Sleep, Screen Device Use, and Concussion Recovery

Each concussion deserves individualized recommendations that seek to strike the delicate balance between a child's need for maintaining social contacts and attempt to continue with school work with a desire to not overwhelm the healing brain and increase post-concussion symptoms. An absolute restriction on screen use might reduce possibility of certain symptoms such as difficulty falling or staying asleep, but can also lead to social isolation contributing to higher symptom reports of anxiety, sadness, and outright depression. 

How can we best strike an appropriate balance between screen use and need for adequate sleep?

Ask most parents if they have worries about sleep issues and amount of electronics/screen device use in their school aged children, and you'll probably get ready nods and smiles of affirmation. 

Ask some of my sports medicine colleagues about why we are seeing more complicated and prolonged post-concussion recoveries, and you'll hear some suggest that the multi-tasking and multiple platforms of communication utilized by smart phones and other screen devices are potential contributing factors.

So since increasing sleep issues and attempts to pry screen-based devices from the hands of kids are common concerns to parents and medical professionals, it should be no surprise that difficulties initiating or maintaining sleep and regulating electronic use are often major challenges in children who have suffered a concussion.

Came across two recent studies on the subject of screen use and sleep that I think shed some interesting light on how we might make recommendations for all children, but particularly in the immediate post-concussion population.

One study from Proceedings of the National Academy of Sciences of the United States of America suggests the use of portable light-emitting devices immediately before bedtime has potential biological effects that may perpetuate sleep deficiency and disrupt circadian rhythms, both of which can have adverse impacts on performance, health, and safety. Such device use can:

•  increase alertness at bedtime, which may lead users to delay bedtime at home
•  suppress levels of the sleep-promoting hormone melatonin,
•  reduce the amount and delays the timing of REM sleep
• and reduce alertness the following morning

While this study used healthy young adults (mean age around 25 years of age), the findings are intriguing enough to be extrapolated to younger patients. Given the frequency where recommended oral melatonin clearly helps with falling and staying asleep, having another pathway to support internal melatonin production can be essential in the recovery process.

An additional study from the journal Pediatrics examined 4th through 7th graders and assessed associations of different screens in sleep environments with sleep duration and perceived insufficient rest or sleep. Particular interest was placed on smartphones which can emit notifications during sleep periods, and relevant findings included:

• Sleeping near a small screen, sleeping with a TV in the room, and more screen time were associated with shorter sleep durations.
• Presence of a small screen, but not a TV, in the sleep environment and screen time were associated with perceived insufficient rest or sleep.

These findings found that small screens could have more adverse effects on sleep than television screens and thus caution against unrestricted screen access in children’s bedrooms for normal, healthy 4th through 7th graders, which again could be extrapolated to include concussed children.

Throwing this all together, a pragmatic approach to screen use after concussion that utilizes the findings of these studies may include the following clinical recommendations:

1) The preponderance of screen devices is an integral reality in the life of many school-aged children and significance of appropriate use cannot be underestimated in expediting post-concussion recovery.

2) Once appropriate, limit screen device time use initially to the middle of the day and not within one hour of any scheduled nap or evening sleep period.

3) All screen device use should be stopped at least one hour before bedtime,

4) Screen devices should be removed from the bedroom to reduce interruptions in sleep from notifications or temptation to check devices for updates during periods of awakening.

Once the child has recovered from the concussion, the child might find that continuing the above screen time recommendations may lead to continued enhanced amount and quality of sleep, which in itself may lead to an enhanced quality of life.

Concussionconnection.com: On-Campus Resources After Concussion

Thanks to colleagues from concussionconnection.com for publishing my blog post focusing on resources for disabled students on college and university campuses, particularly for student-athletes recovering from concussions.

Check out the blog post and a host of concussion-related resources at http://www.concussionconnection.com/knowing-resources/.

Are California Schools and Medical Providers Prepared for New Concussion Law?

