One of the largest problems facing athletes in all levels of contact sports such as football and ice hockey is that of concussions, also known as mild traumatic brain injuries (mTBIs). Each year in the United States alone it has been estimated that there are nearly 300,000 cases of contact sports related mTBIs 1 . Although this statistic includes all levels of athletics, ranging from high school sports to the collegiate and professional levels, this number is still staggering. In recent years, it has been shown that in addition to the immediate effects such as headaches and nausea, concussions in fact may have several long-term consequences on youth and adult athletes alike. These long-term effects have been found to include impaired motor skills, increased forgetfulness, a decrease in memory ability, chronic headaches or migraines, and an assortment of sleep issues 2 . One way in which the prevalence of these injuries is being fought is through the use of newer helmet technologies. Though research efforts of the past several years have been surely been able to lower the numbers of mTBIs to quite a large extent, much more must be done to create a helmet that best protects ones head during the high velocity impacts that frequently occur in contact sports. During the past two years, several new technologies have been developed and tested in order to further reduce the shock absorbed by the head during sports collisions. Likewise, there have been many recent advancements in creating systems that are more easily to identify when a concussion may have occurred. While these research efforts do surely show promising results, more research certainly needs to be performed in order to most effectively reduce the numbers of mTBIs faced by athletes in the future.
Introduction The term concussion refers to a mild traumatic brain injury (mTBI) typically caused by a sudden movement, bump, or jolt to the head. These injuries are often suffered by athletes of contact sports such as ice hockey or football and may lead to serious long-term consequences. As a result many steps are being taken in order to reduce the number of athletes particularly at the high school level and collegiate levels who experience these head injuries. One of the main ways this is being achieved is through the education of sports coaches and athletes on how to not only reduce injuries through safer playing
1 Hauser, John & Meyer, David G (2013). Modeling and exploration of an active helmet design. 2013 American Control Conference. 728-733. Retrieved at http://ieeexplore.ieee.org/servlet/opac?punumber=1000030 2 http://www.cdc.gov/concussion/pdf/facts_about_concussion_tbi-a.pdf 2 practices, but also on how to identify the symptoms of a concussion and what steps should be taken after one is suspected. However, another approach to this problem has been undertaken by the actual manufacturers of the protective helmets themselves. Over the course of the past several years, there have been many advances in helmet technologies that have been shown to statistically reduce the number of mTBIs in their wearers as compared to older models. These advances hope to both prevent concussions from occurring in the first place, and to help aid in the identification of mTBIs as close to the moment of impact as possible. Although the literature being examined in this review will deal primarily with advances in football helmets, the technologies being researched and examined do have several applications in both helmets for other sports such as ice hockey and in other areas of interest such as the military.
Preventative Advancements Although the largest percentage of football-related injuries are still, to this day head- related, the amount of athletes suffering from both head and cervical spine related fatalities has drastically reduced since the creation of the NOCSAE helmet standard in 1978. The NOCSAE, which stands for the National Operating Committee on Standards for Athletic Equipment, was created as a non-profit organization in 1969 as a way to reduce head and neck injuries in contact sports, primarily football. In light of the 32 head-injury related fatalities that had occurred the previous year in the sport of football 3 , the NOCSAE directed their initial funds where it was deemed most necessary developing a standard for football helmets. Through many research studies, the NOCSAE was able to develop a set of standards by which all football helmets were required to conform to. To this day, football helmets at all levels are required to meet their standard, which according to their official website simply states that a helmet must provide a substantial level of protection for serious head injuries, including concussions. However, they also include within their standard definition that no helmets can prevent all concussions, and that future research is
3 History and Purpose of the National Operating Committee on Standards for Athletic Equipment http://nocsae.org/about-nocsae/history-and-purpose/ 3 needed to improve and, identify criteria that could be used in a concussion specific helmet standard.
