Type, Age, Reconditioning History Do Not Affect Concussion Risk, Study Finds
The risk of sustaining a concussion in high school football is not affected by the brand, age of the helmet, or recondition status, or by the type of mouth guard worn, say researchers from the University of Wisconsin in a new study. [1,9,10]*
“According to our research, lower risks of sustaining a sports-related concussion (SRC) and its severity were not improved based on a specific manufacturer. In addition, the SRC rates were similar for players wearing new helmets, as compared to those wearing older ones,” said lead author, Timothy McGuine, PhD, ATC of the University of Wisconsin.
“It is also interesting to note, that players who wore a generic mouth guard provided by the school had a lower rate of SRC compared to players with more expensive mouth guards.”
Some football helmet manufacturers suggest that players who wear their helmets – especially new models – may be at lower risk of concussion than those who wear competitors’ models or older helmets, basing their claims on how well the new or newer helmets absorb and lessen some of the impact forces that cause concussion in biomechanical studies performed in the controlled environment of the laboratory. Some manufacturers of specialized mouth guards have likewise claimed their products reduce the risk of concussion.
To determine which type of football helmets and mouth guards are associated with a lower incidence and severity of concussions in high school football players, McGuine and his colleagues worked with certified athletic trainers (ATCs) to collect data on 2,288 players at 36 public and private high schools in Wisconsin during the 2012 and 2013 football seasons. More players wore helmets by Riddell (51%) than those by Schutt (30%) or Xenith (19%). The most commonly worn helmet models by brand were the Riddell Revolution Speed, Schutt DNA Pro, and Xenith X1.
Because previous research  suggested that a poorly-fitted helmet could increase concussion risk, ATCs were encouraged to follow manufacturers’ recommendations regarding initial helmet fitting and to check helmet fit weekly over the course of the season to make sure that are properly fitted.
The researchers reported:
- 251 players (19%) sustained at least one SRC within the last 6 years;
- 206 (9%) experienced SRC playing high school football, the majority (60%) during games, with the SRC rate 7 times higher for competition versus practices, and 4 times higher during full-contact practice sessions than sessions where no contact was allowed. [For an article discussing the growing concern about repetitive head impacts in football, and the movement to limiting the number of full-contact practices, click here; a 2013 study  found that head impact magnitude was significantly higher during competitions, but that limiting contact during practice sessions could reduce the number of impacts up to 39% over the course of a season];
- Five (2.4%) sustained 2 concussions within the same season, while 1 subject sustained a concussion in both the 2012 and 2013 seasons;
- The most common mechanism of injury was tackling (23%), followed by contact with an opponent (20%), and being tackled (14%);
- no statistically significant difference in the concussion rate by the type of helmet worn, helmet age (determined by purchase year), or helmet recondition status;
- no difference in the severity of the concussion sustained as measured by days lost to practice/games;
- the SRC rate for players who wore a specialized or custom-fitted mouth guard was significantly higher than for players who wore a generic mouth guard provided by their school (a finding McGuine and his co-authors admitted was “unexpected”);
- no increased risk of concussions associated with age, body mass index (BMI), grade in school, level of competition, or years of tackle football experience (contrary to limited retrospective data suggesting that the risk of SRC increases in older players who are competing at a higher level)[11,12];
- players with a history of SRC within the previous 12 months were almost twice as likely to sustain another one compared to players without a history, a finding consistent with numerous earlier studies. [2,3]. That increased risk exists even when controlling for the players’ use of protective equipment, years of football experience, and player characteristics, such as their grade in school and competition level, however, was a finding which the authors said was novel and which “further highlight[ed] the need for medical providers to document a history of SRC in young football players” as well as the need to educate players, parents, and coaches about the increased risk of concussion risk in individuals with a previous history of concussions.
Consistent with earlier research
The finding that no particular brand of helmet lowered concussion risk more than any others is broadly consistent with the results reported in a 2012 paper by researchers at Temple University, the Orthopedic Center in Rockville, Maryland, and the Nationwide Children’s Hospital in Columbus, Ohio.  That paper concluded that there was no definitive data to support the view that advanced football helmet technology and design is more protective against concussion or intracranial hemorrhage, although it bears noting that, because it was never subsequently published in a peer-reviewed journal, that one of the researchers who was listed as a co-author told MomsTEAM that she was listed as an author without her permission, and that emails to the lead author requesting comment were not returned, its findings are not entitled to significant weight.
McGuine’s findings are also consistent with the conclusion reached by the American Academy of Neurology in its 2013 guidelines on concussion management  that “the data is insufficient to support or refute the superiority of one type of football helmet in preventing concussions.”
