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The effect of protective headgear on head injuries and concussions in adolescent football (soccer) players

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To examine the effects of protective headgear in adolescent football (soccer) players. Cross-sectional study. Oakville Soccer Club, Oakville, Canada. Football players aged 12-17 years. A questionnaire examining the 2006 football season using self-reported symptoms. The number of concussions experienced during the current football season, the duration of symptoms, injuries to the head and face and any associated risk factors for these injuries. In the population studied, 47.8% had experienced symptoms of a concussion during the current football year. 26.9% of athletes who wore headgear (HG) and 52.8% of those who did not wear headgear (No-HG) had concussions. Approximately 4 out of 5 athletes in each group did not realize they had suffered a concussion. More than one concussion was experienced by 50.0% of the concussed HG athletes and 69.3% of the concussed No-HG group. 23.9% of all concussed players experienced symptoms for at least 1 day or longer. Variables that increased the risk of suffering a concussion during the 2006 football year included being female and not wearing headgear. Being female and not wearing football headgear increased the risk of suffering an abrasion, laceration or contusion on areas of the head covered by football headgear. Adolescent football players experience a significant number of concussions. Being female may increase the risk of suffering a concussion and injuries on the head and face, while the use of football headgear may decrease the risk of sustaining these injuries.
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doi:10.1136/bjsm.2007.037689
published online 5 Jul 2007; Br. J. Sports Med.
J. Scott Delaney, Ammar Al-Kashmiri, Robert Drummond and José A Correa
Players
and Concussions in Adolescent Football (Soccer)
The Effect of Protective Headgear on Head Injuries
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The Effect of Protective Headgear on Head Injuries and Concussions in Adolescent
Football (Soccer) Players
BY: J. Scott Delaney, MDCM
Ammar Al-Kashmiri, MD
Robert Drummond, MDCM
José A. Correa, PhD
1- McGill Sport Medicine Clinic
2- Department of Emergency Medicine, McGill University Health Center
‡ Accident and Emergency Department, Sultan Qaboos University Hospital, Oman
Department of Emergency Medicine, McGill University Health Center
Department of Mathematics and Statistics, McGill University
Reprint requests: J. Scott Delaney, MDCM
McGill Sport Medicine Clinic
475 Pine Ave. West
Montreal, Quebec, Canada
H2W 1S4
Tel: (514) 398-7007
Fax: (514) 398-4035
E-mail: j.delaney@mcgill.ca
KEY WORDS: football; soccer; head injury; concussion; headgear
BJSM Online First, published on July 5, 2007 as 10.1136/bjsm.2007.037689
Copyright Article author (or their employer) 2007. Produced by BMJ Publishing Group Ltd under licence.
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Abstract
Objective: To examine the effects of protective headgear in adolescent football (soccer)
players.
Design: Cross-sectional study
Setting: Oakville Soccer Club
Participants: Football players aged 12-17 years
Intervention: A questionnaire examining the 2006 football season using self-reported
symptoms.
Main Outcome Measures: The number of concussions experienced during the current
football season, the duration of symptoms, injuries to the head and face and any associated
risk factors for these injuries.
Results: In the population studied, 47.8% had experienced symptoms of a concussion during
the current football year. 26.9% of athletes who wore headgear (HG) and 52.8% of those
who did not wear headgear (No-HG) had concussions. Approximately 4 out of 5 athletes in
each group did not realize they had suffered a concussion. More than one concussion was
experienced by 50.0% of the concussed HG athletes and 69.3% of the concussed No-HG
group. 23.9% of all concussed players experienced symptoms for at least one day or longer.
Variables which increased the risk of suffering a concussion during the 2006 football year
included being female and not wearing headgear. Being female and not wearing football
headgear increased the risk of suffering an abrasion, laceration or contusion on areas of the
head covered by football headgear.
Conclusion: Adolescent football players experience a significant number of concussions.
Being female may increase the risk of suffering a concussion and injuries on the head and
face, while the use of football headgear may decrease the risk of sustaining these injuries.
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Introduction
Head injuries and concussions in football (soccer) have been the focus of much
attention in recent years. Research has shown that football has head injury and concussion
rates similar to American/Canadian football, ice hockey, lacrosse and rugby [1 , 2] [3] [4] [5]
[6] [7, 8] [7-9] [10] [11] [12-14] [15] [16]. These injury rates have been shown to be
comparable for elite athletes competing in certain sports, as well as for recreational and
community athletes participating in these sports [17].
