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Regulating the concussion crisis in sports: Canada’s initiative to bring prevention into focus

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Abstract

The twenty-first century has revealed the existence of a concussion crisis in sports. The crisis is of global reach, and Canada is no exception. In recent years, the Canadian government joined citizens in recognizing sports concussion as a major public health issue. A parliamentary committee investigated the crisis, reported findings, and made recommendations which the government accepted. As far as legal responses to the sport concussion crisis, new among the recommendations was a call-to-action on prevention (Recommendation 13). Since there remains no medical cure for concussions, the government agreed with the view of injured former athletes and injury prevention advocates that prevention is paramount. However, government reports reveal little progress thus far in implementing prevention measures. We confirmed this through an interview, as well as surveys of sports-governing bodies. Our findings show that legal responses continue to focus on previously identified objectives of concussion research, raising awareness, and concussion management—fronts on which substantial progress had already been made over the preceding decade-and-a-half. The article observes that Recommendation 13 calls on government to work with sports bodies on sport-specific prevention measures; however, the government lacks significant experience from its prior work on research, awareness and concussion management protocols with those types of directed collaborative regulatory mechanisms that would most likely be effective for prevention. The article, therefore, examines a range of such mechanisms that the Canadian government could use to make more significant headway on prevention of concussions, as the next phase of its efforts to counter the concussion crisis in sports.

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Notes

  1. McCrory et al. (2017), p. 2.

  2. Malcolm (2019), p. 2.

  3. Blum (2016), pp. 504–5.

  4. Ibid., p. 507.

  5. Ibid.

  6. May 2020: Ongoing study shows continued increase in concussions among high school athletes. In: American Academy of Orthopaedic Surgeons. https://www.aaos.org/aaos-home/newsroom/press-releases/aaos-releases-clinical-news-increased-concussions-among-high-school-athletes/. Accessed 29 July 2022.

  7. (2020) Interventions to Prevent Concussions. In: Public Health Ontario. https://www.publichealthontario.ca/en/Health-Topics/Health-Promotion/Injuries.

  8. Emery C (2020) Concussion affects 1 in 10 youth athletes every year. Here’s what needs to change. In: The Conversation. https://theconversation.com/concussion-affects-1-in-10-youth-athletes-every-year-heres-what-needs-to-change-130061.

  9. Ibid.

  10. See ibid.

  11. HESA Sports-Related Concussions in Canada. https://www.ourcommons.ca/committees/en/HESA/StudyActivity?studyActivityID=11221738. Accessed 17 July 2021, p. 43.

  12. Bill Beacon “'I can't recover my career': Steve Moore reflects on Bertuzzi attack 10 years later” CTV News (17 March 2014) Online: https://www.ctvnews.ca/sports/i-can-t-recover-my-career-steve-moore-reflects-onbertuzzi-attack-10-years-later-1.1719925?cache=yes%3FclipId%3D104062

  13. Sarah Hampson “NHL veteran Dominic Moore opens up about his wife, their life and her death” The Globe and Mail (4 March 2013) Online: https://www.theglobeandmail.com/life/relationships/nhl-veteran-dominic-moore-opens-up-about-his-wife-their-life-and-herdeath/article9262910/

  14. Tremonti AM (2018) ‘Concussions affect a life’: Ken Dryden wants hockey rules changed to save players’ lives. CBC.

  15. Ibid.

  16. Canadian Concussion Collaborative (2014) Leading Canadian Health Organizations’ New Recommendations Call for Concussion Protocols to Protect all Canadians Participating in High Risk Sports. In: Canadian Academy of Sport and Exercise Medicine. https://casem-acmse.org/wp-content/uploads/2018/09/News-Release_CCC_Final-English.pdf. Accessed 18 June 2022.

  17. Taylor T (2019) Concussion Statement and Guidelines. In: U SPORTS HQ. https://usports.ca/uploads/hq/Medical/Concussion/190410_-_Concussion_Statement.pdf. Accessed 18 June 2022.

  18. Kantar TNS, Baseline Survey on Understanding and Awareness of Sport-Related Concussions, 22 January 2018, p. 5.

  19. (2020) Interventions to Prevent Concussions. In: Public Health Ontario. https://www.publichealthontario.ca/en/Health-Topics/Health-Promotion/Injuries.

  20. The Constitution Act, 1867. CanLII, secs 91–92.

  21. Monahan et al. (2017), pp. 117–118.

  22. Ibid., p. 259.

  23. Doherty et al. (2013); Heritage C (2010) Welcome! http://pch.gc.ca.eng/1266037002102/1265993639778. Accessed 11 June 2013.

