Prevention & Education

Progress in designing helmets for concussion management
Traditionally helmets for most sports have been designed to withstand a single severe impact. In an effort simply to keep the athlete alive, helmets have been made from materials that crush on impact, the complication being that if the material is hard enough to protect against a severe impact, it may be too hard to provide much protection against less severe impacts. Ironically, a helmet that would give excellent protection in a 15 mph crash might be no better than a wooden helmet in a 5 mph crash. These helmets have dramatically reduced the number of catastrophic injuries in many sports, most notably American football. However, as the number of deaths in football has dropped, more attention is being given to the many non-catastrophic head injuries that are still occurring.

Recently some football helmet manufacturers1 tackled this problem by placing additional energy absorbing materials inside their traditional helmets, hoping to increase the level of protection against less severe blows while maintaining the existing protection against more severe blows. Laboratory data appear to be encouraging, and helmets with extra padding have been used by a few schools at the collegiate level. Preliminary data from a three-year study of high school football players wearing helmets that included the new technology indicate that the concussion rate was reduced from 7.6% with traditional helmets to 5.3% with the new helmets – a reduction that was statistically significant in the study.2 These results provide proof of the concept, and it is possible that the materials used in these new football helmets might be beneficial in other sports activities as well.

Progress in detecting concussions on the sideline
Professors LaPlaca and Wright at Emory University, in cooperation with Georgia Tech, have developed a system that is somewhat like a bridge between SAC and NP testing. Called Display Enhanced Testing for Concussions and MTBI (DETECT), it is a device that fits onto the injured players head and does abbreviated testing on his working memory, complex reaction time, and multi-tasking. It is claimed to take only seven minutes on the sideline with a laptop computer to determine whether the player has been concussed. The system has undergone laboratory testing, but we have not seen any published reports of clinical testing yet.

Use of Protective Headbands in sanctioned soccer games
In the midst of the discussion about concussions in soccer, three interesting and controversial statements were published by major soccer governing bodies. Prior to mid-2003, Fédération Internationale de Football Association (FIFA) and the United States Soccer Federation (USSF) were curiously silent about the use of head protection in their organizations. The National Federation of State High Schools Association (NFHS) was unique as the only organization that openly banned the use of soccer headgear. Then, beginning in mid-2003 all three bodies posted statements3 allowing the use of this headgear. Not surprisingly, to ensure that headgear is in compliance with the Laws of the Game, all three groups require that headgear be soft and padded, and not pose an injury hazard to the wearer or any other player. The final decision about whether a particular device may be worn in a game is left to the referee, but the statements use terminology suggesting that in most cases the referee "should permit" the use of soft padded headgear. There have been a variety of positions taken since then, primarily by USSF, that seem to discourage but not ban the use of soccer headguards.

Published reports about soccer head protection In the summer of 2005, the British Journal of Sports Medicine issued a supplemental edition4 that included several articles related to soccer heading and head injuries. Much of the work involved in the articles was supported by the FIFA Medical Assessment and Research Centre (F-MARC) as FIFA continues to search for reasonable conclusions about how head injuries occur and how to reduce them. Several noteworthy issues were mentioned in the supplement:

1. Of the incidents that resulted in head injuries, 30% involved foul play by at least one participant, 70% of the instances were within the Laws of the Game5.
2. One observed concussion was caused by a close-range clearing kick that struck a player in the side of his head. None of the observed concussions resulted from deliberate head strikes or foul play6.
3. Females were 2.4 times as likely as males to be concussed7.
4. "Modification of game rules or heading techniques will remain a remote possibility until a greater understanding of the biomechanics and injury potential is obtained."8
5. The authors did not speculate on the possibility of long-term effects of heading "due to the yet undefined injury mechanisms and tolerance levels."9
6. Without going into more detail, one author states that "Direct head contact and heading are implicated in acute and chronic head injuries, respectively."10
7. Regarding the objects struck in concussive impacts, "upper extremity impacts posed low concussion risk, but head to head impacts posed high concussion risk."11
8. Withnall et al12 tested three commercial soccer headgear devices in head to ball and head to head situations. While none of the products provided significant protection in ball to head impacts, "The findings of the head to head impacts show that headgear provides a measurable improvement in head response."
9. While many of these statements would seem to cast soccer headgear in a favorable light, it should be pointed out that a limited number of laboratory simulations of head to head impacts were measured in these studies, and those that were observed were at relatively low velocity – possibly lower than might be seen commonly on the pitch. Also, there were no impacts between heads and harder objects, such as ground or goal post; performance of headguards in these situations in independent studies has not been reported. But overall the authors concluded13 that "there exists a positive potential for headgear to be redesigned specifically to protect against head to head or other non-ball related impact."

Although these comments would appear to be somewhat supportive of the use of headguards (possibly not of the designs that are currently available) as they perform in the lab, they are by no means hard evidence that headguards would have any impact on the number of concussions seen on the pitch. Field studies must be conducted before headguards can be proven beneficial.

Performance specification for soccer headgear
In January 2006 ASTM International (formerly the American Society for Testing and Materials) published a performance specification for headgear to be used in soccer.14 Engineers, medical personnel, consumer advocates and materials experts had been working on development of this standard since 1999, and obtained consensus agreement on the published document based on the best current information available about head injuries in soccer. It must be noted that the testing required by the standard, and the data used in developing the standard, is laboratory testing only. There have been no independent objective studies of the performance of headguards in actual use on the pitch.

soccerheadinjury.org does not take a position on the utility of the tests required in the ASTM standard, because we have not yet seen clinical data regarding the use of products satisfying the standard. The standard states specifically that it does not address the administrative requirements of soccer governing bodies, so a device that satisfies the standard does not automatically ensure acceptance by FIFA, USSF, or NFHS. We are not aware of which, if any, of the products that are currently available satisfy the requirements of the standard, or which of the products may or may not offer real protection against concussions.