Recently, the Canadian Academy of Sport Medicine published a position paper and a
discussion paper in an effort to decrease the incidence of head injuries in football [18]. Other
groups have also published their own recommendations, including the ThinkFirst Foundation
of Canada and the Canadian Soccer Association [19] [20] [21]. Suggestions to decrease head
injuries and concussions in football have included urging referees to ensure that reckless and
potentially harmful actions to other players are not permitted during the game [22]; utilizing
appropriate sized balls for younger athletes [14] [23]; proper maintenance and avoiding
hyperinflation of balls [19] [1]; teaching heading by a qualified individual who has a good
knowledge of the different methods of heading a football so as to lessen the forces applied to
the cranium during heading [9, 19] [24]; limiting the amount of heading in youth football
[18] [24] [19]; strengthening neck musculature in the hopes that strong neck muscles may
help dissipate the energy applied to the head after contact [25] [6, 11, 26]; padding football
goalposts [27]; and finally, using mouthguards [28] [29] [30].
In the past few years, soft football headgear has been utilized by some football
players in an effort to reduce the number of head injuries and concussions. The international
governing organization of football (Fédération Internationale de Football Association or
FIFA) now permits the use of soft football headgear in games [22]. In the United States, a
national standard has been recently adopted for football headgear in an effort to ensure
quality and safety levels for the different football headgear products [31]. While several
leagues and football facilities in North America have already mandated the use of protective
headgear for football [32] [33], its use is not yet widespread. Prospective studies on
concussion in football have shown that head to head contact between players is the most
common mechanism of injury resulting in concussion [2] [34]. Laboratory research on the
potential benefits of headgear has shown that models studied could potentially reduce the risk
of concussion during head to head impact [35]. Despite the possible benefits of football
headgear, no studies examining the actual effects of football headgear on athletes wearing the
product have been published. It was decided by the authors and the university ethics review
board that in the absence of any previous clinical research on headgear, a prospective study
could not commence for fear the headgear could actually have a harmful effect. As such, this
study was done to determine a general effect of headgear on youth football players before any
prospective study which would introduce equipment in a minor aged population. The
findings are to be used in planning a future prospective study examining the effects of
football headgear in youth football.
Methods
The study was undertaken from August to October 2006 in conjunction with the
Oakville Soccer Club (OSC). The OSC is situated in Oakville, Canada. Travel teams from
specific age groups (aged 12-17 years) were targeted for inclusion in the study because
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several of the adolescent teams in the OSC wear football headgear. There were estimated to
be about 440 athletes (220 males and 220 females) competing on travel teams between the
ages of 12 and 17 years of age. It was believed that the limiting factor in any study assessing
the benefits (or risks) of football headgear would be finding enough players who wear
headgear. The study was designed to recruit as many athletes as possible from these teams
during the last few months of the 2006 OSC outdoor football season.
Data was collected primarily through an online survey (www.surveymonkey.com
) via
a link that was placed on the home page of the OSC from August until October 2006. While
the athlete could return to the online survey to update his or her symptoms at later point in the
season, the collection of data is considered retrospective. The online survey allows only one
survey per web address in an effort to ensure no one person can submit more than one
completed survey.
The survey used was anonymous and almost identical to surveys previously used to
assess concussions in professional and university athletes [5, 25, 36]. While this makes it
impossible to confirm or gather further data from a player, it was decided that players would
be less inhibited in answering an anonymous questionnaire and anonymity would be better
for confidentiality given the age of the respondents. The survey inquired about general
background information, past football history, past recognized concussions and episodes of
loss of consciousness (LOC). The players were questioned specifically about the 2006 spring
and summer football season, including different positions, number of games played, if they
considered themselves someone who heads the ball frequently (a “header”), how often on
average they head the ball per game and the use of mouthguards.
When asked about the use of headgear, players were asked if they wear headgear
when playing football, which type of headgear they wear and how often they wear this
headgear during games and practices. They were also asked about any contusions,
lacerations or abrasions around the head and face area that they had sustained during the year,
noting whether they were wearing or not wearing headgear. The players were then
questioned more specifically about any symptoms that occurred immediately after being hit
in the head in 2006 only, using a format identical to previous questionnaires [5, 25, 36], again
noting whether they were wearing or not wearing headgear at the time of injury.
