As the library of concussion information grows, the attitude toward the serious unseen injury is changing among parents and team personnel, hockey executives across Canada say.
But they say it must evolve faster.
"Attitudes are changing. They haven't changed enough," said Phil McKee, executive director of the Ontario Hockey Federation. The OHF is the largest of 13 branches of Hockey Canada governing amateur hockey in the country.
Recognizing concussions, failing to take them seriously and rushing a player back when he or she is still vulnerable are major factors in an "epidemic" of the head injury, studies have found.
Results released Monday by the Hockey Concussion Education Project - led by sports medicine specialist Paul Echlin of London, Ont. - revealed a frequency of concussion that was seven times greater than the highest rate previously reported. In 52 games observed by independent physicians, 21 concussions to 17 junior-age players were reported. Previous reports were by trainers, coaches or players, whose objectivity may have been clouded by club interests.
The number of head injuries was alarming to many, but McKee said that because there is more awareness of concussions than there was 20 years ago, he is not shocked at the news.
"Now there's more understanding of what concussion is, more reporting and it doesn't surprise me," he said. "There's a changing dynamic toward brain injury. It's becoming acceptable to say, 'I need to take time off.' Twenty years ago, it wasn't."
Rushing a skater back onto the ice might be what some parents and coaches want, "but it's not the pros. Every kid, every parent should ask, 'What am I getting paid for this?' You don't put yourself in jeopardy."
Education and surveillance were two recommendations implicit in the study released Monday. Hockey Canada is staging a timely educational seminar on concussions in Montreal Nov. 13. Two of the nine topics to be dealt with are the psychological pressures to return (from peers, parents and coaches) and the guidelines of when to return to play. Five of the 17 injured players cited Monday had a second concussion the same season - possibly because they were hurried back into the contact sport.
"I'm not sure if there's another sport where, when there's been an injury, you blame the victim," physician Paul Dennis says on a Hockey Canada video, referring to hockey's macho ethos that prompts players to come back from concussion too soon.
"We have to make sure we're giving good, accurate information to the grassroots in this sport," says Todd Jackson, Hockey Canada's senior manager of insurance and membership services, who is organizing the Montreal seminar.
He said awareness of concussion has gone up in the past 20 years, from the time of explaining it away as "a little bump of the head. … Now there's a six-step process [devised with the Think First organization]for return - starting with no activity while symptoms are present, only complete rest.
"There's also a change in how to deal with the pressure. You report the symptoms to your mother or father, or the coach or safety personnel. Then the adults should get the player to a physician. Then, follow the doctors' orders on when it's safe to return to play."
Education remains the biggest tool in fighting concussion injuries, he said.
"We've finalized a concussion policy for return to play," said Darren Cossar, executive director of Hockey Nova Scotia. "The onus is on the coach that any player who is even suspected of having a concussion has to be examined by a doctor before returning to play.
"There's an awareness program for players to respect each other and know the seriousness of concussion. We've also been approached by a company to do baseline testing [so there's a measure of how well a player has recovered from a concussion]"
Cossar said five years ago when concussions weren't such a concern, he wouldn't have been surprised to learn of their frequency, but now he is. "We need to do more studies, more work."
Globe and Mail readers responded to the story on the Internet with a number of recommendations, including changing rules to make head shots punishable by suspensions ranging from five games for a first offence to a season for a fourth. One said there was too much big protective equipment; another called for a bigger playing surface; and yet another railed against "the subculture of contact sports. … I'll get my kids into soccer or basketball."