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) will take formal effect on January 1, 2015 and will provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

For my initial reaction to this law, click here

In discussions with coaches, administrators, and fellow sports medicine providers, I'll throw out a few questions that have arose regarding several nuances of the law:

• When is the earliest that the 7-day return protocol begins?
  • Is it potentially at the time of formal diagnosis of a concussion by a licensed provider?
  • Is it when the athlete is fully cleared of post-concussion symptoms?
  • Can the period begin before a formal diagnosis is made?
• What is the formal definition of supervision?
  • Can an athletic trainer assume the role of supervision under the guidance of a physician?
• Given that the bill also limits contact football practices to two 90 minute periods per week, if the timing of those two practices is perhaps a day before a player's progression is ready for contact, can he have alternate contact to possibly play in a game if otherwise having an appropriate recovery?
• Are school and medical providers aware and sufficiently prepared for these new edicts?
  • Is there agreement or clarification on the above terms and concerns?
  • Have concussion management plans, if already in place, been modified or reviewed to address the new mandates?

Certain that there are other questions and thoughts out there- please use this as a forum to share with others.

Be a Smart Coach- Use CoachSmart App to Make Athletes Safer

I have accessed CoachSmart while on the sidelines, and no longer have to guess or try to remember suggested adjustments for practice and games in hot or humid weather.  The information is concisely presented in the palm of my hand.

The iPhone app CoachSmart was developed by colleagues at Vanderbilt Sports Medicine and the Monroe Carell Jr. Children’s Hospital at Vanderbilt and is billed as the ultimate resource for coaches, offering real-time information on heat index and lightning strikes, frequently asked sports medicine and safety questions, and a group contact feature.

The The app is free to download in iTunes with an annual in-app subscription to live lightning data for $1.99.

• If lightning strikes nearby, the app sends an alert to the phone and the resource section provides information on what to do.
• The Home Screen gives current temperature, humidity, heat index and lightning strike information.
• The Map Screen is based on the user’s GPS location. One map shows lightning strikes within 25 miles, while another uses information from nearby weather stations to post current conditions, including heat index and wind chill.
• The Contacts function allows the user to compile team members’ contact info and send a message to the entire team with the touch of a button.
• The Resources section includes information that athletic trainers commonly dispense, such as hydration tips, injury prevention, concussion guidelines, and when to go to the emergency room. The resources will be updated as more information is needed or guidelines change.
• The app includes the Tennessee Secondary School Athletic Association (TSSAA) heat index guidelines.

Developed by Sports Medicine Physicians and Athletic Trainers with close guidance from coaches, the CoachSmart app brings many important topics into one easy location.

Recommending CoachSmart is now part of my pre-season safety talks to coaches, parents, and administrators, and will also be part of an upcoming lecture on Heat Illness.

The CoachSmart App was recently upgraded and returned to active status. I do not have any financial relationship with the CoachSmart App.

Pre-Concussion Mood Disorders May Lead to Prolonged Post-Concussion Recovery

In an effort to better identify young athletes who might be a greater risk of prolonged recoveries after suffering a sport-related concussion, the findings of a recent retrospective study indicate that a personal or family history of mood disorders maybe linked to a longer recovery period.

Researchers at Vanderbilt University compared athletes who had a three week post-concussion symptom resolution period versus those with a three month or longer symptom recovery period, and found that those with pre-concussion anxiety or depression had a 17-fold increased risk of having the prolonged recovery time.

The research team also found that a family history of mood disorders and delayed onset of symptoms were both also associated with an increased risk of prolonged symptoms after a sport-related concussion.

These findings definitely mirror my experiences in working with school-aged athletes who have suffered concussions during sport activities. 

I am more apt to ask about both personal and family history of mood disorders, often in the initial evaluation after a concussion. I will counsel families that any diagnosed or even suspected pre-existing emotional disorder, including Attention Deficit Disorder with/without Hyperactivity (not evaluated in the above study), depression and anxiety will have a tendency to worsen after concussion. 

In some cases, it is the concussion that makes pre-injury issues more clear and out in the open, and in those instances, we both have to manage the concussion issues but also give proper respect and attention to those underlying mood disorders. 

Early identification and aggressive psychological, medical, and school-based interventions are quite helpful in addressing emotional disorders. Key to have mental health colleagues available to assist in more difficult cases.

Failure to address the mood disorders leads to sub-optimal recovery.

I have also found that those pre-existing emotional disorders optimally managed with appropriate therapy and medication (when indicated) tend to have less consequences or flare-ups after an concussion. 