  24. Canada H (2004) Activities and responsibilities – Health Canada. https://www.canada.ca/en/health-canada/corporate/about-health-canada/activities-responsibilities.html. Accessed 1 August 2023.

  25. Canada PHA of (2018) Concussion in Sport. https://www.canada.ca/en/public-health/services/diseases/concussion-sign-symptoms/concussion-sport-infographic.html. Accessed 1 August 2023.

  26. Doherty et al. (2013), p. 325.

  27. See the discussion in Sect. 3 of this article.

  28. See the discussion in Sect. 3 of this article.

  29. SCSC-Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/SCSC/StudyActivity?studyActivityId=10295616#2019-05-01. Accessed 29 December 2019.

  30. Government Response - 8512-432-111 - House of Commons of Canada. https://www.ourcommons.ca/DocumentViewer/en/43-2/HESA/report-7/response-8512-432-111. Accessed 17 July 2021, p. 1.

  31. SCSC - Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/SCSC/StudyActivity?studyActivityId=10295616#2019-05-01. Accessed 29 December 2019, p. 41.

  32. Ibid., p. 41.

  33. Ibid., pp. 1, 26.

  34. Ibid., p. 26.

  35. Ibid., p. 5.

  36. Russell et al. (2017). (2022) Concussion Policy – Parachute. In: Parachute. https://www.parachutecanada.org/en/professional-resource/policy/concussion-policy/. Accessed 20 June 2022.

  37. Russell et al. (2017).

  38. Rowan’s Law (Concussion Safety), 2018, SO 2018, c 1. https://www.canlii.org/en/on/laws/stat/so-2018-c-1/latest/so-2018-c-1.html?autocompleteStr=rowan%27s%20law&autocompletePos=1. Accessed 20 June 2021.

  39. (2011) Hockey Canada’s New Head Contact Rule. https://www.hockeycanada.ca/en-ca/news/2011-gn-018-en. Accessed 20 June 2022.

  40. (2013) Hockey Canada’s 94th Annual General Meeting concludes in Charlottetown, P.E.I.; body-checking rule change approved; Jim Hornell elected chair of Hockey Canada Board of Directors. In: Hockey Canada. https://www.hockeycanada.ca/en-ca/news/agm-concludes-in-charlottetown. Accessed 7 June 2022.

  41. (2019) 2019 Football Canada U8 Mandate. In: Football Canada. https://footballcanada.com/news/2019-football-canada-u8-mandate/. Accessed 20 June 2022.

  42. Ibid.

  43. (2015) Safe Contact Now Mandatory For Football Canada Coaches. In: Football Canada. https://footballcanada.com/news/safe-contact-now-mandatory-for-football-canada-coaches/. Accessed 20 June 2022.

  44. Yeung R (2019) Concussion Prevention in Basketball. In: Sport Information Resource Centre. https://sirc.ca/wp-content/uploads/2021/09/Ron-Yeung-Canada-Basketball.pdf.

  45. Albano et al. (2016).

  46. (2018) Summary Matrix of State Laws Addressing Concussions in Youth Sports. In: The Network for Public Health. https://www.networkforphl.org/wp-content/uploads/2019/11/Summary-of-State-Laws-Addressing-Concussions-in-Youth-Sports-5-28-19.pdf.

  47. (2015) California Code, Education Code.

  48. Youth Tackle Football Ban: A State-By-State Guide To All Proposals & Legislation. In: De Caro & Kaplen, LLP. https://brainlaw.com/youth-tackle-football/. Accessed 20 June 2022.

  49. S.3043 - Protecting Student Athletes from Concussions Act of 2021. https://www.congress.gov/bill/117th-congress/senate-bill/3043/text. Accessed 29 July 2022.

  50. The stand rule’s here to stay, but some changes are coming in 2022. In: afl.com.au. https://www.afl.com.au/news/688886/the-stand-rules-here-to-stay-but-some-changes-are-coming-in-2022. Accessed 19 June 2022.

  51. Ibid.

  52. (2021) 2021 AFL Tribunal Guidelines. In: AFL. https://resources.afl.com.au/afl/document/2021/03/22/221593f5-9b5b-46c7-b038-b032283fcd41/2021-AFL-Tribunal-Guidelines.pdf.

  53. European Parliament Sport | Fact Sheets on the European Union | European Parliament. https://www.europarl.europa.eu/factsheets/en/sheet/143/sport. Accessed 29 July 2022.

  54. Weatherill (2014).

  55. Kornbeck (2018).

  56. Ibid.

  57. (2022) FIFPRO and European Leagues join forces to improve concussion management in professional football. In: European Leagues. https://europeanleagues.com/fifpro-and-european-leagues-join-forces-to-improve-concussion-management-in-professional-football/. Accessed 29 July 2022.