The definition of concussion as put forth by the Concussion in Sport Group (CISG)
was used as the basis for diagnosing concussions [37]. They defined a concussion as any
alteration in cerebral function caused by a direct or indirect (rotational) force transmitted to
the head resulting in one or more of the following acute signs or symptoms: a brief LOC,
light-headedness, vertigo, cognitive/memory dysfunction, tinnitus, blurred vision, difficulty
concentrating, amnesia, headache, nausea, vomiting, photophobia or balance disturbances.
Similarly for this study, a concussion was considered to have occurred if a subject reported a
LOC, confusion or disorientation, or any of the other commonly recognized concussion
symptoms listed above, immediately after being hit in the head playing football [38] [39].
The number of concussions was conservatively estimated to be the maximum number of
times that any one symptom was experienced and not the cumulative number of all symptoms
experienced. A recognized concussion was predefined to have occurred when a respondent
answered affirmative to having experienced one of the common concussion symptoms after
being hit in the head and also answered that they had experienced a concussion during this
episode. An unrecognized concussion was predefined to have occurred when a respondent
answered affirmative to having experienced one of the common concussion symptoms after
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being hit in the head but answered that they had not experienced a concussion during this
episode.
All statistical analyses were carried out using SAS software, version 9.1 (SAS
Institute Inc., Cary, NC, USA). Descriptive analyses were created for all study variables
using means, standard deviations and percentages where appropriate. Two by two tables
correlating concussions with various potential predictors were created to investigate these
relationships. Where statistical inferences are made, the outcome of interest is binary:
whether the subject did or did not have at least one concussion during the 2006 season. For
this type of outcome, the analysis of choice is logistic regression, which models the log-odds
of getting a concussion in terms of other risk factors or predictors and not counts or rates.
Due to the fact that the outcome of interest (concussion) is not rare, Odds Ratios (OR) may
overestimate Relative Risk (RR), and thus methods to get adjusted RR are preferred in this
type of cross sectional study [40] . We have applied a modified version of Poisson regression
[41], as implemented in Proc GENMOD in SAS [42]. Although Poisson regression is often
used as a model for count data, the modified version allows it to be applied to binary data and
results can be interpreted as RR. All statistical tests are two-tailed. A P-value < 0.05 is
considered evidence of statistical significance. The study was approved by the university
ethics review board.
Results
There were 347 completed surveys collected. In large part because the travel teams
with athletes aged 17 years also included athletes aged 18 years, 69 of the completed
questionnaires that did not meet the age inclusion criteria had to be excluded from the
analysis. As such, 278 surveys were completed from athletes aged between 12 and 17 years
and were used for analysis. Of these 278, 216 were included in the non-headgear wearing
group (No-HG) and 52 were included in the headgear wearing group (HG). Ten players could
not be accurately classified as wearing or not wearing headgear. The average player profiles
are listed in Table 1. The HG and No-HG groups were very similar in most respects, save for
the facts that the majority of the HG group were female, had more past recognized
concussions and were more likely to wear a mouthguard.
Table 1- Average player profile
Variable All (n= 278)
a
No Headgear
(n= 216)
Headgear (n=
52)
Age at time of the survey 15. 0 ± 1.3 14.9 ±1.3 15.5 ± 1.1
Male 64.7%
(180/278)
72.7% (157/216) 26.9% (14/52)
Age started football 6.2 ± 2.3 6.2 ± 2.3 6.2 ± 2.12
Years played organized football 6.1 ± 3.2 5.9 ± 3.1 7.2 ± 3.0
Years playing competitive/elite football 4.4 ± 2.7 4.3 ± 2.8 4.6 ± 2.5
Minimum number of games played in
spring/summer 2006
18.0 ± 5.9 18.6 ± 5.3 15.5 ± 7.7
Consider themselves a “header” 49.3%
(137/278)
51.4% (111/216) 44.2 %
(23/52)
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Average number of headings per game 4.6 ± 3.3 4.7 ± 3.4 4.4± 3.2
Experienced a past recognized
concussion
17.3%
(48/278)
11.1% (24/216) 42.3% (22/52)
Experienced 2 or more past recognized
concussions
9.4%
(26/278)
4.6% (10/216) 26.9% (14/52)
Wear a mouthguard 3.6%
(10/278)
1.4% (3/216) 13.5% (7/52)
Note: a: 10 athletes could not reliably be classified as wearing or not wearing headgear
Of the 52 athletes who answered that they wore headgear, 50 answered that they wore
headgear described as “a headgear with no chin strap and protection around the front, sides
and back of the head, but with an opening on the top of the head” (see Figure 1), while only 2
answered that they wore “a thin strap type headgear with no chin strap and most of the
protection on the front of the head”. All of the HG athletes responded that they wore the
headgear all or the majority of the time for games (52/52), while less responded that they
wore it all or the majority of the time for practices (36/52). The breakdown of primary
positions played for each group is listed in Table 2.