The findings of delayed onset of symptoms is also not a major surprise. I do tend to see namely depressive symptoms not fully present for up to 4-6 weeks after a concussion. Not sure why this occurs. Could be part of the anticipated physiologic healing response, but could possibly be a by-product of cumulative mental and physical  fatigue that accumulates by this time period and results in higher reported symptom presentations.

Comments on Recent Study Analyzing NCAA Concussion Policy

Thanks again to my wonderful colleagues at Concussion Connection for posting my comments and analysis on a recent American Journal of Sports Medicine study on NCAA Concussion Policy. 

To read my post, please click here

Addressing the Social Impact of Retiring from Sport due to Concussion

My wonderful colleagues at Concussion Connection have been offering their expert perspectives on retirement from sport due to concussion, and I am pleased to offer thoughts on the Social Impact of Retiring. Strongly recommend checking out the entire Concussion Connection site and praise them for the fine work they do in advocacy and education.

Return to Learn: Resources for Concussed Collegiate Student-Athlete

Have had the awesome fortune of meeting fellow Return to Learn after Concussion advocates/experts in Rachel and Katy from The Academic Agency and Lauren and Samantha from Concussion Connection. Been quite inspired by their passion for assisting athletes and families who suffer from sport-related concussion and also becoming more aware about particular nuances of specific return to learn strategies.  

Please click here to visit the Concussion Connection site and I thank them for this opportunity to review specific Return to Learn concerns for the Collegiate Student-Athlete.

Dr. Koutures Quoted in Well-Written Article on Heading in Soccer

Greatly appreciate the opportunity to share thoughts with Lindsay Barton, who tackled the hot topic of Heading in Youth Soccer for MomsTeam.com with a very well researched and balanced article released this week.

Barton referenced the American Academy of Pediatrics Council on Sports Medicine and Fitness policy statement regarding Injuries in Youth Soccer that I helped co-author, and also reviewed many recent studies and other policy statements on the subject.

Strongly recommend that anyone interested in the health and development of young soccer players take the time to read Barton's piece.

Stronger Necks May Mean Healthier Heads

In the valiant effort to reduce the risks of concussion, must commend colleagues who developed a practical pilot study finding that measured increases in neck strength may reduce the risk of concussion in contact sport high school athletes.

The validation of a hand-held tension scale for neck strength is one important finding, but more readily applicable to athletes and medical personnel "in the trenches" are the following observations:

• Smaller mean neck circumference, smaller mean neck to head circumference ratio, and weaker mean overall neck strength were significantly associated with concussion.
• For every pound of neck strength increase, odds of a concussion decreased by 5%
• Identifying differences in overall neck strength may be useful in developing a screening tool to determine which high school athletes are at high risk of a concussion

Now we have a potential low cost easy to implement primary concussion prevention strategy, and that itself is very exciting news. Honestly, other than proper rule enforcement to reduce dangerous play, other primary prevention techniques including helmets, mouthguards, and teaching of "proper" technique haven't survived scientific scrutiny to be determined statistically valid. It is refreshing to find a strategy that not only has a good initial evidence base, but can readily be used by school/team-based athletic trainers, coaches, and strength and conditioning specialists in large-scale settings. Many football programs already incorporate some aspect of neck strengthening, and these findings should encourage possible expansion of more focused and monitored neck strengthening programs to all contact/collision sport athletes with appropriate on-going evaluation of strength gains and on-field concussion outcomes.

Does this appear to be a useful item to discuss in pre-participation exams? Would this possibly be useful to include in pre-season concussion baseline testing?

Concussion: No Attention Deficit to Ethical Care

Whether it be during a pre-participation exam, evaluation a patient with two previous concussions, or even while watching my kids at soccer practice, getting more and more inquiries that are based on the premise "should I let my child play their chosen sport and risk getting a future concussion?"

Bet most people who ask me don't anticipate the extent of what comes back at them....and often, my responses are formulated with even more questions.

In each case, I have found that there is no textbook or rote answer. Rather, each athlete brings an unique set of past medical concerns, life experiences, expectations,  and level of risk tolerance that deserves a personalized response that engages the athlete and family in that very decision-making process. In efforts to feel that I have adequately educated on individualized possible risks, I sometimes wonder if I overwhelm families with data and information, while in other cases I struggle with a lack of good science to help make evidence-based decisions about that risk.