Nearly all football helmets worn by athletes today utilize similar designs, and are by definition what may be considered passive in their design. That is, helmets being worn today in football contain no moving parts or features that are able to dynamically adjust throughout an athletic event based upon any sort of feedback. Although some literature, such as Meyer and Hausers 2013 Modeling and Exploration of an Active Helmet Design do propose designs for so-called active helmets with the ability to adjust based on piezoelectric feedback systems, they are still in the earliest of design stages 4 . Thus, for the purpose of this literature review all helmet research that will be examined will be based upon technologies that currently exist, and whose effectiveness in actually preventing mTBIs can be tested. And so, nearly all contact sport helmets used today follow the same basic structure: there is a hard plastic shell on the outside of the helmet along with some sort of padding layer used to insulate the forces felt by the wearer during high impact collisions. There is also a facemask in front of the athletes face, which is not nearly as effective preventing impact forces as the rest of the helmet 5 . Consequentially, many of the advancements in helmet design have come in the form of improving the main protecting component the padding layer that sits between the wearers head and the plastic shell, which is where contact primarily occurs. Though traditional helmet designs utilize a foam padding to separate the athletes head from the plastic shell and likewise point of impact, helmets worn today are nearly almost all improved. Instead of containing just foam, many newer helmets today contain pneumatic cushions, or bladders, that are able to be inflated to various pressures depending on the size of the wearers head (Meyer & Hauser 2013). The composition of these bladders may vary from helmet to helmet, and in fact the effectiveness of each at combatting mTBIs has been the subject of much debate since the advent of the very first helmet. Several studies have attempted to rate nearly every model of helmets overall effectiveness at preventing
4 Hauser, John & Meyer, David G (2013). Modeling and exploration of an active helmet design. 2013 American Control Conference. 728-733. Retrieved at http://ieeexplore.ieee.org/servlet/opac?punumber=1000030 5 Jadischke, Ron, Viano, David C., Dau, Nathan, King, Albert I., McCarthy, Joe (2013). On the accuracy of the Head Impact Telemetry (HIT) System used in football helmets. Journal of Biomechanics. 46. 2310 2315. 4 head injuries. However, each time the validity of these studies are called into account due to both a lack of an industry standard when it comes to measuring actual impacts that athletes face and the complexity of even diagnosing when an mTBI has occurred in the first place. This issue will be reexamined later on in this review. However, for the purposes of this section, two different helmets padding technologies will be examined for their effectiveness in reducing the likelihood of concussions from occurring. One of the most popular helmets worn today is the Schutt Ion 4D, which was first released in 2010. This helmet, which boasts a four of five star rating from an independent Virginia Tech helmet rating system, focused on several areas of improvement over traditional helmets. First, the standard expanded polypropylene (EPP) foam in this helmet was replaced with a new type of material called Thermoplastic Urethane (TPU) 6 . Some of the properties that make this a more ideal shock absorber than traditional EPP foams is that fact that with increased temperatures such as those greater that 115F which may be experienced in game conditions the mechanical properties of this material do not change at all. TPU is far more durable than traditional foam and less prone to the degradation faced by EPP over time. It has also been claimed by the manufacturer, Schutt, that TPU is more than 40% better than similar foams at shock absorption than materials such as EPP. Though the metric by which this claim may be substantiated is somewhat unclear, this nonetheless remains a great example of how engineering progress has been working to solve a major health problem in contact sports. Consequently, this helmet is an excellent example of how interdisciplinary research within areas such as polymer chemistry, mechanical and chemical engineering are able to work together to create a product that is effective at further reducing the amount of concussions experienced by athletes today. The next helmet examined was the Xenith X1 football helmet, which also boasts a 4 of 5 star rating from the same Virginia Tech rating system. What makes this helmet so much different than other football helmets is that instead of using standard foam padding to absorb energy from an impact it actually contains many small shock absorbers. These shock absorbers, which borrow engineering principles commonly utilized in the automotive industry, are created from a polyurethane material similar to the Schutt TPU