Table 2- Primary position played by responding athletes
Position All (n= 278)
a
No Headgear (n= 216)
Headgear (n= 52)
Defence 33.6% (94/278) 31.5% (68/216) 36.5% (19/52)
Forward/Striker
20.1% (56//278) 19.1% (43/216) 25.0% (13/52)
Goalkeeper 10.1% (28/278) 9.3% (20/216) 11.5% (6/52)
Midfield 36.0% (100/278)
39.4% (85/216) 26.9% (14/52)
Note: a: 10 athletes could not reliably be classified as wearing or not wearing headgear
While 7.2% (20/278) of all players recognized they had experienced at least one
concussion during the 2006 season, 47.8% (133/278) responded that they had symptoms of at
least one concussion. In other words, of the 133 athletes who actually experienced a
concussion, only 15.0% (20/133) of these realized the symptoms they had experienced
represented a concussion. Of all No-HG athletes, 52.8% (114/216) reported symptoms of at
least one concussion, and out of those only 14.9% (17/114) realized the symptoms they
experienced represented a concussion. For the HG group, 26.9% (14/52) of these athletes
reported signs of a concussion, but only 21.4% (3/14) recognized that they had suffered a
concussion. For those athletes who did experience at least one concussion, the conservative
estimates for the number of concussions (the maximum number of any one symptom only,
not all symptoms combined) are listed in Table 3.
Table 3- Number of concussions per concussed players
Number of concussions
All (n= 133)
a
No Headgear (n= 114)
b
Headgear (n= 14)
c
1 32.3% (43/133)
30.7% (35/114) 50.0% (7/14)
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2 24.8% (33/133)
25.4% (29/114) 21.4% (3/14)
3 10.5% (14/133)
10.5% (12/114) 14.3% (2/14)
4 8.2% (11/133) 7.9% (9/114) 7.1% (1/14)
5 9.8% (13/133) 9.6% (11/114) 7.1% (1/14)
6-10 7.5% (10/133) 7.9% (9/114) 0
>10 6.8% (9/133) 7.9% (9/114) 0
Note: a: 133 out of the 278 total athletes sustained a concussion. 10 athletes overall and 5
who sustained a concussion could not reliably be classified as wearing or not wearing
headgear.
b: 114 athletes were not wearing headgear when they sustained a concussion.
c: 14 athletes were wearing headgear when they sustained a concussion
The independent variables which were examined and their effect on the risk of
concussion are listed in Table 4.
Table 4- Adjusted Relative Risk for concussions during the 2006 season
Variable Relative Risk p Value
Not wearing headgear
2.65
p <0.0001
b
Female Sex 1.97 p <0.0001
b
Previous recognized concussion 0.99
p= 0.96
c
Previous traumatic LOC
a
1.44
p= 0.27
c
Age at time of survey 1.00
p= 0.98
c
Age started organized football 0.97
p= 0.47
c
Years played recreational football 1.00
p= 0.99
c
Years played competitive/travel football 0.99
p= 0.87
c
Average number of headings per game 1.03
p= 0.54
c
Considering oneself a header 1.32
p= 0.16
c
Mouthguard use 0.95
p= 0.87
c
Playing more than 22 games 1.44
p= 0.12
c
Playing between 13 and 21 games
1.13
p= 0.48
c
Note: a: Loss of Consciousness (after being hit in the head)
b: Considered to be statistically significant
c: Not considered to be statistically significant
The percentage of players from each position who experienced at least one
concussion during the 2006 season are listed in Table 5.
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Table 5- Primary position and percentage of players that suffered at least 1 concussion
Primary position Percentage with concussions
Defence 59.1% (55/93)
Goalkeeper 46.4% (13/28)
Midfield 44.9% (44/98)
Forward 37.5% (21/56)
The duration of the concussion symptoms are listed in Table 6. It refers to the length
of time that the longest concussion symptom lasted for each concussed athlete. The data
revealed 23.9% (28/117) of concussed athletes experienced symptoms for one day or longer.
