{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,12,4]],"date-time":"2025-12-04T14:45:34Z","timestamp":1764859534535},"reference-count":37,"publisher":"American Medical Association (AMA)","issue":"5","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"Importance<\/jats:title>National Hockey League (NHL) players are exposed to frequent head trauma. The long-term consequences of repetitive brain injury, especially for players who frequently engage in fighting, remains unknown.<\/jats:p><\/jats:sec>Objective<\/jats:title>To investigate the mortality rates and causes of death among NHL enforcers with more career fights and penalty minutes as compared with matched controls.<\/jats:p><\/jats:sec>Design, Setting, and Participants<\/jats:title>This matched cohort study examined 6039 NHL players who participated in at least 1 game in the seasons between October 11, 1967, and April 29, 2022, using official NHL data. Cohorts designated as enforcer-fighter (E-F) and enforcer-penalties (E-P) were selected. The E-F cohort consisted of players who participated in 50 or more career fights (n\u2009=\u2009331). The E-P cohort included players with 3 or more penalty minutes per game (n\u2009=\u2009183). Control-matched NHL players were identified for each E-F player (control-fighter [C-F]) (n\u2009=\u2009331) and each E-P player (control-penalties [C-P]) (n\u2009=\u2009183).<\/jats:p><\/jats:sec>Exposures<\/jats:title>Fighting and penalty minutes were both used as proxies for head trauma exposure. Players with significantly increased exposure to fighting and penalties (E-F and E-P cohorts) were compared with NHL players with less frequent exposure to head trauma (C-F and C-P cohorts).<\/jats:p><\/jats:sec>Main Outcomes and Measures<\/jats:title>Mortality rates and age at death of the enforcer and control cohorts, and their causes of death using data obtained from publicly available sources such as online and national news sources, including NHL.com.<\/jats:p><\/jats:sec>Results<\/jats:title>Among the 6039 NHL players identified (mean [SD] age, 47.1\u2009[15.2] years), the mean (SD) number of fights was 9.7\u2009(24.5). The mortality rates of E-F and C-F players (13 [3.9%] vs 14 [4.2%], respectively; P<\/jats:italic>\u2009=\u2009.84) or E-P and C-P players (13 [7.1.%] vs\u200910 [5.5%]; P<\/jats:italic>\u2009=\u2009.34) were not significantly different. The mean (SD) age at death was 10 years younger for E-F players (47.5\u2009[13.8] years) and E-P players (45.2\u2009[10.5] years) compared with C-F players (57.5\u2009[7.1] years) and C-P players (55.2\u2009[8.4] years). There was a difference in causes of death between the control and enforcer players (2 neurodegenerative disorders, 2 drug overdoses, 3 suicides, and 4 vehicular crashes among enforcers vs 1 motor vehicle crash among controls; P<\/jats:italic>\u2009=\u2009.03), with enforcers dying at higher rates of overdose (2 of 21 [9.5%] vs 0 of 24) and suicide (3 of 21 [14.3%] vs 0 of 24) (P<\/jats:italic>\u2009=\u2009.02).<\/jats:p><\/jats:sec>Conclusions and Relevance<\/jats:title>The findings of this matched cohort study indicate that there is no difference in overall mortality rates between NHL enforcers and controls. However, being an enforcer was associated with dying approximately 10 years earlier and more frequently of suicide and drug overdose.