  58. SCSC-Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/SCSC/StudyActivity?studyActivityId=10295616#2019-05-01. Accessed 29 December 2019, p. 26.

  59. Parker (2002), p. 245 citing Grabosky 1995:543.

  60. Gilad (2010), p. 486.

  61. Parker (2002), p. 15.

  62. Ibid., p. 245.

  63. Ibid., p. 15 citing Osborne and Gaebler (1992: 25).

  64. Interview with Sport Canada.

  65. HESA-Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/HESA/StudyActivity?studyActivityId=11221738. Accessed 17 July 2021.

  66. Government Response-8512-432-111-House of Commons of Canada. https://www.ourcommons.ca/DocumentViewer/en/43-2/HESA/report-7/response-8512-432-111. Accessed 17 July 2021.

  67. Ibid., p. 2.

  68. Ibid., p. 3.

  69. Ibid., p. 3.

  70. Ibid., p. 3.

  71. HESA-Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/HESA/StudyActivity?studyActivityId=11221738. Accessed 17 July 2021, p. 3.

  72. Government Response-8512-432-111-House of Commons of Canada. https://www.ourcommons.ca/DocumentViewer/en/43-2/HESA/report-7/response-8512-432-111. Accessed 17 July 2021, p. 4.

  73. Ibid., p. 5.

  74. HESA-Sports-Related Concussions in Canada. https://www.ourcommons.ca/Committees/en/HESA/StudyActivity?studyActivityId=11221738. Accessed 17 July 2021, p. 3.

  75. Government Response-8512-432-111-House of Commons of Canada. https://www.ourcommons.ca/DocumentViewer/en/43-2/HESA/report-7/response-8512-432-111. Accessed 17 July 2021, p. 4.

  76. In my view, raising awareness does also collaterally benefit prevention. For example, by drawing attention to the seriousness of concussive injury, it encourages sport community members to think about what action they could take that would enhance prevention. However, we should not include it here, as other recommendations of the SSC Report deal with raising awareness; Recommendation 13 is distinct in prevention being its immediate purpose.

  77. Interview with Sport Canada.

  78. Moore M Instructional Survey Document.

  79. See, e.g., Baldwin et al. (2012), pp. 149–150. See also Gunningham et al. (1998).

  80. Baldwin et al. (2012), p. 150. See also Coglianese (2001), chap. 8.

  81. Ford (2013), p. 77.

  82. Sabel and Zeitlin (2012).

  83. Interview with Sport Canada.

  84. Coglianese (2001); Parker (2002); Gunningham et al. (1998).

  85. Baldwin et al. (2012), p. 150. See also Coglianese (2001), chap. 8.

  86. HESA Sports-Related Concussions in Canada. https://www.ourcommons.ca/committees/en/HESA/StudyActivity?studyActivityID=11221738. Accessed 17 July 2021, p. 3.

  87. Interview with Sport Canada.

  88. Baldwin et al. (2012), p. 150; Parker (2002), pp. 268–269.

  89. Rowan’s Law roughly follows the so-called Lystedt laws in 49 of the 50 US states.

  90. Baldwin et al. (2012), p. 150; Parker (2002), pp. 268–269. Note 54.

  91. Moore (2006), pp. 36–42.

  92. Per the cooperative federalism approach used in this area, noted earlier, where I discuss possible measures below, I assume such intergovernmental coordination as would be necessary, without a measure-by-measure account of the details, which would distract from the question here of methods of hybrid meta-regulation.

  93. It is also reflected, of course, in the first place by the government empaneling the SSC to investigate the crisis and recommend solutions.

  94. See, e.g., Greenhow and Doherty (2021).

  95. Cromwell THT, Final Report: Hockey Canada Governance Review, 2022.

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  1. Faculty of Law, University of British Columbia; Regulation Group, University of Oxford, 1822 East Mall, Vancouver, BC, V6T 1Z1, Canada

    Marcus Moore

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The author, now a law professor, is permanently disabled by postconcussion syndrome from a sports concussion which ended his prior career as a professional ice hockey player from Canada.

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I extend special thanks to Lisa Baek for her assistance with this project. This research was presented at the Peter Allard School of Law's Faculty Colloquium in November 2021, and I am grateful for the comments received from faculty and students of the School. I acknowledge in particular key suggestions I received from Cristie Ford (UBC) and Steve Weatherill (Oxford), besides helpful feedback from the anonymous reviewers and the editor of the International Sports Law Journal. I also thank Charlotte Tan, Jennine Punzalan, Timothy Falco, Solomon Kay-Reid, and Trevor Duncan for research assistance.