Table 6- Maximum duration of symptoms
Symptom duration Percentage of concussed players
Less than 1 min 10.3% (12/117)
1- 5 min 12.8% (15/117)
5-30 min 19.7 % (23/117)
30-60 min 11.1% (13/117)
1 -6 hours 14.5% (17/117)
6-24 hours 7.7% (9/117)
1- 3 days 10.3% (12/117)
3-7 days 7.7% (9/117)
Longer than 1 week 6.0% (7/117)
Note: Duration could not be accurately determined for 16 of the 133 concussed athletes.
Table 7 lists the individual symptoms and frequency they were experienced by the
athletes.
Table 7- Symptoms experienced by players
Symptoms
All athletes (n=
278)
a
No Headgear (n=
216)
Headgear (n= 52)
Loss of Consciousness
6.5% (18/278)
6.9% (15/216) 5.8% (3/52)
Confusion/Disorientation
23.7% (66/278)
26.4% (57/216) 17.3% (9/52)
Headache
34.2% (95/278)
39.4% (85/216) 17.3% (9/52)
Dizziness/Balance
Problems
16.9% (47/278)
17.1% (37/216) 15.4% (8/52)
Memory Difficulties
2.2% (6/278)
2.3% (5/216) 1.9% (1/52)
Blurred/Abnormal
Vision
7.9% (22/278)
8.3% (18/216) 3.8% (2/52)
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Nausea
4.7% (13/278)
5.1% (11/216) 3.8% (2/52)
Hearing Abnormalities 2.9% (8/278)
3.2% (7/216) 0
Other
b
1.1% (3/278)
1.4% (3/216) 0
Note: a: 10 athletes overall and 5 who sustained a concussion could not reliably be
classified as wearing or not wearing headgear.
b: Other included “seeing stars”, “pressure behind the eyes” and “being out of
control and unable to make my body perform”.
Table 8 lists the occurrence of abrasions, lacerations and contusions on the head and
face for the 2006 season. Injuries on the face were the most common for each group,
followed by injuries to the forehead/front of the head. When calculating RR for variables
which may have predisposed to injuries, females were more at risk to have injuries to these
areas (RR = 1.93, p <0.001). As most football headgear covers the front, side, back and
possibly the top of the head, with no coverage for the face, RRs were calculated for different
variables which may have predisposed to injury to the front, back, side and top of the head
only (i.e. not including the face). For this group, athletes who did not wear headgear were
more likely to suffer an injury to these areas (RR= 1.86, p<0.05), as were female athletes
(RR= 1.72, p<0.02).
Table 8- Abrasions, lacerations and contusions on the head and face area
Location All (n= 278) No Headgear (n=
216)
Headgear (n= 52)
Front/Forehead 16.2% (45/278) 20.4% (44/216) 3.8% (2/52)
Side/temporal 11.9% (33/278) 14.8% (32//216) 1.9% (1/52)
Back/Occiput 8.6% (24/278) 10.6% (23/216) 1.9% (1/52)
Top 5.4% (15/278) 6.0 % (13/216) 3.8% (2/52)
Face 17.6% (49/278) 18.1% (39/216) 19.2% (10/52)
Note: Relative Risk (RR) associated with abrasions, lacerations and contusions:
1) For front, side, back, top of head and the face:
a) Female athletes RR= 1.93 (p <0.001)
2) For front, side, back, top of head but not the face
:
a) No-HG: RR= 1.86 (p <0.05)
b) Female athletes: RR= 1.72 (p <0.02)
Discussion
Combining the CISG’s definition of concussion with self-reported symptoms after
being hit in the head, the study revealed that 47.8% (133/278) of all respondents had
experienced at least one concussion during the 2006 football season. Only 15.0% (20/133) of
these concussed athletes realized they had suffered a concussion. When dividing the athletes
into No-HG and HG groups, although the percentage of athletes suffering a concussion was
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less for the HG group (26.9% or 14/52) than the No-HG group (52.8% or 114/216), the
percentage of athletes recognizing they had suffered a concussion was similar. Only 14.9%
(17/114) of concussed athletes in the No-HG group and 21.4% (3/14) of concussed HG
athletes recognized the symptoms they experienced after being hit in the head playing
football were a result of a concussion. While these numbers reveal that roughly 4 out of 5
concussed athletes in this adolescent population studied did not recognize symptoms of a
concussion, these figures are similar to research on professional Canadian football players
[36], university athletes [25] and the general population [43]. Although one might have
assumed that the HG group would have been more cognizant of concussion symptoms given
that, as a group, they had more recognized past concussions, this was not the case in this
population. The fact that an athlete does not realize he or she has suffered a concussion
makes it unlikely that the athlete sought medical attention. Thus, the chances these players
would continue to play while still symptomatic are probably greater than those players who
had recognized they had suffered a concussion. The CISG has recommended that all athletes
experiencing any possible signs or symptoms from a concussion be removed from play that
day, monitored to ensure symptoms do not worsen and be medically evaluated and monitored
during a stepwise return to play process [44].
