© Springer International Publishing Switzerland 2016
Michael O’Brien and William P. Meehan III (eds.)Head and Neck Injuries in Young AthletesContemporary Pediatric and Adolescent Sports Medicine10.1007/978-3-319-23549-3_22. Protective Equipment
(1)
Rhode Island Hospital, Providence, RI, USA
Keywords
Protective equipmentInjury preventionHead injuryNeck injuryYoung athletePediatricIntroduction
Injuries involving the head and neck represent a significant proportion of sports-related trauma incurred by youth athletes. Approximately 6.5 % of over 2.6 million children ≤ 19 years treated for sport and recreation-related injuries in an emergency department setting between 2001 and 2009 had sustained traumatic brain injuries or concussions [1]. In this chapter, we will review the history of protective equipment; evidence supporting the utilization of head, face, and neck protective gear in contact/collision sports; the role protective equipment plays in injury reduction; attitudes among players, medical staff, and coaches toward the use of protective equipment; issues pertaining to enforcement and mandated use of protective gear; advertising and marketing claims regarding protective equipment; and future directions and research regarding head and neck protective equipment.
History of Protective Equipment and Evidence of Effectiveness
Helmets and Headgear
Protective headgear initially was design ed for combat due to the vulnerability of the head in wartime operations. With the advent of sophisticated weapons and twentieth-century manufacturing technological advances, mass production of standard-issue head protection became available for soldiers. Significant morbidity and mortality in American football sparked the adoption of modern head protection in sport. The first documented use of a leather football helmet occurred during the 1893 Army-Navy game. In 1905, 18 deaths and 129 serious injuries occurred in American football, prompting President Theodore Roosevelt to call a conference with representatives of several Ivy League schools, resulting in the formation of the Intercollegiate Athletic Association, the predecessor to the National Collegiate Athletic Association (NCAA) [2, 3]. Helmet technology continued to evolve in the early twentieth century, with leather padding gradually being replaced by metal and plastic components. However, leather helmets continued to be developed and utilized routinely in American football through the 1940s. Mandatory helmet use in American football did not occur until 1939 in the NCAA and 1943 in the National Football League (NFL). Unfortunately, serious head injuries including intracranial hemorrhages and skull fractures remained prevalent in American football throughout the mid-twentieth century, prompting rule changes, coaching changes, and, ultimately, the formation of the National Operating Committee on Standards for Athletic Equipment (NOCSAE) in 1969, which ultimately implemented the first football helmet safety standards in 1973 [4, 5].
American Football
Since the development of modern-day sports concussion assessment and management guidelines [6–8], few studies regarding helmet effectiveness in reducing head injury in American football have been published. Studies conducted prior to the Prague/Zurich era tended to underreport concussive injuries, reported only the most severe concussive injuries, and relied on coach and certified athletic trainer (ATC) diagnosis [4, 9, 10]. Collins et al. performed a prospective cohort study during the 2002–2004 seasons comparing concussion rates and recovery times for 2141 high school football players. Nearly half the sample wore newer helmet technology (Riddell Revolution ), and the remainder used traditional helmet designs from various manufacturers. Over the course of the study, the concussion rate of the Revolution helmet group was 5.3 % compared to 7.6 % in the traditional helmet group (p < 0.03) [11]. However, this study was limited by lack of randomization of helmets among study participants, mean chronologic age discrepancies among study groups, and variability in age of the helmets, as the Revolution helmets were brand new while traditional helmets were reconditioned. Additionally, impact exposure was not accounted for.
Rowson et al. performed a retrospective analysis of head impact data collected from 1833 Division I collegiate football players between 2005 and 2010 utilizing helmet-mounted accelerometers, in an effort to determine whether helmet design reduces the incidence of concussion. Concussion rates were compared between two helmet models: the Riddell VSR4 and the Riddell Revolution. The Revolution helmet had a greater offset and 40 % thicker foam than the VSR4 helmet. The number of head impacts each player experienced were controlled for. ATCs or team physicians diagnosed 64 concussions by from a total of 1,281,444 recorded head impacts. Players wearing the Revolution helmets had a 53.9 % reduction in concussion risk compared to players wearing the VSR4 helmet. When each player’s exposure to head impact was controlled for, a statistically significant difference was found between concussion rates for players wearing VSR4 and Revolution helmets (χ 2 = 4.7, p = 0.04). Players wearing VSR4 helmets had a per-impact concussion rate more than twice as high as players wearing Revolution helmets (8.4 vs. 3.9 concussions per 100,000 head impacts, respectively). Additionally, players wearing VSR helmets experienced higher acceleration impacts more frequently, regardless of the position they played. The authors concluded that differences in the ability to reduce concussion risk between helmet models in American football indeed exist [12]. Limitations of this study included lack of randomization of helmets among study participants and widespread underreporting of concussion in Division I college football during the study period.
