Sports-Related Concussion in Helmeted vs. Unhelmeted Athletes: Who Fares Worse?^[*]

Abstract

In the management of sports-related concussion, little is known about the effect of wearing or not wearing a helmet (i. e., helmet status) on the acute outcomes of concussed athletes. We endeavored to assess acute neurocognitive and symptom changes after SRC in helmeted vs. unhelmeted athletes. In a retrospective study, 1 025 athletes from 2 regional databases sustained a SRC. Athletes were matched by age, gender, number of prior concussions, and days to post-concussion test, yielding a final cohort of 138 athletes. For each group of 69, differences in post-concussion neurocognitive and symptom scores were compared using group mean differences as well as reliable change index (RCI) scores set at the 80% confidence interval. With gender, prior concussions, and days to post-concussion test similar in each group, using group mean change scores and RCI methodology, we found no significant differences between the helmeted and unhelmeted groups in 4 neurocognitive tests and one total symptom score. In a cohort of carefully matched athletes from 2 regional concussion centers, helmet status was unrelated to neurocognitive scores and total symptoms in athletes after suffering a SRC. These findings suggest that acute outcomes in helmeted vs. unhelmeted sports are quite similar.

Key words

concussion - sports - helmet - unhelmeted - protective headgear - mild traumatic brain injury - imPACT