The study showed that in this adolescent population, females and athletes who did
not wear headgear were more likely to suffer a concussion during the 2006 football season.
While research has shown that females are more likely to suffer a concussion in football [45]
[25], this is the first clinical study to examine the effects of protective headgear in football.
One study has shown that in the biomechanical laboratory, these headgear have the potential
to decrease concussions during a head to head impact on average 32.6 % [35]. In keeping
with these findings, wearing football headgear in this study population did decrease the risk
of suffering a concussion during the 2006 football season. In addition, the headgear also
decreased the risk of suffering an abrasion, laceration or contusion around the front, side,
back and top of the head. These are the areas commonly covered by most football headgear,
although some provide more protection than others around the top, side and back of the head.
The headgear did not provide any protective effect for abrasions, lacerations or contusions on
the face. In fact the percentage of athletes suffering these injuries around the face was similar
for the HG and No-HG groups. There have been some suggestions that the use of such
protective equipment may change the style of play of athletes, perhaps making them more
aggressive and prone to injury. Although only examining one area, at least for certain
injuries around the face, wearing headgear did not seem to make the athletes more prone to
these injuries.
Although not reaching statistical significance, playing more games and a past
traumatic LOC showed a trend toward increasing the risk of suffering a concussion during
the 2006 season. Similarly, considering oneself a header did show a trend towards increasing
the risk of suffering a concussion. This may have more to do with the style of play and
perhaps aggressiveness, given that the player’s perception of the average number of headings
per game, while known to not always be accurate, did not show any effect on the risk of
suffering a concussion. The HG athletes also had more past recognized concussions and this
may have influenced their choice to wear headgear. While it can be argued that this group’s
past history of recognized concussions would have made them more at risk for concussion
and thus any protective effect of headgear may be even more substantial in this group, this
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study is unable to determine this possible effect. As this is a preliminary study, all results and
effects will need to be confirmed in a larger prospective study on similar athletes.
As in previous research, headache and confusion/disorientation were the two most
common symptoms in all concussed athletes, followed by dizziness/balance problems [5]
[36] [46] [25]. Of those athletes who suffered a concussion, over two thirds of the No-HG
group and half of the HG athletes suffered more than one concussion. The study also showed
that the majority of concussions suffered by this population would be considered “simple
(symptoms resolve without complication over 7–10 days) by the new concussion
classification suggested by the CISG [44]. Only 6.0% (7/117) of concussed players had their
longest symptom last for 1 week or longer.
As in previous studies, this study used what, in the past, may have been considered a
liberal definition of inclusion in that a concussion was considered to have occurred if an
athlete reported a LOC, confusion or disorientation, or any of the other most commonly
accepted symptoms of a concussion (headaches, dizziness/balance problems, memory
difficulties, blurred or abnormal vision, nausea, hearing problems or light sensitivity)
immediately after being hit in the head playing football. Although the players were asked
about only those common concussion symptoms that occurred immediately after being hit in
the head, it is possible that the inclusion criteria overestimated the number and severity of
concussions. It is difficult to interpret an athlete’s recollection of a LOC, as they may
overestimate this occurrence. At the very least, this usually implies amnesia for the event and
would nevertheless indicate a concussion. Also, the symptom of headache may be difficult to
attribute solely to concussions, especially since recent research has shown that around 20% of
athletes who play American football in high school and college may experience headaches
during games [47]. As such, Table 7 allows the reader to see the list and occurrence of the
individual symptoms suffered by the concussed athletes.
Limitations
Although the study was conducted during the last part of the 2006 football season and
players could update their symptoms on the online survey, the information was collected in a
retrospective survey fashion, thus not ideal in that the study is non randomized, athletes can
forget symptoms and are often less accurate with respect to duration and frequency of
symptoms. It does however allow an athlete the opportunity to reveal symptoms that may not
have been identified prospectively. This may occur if the athlete is unaware that his or her
symptoms are secondary to a concussion, or if the athlete is afraid to mention symptoms to a
trainer or a physician, for fear of being prevented from returning to play [46] [48] [49].
