Original paper
The effect of visors on head and facial injury in National Hockey League players

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Summary

There has been an increase in the number of concussions sustained by players in the National Hockey League (NHL). While wearing a helmet is now required by the NHL, the face visor remains optional. It is unknown to what degree face visors influence concussion, other head injury and eye-injury rates at the professional level. Data from the 2001–2002 NHL season were examined. It was found that wearing a face visor did not significantly influence the prevalence of concussion. Visor protection did, however, minimise eye-injuries and other, non-concussion head injuries. These data suggest that, while a visor may prevent some head and eye-injuries, other measures may be necessary to reduce the number of concussions.

Introduction

The increased rate of reported head injuries in ice hockey has caused a growing concern over the short- and long-term effects of concussions. Physical contact is expected and often a desirable part of the game.1, 2 As the game has evolved, players have increased in size.3, 4 Rapid growth, combined with bigger and faster players, is thought to have resulted in an increased number of injuries.1, 5, 6 Regardless, coaches, peers, broadcasters and experts praise players who have a physical and rough demeanour.7

The National Hockey League (NHL) has expanded from 6 teams in 1967 to 30 teams in 2000.8 During this time, a migration of many highly skilled players from Europe and the former Soviet Union to the NHL has occurred.3 A further transformation that has taken place during this time involved the improvement of equipment and the attention paid to player safety. For example, the helmet was made mandatory in the 1979–1980 NHL season for any player entering the league from that point on.3

Despite the helmet's introduction, there has been an alarming increase in concussion rates in the NHL.4, 6 Wennberg and Tator analysed the increase of concussion in the NHL over a 15-year period (1986–1987 to 2001–2002) and from 1997–1998 to 2001–2002 the reported concussion rate tripled that of the previous decade.4 Even with this considerable increase some researchers suggest that many instances of concussion still go undiagnosed.9, 10 Athletes may be hesitant to describe concussive symptoms and may be under significant stress or pressure to return to play.10 It is also possible that, when a concussion grading system is used, low grade injuries are missed.9

The identification of a concussion and post-concussion symptoms (PCS) is one of the most challenging issues facing medical professionals. Headaches, dizziness, nausea, decreased concentration, fatigue and/or memory alteration may be symptoms of concussion but also commonly occur in normal populations. Historically it has been difficult to measure severity or recovery from concussion objectively and until recently the universally accepted definition was considered to be rather limited.11 The adoption of universal criteria has standardised the diagnosis of concussion, increasing the validity of findings based on such diagnoses.11

A significant body of research has focused on the prevalence of concussions in ice hockey, in an attempt to identify factors that may increase the likelihood of concussions. These include: (a) players being bigger and faster4; (b) the introduction of newer glass and equipment and harder boards4; (c) the sport's inherent physical nature1, 2, 4; (d) differences in facial protection12, 13, 14; and (e) differences in individual playing time.14 Other factors include gender differences (females more likely than males to suffer a concussion),15 and pre morbid expectations that result in making symptoms consistent with one's expectations.16

Of particular interest is research that indicates that differences in facial protection might play a role in the prevalence of concussion and/or other head and eye-injuries. These studies have suggested that players wearing no facial protection are injured at significantly higher rates than those wearing partial (i.e., half-visors) and full protection.14, 17, 18 Despite this, the majority of players in the NHL do not wear a visor.19, 20 Visors have been reported to reduce peripheral vision while not offering significantly greater protection against head injuries.14, 19 Further, visors can fog up during the course of a game and may potentially limit vision.19 Many players “look down” upon the visor, believing that wearing no facial protection is a sign of increased masculinity and toughness, while wearing facial protection made them feel like a target for the opposition.14

Research on ice hockey has indicated that, while facial protection does not significantly reduce the occurrence of concussion, it may reduce severity. These studies compared partial and full facial protection and did not include data on players with no facial protection.12, 13 Stuart et al.14 did compare the concussion rates of players wearing no, partial and full facial protection and found no significant difference in the rate of concussion. Because of this, it was hypothesised that the difference in the use of facial protection and style of play might affect the number of concussions and related head injuries, including eye-injuries. Unlike the studies of Benson et al.12, 13 and Stuart et al.14 who examined data from the United States Junior A level14 and Canadian university hockey teams,12, 13 this study analysed data from the NHL. This allowed for a significantly larger participant pool. Statistics for all games played in the season were available, unlike previous studies.12, 13, 14 Finally, this study examined data on players whose concussions are likely most accurately diagnosed because of the NHL's Neuropsychological Program, started in 1997.4

Section snippets

Method

Statistical and injury data were compiled on the 2001–2002 NHL season. For purposes of this study an injury was therefore defined as any injury (concussion, eye-injury or other non-concussion head injuries) that resulted in at least one full game of missed playing time. Non-concussion head injuries included injuries such as breaks (e.g., fractured nasal bones). This category did not include minor facial injuries such as lacerations.

All injury data (concussions, eye-injuries, non-concussion head

Results

There were a total of 874 players included in the preliminary analysis. Injury and visor data on 70 players (8.0%) were unobtainable, leaving the final data set at 787 players. There were a total of 45 players who had concussions (4.5%), 19 who had non-concussion head injuries (2.4%) and 10 who had eye-injuries (1.3%). In terms of visors, 606 players were found not to wear visors (77%), while 181 players did wear visors (23.0%).

There was no significant difference between the number of

Discussion

The results of the current study indicated that there was no significant difference in the occurrence of concussions in players who wore helmets without a visor and those with a visor. This result is consistent with previous findings.12, 13, 14 Benson et al.12, 13 compared the use of a full cage with the use of a visor but did not analyse differences between no facial protection and visors. They found a significant difference in time missed due to injury but not a significant difference in

Practical implications

  • The visors worn by National Hockey League (NHL) players reduce the number of concussions they receive.

  • Wearing a visor also significantly reduces the number of non-concussion head injuries.

  • Visor use also significantly reduces the number of eye-injuries in the NHL.

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