6 Product specifications found on the manufacturers website at http://www.schuttsports.com/aspx/Sport/ProductCatalog.aspx?id=787 5 padding, and are each embedded within holes of a flexible bonnet. Each shock absorber is fitted with a small attenuation chamber which contains a small hole to release air. Essentially, when an impact occurs, air is released from these small chambers within the absorbers, which is in turn able to reduce the impact experienced on the actual head of the wearer. During normal football gameplay (low impact situations) air is able to flow smoothly in and out of the chambers with little resistance. However, during high impact situations the air becomes turbulent and more rigid, thus absorbing more impact energy. This idea may be best compared to that of a bicycle pump. While pumping a bicycle tire slowly, it is relatively easy to fill the tire with air. However, when the pump is pressed down very quickly, one is met with a great amount of resistance, and the pump becomes very rigid. Though more data is certainly needed to further substantiate the claims that the shock absorbers in this system are working the specific way that they claim to be, these helmets do consistently perform in independent tests as one of the most effective at fighting head injuries 7 . Whether or not these are able to outperform helmets with newer padding technologies such as the Schutt Ion 4D is still up in the air. The biggest flaw in these two helmet designs that I was able to find while researching them was the incredibly limited availability of testing data provided by the manufacturers. Although I was able to find some quantitative data supporting Schutt and Xeniths claims in literature such as the findings at Virginia Tech 8 , it was very difficult to find substantial scientific literature within the engineering discipline that could further support the manufacturers claims regarding their specific materials and their properties related to high impact collisions. Though I understand that many of the technologies involved in products such as helmets are important trade secrets, the lack of transparency amongst helmet manufacturers is certain a major problem facing the research community in this sector today. More information needs to be shared with the scientific community regarding the composition of the padding materials used by some of the major
7 Maw, S., Lun, V., Clarke, A. (2012). The influence of helmet size and shape on peak linear decelerations when impacting crash pads. Procedia Engineering. 34 (12) 819 824. 8 Rowson, Steven & Duma, Stefan F. (2012). The Virginia Tech Response. Annals of Biomedical Engineering, Vol. 40, No. 12, December 2012 pp. 25122518. 6 manufacturers such as Xenith and Schutt so that they can be independently tested as compared to the traditional foam material used in helmets, expanded polypropylene (EPP).
Concussion Identification Systems Moreover, one of the largest holes in the scientific literature regarding advances in helmet design is the lack of a universal testing standard for them. This idea was explored in great length in the articles On the accuracy of the Head Impact Telemetry (HIT) System used in football helmets (Jadischke, R et. al 2013) and Evaluation of a flexible force senor for measurement in helmet foam impact performance (Ouckama, R. & Pearsall, D. J. 2010). In each of these articles, researchers attempted to evaluate preexisting methods for measuring head impacts such as Riddells HITS system. In the case of the second article, a newer system design for use in helmets was proposed that would use sensors to capture more information than just translational head motion when identifying concussions. One of the most widely used systems for measuring head impacts in football helmets today is Riddells Head Impact Telemetry System, commonly known as HITS. Created in 2003, HITS is comprehensive multi-faceted system in which head impacts during athletic events are able to measured as they occur. The HIT system includes three primary components : the player unit, which contains five point built-in accelerometers actually inside of the helmets (these are used to determine both the linear and angular accelerations experienced by the wearer), a handheld alert monitor to work in conjunction with the player unit, and management software where data can be further analyzed post- gameplay. The way this system works is by determining when impacts greater than 100 g have occurred, and when they do by alerting the coach or trainer on the sideline. Furthermore, the system gauges when impacts above, below, and at a certain threshold (generally 100g, maybe 85 g) occur, and electronically registers where on the helmet the occurred. Highly advanced at the time of creation, this was the very first system of its kind and was almost immediately adopted by teams at every level of play, from high school teams to the professionals. The problem with this system however is that it does not take several necessary factors other than translational head motion into account when determining whether or not an mTBI has occurred. 