In addition, our results suffer the limitations of cross sectional data, namely, the inability to
control for all variables and assess a temporal association between risks factors and
‘outcome’. We do believe, however, that useful data can be gathered from a cross sectional
study, especially as an initial step in gathering information about an as of yet unstudied piece
of protective equipment.
Conclusion
Adolescent football (soccer) players experience a significant number of concussions
and recognize their symptoms as a concussion at a degree similar to previously studied
populations. While being female increased the risk of experiencing a concussion, the use of
football headgear decreased this risk during the 2006 football season. Similarly, being
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12
female increased the risk of suffering an abrasion, laceration or contusion around the head
and face, while wearing headgear decreased the risk of these injures over the areas covered
by headgear.
What is already known on this topic
Head injury and concussion rates in football are similar to American football and ice hockey
for both elite and recreational athletes.
Head to head collisions are believed to be the most common mechanism causing concussions
in football. Laboratory testing has shown football headgear may protect against concussion in
head to head collisions.
Most sport related concussions are unrecognized or unreported by athletes.
What this study adds
In the adolescent population studied, athletes who were female and those who had suffered a
previous concussion were more likely to wear football headgear.
Football headgear provided protection against concussions in the population studied.
Football headgear provided protection against soft tissue injuries (contusions, lacerations,
abrasions) over areas covered by the headgear.
Athletes who wore football headgear were at no increased risk of injury over areas of the
head and face not covered by the headgear.
Similar to university and professional athletes, the vast majority of concussions in adolescent
football players go unrecognized.
Acknowledgements
The authors would like to thank John Freihaut and the players, parents and coaches of
the Oakville Soccer Club. Without their interest and involvement, the study would not have
been accomplished.
Competing Interests
: The authors declare they have no competing interests
Funding:
None
Authors' consent to publication (copyright):
The Corresponding Author has the right to
grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or
non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group
Ltd and its licencees, to permit this article (if accepted) to be published in BJSM and any
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other BMJ Group products and to exploit all subsidiary rights, as set out in our licence
(http://bjsm.bmjjournals.com//ifora/licence.pdf
)
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on 2 September 2007 bjsm.bmj.comDownloaded from
... The results for quality assessment and levels of evidence for cohort studies can be seen in table 2. Selection bias was considered low in all studies. Only one study was not awarded full points in this domain, as Delaney et al. 26 did not ascertain the exact number of exposures to SRC reliably due to using selfreport, as opposed to direct observation or secure record. For comparability of cohorts, all studies controlled for age, sex and injury history, with only one study not controlling for additional factors. ...
... 27 For the final domain, three studies did not assess SRC and injury outcomes using an independent observer. The findings of Delaney et al 26 were deemed to have the highest risk of bias due to a cross-sectional survey design with the survey accessible online to players (aged 12-17 years) who could reaccess it multiple times to update SRC symptoms. In addition, the injury definition used did not relate to time lost from participation in sport and/or medical-attention received for injury, the most common definition 28 used in all other studies. ...
... The two studies who did not conform to this, were subject to retrospective self-report bias. For instance, Marshall et al., 30 obtained injury data from players at weekly intervals and therefore reported by 'player week', and Delaney et al., 26 reported injuries 'per player', likely because players reported SRC at a single survey time point. These studies likely reported injuries in this way because they did not capture players' true exposure to injury, and therefore could not report per hour. ...
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Objectives To assess the association between soft-shell headgear (HG) use and sports-related concussion (SRC). Secondary objectives were to assess the association between HG and superficial head injury and investigate potential increase in injury risk among HG users. Design A systematic search in Ovid MEDLINE, Cochrane Library, Scopus, PsycINFO and SPORTDiscus was conducted in April 2020. Inclusion criteria were youth <18, English language, in vivo studies published after 1980 that evaluated SRC and other injury incidence in HG users compared with non-users. Outcome measures Incidence rates of SRC, superficial head injury or other injuries. Results Eight studies were eligible. The majority (n=5) reported no difference in the rate of SRC among HG users versus non-users. One rugby study identified significantly lower risk of SRC for non-HG users (risk ratio (RR) 0.63; 95% CI 0.41 to 0.98) compared with HG users, whereas a cross-sectional survey of soccer players indicated higher risk of SRC for non-HG users (RR 2.65; 95% CI 1.23 to 3.12) compared with HG users. Three of the four studies investigating superficial head injury found no significant differences with HG use, though the soccer survey reported reduced risk among HG users (RR 1.86; 95% CI 0.09 to 0.11). Increased incidence of injuries to all body regions for rugby HG users was reported in two studies with adjusted RRs of 1.16 (95% CI 1.04 to 1.29) and 1.23 (95% CI 1.00 to 1.50). Conclusions HG use was not associated with reduced rates of SRC or superficial head injury in youth soccer and rugby. The possibility of increased injury risk to all body regions for rugby HG users was raised. The need for research specific to youth and female athletes was highlighted. PROSPERO registration number CRD42018115310.