The protection from future harm is a direct correlate of the principles of the Hippocratic Oath "First of all, do no harm" that does seem relatively basic in its premise, but in practice can be fraught with difficult dilemmas.

Case in point: how about the football player with Attention Deficit Disorder (ADD) who wants to play football? In practice, have had many patients with diagnosed or suspected pre-existing ADD have worsening of ADD symptoms after a head injury. Many have required re-starting or increasing medication doses as part of their treatment, and have had extended periods of recovery that have adversely affected grades for entire academic semesters or longer.

Looking at the medical literature, the studied relationship between pre-existing ADD and recovery from Concussion is inconclusive. My patient experiences more seem to mirror the findings that patients with pre-morbid ADD are more likely to have moderate disability after mild Traumatic Brain Injury (I do have some issues with this article, including definitions of brain injury, lack of comment on pre-injury treatment, and reporting of academic progress after injury).

So, if I have a professional regard that young athletes with ADD may have more complicated recoveries from concussion, how do I best convey this information to families?

Do I categorically discourage participation in all risky activities? If so, how do I define such activities, or do I leave that up to the family? Is it more proper to bring up this potential risk as a matter of appropriate patient education and let the athlete and family make the ultimate decision? Do the documented benefits of regular physical activity and structure of a team or individual sport outweigh the potential risks in this particular child? Do I have enough experience and data to make an evidence-based statement about ADD and concussion, and thus fulfill a primary duty to reduce future risk?

The legal and ethical implications in the evaluation and management of sport concussion published in Neurology , July 2014  provided an interesting review of how to frame approaches to these discussions. Important elements, which I hope I try to abide by in my practice, include:

• Staying current with state-based concussion legislation and prevailing standards of concussion practice
• Allowing patients and families to participate in making medical decisions, and to even refuse to comply with recommended treatment
• Providing appropriate education to allow informed decisions
• Respecting patient medical privacy by clarifying early in encounters whether health information can and will be shared with medical colleagues and school/team personnel
• Protect athlete as much as possible from future harm
• Acknowledge conflicts of interest that might cloud judgement 
• Provide equal access to concussion evaluation for all athletes

So, it is probably now readily apparent that an appropriate response for such as seemingly brief query ""should I let my child play their chosen sport and risk getting a future concussion?" is anything but brief. Just like each concussion is an individualized experience, assessing and counseling on risk stratification requires a personalized and methodical approach. 

In the particular case of ADD and contact sports, I find myself more apt to present my professional experience about those athletes with protracted recoveries to fulfill my duty as part of the informed decision making process that involves the athlete and his/her family. I also am more aggressive in reviewing and optimizing all aspects of their ADD management (school modifications, homework environment, tutoring, counseling, and medications) in hopes that in the case of a concussion, more comprehensive pre-injury ADD treatment may reduce post-injury complications.

What are your thoughts about counseling for concussion risk reduction? How would you best handle an athlete at higher risk?

Initial Thoughts:CA Limits Contact Practice, Mandates 7 Day Minimum Return after Concussion

California Assembly Bill 2127 authored by  Assembly Member Ken Cooley (D-Rancho Cordova) has been passed by both legislative houses and now awaits the likely signature of Governor Jerry Brown. The date of implementation is uncertain at this time, but the following changes are certain to come to high school football in the Golden State:

• All high school football teams (public, private and charter) would be limited to no more than 2 full-contact practices per week during the pre-season and regular season.
• The full contact portion of each practice cannot exceed 90 minutes per day
• Full-contact practices are prohibited during the off-season
• “Full-contact practice” means a practice where drills or live action is conducted that involves collisions at game speed, where players execute tackles and other activity that is typical of an actual tackle football game

In addition to the contact practice limitations, the bill would further provide that, if a licensed health care provider determines that the athlete sustained a concussion or a head injury, the athlete is required to complete a graduated return-to-play protocol of no less than 7 days in duration under the supervision of a licensed health care provider. This stipulation is an extension of previous California legislative mandates passed in 2011 and 2012 that require:

• Immediate removal for the remainder of the day of any high school athlete suspected of having a concussion
• Prohibit the return of the athlete to that activity until he or she is evaluated by, and receives written clearance from a licensed health care provider
• Each year, a concussion and head injury information sheet must be signed and returned by athletes and parent/guardian
• Concussion education must now be part of required first aid training of every high school coach