McGuine et al. performed a prospective cohort study of 2081 high school football players during the 2012 and 2013 seasons to determine whether the type of protective equipment and player characteristics affect the incidence of sports-related concussion (SRC). There were 211 SRCs sustained by 206 players (9 % of included athletes), for an incidence of 1.6 SRCs per 1000 athletic-exposures. No difference in incidence of SRC for players wearing Riddell, Schutt, or Zenith helmets was identified. Additionally, helmet age and recondition status did not affect the incidence of SRC [13]. Limitations of this study included lack of randomization of helmets among study participants and lack of collection of impact exposure data.
Ice Hockey
Similar to American football, ice hockey protective headgear underwent technological advances, beginning with leather and felt construction in the 1950s and the introduction of plastic shells and foam liners in the 1970s which could absorb energy and provide a comfortable fit. In 1979, the National Hockey League (NHL) adopted head protection 11 years following a fatal head injury during NHL play [2]. Despite the widespread use of helmets at both amateur and professional levels, brain injuries remain a serious concern [14]. Recent literature has focused on the role that facial protection plays in modifying head injury risk in ice hockey and will be discussed in a later section .
Cycling
Early bicycle helmets were very rudimentary, constructed from strips of leather sewn together and reinforced with padding. Such designs were largely ineffective in reducing head injury and were replaced in the 1970s with a hard shell and expanded polystyrene (EPS) liner. Over the past several decades, this hard shell has waned in popularity and has been replaced by a thin microshell covering an EPS liner [2]. Wearing a properly fitted helmet has been shown to decrease head injuries by 63–88 % in cyclists of all ages [15]. While the debate and dispute over mandatory helmet use legislation continue, currently only two countries mandate bicycle helmet use for all cyclists: Australia and New Zealand.
Amoros et al. performed a retrospective case-control study utilizing a road trauma registry in France between 1998 and 2008. Thirteen thousand seven hundred ninety-seven cyclist injuries involving the head, face, or neck were identified. The control group consisted of cyclist injuries below the neck. Authors adjusted for age, gender, type of crash, injury severity, and crash location (road type, urban/rural). For head injury of any severity, the crude odds ratio (OR) for helmeted cyclists was estimated at 0.8 (95 % CI 0.7–0.9), whereas the crude OR for serious head injury was estimated at 0.4 (95 % CI 0.2–0.7). When adjusted for confounders, ORs were lower for both injury subgroups. Authors concluded that bicycle helmet use resulted in a decreased risk of head injury regardless of severity, with a greater decrease for risk of serious head injuries [16].
Bambach et al. performed a retrospective case-control study using linked police-reported road crash, hospital admission, and mortality data in Australia during 2001–2009. One of the primary objectives of the study was to assess the effectiveness of bicycle helmets in preventing head injuries (HIs) among cyclist crashes involving motor vehicles (CCMVs). Cases were those cyclists who sustained HIs and weren’t admitted to hospital, while controls were those admitted/not admitted to hospital without HIs. A total of 6745 CCMVs were identified where helmet use was known, and the overall helmet wearing rate was 75.4 %. Of the 639 cyclists with HIs, 42.9 % sustained intracranial injury, 18.5 % sustained skull fracture, and 14.4 % sustained open wounds. Helmet use was associated with up to 74 % reduced risk of HIs in CCMVs. Cyclists not wearing a helmet had 3.9 (95 % CI 2.2–6.8) times higher odds of sustaining moderate, serious, or severe head injuries, with p < 0.0001 for all three injury severities. Nearly 50 % of children and adolescents 19 years and younger in the study were not wearing a helmet [17].