... There are a variety of clinical outcome measurements that can assist in diagnosing a concussion including somatic symptoms, balance, and neurocognitive functioning (Table 4). Following a concussion in the youth population, the most common symptoms reported are headache and dizziness [58,65] with females tending to report more symptoms than males [66]. Following a concussion in high school, collegiate, and amateur athletes, decreased performance in balance and neurocognitive functioning have been reported [67][68][69]. ...
... Overall, the research on headgear use in soccer demonstrates that it may lower the risk of concussion but not mitigate the impacts from heading the ball. Delaney et al. [65] conducted a study in 2008 which reported that soccer players who did not wear headgear had a higher concussion rate than those who wore headgear. In 2005, Withnall et al. [80] observed that headgear did not mitigate magnitudes during soccer ball impacts, but did reduce impact magnitudes during head-to-head impacts. ...
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... However, different findings exist across independent studies. While many studies have shown that wearing a helmet reduces the risk of obtaining a concussion, other research has opposed this finding (Delaney, 2008). One such study tested head acceleration values during football-to-head impacts on a surrogate headform. ...
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... La fédération Nord Américaine de football promeut actuellement le port d'un casque de protection, en particulier chez les jeunes joueuses [28]. Ces casques souples protègent essentiellement du risque d'hématome sous-cutané voire de fracture, mais la biomécanique des commotions a montré que le facteur vitesse de déplacement de la tête é tait le facteur prédominant lors de la survenue d'une commotion, ce qui limite l'utilité du casque dans la prévention des commotions [29]. ...
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Head injuries have been shown to account for between 4 and 22% of soccer injuries. Clinical and neuropsychological investigations of patients with minor head trauma have revealed organic brain damage. 69 active football (soccer) players and 37 former players of the Norwegian national team were included in a neurological and electroencephalographic (EEG) study to investigate the incidence of head injuries mainly caused by heading the ball. 3% of the active and 30% of the former players complained of permanent problems such as headache, dizziness, irritability, impaired memory and neck pain. 35% of the active and 32% of former players had from slightly abnormal to abnormal EEG compared with 13 and 11% of matched controls, respectively. There were fewer definitely abnormal EEG changes among typical 'headers' (10%) than among 'nonheaders' (27%). The former players were also subjected to cerebral computed tomography (CT), a neuropsychological examination and a radiological examination of the cervical spine. One-third of the players were found to have central cerebral atrophy and 81% to have from mild to severe (mostly mild to moderate) neuropsychological impairment. The radiological examination of the cervical spine revealed a significantly higher incidence and degree of degenerative changes than in a matched control group.
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We registered all new injuries among 496 male youth soccer players, aged 12 to 18 years, during the course of one year. The incidence of injury was 3.7 injuries per 1000 hours of soccer per player. The incidence in creased with age, and at the higher ages within the youth players, approached the incidence rate of senior players (age ≥18 years). Seventy percent of the injuries were located in the lower extremities, particularly the knee (26%) and ankle (23%). Back pain occurred in 14% of players. Fractures, which accounted for 4% of injuries, were most often in the upper extremities. We conclude that youth soccer is a relatively low-risk sport with an injury pattern that differs slightly from that of senior players.
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Thirty-seven former soccer players of the National Football Team of Norway were individually examined with an extensive battery of psychologic tests. The neuropsychologic examination demonstrated mild to severe deficits regarding attention, concentration, memory, and judgment in 81% of the players. This may indicate some degree of permanent organic brain damage, probably the cumulative result of repeated traumas from heading the ball.
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Thirty-three former football players from the National Football Team of Norway were examined by cerebral computer tomography (CT). The CT studies, evaluated for brain atrophy, visually and by linear measurements compared two different normal materials. One third of the players were found to have central cerebral atrophy. It is concluded that the atrophy probably was caused by repeated small head injuries during the football play, mainly in connection with heading the ball.