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Helmet Wars Redux

Type, Age, Reconditioning History Do Not Affect Concussion Risk, Study Finds

Surprise finding: concussion risk for boil-and-bite mouth guards lower than for more expensive guards

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. [4] 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 [5] 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."

New study finds helmet design does matter 

A 2014 study in the Journal of Neurosurgery [8], 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.[4]

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.

Silver lining

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 [6] 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 [7] 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]



1. McGuine TA, Hetzel S, McCrea M, Brooks AM.  Protective Equipment and Player Characteristics Associated With the Incidence of Sport-Related Concussion in High School Football Players.  Am J Sports Med. 2014;20(10)(published online ahead of print, July 24, 2014 as doi:10.1177/036354651541926.

2. Castile L, Collins CL, McIlvain NM, Comstock RD. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br. J. Sports Med 2012; 46:603-610.

3. Marar M, McIlvain NM, Fields SK, Comstock RD. Epidemiology of concussions among United States high school athletes in 20 sports. Am J Sports Med 2012;40:747-755.

4. Torg J, Boden B, Hirsch H, Fowler J, Gaughan J, Comstock RD, Tierney R, Kelly P.  "Athletic Induced mTBI and Catastrophic Intracranial Injuries: Determining Helmet Efficacy and Predisposing Injury Profiles."  Presentation Paper AOSSM 2012

5. Giza C, Kutcher J, Ashwal S, et al. Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology 2013;DOI:10.1212/WNL.0b013e31828d57dd (published online before print March 18, 2013)  

6.  McCrory P, et al. 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.

7. Benson B, McIntosh A, Maddocks D, Herring S, Raftery M, Dvorak J. What are the most effective risk-reduction strategies in sport concussion. Br J Sports Med 2013;47:321-326. 

8. Rowson S, Duma SM, Greenwald RM, Beckwith JG, et al. Can Helmet Design Reduce the Risk of Concussion in Football? J Neurosurg 2014; 10.3171/2014.1.JNS13916 (published online ahead of print January 31, 2014).

9. McGuine T, Brooks A, Hetzel S, Rasmussen J, McCrea M. "The Association of the Type of Football Helmet and Mouth Guard With the Incidence of Sport-Related Concussion in High School Football Players." Presentation Paper AOSSM, July 13, 2013; Presentation Paper, American Academy of Pediatrics National Conference & Exhibition, October 28, 2013.

10. American Medical Society for Sports Medicine. "Brand/type of helmet, mouthguard may not significantly reduce risk of sport-related concussion in high school football players." ScienceDaily. ScienceDaily, 14 April 2014.  

11. Abrahams S, Fie S, Patricios J. Posthumus M, September AV. Risk factors for sports concussion: an evidenced based review.  Br J Sports Med. 2014;48:91-97.

12. Demorest R. The future of preventing concussion in children and adolescents. In: Niskala Apps J, Walter KD, eds. Pediatric and Adolescent Concussion. New York, NY. Springer; 2012: 177-194. 

13.  Broglio SP, Martini D, Kasper L, Eckner JT, Kutcher JS. Estimation of Head Impact Exposure in High School Football: Implications for Regulating Contact Practices. Am J Sports Med 2013;41(12):2877-2884.

Most recently updated and revised July 29, 2014

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