Behavioral Modification to Reduce Concussion in Collision Sports

Abstract

IntroductionConcussion awareness in contact or collision sports likeice hockey has escalated recently (16) in both genders at alllevels (2). The increase in sport-related concussion (SRC) isattributed to better symptom recognition, increased playerspeed and size and perceived player invincibility. For ex-ample, sales of the Cascade M11 hockey helmet soared in2009, when it was marketed as the ‘‘Enemy of Concussion.’’Parents rushed to ensure their youth hockey player’s brainwas protected by this ‘‘special’’ helmet. The aggressive ad-vertising campaign was withdrawn due to a lack of evidencesupporting the contention that the helmet reduced con-cussion risk. In fact, none of the commercially availablehelmets reduce the large linear and rotational forces trans-mitted to a hockey player’s head (8,9), Contrary to theplayers’ perception, equipment may not have protectivevalue and modern equipment design may actually increasethe incidence and severity of concussion. For example,hard shell elbow and shoulder pads may protect the wearerbut may injure opponents or teammates in collisions (1).Concussion reduction efforts must address the multifac-eted aspects of brain injury (16). Significant effort and ex-pense have been directed toward producing safer equipmentand better understanding of the injury process with respectto single or repetitive exposure to linear and rotational ac-celeration and deceleration forces. Finite element modeling(4,11) has been used to detect the strain and strain rates thatcause tissue damage. New evidence is emerging on the ben-efits and limitations of neuroimaging and neuropsychologi-cal testing in assessing concussion severity and return to play(5,6). Fundamental research into the role of biomarkers,proteins, and enzymes was released after trauma; diffuseaxonal injury, the metabolic cascade (3), and the behavior ofglial cells that engulf traumatized neurons also have helpedus better understand the neuropathology of concussion. De-spite this body of scientific data, we have not advanced thetreatment of SRC beyond removal of the concussed athletefrom sport for cognitive and physical rest until the symptomshave resolved completely with vigorous activity.Considering the dictum ‘‘an ounce of prevention is wortha pound of cure,’’ it is surprising that little effort has beendirected toward behavioral modification in injury and con-cussion prevention. This simple, inexpensive, evidence-basedmethod of changing behavior is a major construct in thepractice of medicine, coaching, and officiating that shouldbe applied to injury reduction in hockey and other sports.The principles of behavioral modification, known as op-erant conditioning, are based on the work of Skinner (10,13).The central premise of operant conditioning (10) is that be-havior is governed by reinforcing desirable behavior andpunishing undesirable behavior. For example, law enforce-ment and insurance companies reduce the risks of speedingby suspending a driver’s license after too many citations.Conversely years of violation-free driving results in lowercar insurance premiums Vpunish the bad behavior and re-ward the good. In sports medicine, patients who adhere toa daily regimen of strengthening muscle groups followinginjury are ‘‘rewarded’’ by a faster return to pain-free move-ment. The most effective way to decrease concussion preva-lence is to implement a behavior modification program toalter the culture of collision sports where equipment im-provements have made players feel ‘‘invincible.’’ Reducingaggressive and violent on-ice behavior will prevent the ma-jority of SRC that are associated with illegal and unneces-sarily rough behavior. Accidental collisions will still occur,but most SRCs result from on-ice infractions, many ofwhich are not noticed by the officials. Sadly infractionsmay be encouraged by some coaches and general man-agers, who try to win by intimidation, and by fans whoenjoy the violence (15). An example of a perverse use ofbehavioral modification in football is the provision of afinancial reward when an opposing player is injured andremoved from the game.Aggressive behavior is defined by most sport scientistsas physical or psychosocial behavior intended to intimidateor injure (18). Most major hockey penalties are levied for