The data collected by McGuine and his colleagues, however, appears at odds with the suggestion by Virginia Tech in its STAR rating system that a 5-STAR-rated helmet is “better” or provides more protection against concussion than a 4-STAR helmet or a 3-STAR helmet, echoing criticism by the National Operating Committee on Standards for Athletic Equipment (NOCSAE) in a July 2013 statement in which it asserted that an independent statistical review of the scores and categories upon which the STAR number is based found “no significant statistical difference between helmets in the 5 STAR, 4 STAR, and 3 STAR categories.”
In fact, says McGuine, a comparison of the 780 helmets in his group’s sample that were among the brands and models tested and rated by Virginia Tech for its 2012 ratings not only failed to show that 5- or 4-STAR-rated helmets provided any greater protection against concussion than 3-STAR-rated helmets, but, if anything, “there was a trend towards the 3-STAR helmets performing better.”
Separate study finds helmet design does matter
A 2014 study in the Journal of Neurosurgery , whose co-lead authors, Steve Rowson and Stephan Duma of the Virginia Tech – Wake Forest School of Biomedical Engineering, developed the STAR rating system, appears at first glance to reach a conclusion opposite to that reached by McGuine. It reported a 54% reduction in concussion risk for college football players wearing a Riddell Revolution helmet, a 4-star helmet in the STAR ratings introduced in 2000, compared to those wearing a Riddell VSR4 helmet, a 1-star helmet no longer on the market and employing a 20-year old design with 40% less padding,
On closer examination, however, McGuine said that, while he viewed it as “an excellent study with outstanding authors” and supported a finding that “current helmet designs are better than those from 6 to 10 years ago,” the Rowson study did not, in his view, contradict his findings because the two study’s objectives and data collection methods were different in a number of ways:
“First the Rowson study was a retrospective study that went back and looked at SRC [sport-related concussions] using impact data (HITS system) and medical records. Their data collection took place over a 5-year range in college players [and] compared the VSR-4 and Revolution models. They had excellent data reporting at the university level with outstanding medical staffs and unlimited access to medical records and imaging.”
On the other hand, he said, his study looked prospectively at helmets brands currently being used in 2012 and 2013, two-thirds of which had been purchased since 2010, and included only a total of 11 old VSR-4 helmets. “Our goal was to look at the rate of SRC in helmets available and being purchased now,” he said, “so school ATC’s, coaches and parents would have information they could use to help guide their decision-making processes. These [are] people [who] are not asking if the Riddell Revolution is better than a VSR-4. They want to know if one helmet brand, currently available, that may cost $400+ dollars, is better than a helmet costing $200. Same with mouth guards.”
“I agree that measuring impacts with the HITS [the head impact sensor array used in most research studies of impacts in football] will give a better picture of the actual helmet performance,” conceded McGuine. “We are not able to provide that level of information and list it as a study limitation. I would love to use the HITS system to do a study on actual brands/models being used currently by high school players.”
In addition, we note that collecting data in 50 communities is difficult, since the kids who are injured do not all see the same medical provider or undergo the exact same diagnostic procedures [as in the 1800 plus athletes at the 8 universities involved in the Rowson study who were all seen by the same team doctors].”
“Implementing that level of data collection in 50+ high schools would require over $1 to $2 million. If someone is willing gave us that level of funding, we would do it. Unfortunately, we could not get any external support for this research, and were limited to using $50,000 of our own money and could only report data that level of funding would allow.”
Nevertheless, McGuine expressed “confidence in our data collection procedures and results, given the variables we could control. The scope of the variables we measured also gives us insight into other factors that may play a role in SRC susceptibility. I see these data as being just as important for high school ATC’s coaches and parents,” and I don’t see those other variables mentioned in [the Rowson study].”
Helmets can’t prevent all concussions
Commenting on the findings reported by McGuine in research papers presented at the AOSSM annual meetings in 2013 and 2014, Robert Erb, CEO of Schutt Sports, told MomsTEAM that, “We are not all surprised by the data collected by this study, nor are we surprised by the conclusions drawn by the researchers. Our position based upon the current known science, data and materials has been that football helmets can do very little to directly reduce the risk of concussions and that any organization, academic study or company saying otherwise is not telling the truth to consumers.”
“There are simply too many factors that cause concussions that are virtually unaffected by helmets. That’s why our product claims have never related to concussions; our claims have always been based upon the superior impact absorption of our technology; claims that have been verified by certified, independent testing labs for the past three years in a row.”