*

^* There were no external sources of financial support for this manuscript

• References

• 1 Associations NFoSHS. 2011-12 High School Athletic Participation Survey Results. DOI: DOI http://www.nfhs.org/content.aspx?id=3282:
• 2 Athiviraham A, Bartsch A, Mageswaran P, Benzel EC, Perse B, Jones MH, Schickendantz M. Analysis of baseball-to-helmet impacts in major league baseball. Am J Sports Med 2012; 40: 2808-2814
• 3 Bartsch A, Benzel E, Miele V, Prakash V. Impact test comparisons of 20th and 21st century American football helmets. J Neurosurg 2012; 116: 222-233
• 4 Bartsch A, Benzel E, Miele V, Prakash V. Editorial: Leather football helmets. J Neurosurg 2013;
• 5 Bishop PJ, Norman RW, Kozey JW. An evaluation of football helmets under impact conditions. Am J Sports Med. 1984; 12: 233-236
• 6 Breedlove EL, Robinson M, Talavage TM, Morigaki KE, Yoruk U, O'Keefe K, King J, Leverenz LJ, Gilger JW, Nauman EA. Biomechanical correlates of symptomatic and asymptomatic neurophysiological impairment in high school football. J Biomech 2012; 45: 1265-1272
• 7 Broglio SP, Surma T, Ashton-Miller JA. High school and collegiate football athlete concussions: a biomechanical review. Ann Biomed Eng 2012; 40: 37-46
• 8 Cantu RC, Mueller FO. Brain injury-related fatalities in American football, 1945-1999. Neurosurgery 2003; 52: 846-852 discussion 852-843
• 9 Caswell SV, Deivert RG. Lacrosse helmet designs and the effects of impact forces. J Athl Train 2002; 37: 164-171
• 10 Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery 2006; 58: 275-286 discussion 275-286
• 11 Crisco JJ, Wilcox BJ, Machan JT, McAllister TW, Duhaime AC, Duma SM, Rowson S, Beckwith JG, Chu JJ, Greenwald RM. Magnitude of head impact exposures in individual collegiate football players. J App Biomech 2012; 28: 174-183
• 12 CW G. Tolerable severity index in whole-head. Nonmechanical Impact. Proceedings of the 15^th Stapp Car Crash Conference New York (NY): SOciety of Automotive Engineers; 1971
• 13 Daneshvar DH, Nowinski CJ, McKee AC, Cantu RC. The epidemiology of sport-related concussion. Clin Sports Med 2011; 30: 1-17 vii
• 14 Duhaime AC, Beckwith JG, Maerlender AC, McAllister TW, Crisco JJ, Duma SM, Brolinson PG, Rowson S, Flashman LA, Chu JJ, Greenwald RM. Spectrum of acute clinical characteristics of diagnosed concussions in college athletes wearing instrumented helmets: clinical article. J Neurosurg 2012; 117: 1092-1099
• 15 Duma SM, Manoogian SJ, Bussone WR, Brolinson PG, Goforth MW, Donnenwerth JJ, Greenwald RM, Chu JJ, Crisco JJ. Analysis of real-time head accelerations in collegiate football players. Clin J Sports Med 2005; 15: 3-8
• 16 Elbin RJ, Kontos AP, Kegel N, Johnson E, Burkhart S, Schatz P. Individual and combined effects of LD and ADHD on computerized neurocognitive concussion test performance: Evidence for Separate Norms. Arch Clin Neuropsychol 2013;
• 17 Fedor A, Gunstad J. Higher BMI is associated with reduced cognitive performance in division I athletes. Obes Facts 2013; 6: 185-192
• 18 Finklestein ECP, Miller T. The Incidence and Economic Burden of Injuries in the United States. New York, NY: Oxford University Press; 2006
• 19 Forbes JA, Awad AJ, Zuckerman S, Carr K, Cheng JS. Association between biomechanical parameters and concussion in helmeted collisions in American football: a review of the literature. Neurosurg Focus 2012; 33: 11-16
• 20 Forero Rueda MA, Cui L, Gilchrist MD. Finite element modelling of equestrian helmet impacts exposes the need to address rotational kinematics in future helmet designs. Comput Methods Biomech Biomed Engin 2011; 14: 1021-1031
• 21 Gay T. The physics of football: Discover the science of bone-crunching hits, soaring field goals and awe-inspiring passes. New York (NY): Rodale Inc; 2004: 212
• 22 Gessel LM, Fields SK, Collins CL, Dick RW, Comstock RD. Concussions among United States high school and collegiate athletes. J Athl Train 2007; 42: 495-503
• 23 Guskiewicz KM, Mihalik JP, Shankar V, Marshall SW, Crowell DH, Oliaro SM, Ciocca MF, Hooker DN. Measurement of head impacts in collegiate football players: relationship between head impact biomechanics and acute clinical outcome after concussion. Neurosurgery 2007; 61: 1244-1252 discussion 1252–1243