Click here for more information on football safety

Click here for more information on concussions

Upon initial review of this legislation, l commend efforts to reduce concussive injuries and rushed returns to play after concussion, and also realize that many teams at all levels of football have already made live contact limitations. I also realize that there are several unanswered questions and controversies to share:

• The current scientific literature does not have a sufficient body of evidence to declare with certainty the precise risks and benefits of live contact limitations in football. The thought that reducing cumulative sub-concussive head impacts is indeed commendable, but the counter-result of potentially having athletes participate in game situations without adequate exposure of didactic hitting instruction has not been fully studied. Ideally, live contact football limitations would have the same injury reduction outcomes as seen with ice hockey checking limitations. Raising the age of initiating checking actually reduced injuries at all levels, thus countering the argument that early and more frequent exposure to checking was important to reduce injuries in older athletes. However, these proposed checking limitations were debated (and probably still questioned in some circles) for years until good studies were done that provided a sufficient supporting evidence base. It is sensible to think that less live contact overall reduces cumulative risk, but would be more appealing to eventually have good science to further support this contention.
• Is this global reduction on contact practice equally beneficial for all levels of high school football? Does maybe the freshman team with several members playing tackle football for the first time need more live contact versus the varsity program with more experienced athletes? Again, I have no numbers or science to support this statement, but do have to wonder.
• Could teams try to maximize the 90 minute sessions of live contact with more drills or hitting repetitions? Is that increased exposure better or worse than spreading it out over more days?
• I do wonder if the tackling limits will encourage the expansion of football camps and other training programs outside the formal high school environment that will allow greater exposure to live contact tackling drills and instruction? If players, parents, and coaches are concerned about receiving sufficient instruction, will they look elsewhere and if so, will those venues have appropriate coaching along with proper medical support (especially Certified Athletic Trainers) and referral mechanisms? 
• How do other medical professionals who routinely manage concussed patients feel about the mandatory 7 day minimum return progression? Don't think that anyone out there is ever excited to speed a player's return to play (in fact, we might actually appreciate having "the law" force us to slow down eager players), but one unintended consequence might be the challenge of even more players and families reluctant to present for medical evaluation with the knowledge that they will be required miss the next game. On the other hand, will it possibly increase demand for immediate post-concussive evaluation to "start the clock" as quickly as possible for the small subset of concussed athletes who truly become symptom free within 24-48 hours of injury? 
• The bill urges the California Interscholastic Federation to work in consultation with the  American Academy of Pediatrics and American Medical Society for Sports Medicine to adopt rules and protocols for developing the return to play progression. I am a member of both organizations, and can state that they are populated by caring and scientifically rigorous members who strive for the best safety interests of children and adolescent athletes. I implore my colleagues in these groups to rigorously evaluation these new mandates in hopes of developing more evidence-based answers to the queries and uncertainties raised above.

What do you think about the live contact tackling limitations? Do you also have any thoughts about the minimum 7 day return progression after a concussion? Very curious to hear from football players, parents, coaches, school administrators and fellow medical professionals.

Cheering for Cheerleading to be Classified as a Sport

Add the American Medical Association to the growing list of prominent medical groups advocating for cheerleading to be formally classified as a sport.

This policy adoption at the annual AMA meeting this week in Chicago recognizes the rigors and risks of cheerleading to be as demanding as many other high school and collegiate level sports. The AMA statements reinforces the findings of a well-documented American Academy of Pediatrics Council on Sports Medicine and Fitness Policy Statement that describes the epidemiology of cheerleading injuries and provides sensible recommendations for injury prevention. (Full disclosure: I was on the committee that reviewed this paper and approved the findings and recommendations).