<\/jats:p><\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2023.11308","type":"journal-article","created":{"date-parts":[[2023,5,10]],"date-time":"2023-05-10T16:17:55Z","timestamp":1683735475000},"page":"e2311308","source":"Crossref","is-referenced-by-count":3,"title":["Fighting and Penalty Minutes Associated With Long-term Mortality Among National Hockey League Players, 1967 to 2022"],"prefix":"10.1001","volume":"6","author":[{"given":"Charles A.","family":"Popkin","sequence":"first","affiliation":[{"name":"Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Cole R.","family":"Morrissette","sequence":"additional","affiliation":[{"name":"Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Thomas A.","family":"Fortney","sequence":"additional","affiliation":[{"name":"Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kyle L.","family":"McCormick","sequence":"additional","affiliation":[{"name":"Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Prakash","family":"Gorroochurn","sequence":"additional","affiliation":[{"name":"Department of Biostatistics, Columbia University Medical Center, New York, New York"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michael J.","family":"Stuart","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"10","published-online":{"date-parts":[[2023,5,10]]},"reference":[{"issue":"2","key":"zoi230358r1","doi-asserted-by":"publisher","first-page":"153","DOI":"10.2307\/3340350","article-title":"Honor, ritual and violence in ice hockey.","volume":"10","author":"Colburn","year":"1985","journal-title":"Can J Sociol"},{"issue":"5","key":"zoi230358r2","doi-asserted-by":"publisher","first-page":"458","DOI":"10.1177\/1941738113491711","article-title":"\u201cI went to a fight the other night and a hockey game broke out\u201d: is professional hockey fighting calculated or impulsive?","volume":"5","author":"Goldschmied","year":"2013","journal-title":"Sports Health"},{"key":"zoi230358r3","doi-asserted-by":"publisher","DOI":"10.3389\/fspor.2022.890429","article-title":"National Hockey League fights per game and viewership trends: 2000\u20132020.","author":"Fortney","journal-title":"Front Sports Act Living"},{"issue":"2","key":"zoi230358r6","doi-asserted-by":"publisher","first-page":"416","DOI":"10.2466\/pms.1995.80.2.416","article-title":"Fighting behavior and winning National Hockey League games: a paradox.","volume":"80","author":"Engelhardt","year":"1995","journal-title":"Percept Mot Skills"},{"issue":"2","key":"zoi230358r7","doi-asserted-by":"publisher","first-page":"231","DOI":"10.1111\/ajes.1996.55.issue-2","article-title":"From the arena into the streets: hockey violence, economic incentives and public policy.","volume":"55","author":"Jones","year":"1996","journal-title":"Am J Econ Sociol"},{"issue":"4","key":"zoi230358r8","doi-asserted-by":"publisher","first-page":"292","DOI":"10.1080\/00036846.2015.1078446","article-title":"Fighting as a profit maximizing strategy in the National Hockey League: more evidence.","volume":"48","author":"Rockerbie","year":"2016","journal-title":"Appl Econ"},{"key":"zoi230358r9","doi-asserted-by":"publisher","first-page":"538","DOI":"10.1177\/1527002510389869","article-title":"The effect of home advantage, momentum, and fighting on winning in the National Hockey League.","volume":"12","author":"Leard","year":"2010","journal-title":"J Sports Econ"},{"issue":"7","key":"zoi230358r10","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0069122","article-title":"Bodychecking rules and concussion in elite hockey.","volume":"8","author":"Donaldson","year":"2013","journal-title":"PLoS One"},{"key":"zoi230358r11","doi-asserted-by":"publisher","DOI":"10.1155\/2022\/7024766","article-title":"The impact of the instigator rule on fighting in the National Hockey League.","volume":"2022","author":"Morrissette","year":"2022","journal-title":"Transl Sports Med"},{"issue":"1","key":"zoi230358r12","doi-asserted-by":"publisher","first-page":"55","DOI":"10.1515\/pcssr-2016-0013","article-title":"NHL heavyweights: narratives of violence and masculinity in ice hockey.","volume":"70","author":"Tj\u00f8nndal","year":"2016","journal-title":"Phys Cult Sport Stud Res"},{"issue":"1","key":"zoi230358r14","doi-asserted-by":"publisher","first-page":"35","DOI":"10.1249\/JSR.0000000000000556","article-title":"Eliminating fighting and head hits from hockey: opportunities and