617.
- 7. Stevens ST, Lassonde M, de Beaumont L, Keenan JP (2006) The effect of visors on head and facial injury in National Hockey League players. J Sci Med Sport 9: 238–242.
- 8. Wennberg RA, Tator CH (2003) National Hockey League reported concussions, 1986–1987 to 2001–2002. Can J Neurol Sci 30: 206–209.
- 9. Wennberg RA, Tator CH (2008) Concussion incidence and time lost from play in the NHL during the past ten years. Can J Neurol Sci 35: 647–651.
- 10. Benson BW, Meeuwisse WH, Rizos J, Kang J, Burke CJ (2011) A prospective study of concussions among National Hockey League players during regular season games: the NHL-NHLPA Concussion Program. CMAJ 183: 905–911.
- 11. Marchie A, Cusimano MD (2003) Bodychecking and concussions in ice hockey: Should our youth pay the price? CMAJ 169: 124–128.
- 12. Cusimano MD, Taback NA, McFaull SR, Hodgins R, Bekele TM, et al. (2011) Effect of bodychecking on rate of injuries among minor hockey players. Open Med 5: 57–64.
- 13. Widmeyer WN, Birch JS (1984) Aggression in professional ice hockey: a strategy for success of a reaction to failure? J Psychol 177: 77–84.
- 14. Gee CJ (2010) Aggression in competitive sports: Using direct observation to evaluate incidence and prevention focused intervention. In: Luiselli JK, Reed DD, editors. Behavioural sport psychology: Evidence-based approached to performance enhancement. New York: Springer. pp.199–210.
- 15. Sheldon JP, Aimar CM (2001) The role aggression plays in successful and unsuccessful ice hockey behaviours. Res Q Exerc Sport 72: 304–309.
- 16. Cusimano MD, Chipman ML, Volpe R, Donnelly P (2009) Canadian minor hockey participants' knowledge about concussion. Can J Neurol Sci 36: 315–320.
- 17. Kepner T (2012) Line drive strikes Tigers starter, and prompts concerns. New York Times: New York.
- 18. Bandura A (1978) Social learning theory of aggression. J Commun 28: 12–29.
- 19. Stuart MJ, Colbenson CM, Kronebusch SP (2000) A psychosocial perspective of aggression in ice hockey. In: Ashare, editor. Safety in ice hockey. West Conshohocken: American Society for Testing and Materials. Pp. 199–200.
- 20. Audit Bureau of Circulations (2011) Average circulation at the top 25 U.S. daily newspapers. ABCInteractive, United States.
- 21. Newspapers Canada (2011) Daily Newspaper Circulation by Province. Newspapers Canada, Canada.
- 22. Patton MQ (2002) Qualitative research and evaluation methods (3rd ed.). California: Sage Publications. 688 p.
- 23. Bauer MW, Gaskell G (2000) Qualitative researching with text, image and sound: A practical handbook. London: Sage Publications. 374 p.
- 24. Strauss A, Corbin JM (1998) Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory. California: Sage Publications. 336 p.
- 25. Tesch R (1991) Computer programs that assist in the analysis of qualitative data: An overview. Qual Health Res 1: 309–325.
- 26. Bergeron RL (2002) Family preservation: An unidentified approach in elder abuse protection. Fam Soc 83: 547–556.
- 27. Putnam JM (2007) Combining telehealth and e-learning: A case study in smoking cessation programming. Am J Health Stud 3: 130–138.
- 28. Ward-Smith P, Forred D (2005) Participation in a dementia evaluation program: perceptions of family members. J Neurosci Nurs 37: 92–96.
- 29. Morse JM (1995) The significance of saturation. Qual Health Res 5: 147–149.
- 30. Youl PH, Janda M, Kimlin M (2009) Vitamin D and sun protection: The impact of mixed public health messages in Australia. Int J Cancer 124: 1963–1970.
- 31. Macciocchi SN, Barth JT, Alves W, Rimel RW, Jane J (1996) Neuropsychological functioning and recovery after mild head injury in collegiate athletes. Neurosurgery 39: 510–514.
- 32. Rabadi MH, Jordan BD (2001) The cumulative effect of repetitive concussion in sports. Clin J Sport Med 3: 194–198.
- 33. Bowen AP (2003) Second impact syndrome: a rare, catastrophic, preventable complication of concussion in young athletes. J Emerg Nurs 29: 287–289.
- 34. Iyengar S (1991) Is anyone responsible?: How television frames political issues. Chicago: University of Chicago Press. 206 p.
- 35. McGuire WJ, Rice RE, Atkin CK (2001) Input and output variables currently promising for constructing persuasive communications. In: Rice RE, Atkin CK, editors. Public communication campaigns. Thousand Oaks: Sage. pp.22–48.
- 36. Herman ES, Chomsky N (2002) Manufacturing consent: The political economy of the mass media. New York: Pantheon Books. 412 p.
- 37. Katz E, Lazarsfeld PF (1955) Personal influence: The part played by people in the flow of mass communication. New York: The Free Press. 434 p.
- 38. Kirsh SJ (2010) Media and youth: A developmental perspective. United Kingdom: Wiley-Blackwell. 328 p.
- 39. Boxer PL, Huesmann R, Bushman BJ, O'Brien M, Moceri D (2009) The role of violent media preference in cumulative developmental risk for violence and general aggression. J Youth Adolesc 38: 417–428.
- 40. Anderson CA, Huesmann LR (2007) Human aggression: A social-cognitive view. In: Hogg MA, Cooper J, editors. The SAGE Handbook of Social Psychology. Thousand Oaks: Sage. pp.296–323.
- 41. Cantor J (2000) Media violence. J Adolesc Health 27: 30–34.
- 42. Anderson CA, Bushman BJ (2002) Human Aggression. Annu Review Psychol 53: 27–51.
- 43. Lupton D, McLean J (1998) Representing doctors: discourses and images in the Australian press. Soc Sci Med 46: 947–958.
- 44. Ali SH, Keil R (2006) Global cities and the spread of infectious disease: The case of severe acute respiratory syndrome (SARS) in Toronto, Canada. Urban Stud 43: 491–509.
- 45. Chapman S, McLeod K, Wakefield M, Holding S (2005) Impact of news of celebrity illness on breast cancer screening: Kylie Minogue's breast cancer diagnosis. Med J Aust 5: 247–250.