Sports Medicine Research: In the Lab & In the Field: If the Helmet Don’t Fit, You May Have to Sit (Out Longer with a Concussion) (Sports Med Res)


Monday, May 2, 2016

If the Helmet Don’t Fit, You May Have to Sit (Out Longer with a Concussion)

Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players

Greenhill DA, Navo P, Zhao H, Torg J, Comstock RD, Boden BP. Sports Health. March 2016. doi:10.1177/1941738116639027.

Take Home Message: An athlete with a poorly fit helmet that sustains a concussion may have an increased risk of more severe symptoms and prolonged recovery.

There has been much discussion and research into the potential for protective equipment to alter the risk of sports-related concussion.  However, there is insufficient evidence to suggest that any type of helmet or protective equipment used in football can reduce the risk of sustaining a sports-related concussion.  Investigation into the effects of proper fit and concussion risk is currently limited. Thus, Greenhill, et al. sought to understand if an athlete with an improperly fit helmet at the time of an injury is more likely to have longer recovery and more severe symptoms after sustaining a concussion. For a nine-year period, data was collected from a sample of 100 high schools participating in a national surveillance system. A Certified Athletic Trainer determined if an athlete had an improperly fit helmet at the time of injury. Of the 4580 concussions that were sustained during this time period, 3172 had information regarding helmet fit. Among those concussions, athletic trainers determined that 102 helmets had an improperly fitted helmet. When compared to athletes with a properly fit helmet, concussed athletes with an improperly fitted helmet had averaged more symptoms during recovery and were more likely to have symptoms that persisted longer than 7 days (37% versus 31%). The 2012 NFHS helmet rule change failed to influence the number of helmets that were properly fit. Independent of fit, an athlete who wore a helmet with a gel or foam liner was more likely to lose consciousness after a concussion compared with an athlete with an air-filled liner helmet.  However, there was no association between helmet liner type and symptom severity.

Very few medical professionals will argue the merits and necessity of the helmet in football. The results of this study are noteworthy because they bring to light a completely different issue with helmets, which seems obvious but unfortunately is still an issue: sports equipment should fit properly. Maintaining proper fit should be emphasized to athletes as a fundamental of the game, just as important as proper tackling and following the rules of play.  Athletes on the professional and colligate level sometime set poor examples on proper equipment fit. Clinicians need to make emphasizing injury risk associated with poorly-fit equipment to the youth athlete a priority. While these results are interesting, they should be viewed carefully. Data was not cited for symptoms in a category beyond seven days.  It is widely accepted that the majority of young adults will recover in 7–10 days, with youth athletes taking longer, so it is possible that the results of this study could normalize between the fit and poorly-fit helmet groups if the endpoints were more specific of time of recovery. Additionally, as the authors mention, this study lacked uniformity for method of helmet fit assessment. Further research is necessary to determine reproducibility and clarify assessment protocol. Perhaps a simple real-time method to assess helmet fit on the side line could become an important risk reduction tool for an easily modifiable risk factor. In the meantime, clinicians need to educate their athletes about the risk associated with poorly-fit helmets and that it could lead to them missing more time after a concussion.

Questions for Discussion: Do you think there is an easy way to quickly and effectively assess helmet fit on the sideline? Do you think protective equipment will ever evolve enough to reduce concussion rates or severity in sports that require a helmet?

Written By: Stephen Stache, MD
Reviewed By: Jeffrey Driban

Related Posted:

Greenhill, D., Navo, P., Zhao, H., Torg, J., Comstock, R., & Boden, B. (2016). Inadequate Helmet Fit Increases Concussion Severity in American High School Football Players Sports Health: A Multidisciplinary Approach DOI: 10.1177/1941738116639027


boosh said...

This is association not causation. Many cofactors could be involved such as the less athletic players are getting the improperly fit gear. Just telling the athlete "your helmet doesn't fit you right" after his concussion can have a psychological effect on the players perception of his symptoms.

Jeffrey Driban said...

Thanks for the comment. You're right. As suggested in the first paragraph this is association. There's plenty of unmeasured factors that may exist that can help explain why poor helmet fit relates to concussion severity but this is also one that is easy to address (shouldn't we pick the low hanging fruit?). I don't think anyone would advocate for telling a patient "your helmet doesn't fit you right" after a concussion. Instead, this is an easy thing that should be checked throughout the season. Also, as Steve pointed out we should educate their athletes about the risk associated with poorly-fit helmets - this needs to happen before they get hurt. It'll be interesting to see if future studies support these findings and if future studies can inform us about other factors that may influence poor outcomes.

boosh said...

The title of the paper states causation!

Also do we need a study to advocate properly fitting equipment? Should we study if well prepared parachutes make a difference in sky diving?

This is just my rant on my pet peeves of how people make conclusions from these association studies.

We could easily find other risks with concussion severity like benchwarmers may have more risk. Should we start more players then??? No, these associations should be looked into more further with more focused studies before we make bigger clinical/policy decisions. Until then use common sense.

Jeffrey Driban said...

I believe we do need more work to advocate for properly fitting equipment. The study noted that just over 3% of helmets were found to be not fitted correctly. We could avoid this at a low cost and its easy to avoid. I'm sure many people can remember games where a helmet came off on a play it should not have come off during. This is a low cost, low risk suggestion to educate athletes about the importance of properly fit equipment and the need to monitor proper fit. Despite the lower level of evidence the potential benefits out way the risks.
Thanks for the great discussion!

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