Soccer
Headgear use in soccer is a relative newcomer to the landscape of protective equipment in contact sports. Federation International de Football Association (FIFA), the global governing body of soccer, began permitting its use in 2003. Most headgear is comprised of a thin layer of shock-absorbing foam fit between outer layers of fabric. American Society for Testing and Materials (ASTM) International set a performance standard for headgear in 2006; currently, five headgear products meet this standard [18].
Withnall et al. conducted controlled laboratory testing utilizing a human volunteer and test dummy headforms in an effort to determine whether soccer headgear had an effect on head impact responses. Impact attenuations of three commercial headgears during ball impact speeds of 6–30 m/s and in head-to-head contact with a closing speed of 2–5 m/s were measured. For ball impacts, none of the headgear provided attenuation over the full range of impact speeds. Head responses with or without headgear were not significantly different (p > 0.05) and remained well below levels associated with mild traumatic brain injury. The authors concluded that while headgear provided a measurable benefit during head-to-head impact (both linear and rotational acceleration were reduced by nearly 33 % for all three headgear in head-to-head contacts), the headgear models tested did not provide any benefit during ball impact, likely due to the large amount of ball deformation relative to the headband thickness [19].
Delaney et al. performed a retrospective online survey of 278 Canadian youth soccer players aged 12–17 years old in an effort to assess the role of headgear on concussion symptoms . Respondents were asked how many concussions they had experienced in the prior season, as well as how many times they had experienced concussion-specific symptoms in response to a collision. 7.2 % of players reported at least one concussion, while 7.8 % reported experiencing concussion symptoms at least once in the prior season. Players self-selected on the decision to wear headgear, and those players who had suffered a previous concussion were more likely to wear headgear. Players who did not wear headgear were 2.6 times more likely to sustain a concussion compared to those players who did [20]. Limitations of this study include the lack of randomization of headgear use and recall bias as information in this retrospective study was collected from athletes at the conclusion of the season.
Facemasks and Face Shields
Ice Hockey
Variable standards are imposed at different levels of ice hockey with regard to the use of face shields. Full-face shields cover the entire face and can either be made of impact-resistant plastic or metal cages, while half-face shields or visors cover only the upper half of the face. The National Federation of State High School Associations (NFHS) and the NCAA require all players to wear full-face shields, while USA Hockey only requires the use of full-face shields until the adult level [21]. Asplund et al. found that wearing facemasks significantly reduced the occurrence of facial, ocular, and dental injuries in hockey [14]. Lemaire and Pearsall demonstrated that ice hockey helmets with full-face shields produce lower post-impact peak acceleration (10–100 g) than do helmets alone (100–130 g), consequently concluding that facial protector use may lower the incidence as well as severity of head injuries by decreasing post-impact head acceleration [22].
Reduction of facial injuries by facemasks should not be confused with evidence for the reduction of concussions in ice hockey. Injury data obtained from the NHL (n = 787 players) during the 2001–2002 season found that players wearing half visors were not less likely to sustain concussions than those players without face shields. Visors were shown to prevent eye injuries and significantly reduce non-concussion head injuries. The data provided by the NHL is representative of the visor trends throughout North American and European hockey leagues [23]. Similarly, at the amateur level, Asplund et al. found no difference in the concussion rates between players who wear half vs. full-face shields [14]. Although there is a lack of evidence that visors and full-face shields prevent concussions, there is evidence demonstrating that the use of visors and face shields reduces the recovery time from a concussion. In a study by Benson et al., concussed hockey players wearing visors missed over twice as many practices and games compared to those wearing a full-face shield (4.1 vs. 1.7 sessions; 95 % CIs 3.5–4.7 and 1.3–2.2, respectively) [24]. Despite this, NHL players have claimed that wearing a visor shows lack of toughness, making them a prime target for the opposing team [23, 25].
Baseball/Softball
In baseball and softball , catchers are required to wear a facemask, and for good reason: a 2010 study showed that facemask wear reduced the resultant post-impact peak acceleration by 85 %, from a range of 140–180 to a range of 16–30 g. Not only did the catcher’s mask reduce the peak acceleration post-impact, but it was also shown to reduce the head injury criterion number from 93–181 without a mask to 3–13 with a mask, as well as the severity index from 110–210 to 3–15 with a mask [26]. Recent discussions have focused on the idea of requiring headgear and facemasks for pitchers, who have suffered rare albeit serious injuries from receiving baseballs to the head.