Appendix

Appendix

Appendix A

Basketball

Rugby

Hockey

Football

Soccer

Raising awareness

·Concussion Policy on Canada Basketball website

Concussion resources coordinated with FPT Workgroup

·Concussion knowledge integrated into National Coach Certification Program workshops

·Creating basketball-specific concussion website and resource hub*

·Creating a basketball-specific version of Making Headway Concussion elearning tool for coaches*

·Creating a concussions in basketball PSA video *

·Mandatory concussion management training for all coaches, match officials

·Concussion Management Policy, harmonized with World Rugby and Parachute

·Updating Concussion Management *

·Relay to hockey community latest concussion guideline, statements and recommendations through organizational educational materials

·Consulting with Parachute on the content related to concussion education and resources for hockey

·Member of the FPT Workgroup on Concussion in Sport

·Hockey Canada Safety Program for teams, which includes concussion education and protocols. All teams must have someone who has completed the Hockey Canada Safety Program

·Tools: Distribute electronic card highlighting concussion signs and symptoms, protocols. Web-based concussion toolbox. Concussion awareness and prevention app created in collaboration with PHAC

·Continuous review and update of concussion policy (applies to all players, coaches, trainers, officials, safety personnel, parents, and administrators)

·Distribute concussion guidelines from Parachute to football community

·Implementation in football of concussion protocols

·Tools: Concussion pathway, policy (all community members informed); Concussion app to report and track all concussions

·Concussion assessment report form

Concussion policy on Soccer Canada website

·Concussion education sessions at the annual meeting of the membership

·Regular review of concussion handling methodologies by technical experts, with updates relayed to coaches

Cultural shift

  

·Long-Term Player Development focuses on age-appropriate development in the game, which enhances safety

·U7 hockey programming emphasizes safe, fun, fair play in introducing the game to beginners

  

Rules of game

 

·Law variations to tackle height at certain ages

·Emphasis on head contact process and sanctioning for head contact and dangerous actions (consistent sanctioning across all levels of rugby)

·All law variations must be approved by Rugby Canada for consistency, and ensure they are aligned with World Rugby and the latest research and evidence of game welfare

·Revised “no head contact” rule (2011). Zero tolerance enforcement of this and rule against checking from behind emphasized annually

·Banned body checking U13 and younger in competitive leagues (2013). Increasing number of non-contact recreational leagues at all levels of play are also being created

·“Constantly reviewing and updating” game rules around player safety

·Review of blocking below the waist

·Increasing popularity of flag football (no-contact) in lieu of tackle football (contact). Partly driven by being safer, partly driven by incentives (insurance rates/policies, registration and equipment costs higher for tackle football). Significant growth in flag football for girls and women

·Involved in International Football Association Board concussion trials in professional soccer, where teams permitted up to two concussion substitutions after medical assessment

Training methods

·Mandatory concussion prevention and recovery education for coaches as part of Competition Development Pathway

·Created resources for teaching prevention of concussions in basketball, addressing, e.g., undercutting, blocking out, rebounding, closeouts, screening

·Mandatory injury prevention training for all coaches, match officials

·Tackle Smart resource*

·Updating Head Contact Process*

·Neuro-muscular training resources from World Rugby Activate, University of Calgary, and SHRED

·National Coach Certification Program improves coaching competencies, including safety

·Smart Hockey video (2011)

·Mandatory body checking instructional resource program to better prepare players for body checking (2013)

·Mandatory training using graduated-size subsections of ice surface as another effort to increase skill development and reduce concussions

·Safe-Contact program mandatory training for players and coaches on tackling skills not using the head in tackling, avoiding head-to-head contact

·Research project with University of Calgary on safety. Examining where concussions are occurring most frequently including contact point or head position. Hope is to adapt coaching*

·Research project with Queens University Elite Neuro Kinetix (with funding from Sport Canada) studying video and correcting players on how to avoid concussing themselves or others*

·Recommending decreased exposure to high velocity ball impacts to the head

·Recommending decreased exposure to long headers, which research has associated with high forces transmitted to the head

·Besides headers (above), identified other sources of concussion as ball to head (not header), elbow, fist, and foot to head. Not yet identified effective means to control these

·Guidance for technical development of players contributes to increasing awareness and reducing concussions

Community member behaviors

 

·Research project with University of Toronto on match officials’ behaviors and approaches to concussion management, with aim of exploring possible interventions*

·Blue Card Initiative (match official removes concussed player from play)*

·Parent and Volunteer education emphasizing positive behaviors at arenas

·Suspension of insurance and/or participation for failure to complete or abide by Safe-Contact training

 
  1. *Measures not yet completed, but in the works

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Moore, M. Regulating the concussion crisis in sports: Canada’s initiative to bring prevention into focus. Int Sports Law J 23, 390–404 (2023). https://doi.org/10.1007/s40318-023-00248-3

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