barriers.","volume":"18","author":"Smith","year":"2019","journal-title":"Curr Sports Med Rep"},{"issue":"5","key":"zoi230358r15","doi-asserted-by":"publisher","first-page":"347","DOI":"10.1136\/injuryprev-2013-041016","article-title":"Economic burden of time lost due to injury in NHL hockey players.","volume":"20","author":"Donaldson","year":"2014","journal-title":"Inj Prev"},{"issue":"8","key":"zoi230358r16","doi-asserted-by":"publisher","first-page":"552","DOI":"10.1136\/bjsports-2013-092235","article-title":"A systematic video analysis of National Hockey League (NHL) concussions, part II: how concussions occur in the NHL.","volume":"49","author":"Hutchison","year":"2015","journal-title":"Br J Sports Med"},{"issue":"1","key":"zoi230358r17","first-page":"CNC1","article-title":"Concussion in the National Hockey League: a systematic review of the literature.","volume":"1","author":"Kuhn","year":"2015","journal-title":"Concussion"},{"issue":"8","key":"zoi230358r18","doi-asserted-by":"publisher","first-page":"547","DOI":"10.1136\/bjsports-2013-092234","article-title":"A systematic video analysis of National Hockey League (NHL) concussions, part I: who, when, where and what?","volume":"49","author":"Hutchison","year":"2015","journal-title":"Br J Sports Med"},{"issue":"Pt 1","key":"zoi230358r19","doi-asserted-by":"publisher","first-page":"43","DOI":"10.1093\/brain\/aws307","article-title":"The spectrum of disease in chronic traumatic encephalopathy.","volume":"136","author":"McKee","year":"2013","journal-title":"Brain"},{"key":"zoi230358r20","doi-asserted-by":"publisher","first-page":"30","DOI":"10.3389\/fnhum.2013.00030","article-title":"Long-term effects of mild traumatic brain injury on cognitive performance.","volume":"7","author":"Dean","year":"2013","journal-title":"Front Hum Neurosci"},{"issue":"13","key":"zoi230358r21","doi-asserted-by":"publisher","first-page":"1122","DOI":"10.1212\/WNL.0b013e3182a55f7f","article-title":"Clinical presentation of chronic traumatic encephalopathy.","volume":"81","author":"Stern","year":"2013","journal-title":"Neurology"},{"issue":"4","key":"zoi230358r22","doi-asserted-by":"publisher","first-page":"360","DOI":"10.1001\/jama.2017.8334","article-title":"Clinicopathological evaluation of chronic traumatic encephalopathy in players of American football.","volume":"318","author":"Mez","year":"2017","journal-title":"JAMA"},{"issue":"5","key":"zoi230358r23","doi-asserted-by":"publisher","DOI":"10.1001\/jamanetworkopen.2019.4223","article-title":"Mortality among professional American-style football players and professional American baseball players.","volume":"2","author":"Nguyen","year":"2019","journal-title":"JAMA Netw Open"},{"issue":"5","key":"zoi230358r25","doi-asserted-by":"publisher","first-page":"1086","DOI":"10.1227\/01.NEU.0000245601.69451.27","article-title":"Chronic traumatic encephalopathy in a National Football League player: part II.","volume":"59","author":"Omalu","year":"2006","journal-title":"Neurosurgery"},{"issue":"1","key":"zoi230358r26","doi-asserted-by":"publisher","first-page":"23","DOI":"10.1249\/JSR.0000000000000557","article-title":"Proceedings from the Ice Hockey Summit III: action on concussion.","volume":"18","author":"Smith","year":"2019","journal-title":"Curr Sports Med Rep"},{"issue":"3","key":"zoi230358r27","doi-asserted-by":"publisher","first-page":"206","DOI":"10.1017\/S0317167100002596","article-title":"National Hockey League reported concussions, 1986-87 to 2001-02.","volume":"30","author":"Wennberg","year":"2003","journal-title":"Can J Neurol Sci"},{"issue":"2","key":"zoi230358r28","doi-asserted-by":"publisher","first-page":"128","DOI":"10.1136\/bjsm.2005.021832","article-title":"Converging evidence for the under-reporting of concussions in youth ice hockey.","volume":"40","author":"Williamson","year":"2006","journal-title":"Br J Sports