Marshall et al. analyzed data from over 6.7 million player-seasons when studying the effectiveness of faceguards in youth baseball. They found that the use of faceguards reduced the risk of facial injury (adjusted rate ratio, 0.7, 95 % CI 0.4–1.0) [27].
Lacrosse
Lincoln et al. studied 507,000 high school and 649,573 collegiate lacrosse players of both genders to find the most common occurrences of head, face, and eye injuries. At the high school level, the rate of head, face, and eye injuries for girls was significantly higher than that for boys (0.5 vs. 0.4 per 1000 AEs, respectively). The same trend was found among college athletes, with women having a higher injury rate than men (0.8 vs. 0.4 per 1000 AEs, respectively). Of these injuries, boys and men were more likely to sustain concussions (73 % for boys, 85 % for men vs. 40 % for girls and 41 % for women), while girls and women presented higher rates of face injuries. The majority of concussions for men were the result of direct contact with another player, whereas female concussions were usually due to stick, ball, or ground contact [28]. It remains unclear, from such striking evidence, why helmets and protective gear are required for men’s but not women’s lacrosse. As in all contact sports, there is a concern that players who wear more protective equipment will play more aggressively and possibly incur injury more frequently. However, studies of the implementation of additional protective equipment in ice hockey and field hockey do not support such claims [29, 30].
Protective Eyewear
Sports are responsible for a third of eye injuries in the United States that lead to blindness [31]. Recent studies reviewing data from the National Electronic Injury Surveillance System reveal that 208,517 sports-related eye injuries were treated in US emergency departments between 2001 and 2009. Data from the National Eye Trauma System show that sports account for 13 % of all penetrating ocular injuries. While eye injury trends declined from 2001 to 2005, recent data show increasing injury rates from 2007 to 2009 [32, 33]. Despite policy and position statements that strongly recommend certified protective eyewear from organizations including the American Academy of Ophthalmology and the American Academy of Pediatrics [34], few youth sports organizations mandate protective eyewear, and few studies have been published which demonstrate the effectiveness of protective eyewear in reducing eye injuries.
Lincoln et al. performed a prospective cohort study involving American female high school lacrosse players during the 2000–2009 seasons, comparing eye injury rates before and after implementation of a protective eyewear mandate during the 2004 season. The study population included 9430 player-seasons over the study period. ATCs recorded all injury and athletic exposure data. Eye injury rates were reduced from 0.1 injuries per 1000 AEs in 2000–2003 to 0.02 injuries per 1000 AEs in 2004–2009. Injuries to the eyelid, eyebrow, eye orbit, and eye globe were virtually eliminated after mandated use of eyewear, with the exception of injuries that occurred when standard eyewear was not being worn [35].
Kriz et al. performed a prospective cohort study involving American female high school field hockey players during two seasons of play immediately before (fall 2009 and fall 2010) and immediately after (fall 2011 and fall 2012) a national mandate for protective eyewear in girls’ field hockey was exercised by the National Federation of High School Associations. Eye injury incidence rates were compared between players competing in US states that mandated protective eyewear (MPE), players competing in states with no protective eyewear mandate (no MPE), and the postmandate group. Players from 16 of the 19 states that sanctioned high school field hockey at the time of the study were represented. Four hundred fifteen eye/orbital, head, and facial injuries were recorded during 624,803 AEs. The incidence of eye/orbital injuries was significantly higher in states without MPE (0.080 injuries per 1000 AEs) than in states with MPE (before the 2011/2012 mandate) and the postmandate group (0.025 injuries per 1000 AEs) (odds ratio 3.20, 95 % CI 1.47–6.99, p = 0.003). There was no significant difference in concussion rates for the two groups (odds ratio 0.77, 95 % CI 0.58–1.02, p = 0.068), challenging a perception in contact/collision sports that increased protective equipment yields increased injury rates [30]. After the 2011/2012 MPE, severe eye/orbital injuries (time loss > 21 days) were reduced by 67 %, and severe/medical disqualification head/face injuries were reduced by 70 %. Limitations of this study included lack of randomization as enrollment in MPE and non-MPE groups was predetermined by individual state interscholastic league mandates .
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