7 Furthermore, it was found in a 2013 paper that the results of HITS are not in fact always even accurate themselves. In the paper On the accuracy of the HIT System used in football helmets independent researchers from Wayne State University found huge inaccuracies from each specific impact to impact 9 . Although over an average amount of impacts the total impact experienced by a player tends to even out, in a system where it only takes one data point to permanently cause damage to a player, this is not okay. A staggering statistic found by researchers was that an impact recorded by HIT as 100 g will actually be <85 g or >115g 55% of the time. This may lead to not only non-concussed players being forced to sit out when they really dont need to, but may also lead to many concussions being missed! Clearly detection systems are missing something. One idea proposed that has the potential to replace the HIT System has its roots in the first section of Ouckama and Pearsalls 2010 paper Evaluation of a flexible force sensor for measurement of helmet foam impact performance. Within this paper, these two researchers from McGill University proposed that the FEA models used to identify head injuries needed to be updated 10 to incorporate more knowledge of the neurobiological structures. Next, they went on in this paper to test the effectiveness of various density EPP foams at absorbing forces during high impact collisions using 13 Flexiforce sensors placed in a 5 x 5 cm array. Although they acknowledged that lateral and angular accelerations as measured in preexisting systems such as HITS do provide important information when diagnosing head injuries, Ouckama and Pearsall also proposed the idea that global head acceleration criterion measures alone are poor indicators of neurocognitive injuries. Though they did not actually propose a new model for identifying these injuries, they suggested that a better understanding of the dynamics at the actual small region of contact would be necessary for future systems. This suggests that although they are aware that there are many more factors involved in a collision that simply one lateral movement, that more research needs to be done to really figure out what causes these traumas in the first place. Finally, their research does substantiate the claim that
9 Jadischke, Ron, Viano, David C., Dau, Nathan, King, Albert I., McCarthy, Joe (2013). On the accuracy of the Head Impact Telemetry (HIT) System used in football helmets. Journal of Biomechanics. 46 (2013) 2310 2315. 10 Ouckama, Ryan, & Pearsall, David J. (2010). Evaluation of a flexible force sensor for measurement of helmet foam impact performance. Journal of Biomechanics. 44 (2011) 904 909.
8 higher density newer foams with greater surface areas may work better at absorbing energy and thus lessen blows to the head.
Conclusion / Future of Helmet Design Clearly, the future of helmet design still has a lot of room for progress. Although much advancement has occurred already in the development of energy absorbing padding systems, researchers are far from finding the most effective solution at preventing concussions from occurring at all. In order to design a helmet that can more likely reduce traumatic head injuries that are so common in sports such as football and hockey, more needs to be understood from a neurobiological standpoint about what is actually happening when a concussion occurs. Once the intricate nature of head impacts are able to be more understood, it will be easier to design systems that can help stop them from occurring. When an impact occurs it is known now that many factors come into play as to whether or not a concussion will occur. Sure, the translational motion of the actual opposing player is important if a player is hit with 120 g of force they are sure to stop in their tracks. However, it is not currently understood very well at all how important where they are hit has to do with the likelihood of an mTBI ensuing. For example, if a player is hit with 120 g of force straight on they may be fine afterwards. However, if that same motion was a lateral force impact to the thin squamous temporal bone, that may in turn induce transient focal cranial deformations that in turn could propagate stress waves to the underlying cortex leading to any sort of traumatic head injury 11 . In other words, the loading force distribution of impacts, the underlying cranial and neurobiological structures, and many more factors must be continued to be researched and understood in regards to their roles in a concussion in order to create the most effective ways at preventing concussions in helmets. In order to advance helmet research to the next level, there are several steps that must be taken. Because this topic is interdisciplinary by nature, there are quite a few different areas of research that this must occur within. In order to more accurately evaluate
11 Ouckama, Ryan, & Pearsall, David J. (2010). Evaluation of a flexible force sensor for measurement of helmet foam impact performance. Journal of Biomechanics. 44 (2011) 904 909.
9 the effectiveness of helmets at preventing concussions, biologically speaking much more research needs to be done into understanding just what specifically is occurring when a patient is concussed and which areas of the head should require more protection than others. Next, a new industry standard needs to be created and put into place to evaluate the claims of manufacturers such as Riddell, Xenith, and Schutt. There needs to be some quantitative measure by which any helmets impact absorption can be measured and compared to others. Likewise, a new sensor system needs to be created for use during practices and gameplay that is more accurate than the HIT system, possibly one that simple utilizes newer technologies than that which was available in 2003 with HITS was released so as to increase the accuracy of each measurement. Finally, new active helmet designs such as that which was proposed by Meyer and Hauser show lots of potential in reshaping the way future helmets will be able to transfer high impact collisions energy away from the head of the athlete.