Med"},{"issue":"5","key":"zoi230358r29","doi-asserted-by":"publisher","first-page":"647","DOI":"10.1017\/S031716710000946X","article-title":"Concussion incidence and time lost from play in the NHL during the past ten years.","volume":"35","author":"Wennberg","year":"2008","journal-title":"Can J Neurol Sci"},{"issue":"1","key":"zoi230358r31","doi-asserted-by":"publisher","first-page":"193","DOI":"10.1186\/s13195-021-00928-y","article-title":"Structural MRI profiles and tau correlates of atrophy in autopsy-confirmed CTE.","volume":"13","author":"Alosco","year":"2021","journal-title":"Alzheimers Res Ther"},{"issue":"4","key":"zoi230358r32","doi-asserted-by":"publisher","first-page":"370","DOI":"10.1055\/s-0040-1713624","article-title":"Clinical presentation of chronic traumatic encephalopathy.","volume":"40","author":"Mariani","year":"2020","journal-title":"Semin Neurol"},{"issue":"5","key":"zoi230358r33","doi-asserted-by":"publisher","first-page":"68","DOI":"10.1186\/s13195-014-0068-z","article-title":"Clinical subtypes of chronic traumatic encephalopathy: literature review and proposed research diagnostic criteria for traumatic encephalopathy syndrome.","volume":"6","author":"Montenigro","year":"2014","journal-title":"Alzheimers Res Ther"},{"issue":"6","key":"zoi230358r37","doi-asserted-by":"publisher","DOI":"10.1371\/journal.pone.0269889","article-title":"Tooth for a tooth: does fighting serve as a deterrent to greater violence in the modern NHL.","volume":"17","author":"Betz","year":"2022","journal-title":"PLoS One"},{"key":"zoi230358r4","doi-asserted-by":"crossref","DOI":"10.5406\/j.ctv80c98f","volume-title":"Hockey: A Global History","author":"Hardy","year":"2018"},{"key":"zoi230358r5","volume-title":"The Code: The Unwritten Rules and Fighting and Retaliation in the NHL","author":"Bernstein","year":"2006"},{"key":"zoi230358r13","doi-asserted-by":"crossref","unstructured":"Plassche? GC, Fortney? TA, Morrissette? C, Korzelius? JF, Popkin? CA. Fighting in professional ice hockey: it\u2019s time for a change.? Phys Sportsmed. Published online May 30, 2022. doi:10.1080\/00913847.2022.2078170?","DOI":"10.1080\/00913847.2022.2078170"},{"key":"zoi230358r24","unstructured":"National Hockey League. Statistics. Accessed August 25, 2022. https:\/\/nhl.com\/stats"},{"key":"zoi230358r30","unstructured":"National Hockey League. Official Rules 2021-2022. 2021. Accessed August 25, 2022. https:\/\/cms.nhl.bamgrid.com\/images\/assets\/binary\/326142322\/binary-file\/file.pdf"},{"key":"zoi230358r34","unstructured":"National Basketball Association. 2019-20 NBA Rulebook. Accessed August 25, 2022. https:\/\/official.nba.com\/rulebook\/"},{"key":"zoi230358r35","unstructured":"Perry D. MLB\u2019s safety proposal for 2020 season includes \u201csevere discipline\u201d for fighting, report says. CBSSports.com. May 18, 2020. Accessed July 8, 2022. https:\/\/www.cbssports.com\/mlb\/news\/mlbs-safety-proposal-for-2020-season-includes-severe-discipline-for-fighting-report-says\/"},{"key":"zoi230358r36","unstructured":"2020 Official Playing Rules of the National Football League. 2020. Accessed August 25, 2022. https:\/\/operations.nfl.com\/media\/4693\/2020-nfl-rulebook.pdf"}],"container-title":["JAMA Network Open"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/articlepdf\/2804675\/popkin_2023_oi_230358_1683052051.56317.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,5,10]],"date-time":"2023-05-10T16:18:08Z","timestamp":1683735488000},"score":1,"resource":{"primary":{"URL":"https:\/\/jamanetwork.com\/journals\/jamanetworkopen\/fullarticle\/2804675"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,5,10]]},"references-count":37,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2023,5,1]]}},"URL":"https:\/\/doi.org\/10.1001\/jamanetworkopen.2023.11308","relation":{},"ISSN":["2574-3805"],"issn-type":[{"value":"2574-3805","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,5,10]]}}}