• 24 Gwin JT, Chu JJ, Diamond SG, Halstead PD, Crisco JJ, Greenwald RM. An investigation of the NOCSAE linear impactor test method based on in vivo measures of head impact acceleration in American football. J Biomech Engin 2010; 132: 011006
• 25 Gysland SM, Mihalik JP, Register-Mihalik JK, Trulock SC, Shields EW, Guskiewicz KM. The relationship between subconcussive impacts and concussion history on clinical measures of neurologic function in collegiate football players. Ann Biomed Engin 2012; 40: 14-22
• 26 Haider AH, Saleem T, Bilaniuk JW, Barraco RD. An evidence-based review: efficacy of safety helmets in the reduction of head injuries in recreational skiers and snowboarders. J Trauma Acute Care Surg 2012; 73: 1340-1347
• 27 Hansen K, Dau N, Feist F, Deck C, Willinger R, Madey SM, Bottlang M. Angular Impact Mitigation system for bicycle helmets to reduce head acceleration and risk of traumatic brain injury. Accid Anal Prev 2013; 59C: 109-117
• 28 Harriss DJ, Atkinson G. Ethical standards in sport and exercise science research: 2014 update. Int J Sports Med 2013; 34: 1025-1028
• 29 Hinton-Bayre AD. Choice of reliable change model can alter decisions regarding neuropsychological impairment after sports-related concussion. Clin J Sports Med 2012; 22: 105-108
• 30 Iverson GL, Lovell MR, Collins MW. Interpreting change on ImPACT following sport concussion. Clin Neuropsychol 2003; 17: 460-467
• 31 Karton C, Rousseau P, Vassilyadi M, Hoshizaki TB. The evaluation of speed skating helmet performance through peak linear and rotational accelerations. Br J Sports Med 2013;
• 32 Karton C, Rousseau P, Vassilyadi M, Hoshizaki TB. The evaluation of speed skating helmet performance through peak linear and rotational accelerations. Br J Sports Med 2014; 48: 46-50
• 33 Kernan CL, Asarnow R, Siddarth P, Gurbani S, Lanphier EK, Sankar R, Caplan R. Neurocognitive profiles in children with epilepsy. Epilepsia 2012; 53: 2156-2163
• 34 Kis M, Saunders FW, Kis Sr M, Irrcher I, Tator CH, Bishop PJ, ten Hove MW. A method of evaluating helmet rotational acceleration protection using the Kingston Impact Simulator (KIS Unit). Clin J Sports Med 2013; 23: 470-477
• 35 Kumar S, Herbst B, Strickland D. Experimental biomechanical study of head injuries in lateral falls with skateboard helmet. Biomed Sci Instrum 2012; 48: 239-245
• 36 Langlois JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumatic brain injury: a brief overview. J Head Trauma Rehabil 2006; 21: 375-378
• 37 Lincoln AE, Caswell SV, Almquist JL, Dunn RE, Norris JB, Hinton RY. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sport Med 2011; 39: 958-963
• 38 Lipton ML, Kim N, Zimmerman ME, Kim M, Stewart WF, Branch CA, Lipton RB. Soccer heading is associated with white matter microstructural and cognitive abnormalities. Radiology 2013;
• 39 Lovell MR, Iverson GL, Collins MW, Podell K, Johnston KM, Pardini D, Pardini J, Norwig J, Maroon JC. Measurement of symptoms following sports-related concussion: Reliability and normative data for the post-concussion scale. Appl Neuropychol 2006; 13: 166-174
• 40 Manoogian SMD, Duma S, Brolinson G, Greenwald R. Head acceleration is less than 10 percent of helmet acceleration in football impacts. Biomed Sci Instrum 2006; 42: 383-388
• 41 Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med
• 42 Maroon JC, Lovell MR, Norwig J, Podell K, Powell JW, Hartl R. Cerebral concussion in athletes: evaluation and neuropsychological testing. Neurosurgery 2000; 47: 659-669 discussion 669-672
• 43 McCrory P, Meeuwisse WH, Aubry M, Cantu B, Dvorak J, Echemendia RJ, Engebretsen L, Johnston K, Kutcher JS, Raftery M, Sills A, Benson BW, Davis GA, Ellenbogen RG, Guskiewicz K, Herring SA, Iverson GL, Jordan BD, Kissick J, McCrea M, McIntosh AS, Maddocks D, Makdissi M, Purcell L, Putukian M, Schneider K, Tator CH, Turner M. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med 2013; 47: 250-258
• 44 McGrath N, Dinn WM, Collins MW, Lovell MR, Elbin RJ, Kontos AP. Post-exertion neurocognitive test failure among student-athletes following concussion. Brain inj: [BI] 2013; 27: 103-113