1. Strength and conditioning
   
2. Enhanced officiating
   
3. Equipment changes
   
4. Heading training

Prevent the first one
All concussions are bad, so no matter how many you’ve had, do all you can to avoid having more. Because of the increased risk and increased severity after the first concussion, not to mention second impact syndrome, prevention of the first concussion is tantamount. Once you’ve had that first one, your resistance to another one is permanently reduced. Take all reasonable precautions, such as those mentioned by Withnall15. Note, however, that direct protection of the head is not listed among the potential methods of reducing head injuries. The use of headguards and mouthguards, regardless of the eventual decision about their utility with respect to concussions, should be included as a topic for consideration.

Continuing medical research
Without the cooperation of the soccer organizations and the medical community, it will be nearly impossible to reach medically sound conclusions about reducing soccer head injuries. Several studies are now underway that have potential bearing on reducing the risk of concussions, including a ten-year study of heading being conducted by the Football Association. We will do what we can to stay abreast of these studies, and will report them on www.soccerheadinjury.org as they become available. We encourage our readers to inform us of additional work that we may not have reported.

In particular, we need formal controlled field studies of the potential benefits of both mouthguards and headguards in reducing the number of concussions. If it is determined that concussions can be prevented without the addition of more player equipment, that will be ideal; if not, however, it may be necessary for us to consider using the least obtrusive equipment that will provide the greatest injury-prevention benefit without affecting the game. It is likely that no single step will accomplish the desired reduction of injury risk; it may be necessary to combine several partial solutions in order to reduce head injuries to an acceptable level.

Symposia and conferences
A vital step in reporting and discussing progress in clinical studies is medical symposia and conferences that specifically address traumatic head injuries. Such meetings have become more frequent as realization of the frequency of sports-related head injuries has increased. Two notable examples have been the First International Conference on Concussion in Sport16, held in Vienna in 2001, and the follow-up 2nd International Conference on Concussion in Sport in Prague in 2004. We encourage the continuation of this series of conferences, as well as all other meetings that address head injuries. The findings that are reported and evaluated at these meetings help to define additional steps that must be taken.

Risk homeostasis
Although it is not a factor in diagnosing or responding to a concussion, one argument that has been raised in opposition to the use of protective headgear in soccer is risk homeostasis. This is the theory that each person has his own particular acceptable level of risk. If his risk level in one area is reduced, he will increase his risk-taking in some other area to compensate for the reduced risk, so his overall threshold for risk-taking will be unchanged. In soccer, it is argued that players who believe they are reducing the risk of head injury by wearing protective headgear will, possibly unconsciously, play more aggressively, thus counteracting any positive effect of the headgear by increasing the risk of injury to themselves and others. This argument has been applied to many kinds of protective equipment for many years, such as seat belts, motorcycle helmets, and shin guards. It is very difficult to measure the total effect of any safety product, so this question is likely to remain unresolved.

As an example, when ski helmets were introduced several years ago, an uncontrolled and unpublished study found that skiers wearing helmets traveled about 10% faster than unhelmeted skiers on the same course. However, there was no way to determine whether skiers went faster because they wore helmets, or they wore helmets because they ski faster. Either conclusion might be correct, so this study gave us no direction as to whether risk homeostasis should be a real concern in the issue of soccer head protection.

Risk homeostasis has strong adherents on both sides. For opinions for and against the compensation theory, see Thompson17 and response from Adams18. Other positive and negative opinions are expressed by Wilde (for) and Robertson (against)19.

Why not use real helmets?
Because of the misuse of terminology, many people are still unclear about the type of soccer headgear that is now being offered. Reporters often equate soccer head protection devices with "helmets," thus eliciting the idea in their audience that manufacturers want to put large, hard, bulky things like motorcycle helmets or football helmets on soccer players’ heads. It should be pointed out that most of the commercial products are not "helmets" in the usual sense of the word. Rather, they are more closely related to headbands, similar to those worn by many basketball players, but with the addition of some amount of energy absorbing material to reduce the forces reaching the head.

This is not an argument favoring or opposing any of the products that are on the market, but in the interest of fair reporting, we suggest that our readers should look at the devices that are being manufactured before concluding that "helmets" are obviously inappropriate for soccer.

What about mouthguards?
It has been suggested, and sometimes stated as fact, that mouthguards can prevent concussions. Even those who make these claims generally specify that the only types of impacts for which mouthguards would be beneficial in concussion prevention are blows to the chin, which cover only a small number of the concussions incurred in soccer. Mouthguards are believed to provide significant protection against dental and orofacial injuries, though data are scant. Some of the statements that can be found on the Internet are, "The American Dental Association estimates that mouthguards prevent approximately 20,000 injuries each year. An athlete is 60 times more likely to sustain damage to the teeth when not wearing a protective mouthguard,"20 and, "Since 1962 when it became a requirement to wear mouthguards in high school and college football ... the percentage of orofacial injuries dropped from 50% to .5%."21 A good brief summary of the data related to mouthguards is given by McCrory22. Although his review was written a few years ago, there doesn’t seem to be much more recent evidence regarding the clinical benefits of mouthguards. As recently as 2004 Beachy23 said, "Unfortunately, speculative anecdotal reports regarding mouthguard use and the prevention of concussions have been given unwarranted credibility." Clearly we need more hard data.