Like Schutt’s Erb, the Virginia Tech researchers conceded that any player can sustain a head injury even with the very best protection, that a “specific person’s risk of concussion may vary as a result of a number of factors” having nothing to do with the helmets, including genetic differences (some athletes may be genetically predisposed to concussion), age, health history (e.g. history of migraines, depression or other mental health disorders, attention deficit hyperactivity disorder, learning disabilities, sleep disorders, and/or previous history of concussion), impact factors (e.g. neck muscle strength/weight), and style of play, etc.
Advice to parents: get all the facts
In its July 2013 statement, NOCSAE likewise urged parents, players, coaches, and athletic directors to recognize the many limitations in the Virginia Tech helmet ratings, and expressed the fear that, unless such limitations were considered, “the potential exists for players, parents, coaches, and administrators to overemphasize the role of the helmet in protecting against concussions. This overemphasis increases the likelihood that less attention will be given to other steps that have a more immediate and much greater impact on concussion reduction,” such as teaching proper tackling and blocking technique minimizing helmet-to-helmet contact, neck strengthening, proper helmet fit, and better rules enforcement).
NOCSAE thus urged parents of athletes and athletes to get all the facts about football helmets and concussion protection because “the safety of young athletes is too important to rely on only one partial measurement of helmet performance.”
Indeed, a recent New York Times article suggests that this is exactly what is happening, with NOCSAE’s longtime Executive Director, Mike Oliver, telling The Times’ Jeff Klein that, “There has been a dramatic change in sales in football helmets since 2011 [when the first STAR ratings were issued],” with high school football athletic directors submitting purchase orders for 500 five-star helmets and parents saying, ‘I don’t want a four-star helmet, I want the best for my kid.'”
Most important than helmet brand, many experts say, is helmet fit. As not every helmet is going to fit every player, selecting a helmet that fits correctly – snugly almost to the point of being uncomfortable – will allow the helmet to perform at its best in protecting the player from injury. which includes staying on the player’s head and not coming off during play.
McGuine agreed that a football program buying more than one brand of helmet was ideal, but recognized why doing so might present school personnel with such an “administrative headache” that they would find it easier to buy a single brand.
There was, however, good news in the results of the Wisconsin study for parents, school administrators and equipment managers, says McGuine. The finding that newer helmets were not appreciably more protective against concussion than older helmets (assuming, of course, that they have been properly reconditioned), means that “Parents shouldn’t be alarmed if their kid is being asked to wear a helmet that is three years old, and administrators shouldn’t be worried about purchasing the most expensive and/or newest helmets.”
The same holds true about mouth guards. The good news for parents is that they don’t have to buy an expensive custom-fitted mouth guards in the belief that they provide additional protection against concussions (as some manufacturers would have them believe). Parents should buy a good mouth guard for their child because it is “going to offer the best protection against dental injuries,” McGuine says. Mouth guards should be seen as a “dental device, not a concussion device.”
More research needed
McGuine also cautioned against viewing his group’s finding that one helmet model was no better than another in terms of concussion protection as meaning that they don’t provide any protection against concussion at all, although he emphasized that, while football helmets do a “great job of preventing skull fractures, they can’t stop the brain from sloshing around in the skull,” which is what causes concussions.
As the authors of the 2013 international consensus statement on concussions  observed, although there is “no good clinical evidence that currently available protective equipment will prevent concussions, … biomechanical studies [such as those performed by the engineers at Virginia Tech] have shown a reduction in impact forces to the brain with the use of helmets.”
That his group’s research did not find any brand of helmet more effective than another in concussion reduction under actual playing conditions does not mean, cautioned McGuine, that the biomechanical test results have no value, nor is it the same as saying that helmets aren’t reducing that risk; just that, as a 2013 study  noted, proving that they do with the methodological and statistical rigor required by a peer-reviewed journal is “complex, challenging methodologically, resources intensive and expensive.”
“When we get out of the lab into the field,” noted McGuine, “it is harder to control every variable. We need to design, fund and conduct studies to isolate their protective effect under real world conditions.”
“Additional screening to identify those players with increased concussion risk is a key to prevention and hopefully will help reduce rates in the future,” concluded McGuine.
[Editor’s Note: For more on ways to minimize head injuries in contact and collision sports, click here; for an article on MomsTEAM’s Six Pillars of concussion risk management, featured in our new high school football documentary, “The Smartest Team,” now airing on PBS stations around the country, click here].
* The results of the study published in the American Journal of Sports Medicine in July 2014 were previously presented to the American Orthopaedic Society for Sports Medicine’s 2013 and 2014 Annual Meetings. [9,10]
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Most recently updated and revised July 29, 2014