• 45 Meehan 3rd WP, Lee LK, Fischer CM, Mannix RC. Bicycle helmet laws are associated with a lower fatality rate from bicycle-motor vehicle collisions. J Pediatrics 2013;
• 46 Naunheim RS, Bayly PV, Standeven J, Neubauer JS, Lewis LM, Genin GM. Linear and angular head accelerations during heading of a soccer ball. Med Sci Sports Exerc 2003; 35: 1406-1412
• 47 Pellman EJVD, Withnall C, Shewchenko N, Bir CA, Halstead PD. Concussion in professional football: helmet testing to assess impact performance–part 11. Neurosurgery 2006; 58: 78-96
• 48 Pellman EJ, Viano DC, Tucker AM, Casson IR, Waeckerle JF. Concussion in professional football: reconstruction of game impacts and injuries. Neurosurgery 2003; 53: 799-812 discussion 812-794
• 49 Post A, Oeur A, Walsh E, Hoshizaki B, Gilchrist MD. A centric/non-centric impact protocol and finite element model methodology for the evaluation of American football helmets to evaluate risk of concussion. Comp Methods Biomech Biomed Engin 2013;
• 50 Post A, Oeur A, Walsh E, Hoshizaki B, Gilchrist MD. A centric/non-centric impact protocol and finite element model methodology for the evaluation of American football helmets to evaluate risk of concussion. Comp Methods Biomech Biomed Engin 2014; 17: 1785-1800
• 51 Ranson C, Peirce N, Young M. Batting head injury in professional cricket: a systematic video analysis of helmet safety characteristics. Br J Sports Med 2013; 47: 644-648
• 52 Rowson S, Daniel RW, Duma SM. Biomechanical performance of leather and modern football helmets. J Neurosurg 2013;
• 53 Rowson S, Duma SM. Development of the STAR evaluation system for football helmets: integrating player head impact exposure and risk of concussion. Ann Biomed Engin 2011; 39: 2130-2140
• 54 Rowson S, Duma SM, Beckwith JG, Chu JJ, Greenwald RM, Crisco JJ, Brolinson PG, Duhaime AC, McAllister TW, Maerlender AC. Rotational head kinematics in football impacts: an injury risk function for concussion. Ann Biomed Ening 2012; 40: 1-13
• 55 Schatz P, Moser RS, Solomon GS, Ott SD, Karpf R. Prevalence of invalid computerized baseline neurocognitive test results in high school and collegiate athletes. J Athl Train 2012; 47: 289-296
• 56 Schmidt JD, Register-Mihalik JK, Mihalik JP, Kerr ZY, Guskiewicz KM. Identifying Impairments after concussion: normative data versus individualized baselines. Med Sci Sports Exerc 2012; 44: 1621-1628
• 57 Schneiders AG, Sullivan SJ, Gray AR, Hammond-Tooke GD, McCrory PR. Normative values for three clinical measures of motor performance used in the neurological assessment of sports concussion. J Sci Med Sport 2010; 13: 196-201
• 58 Scott Delaney J, Puni V, Rouah F. Mechanisms of injury for concussions in university football, ice hockey, and soccer: a pilot study. Clin J Sports Med 2006; 16: 162-165
• 59 Somers JT, Granderson B, Melvin JW, Tabiei A, Lawrence C, Feiveson A, Gernhardt M, Ploutz-Snyder R, Patalak J. Development of head injury assessment reference values based on NASA injury modeling. Stapp Car Crash J 2011; 55: 49-74
• 60 Stojsih S, Boitano M, Wilhelm M, Bir C. A prospective study of punch biomechanics and cognitive function for amateur boxers. Br J Sports Med 2010; 44: 725-730
• 61 Viano DC, Halstead D. Change in size and impact performance of football helmets from the 1970s to 2010. Ann Biomed Engin 2012; 40: 175-184
• 62 Zhang L, Yang KH, King AI. Comparison of brain responses between frontal and lateral impacts by finite element modeling. J Neurotrauma 2001; 18: 21-30
• 63 Zhang L, Yang KH, King AI. A proposed injury threshold for mild traumatic brain injury. J Biomech Engin 2004; 126: 226-236
• 64 Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Forbes JA, Sills AK. Recovery from sports-related concussion: Days to return to neurocognitive baseline in adolescents versus young adults. Surg Neurol Int 2012; 3: 130
• 65 Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Sills AK. Baseline neurocognitive scores in athletes with attention deficit-spectrum disorders and/or learning disability. J Neurosurg Pediatr 2013;
• 66 Zuckerman SL, Solomon GS, Forbes JA, Haase RF, Sills AK, Lovell MR. Response to acute concussive injury in soccer players: is gender a modifying factor?. J Neurosurg Pediatr 2012; 10: 504-510