As a sports medicine professional who sees a fair number of bases, flyers, spotters, and tumblers, the designation of cheerleading as a sport would have a multitude of benefits:

• Cheerleaders would have better and essential access to certified athletic trainers (ATC) for injury prevention and evaluation along with assistance in return to activity progression. Deciding how to return any athlete or performer can be a difficult and individualized concern, but doing it without an on-site medical professional such as the school-based ATC is even more overwhelming.
• Requiring cheerleaders to have pre-participation athletic screening exams affords the opportunity to identify medical and orthopedic concerns and develop comprehensive management plans before these issues become major problems. A timely pre-participation exam could tag team with starting an appropriate strength and conditioning program focusing on common shoulder, back, wrist, knee, and ankle issues.
• A sport designation would hopefully lead to safer facilities including use of mats and not inappropriate types of flooring, higher ceilings, and institution of emergency action plans in the event of injury.
• Encouraging coaches to follow rules for execution of technical skills set forth by national cheerleading governing bodies
• Including cheerleading injuries in national injury monitoring programs to increase information on the type, frequency, and severity of cheerleading-specific injuries at the high school and collegiate levels.

Today's cheerleaders often start well before high school and participate on competitive cheer teams in addition (or in many cases, in place of) to cheering for particular schools and teams. The high level of skill and training asked of these performers places them at risk for both acute and overuse injuries often at similar levels to contadt or collision sport athletes. Denying cheerleaders the right to appropriate medical care and supervision only increases the chance for catastrophic outcomes.

That would be something no one would cheer about...

Click here for more information about cheerleading safety and injury prevention.

NCAA says No to Padded Cap Use in Water Polo

Intrigued by the recent announcement from the NCAA Playing Rules Oversight Committee prohibiting the use of padded caps underneath water polo caps. The committee based its decision on the fact that, according to the NCAA Sports Science Institute, no scientific evidence supports the notion that padded headgear helps prevent concussions.

Have been asked several times by patients and families about using soft, padded caps or helmets to reduce potential for concussion in contact/collision sports such as soccer, water polo and volleyball. 

While I commend the intent of trying to reduce injury risk, have been hesitant to endorse any product that doesn't have solid science to support use, or one that while appearing to reduce risk, might actually increase such risk.

Soft headgear or padded helmets have not been consistently shown to reduce the rotational forces about the brain that are thought to be primary contributors to concussive injuries. 

How could they actually increase concussion risk?

• By wearing a this supposed protective gear, an athlete may opt to play more aggressively or even base a return to at-risk activity, but not receive a true aspect of risk reduction by wearing the device.
• My biggest concern- and this is from living in the real world and hearing talk like this straight from the athletes themselves- "I see someone wearing a helmet, it looks like a target."  Who really wants to be putting themselves at risk without proper backup?

In the final analysis, until we obtain better information, I think this NCAA directive appropriately takes pressure off families and eliminates the discussion about "requiring" helmets as a criteria for returning or continuing to play.

Limiting Ice Hockey Checking Until 15: Where Good Science Leads to Good Policy

Very proud of colleagues Keith Loud, MD, M.SC., FAAP and Alison Brooks, MD, FAAP for their lead roles in publishing the new American Academy of Pediatrics Council on Sports Medicine and Fitness (COSMF) policy statement on Reducing Injury Risk from Body Checking in Boys’ Youth Ice Hockey. 

Before I comment further on the importance of this paper, I will disclose that as a member of the COSMF Executive Committee at the time of the statement development, I reviewed their work and provided insight on the final product. 

I was most impressed with the solid scientific and epidemiology citations utilized to develop their recommendations, including the admonition that limiting checking until age 15 will reduce risk of concussion and likely lead to more years of participation in a potentially life-long activity.

Until this data was assessed, the debate on checking was vocal and valid. Would checking restrictions at young ages decrease head injury risk, or would they lead to higher risk of concussion as players would not be able to safely absorb hits if only taught at an older age? 

Now we can address this questions not just with emotional responses or hearken to tradition, but rather use good evidence to base policy that should not alter the sport, but enhance long-term participation. 

The discourse on checking mirrors the current concerns over tackling limitations in youth football, and the COSMF is in the process of producing a policy statement on this subject. Here the debate is between limiting contact to reduce cumulative burden of head impacts versus needing adequate tackling time to reduce injuries from improper technique, especially on game days.

Much like the Ice Hockey statement, the hope is that good science will drive tackling recommendations, for now there is a lack of consistent evidence upon which to counsel players, families, coaches, and policy makers. 

Proposing changes that affect the nature of a sport are fraught with emotional and passionate responses, but this Ice Hockey statement is a balanced scientific effort that truly strives to create a safer and more prolonged ability for players to enjoy a wonderful and engaging sport.